Contents

• Foreword
• Executive Summary and Key Recommendations

First Term of Reference

• Introduction
• Equity, diversity, and inclusion
• Mental Health and Wellbeing
• Supply pathways – domestic/international
• Medical Schools
• Supporting doctors with disabilities
• Post Medical School Training and the Colleges
• Workforce Planning
• Intern and Post Intern Training (The First Two Years)
• Training to be a Specialist
• International Medical Graduates (IMGs)
• Appropriate resourcing levels for the Victorian public health system
• Long Service Leave (LSL)

Second Term of Reference

• Introduction
• Classification and Roles
• Development of a Career Medical Officer stream
• Recognition for Department Heads
• Senior Registrar/Junior Specialist/Fellows
• Unaccredited Registrars

Third Term of Reference

• Introduction
• Remuneration
• Work-life balance
• Entitlements
• Alignment of Specialist pay rates
• Casual employment and ‘zero-hours’ Contracts
• Accreditation and “onboarding” processes
• Fee for Service payments
• Market Rates

Fourth Term of Reference

• Rostering Practices and Shift Lengths
• Workload Management
• Shift Loadings

Fifth Term of Reference

• Introduction
• Out of hours work
• Continuous Duty
• Meal Breaks
• The “Patient Needs” criterion
• Overtime
• On-call and Recall

Sixth Term of Reference

• Introduction
• Seventh Term of Reference
• Job Roles
• Conclusion
• Appendices
• Appendix A – Comparison of out-of-hours remuneration for Fractional Specialists as at 1 January 2005

Foreword

The Australian Medical Association (Victoria) Ltd (AMA Vic) and the Australian Medical Officers’ Federation (Victorian Branch) (ASMOF Vic) welcomed the announcement by the Victorian Minister for Health (Minister) of this Ministerial Review: Victorian Public Sector Medical Staff – Workplace Systems and Employment Arrangements (Ministerial Review) and the Minister’s appointment of the Panel to undertake this Ministerial Review.

Like its predecessor ministerial reviews in 1995 (the ‘Lochtenberg Review’), 2000 (the ‘Wellington Review’) and 2007 (the ‘Morey Review’) (collectively, the ‘past Reviews’), this Ministerial Review comes on the back of a round of enterprise bargaining between doctors and the Victorian public hospitals and health services that employ them.¹ Although the impetus for this current Ministerial Review was provided by an enterprise bargaining process, the matters for consideration go beyond that which can be captured within an industrial instrument, as with the past Reviews. The Terms of Reference allow the Panel to consider broader issues and implications and make recommendations to the Minister that are relevant to how doctors are attracted to, engaged by, and supported in and by the Victorian public health and hospital systems. Relevantly, past Reviews have heard from and considered issues relating to doctors who provide services to Victorian public hospitals on a fee-for-service or ‘contractor’ basis, as well as Community Health Centre Medical Practitioners².

The Victorian health system has dramatically changed in recent years. The COVID-19 Pandemic had a significant and long-lasting impact on the practice of medicine in the public health sector. The concepts of remote working, working from home, and telehealth have become increasingly common.

The COVID-19 pandemic has changed perceptions of the attractiveness of medicine as a career. The extreme workloads of doctors both in the public and community health sectors and in general practice during the pandemic have led to high rates of burnout among medical professionals and appear to have reduced the desire to become or continue to work as a doctor.

It is disappointing to read previous Ministerial Review recommendations and to realise that Victorian public health medical staff still face the same problems, and that recommendations from our previous submissions have not been implemented, or not effectively implemented. In some cases, the problems have worsened - for example, recommendations to support International Medical Graduates (IMGs) and supporting doctors with carers’ responsibilities.

While not an explicit term of reference for this Ministerial Review, we believe the Panel should consider issues and impacts of gender and intersectionality within the Victorian public hospital system, its medical workforce, and its patients. We must explicitly acknowledge the changing face of the medical workforce, which is increasingly diverse and now has a gender balance that reflects the Victorian population more than ever. Our workplace systems and employment arrangements require change to reflect this.

Much of the Victorian public hospital medical workforce is covered by one of two industrial instruments:

1. The Doctors in Training (Victorian Public Health Sector) (AMA Victoria/ASMOF) (Single Interest Employers) Enterprise Agreement 2022-2026 (the DITs Agreement); and
2. The Medical Specialists (Victorian Public Health Sector) (AMA Victoria/ASMOF) (Single Interest Employers) Enterprise Agreement 2022 – 2026 (the Specialists Agreement).

Some of the changes we recommend in our submission will require a consensus between the industrial parties and their constituents on the one hand, and funding support from the Victorian Government on the other, to bring about either amendments to the existing agreements, or replacement agreements. We believe such consensus and support is achievable and would reflect a genuine commitment by those other parties to supporting the Victorian public health system medical workforce.

To have a world-class health system, Victoria must attract and retain quality medical staff. It must offer remuneration and terms and conditions of employment that compete effectively with those offered in other state jurisdictions and the private hospital sector.

This Ministerial Review provides a greatly welcomed opportunity to modernise workplace systems and employment arrangements for Victorian doctors. We need significant change if we are to appropriately reward and support doctors in delivering safe, quality healthcare to the Victorian community, and to reinvigorate the post-pandemic medical workforce.

December 2023

Executive Summary and Key Recommendations

This document presents a comprehensive set of proposals from the Australian Medical Association (Victoria) Ltd and the Australian Salaried Medical Officers’ Federation (Victorian Branch) (AMA/ASMOF) for the 2023 Ministerial Review on Victorian Public Sector Medical Staff – Workplace Systems and Employment Arrangements. The proposals aim to reform the healthcare system in Victoria, focusing on areas such as government accountability, job security for healthcare professionals, adequate staffing, and improved working conditions.

The key points of the submission include:

1. Job Security Enhancement: Eliminate precarious employment contracts and create greater stability for healthcare workers.
2. Adequate Staffing Levels: Ensuring adequate staffing to cover all planned leaves, thus preventing the overburdening of existing staff.
3. Implement measures to improve gender equity, inclusion and diversity at all levels of medicine: Disaggregate medical workforce gender data; address gender pay gaps.
4. Improved Implementation of Enterprise Agreement Terms and Conditions: Provide greater oversight in the implementation of employment terms and conditions.
5. Fair Remuneration for Unsocial Hours: Appropriate compensation for doctors working unsocial hours and on-call duties.
6. Streamlined Credentialing Process: A more efficient credentialing process across the public health system, facilitating flexible work and reducing the administrative burden for doctors.
7. Rural and Regional Infrastructure Investment: Develop infrastructure in rural and regional areas to support healthcare service delivery, including student recruitment and training.
8. Carer Support Provisions: Providing a carers allowance or support.
9. Support for International Medical Graduate (IMG) doctors: Improve support for IMG doctors particularly in regional and rural areas, with appropriate supervision, support networks and fair employment and training systems.
10. Increased Transparency in Workforce Planning: Greater transparency and involvement of doctors in medical workforce planning.
11. Oversight of Specialist Colleges: Greater oversight, equity and fairness of specialist colleges' policies and procedures.
12. Doctor-to-Patient Ratio Standards: The introduction of doctor-to-patient ratios following on from the successful introduction of Nursing-to-patient ratios to maintain quality of care and manage workloads effectively.

The document also discusses the historical context of the Victorian public hospital system, highlighting the unique challenges and changes it has undergone, particularly during the Kennett Government era. The current state of affairs, with its diverse and competitive approaches, has led to inconsistencies in employment terms and conditions, especially for specialist doctors.

AMA/ASMOF argue for the re-establishment of commonality in employment terms and remuneration across Victorian public hospitals to create a more consistent, transparent, and cohesive system. Our proposal aims to address ongoing issues, such as doctors' distrust and dissatisfaction with the employment culture in many Victorian public hospitals, reflected in recent class actions and surveys.

In conclusion, the proposals are designed to create a more efficient, equitable, and sustainable healthcare system in Victoria, prioritising the well-being of healthcare professionals and patients.

First Term of Reference

Recruitment, retention, supply of doctors (including local graduates and IMGs), training, training pathways and coordination of doctors across the public health sector recognising that this is a particular issue in regional and rural settings and hard to fill specialities.

Introduction

The Victorian healthcare sector is grappling with a critical challenge: ensuring a sufficient supply of medical practitioners to meet the growing demands of public health services. This issue extends beyond the mere number of healthcare professionals; it involves a complex web including training pathways, recruitment strategies, and retention and advancement mechanisms. These elements are essential for maintaining a robust healthcare system capable of providing high-quality care. A nuanced understanding of these dynamics is crucial, especially given significant gaps and opportunities for improvement.

A core issue is the lack of transparency and data availability concerning the number of medical practitioners or effective full-time hours required for effective healthcare delivery. The last comprehensive report by the Australian Institute of Health and Welfare (AIHW) in 2016, published three years later, revealed that Victoria lags behind in the national ranking for the number of full- time equivalent medical practitioners per 100,000 population. This contributes to increased workloads and diminishing morale among medical staff.

The pathway to becoming a medical practitioner is multifaceted, involving various stages of education, training, and professional development. The role of medical schools and the subsequent training programs, including internships and specialisation, are pivotal in shaping the future medical workforce. However, there has been a lack of long-term planning and support, particularly for IMGs, who face significant challenges in adapting to the Australian healthcare system. This gap in planning and support has implications for both urban and rural healthcare services, exacerbating the issues of understaffing and inadequate healthcare provision in different regions of Victoria.

Furthermore, a strategic approach to medical education and training must consider the evolving needs of the community and the healthcare system. The current structures and practices within medical schools and specialist training colleges often do not align with community needs, leading to a mismatch in the number of specialists trained and the actual demand for various specialisations. There is a pressing need to reevaluate and reform these educational and training pathways to ensure that they are responsive to the changing demographics and health requirements of the Victorian population. Such reforms should aim to create a more inclusive, diverse, and efficient system that not only addresses the current challenges but also lays a strong foundation for the future delivery of healthcare in Victoria.
 

Equity, diversity, and inclusion

Of key importance to the success of this review is the introduction of steps to address equity and inclusivity in medicine across the medical lifecycle.

AMA/ASMOF is often called on to support addressing discrimination and workplace culture issues, including those related to pregnancy, breastfeeding, and carer responsibilities. This assistance is crucial both within health services and in the context of medical training colleges, where there's often a lack of flexibility for trainees juggling their professional training with parental or other caregiving duties.

Furthermore, our members frequently encounter a range of problematic workplace situations, such as sexual harassment, biased recruitment and promotion practices, and limited options for flexiblework and leave. The absence of detailed medical practitioner-specific data in the audits conducted by the Gender Equality Commission for public health services hinders our understanding of the extent and nuances of gender inequality within the medical workforce. Addressing these gender inequity issues and broader inequities is vital not only for enhancing workplace culture and satisfaction but also for improving patient safety and ensuring equitable access to healthcare.

The importance of workplace inclusion cannot be overstated, as it directly affects the morale and retention of medical professionals. Every member of the medical profession deserves fairness, impartiality, and equal consideration. Promoting inclusion is essential so that all medical workforce members feel:

• Respected: Recognised for their unique identities and comfortable being themselves.
• Connected: Integrated with their colleagues and a sense of belonging.
• Contributing: Valued for their diverse perspectives and talents.
• Able to Progress: Supported in their career and training advancement.

AMA/ASMOF recommends focussing on three key areas to foster equity, diversity, and inclusion in the public hospital medical workforce:

1. Work Participation: Advocating for pathways that facilitate work participation and career development for IMGs, doctors with disabilities, and those returning to work after a prolonged absence.
2. Cultural Safety: Collaborating to create culturally safe work and training environments, especially for Aboriginal and Torres Strait Islander doctors and those from culturally and linguistically diverse backgrounds, ensuring an environment free from racism.
3. Equity and Inclusion: Striving for diverse representation in public hospitals and fostering a culture where all medical practitioners feel a sense of belonging.

Additionally, it is crucial to highlight the need for Victorian audits to disaggregate medical workforce gender data. This data is needed to examine the state of gender equity in health services, allowing for the development and monitoring of effective gender equity plans akin to those implemented by the Department of Health (as seen in their Gender Equality Action Plan 2022-2025). This approach is essential for tracking progress and identifying areas for improvement.

AMA/ASMOF would also like to see a comprehensive analysis of the gender pay gap in medicine, taking account of factors such as the effects carers' responsibilities have on any gaps and career pathways and gendered differences in overtime claiming. It is our view, as described below, that the need to take time away from work is severely impacting the ability of doctors with childcare responsibilities to fulfil their potential as doctors and hampering the health system.
 

Mental Health and Wellbeing

Physically and psychologically safe workplaces are intrinsically linked to the ability to recruit and retain doctors in the public health system. One 1 in 5 doctors report that they are considering leaving the profession (AMC Medical Training Survey Report 2022), with many citing burnout as the reason. Given the time it takes to qualify as a doctor, this figure is alarming. In the same report, 50% of trainee doctors report they have experienced (received or witnessed) bullying, discrimination, harassment, or sexual harassment in the workplace. Despite half of trainee doctors reporting experiencing these issues, fewer than 30% reported that behaviour to management. With 57% of doctors who had experienced these types of behaviours fearing the repercussions, whilst 49% believed that nothing would be done in response to any complaint that they would raise. Most concerningly, 70% of respondents stated that this had an impact on their medical training.

The recent Victorian Auditor-General’s (VAGO) Report Employee Health and Wellbeing in Victorian Public Hospitals concluded that:

• The department and the audited hospitals do not effectively support hospital workers' mental health and well-being.
• Data shows that workers' mental health and wellbeing has deteriorated since 2019.
• There are gaps in hospitals' processes to identify and control psychosocial hazards.
• The department does not effectively oversee hospitals to make sure they protect staff.

We support the VAGO Report recommendations that

• The Department develop and implement a framework to monitor and report on hospital employees’ mental health and well-being.
• Health services develop and implement a comprehensive framework for their hospital that effectively manages psychosocial hazards to protect their employees.

We do not support the Government’s current proposal to water down eligibility to WorkCover supports through the Workplace Injury Rehabilitation and Compensation Amendment (WorkCover Scheme Modernisation) Bill 2023.
 

Supply pathways – domestic/international

Obtaining comprehensive data and modelling regarding the number of medical practitioners needed for adequate healthcare delivery is challenging in the absence of an independent health workforce planning and analysis agency. The most recent detailed analysis of Victoria's health system performance, conducted in 2016 and published in 2019 by AIHW, indicates that Victoria is near the bottom nationally in terms of full-time equivalent (FTE) medical practitioners per 100,000 population, only surpassing Western Australia. Despite having an average number of hospital beds per capita, Victoria's relatively low number of doctors per capita contributes significantly to high workloads and low morale among medical staff.

There appears to be a lack of long-term workforce strategic planning aimed at enhancing the supply of doctors while simultaneously creating appealing career opportunities. IMGs, who are often recruited into the system, particularly in regional and rural areas, receive inadequate support. Workplace issues arising with IMGs are generally more complex and time-consuming, largely due to unfamiliarity with the Australian healthcare system. Consequently, health services need to provide better resources and support services for this cohort.

Only increasing the number of intern positions won't address the workforce shortages. We need a rebalancing of supply and distribution, reform to training pathways and an increase in the number of training positions offered by medical colleges. For the first time in recent history, Victorian intern places for 2024 are undersubscribed, leading to health services allowing IMGs, who require supervision, to fill these spots.

The number of specialists being trained is effectively controlled by the colleges through their regulation of the number of doctors permitted to undertake Registrar training. While colleges continue to play a gatekeeper role, the number of specialists in training will be driven more by the colleges' self-interest rather than community needs.

In addition to supply issues, the training pathway in Victoria also suffers from attrition with a significant number of doctors discontinuing their training with various colleges every year. Common reasons cited include the burden of caregiving responsibilities and the inability to balance a family against full-time training, further exacerbated by the lack of clear pathways to resume their training. This is compounded by the difficulty of leveraging their experience and previous learning into other speciality courses. It is essential that our system have pathways to accommodate and support these doctors, as well as unaccredited registrars and Career Medical Officers.
 

Medical Schools

The pathway to becoming a doctor commences with entry into a medical school. It is thus logical that for the Ministerial review to achieve one of its stated aims of increasing the recruitment, retention, and supply of doctors in regional and rural areas, both the entrance and structure of medical schools within Victoria should be considered within the scope of this Review.

Members tell us that doctors who come from a rural background or spend time training in a rural area are more likely to take up long-term practice in a rural location. As a result, AMA Victoria recommends that there is a focus on increasing the intake of medical students from rural backgrounds.

We note the recent introduction of Deakin’s Rural Training Scheme ‘RTS’ – which included a modification to entry requirements, such as the removal of the GAMSAT requirement (a standardised test required for ranking prospective students) whilst focusing on those from a rural background, and the increased selection focus upon written applications demonstrating commitment to rural practice or connection. This is one such model that could show promise, and we recommend further investigation of similar programs that focus on the prioritisation of medical students from rural backgrounds to increase the likelihood of their return to the rural setting.

Medical school experiences also have an impact on the future desire/plan to work in rural post- graduation. It is thus important that rural students who are recruited are supported throughout their training. In addition, it is important that medical students are exposed to positive rural working role models, in addition to meaningful and high-quality rural experiences.

Medical school teaching is also Metropolitan Melbourne-centric. Given that the major universities and their AMC-accredited medical schools are largely based within the city boundary, the majority of students who enter medical school will spend the majority amount of their university years within an urban environment. Rural exposure and rotations do exist, but they are usually reserved for later-year students, and most students will only be offered brief exposure to this work environment.

We believe that there should be a focus on increasing rural exposure within medical school. This could include increasing the rural rotations available to students and progressing as far as considering the implementation of end-to-end rural training. We believe that this will ensure that the positive aspects of rural practice are conveyed to students and that the barrier to entry to rural practice is lowered by not having spent a number of years in urban settings.

Beyond medical school, it is essential that both support and incentives for doctors working rurally are also considered. This could include:

Support for doctors to train in rural areas could include.

• Direct payments such as salary, bridging payments, or allowances.
• Training and examination fee discounts for trainees in MMM3-7 locations
• Decentralised examinations for rural trainees (reduces travel costs)
• Addressing housing, spousal employment, and childcare barriers
• Ensuring rural health services are resourced to meet industrial requirements, including accommodation and security, adequate staffing capacity, safe rostering practices, and teaching and training requirements.

The 2023 AMA Rural Medical Training Summit examined many of the issues raised in this submission regarding training and retention in rural and regional areas. The report can be found at https://www.ama.com.au/articles/ama-rural-medical-training-summit-report. In summary, this document calls on governments to reform Specialist Training Programs to create quality places in rural and regional areas and greater support for IMGs through appropriate supervision and the creation of support networks.

Supporting doctors with disabilities

The current system for selecting entrants into medical schools fails to adequately cater for persons with disabilities and for persons who are neuro diverse. In April 2021, the Medical Deans of Australia and New Zealand issued a position paper which appears on paper to address the issue. However, the reality is that there are still barriers effectively preventing students with disabilities from entering medical school ³.

AMA Victoria advocates four areas of action to create inclusive training and work environments that support participation and a career in medicine for people with a disability:

• inclusion, fair selection and support
• organisational support
• flexibility and reasonable adjustments
• research

These four action areas are described in the AMA position statement Supporting doctors and medical students with disability available for download at https://www.ama.com.au/articles/supporting-doctors-and-medical-students-disability

Post Medical School Training and the Colleges

The current training pathways to become a Specialist are controlled by the Colleges who have a broad role to play in advancing the interests of different Specialities within the medical profession. Colleges are directed by Specialists who have a vested interest in protecting their Specialty both in terms of the clinical and professional aspects of the Specialty, but also controlling the number of new entrants into the Speciality and thus the overall size and service capacity of that specialty.

The Colleges are neither the employers of doctors who are training to become a Specialist nor are they agents for, nor acting on behalf of, the Health Services or the Department of Health. The Colleges have no contractual relationship with the doctors who are undertaking training to become a Specialist, yet it is the Colleges who determine whether or not a doctor can be a Specialist.

The actual training of doctors who want to become specialists is provided by specialists employed by Health Services. However, despite the Health Service designate being responsible for this training, a trainee can fail one or more training terms, and/or be dismissed from training entirely without that decision being reviewable by the Doctor under either of the DiT or Specialists Enterprise Agreements nor under a Health Services internal processes.

There is a complete lack of transparency from the Colleges in how they engage with and support current and previous fellows either returning to practice and/or training where there has been a gap or specialist registration has lapsed. When AMA/ASMOF has dealt with these situations our experience is that it is not possible to obtain clear answers from the Colleges. This creates uncertainty and bureaucratic hurdles, impeding the supply of specialists.

Given the monopoly of college training, the colleges also unilaterally control the assessment and pass rate of prospective specialists through their pathways. We believe there is a need to review and reform these college examination processes. In some cases, colleges set an arbitrary pass rate for candidates per year, irrespective of the performance of the cohort. In other cases, unrealistic pass marks are required to pass the exam, e.g. 79% of marks obtained, but the candidate ‘fails’ the exam, requires either a 12-month delay before another exam attempt or being ineligible to progress with training entirely. These actions from colleges skew the training outcomes and the number of doctors who can become Specialists. This can result in either a glut in various craft groups at various times or a drought of new Specialists at others.

Colleges do not appear to be driven by any sense of needing to act in a way that addresses Doctor shortages in regional or rural areas. Consideration should be given to imposing requirements on colleges in two specific areas:

• A requirement for colleges to recruit a percentage of trainees with predominantly regional experience or from regional health services.
• A requirement that Colleges work with health services to create more training positions in regional centres where they are based regionally and rotate into metro for rotations they can’t do regionally, i.e. an end-to-end specialist training model in a rural/regional setting.

The above discussion suggests that, left to their own devices and motives, the current college model may not be sufficient to serve the needs of Australians moving forward. Consideration thus should be given as to whether a fundamental change to the role of colleges in training doctors who want to become Specialists is required to meet the needs of our population going forward.

Workforce Planning

Australia urgently needs an independent health workforce planning and analysis body that provides evidence-based, high quality and contemporary data to inform health workforce planning and development. Workforce shortages and maldistribution sit at the heart of many issues that the Ministerial Review is examining. Australia has lacked central direction and transparency around the health workforce since the body Health Workforce Australia was abolished in 2014 when its functions and programmes were moved to the Commonwealth Department of Health. Australia (and Victoria) does not produce sufficient medical graduates to satisfy the medical workforce demand, and there has been a lack of co-ordinated strategy between education, training, employment and regulation. Rectifying this is crucial if we are to train a domestic medical workforce sufficient for community needs.

AMA policy (https://www.ama.com.au/articles/commonwealth-supported-places-and-medical- workforce-supply-and-distribution) calls for the establishment of an independent health workforce planning and analysis body. The National Medical Workforce Strategy 2021-31 (https://www.health.gov.au/our-work/national-medical-workforce-strategy-2021-2031) seeks to establish a National Medical Workforce Data Strategy, and a joint medical workforce planning and advisory body. The Data Strategy will require a joint agreement between the Commonwealth, Victorian Government, Specialist medical colleges and relevant peak bodies to share data.

Intern and Post Intern Training (The First Two Years)

AMA and ASMOF acknowledge and commend the Health Services and PMCV for the quality of training provided to Doctors in their Intern year. Going forward, there is a need for change to ensure that the needs of the Victorian health sector are met by having well-trained and broadly experienced Doctors.

Of particular concern is the hospital-centric base for Intern training. The hospital-centric internship has existed to try to expose interns to the widest ‘range’ of clinical areas possible, e.g. an emergency department rotation, a surgical rotation, or a medical rotation. This reflects the desire to expose interns to the widest range of clinical areas in medicine. While this approach has its positives in terms of exposure, it neglects the entire area of primary care. These early years of a doctor’s life and the experiences that they often shape their choices about future career aspirations. By failing to expose our Interns and early-year doctors to primary care, we are depriving them of the opportunity to ‘try it on for size’ as we do with other specialities, as well as the opportunity to understand primary care and the way that it functions. Ultimately, this contributes to the sharp decline in the number of doctors choosing to pursue general practice training.

While the general practice workforce crisis is not directly in scope for the Panel and Review, it is nevertheless clear that if Victoria does not re-establish a strong general practice workforce, the demands on medical practitioners working within public health services will continue to rise along with the cost to deliver those services.

To reduce the silos between general practice and health services, it is desirable that the current Intern training system be revised to require that all Interns, in either their first or second year, undertake a rotation to a General Practice (or Rural Generalist Practice) setting. The most appropriate General Practice (or Rural Generalist Practice) setting would be Community Health organisations, as these are not for profit and are already part of the Victorian Government health system. Rotation to a Community Health organisation would avoid any conflict of interest that may arise by having Health Service employed Interns working in “for profit” GP practices.

A further concern in relation to ensuring that Victoria continues to have highly trained and skilled Interns is the recent announcement from the Department of Mental Health that there will no longer be a requirement for Interns to undertake a Psychiatry rotation. This action reverses the specific Interim Report Recommendation 7 of the Mental Health Royal Commission that:

• an agreed proportion of junior medical officers to undertake a psychiatry rotation, effective from 2021, with it being mandatory for all junior medical officers by 2023 or earlier.

With the rise of mental health presentations to either primary care or emergency health care, we require clinicians who are skilled in the identification and management of mental health presentations. Strong consideration should be given to the continued implementation of the Royal Commission recommendation making Psychiatry a mandatory rotation for intern training at least in their first year of pre-vocational training.

Training to be a Specialist.

Currently, training to be a Specialist through the Registrar training pathway is controlled by the various Colleges. As noted earlier there are problems in having the Colleges who have mixed motivations between protecting their Specialty, whilst also acting as the bodies controlling the training of future Specialists.

This section of the submission deals with other issues associated with Registrar training.

Victorian doctors who have been accepted onto accredited College training pathways (“accredited registrars”) have limited and poor access to flexible work and training arrangements. The number of accredited registrars who desire access to less than full-time training far exceeds the number of available flexible working roles. In situations where health services have offered part-time roles, it is not uncommon that they are offered as a “job share” position, where the onus is on the doctor applying for the role to locate and nominate a colleague who wishes to share the full time position. This creates a massive hurdle for people applying for these positions and can cause significant issues if one of the ‘pair’ needs to drop out before or during training.

A significant issue is that the current system of Registrar training, with its system of rotations and structured training modules, effectively requires a registrar to work full time.

It is undeniable that there are currently some accredited registrars who are working part-time, but such roles are not easy to find, and part-time training requires specific permission from the relevant College. Flexible work and training is not encouraged or readily facilitated by health services or training Colleges. This has implications for doctors who have carer and other responsibilities outside the workplace. If part-time and flexible training and work is not readily available, these doctors may be unable to work and train and simply steered away from the speciality they wish to pursue. Alternatively they must work under circumstances and a workload that far exceeds their desired capacity, with detrimental effects on the health and wellbeing of both themselves and/or their family.

An additional issue is that the current system requires completion of the full training program to receive any recognition. There is no recognition or qualification for having completed half of an accredited Registrar training program rotation. This all-or-nothing approach is too rigid and is not in the interest of encouraging doctors who have General Registration only to take on further training. A partial recognition system could incentivise General Practitioners to upskill in particular areas prior to, or during, their General Practice years, further bolstering the skill set of our primary care system and reducing the reliance on Hospital emergency departments and outpatient settings.

There would be benefits from restructuring accredited training pathways so that a doctor could complete part of a Specialty training program and receive recognition or a qualification for doing so. Such a doctor will still only have General Registration but at the practical level will be of more value to the public health sector by having recognition or a qualification in a particular part of the Specialty training program.

The current structure of Specialist training is based upon an expectation that a Doctor undertaking a Registrar training pathway will be a Specialist in that Specialty and that further post-specialist (subspecialty) training will also be within that Specialty. This approach is not unexpected or necessarily wrong as a Specialist is only permitted to practice as a Specialist within their recognised Specialty. With all Specialities having recognised sub-Specialties the natural perception is that a doctor progresses from being a generalist to becoming a Specialist and then becoming a Specialist with a focus on a sub-Speciality.

A Doctor wanting to work in two Specialist areas must complete two separate accredited training programs and qualify in two separate Specialties.

There are exceptions to the above namely in relation to General Practice (and Rural Generalists) where general practitioners have undertaken additional training in another Speciality, most commonly in Anaesthetics or Obstetrics.

This approach can be broadened to include all Specialities.

There is workforce benefit in having more defined niche training elements (limited or micro credentialling) that are linked to specific work, tasks or procedures.

Career Medical Officers (CMOs) would gain benefit from a more flexible approach to delivering niche or limited or competency-based credentialling training. For a range of reasons some Doctors choose not to pursue the traditional medical training pathways but instead remain working in the public health sector with General Registration. This may reflect personal preference, or it may reflect a lack of attractive or viable alternatives. Currently, CMOs may work in emergency departments and across all inpatient areas of a health service. CMOs often have a wealth of experience gained through their years of work, but this experience is not formally recognised and, therefore, not readily identifiable for credentialing, rostering or determining the appropriate scope of practice. Providing flexible learning (including experienced-based learning) would enable CMOs to gain recognised qualifications which would permit the CMOs to be better utilised within health services.

The current DiT Agreement provides no financial incentive for a CMO to advance their skill set. Many CMOs are abandoning these roles in favour of more lucrative locum positions. Incentivising CMOs to gain additional qualifications through the provision of a revised career and pay structure for CMOs with additional qualifications would encourage individual CMOs to pursue such training, if it were available, and would appropriately recognise the time and expense invested to obtain such qualifications.

International Medical Graduates (IMGs)

IMGs play a vital role in staffing the Victorian health sector, particularly in regional and rural health services. The 10-year moratorium means that IMGs first taste of practicing medicine and training in Australia is often outside of major cities, and for an extended time. This journey is far from easy, with red tape, isolation, and insufficient support the reality for many IMGs. More needs to be done to recognise and support IMGs in the Victorian public health sector.

The recruitment of IMGs into the Victorian public health sector could be improved by

• having IMGs assisted and sponsored by a Health Service.
• Health Service financial support through addressing all visa requirements and relocation costs for the IMG and their immediate family.

We believe more could be done to encourage IMG’s to settle in regional areas. Health services should be encouraged to take a holistic approach to the employment of IMG’s making sure that they do what they can to support the doctor and their families to settle into their area.

Establishing an accredited IMG (foundation year / internship) pathway for doctors who have trained overseas, have satisfied all AMC requirements and are not eligible for Specialist training/work experience pathway would benefit IMGs and the Victorian public health sector by ensuring that the IMG is provided with a supported opportunity to be enculturated into the Victorian public health sector, and into regional or rural community life. An accredited IMG foundation year would need funding and at least 2 intakes per year. There should also be a focus on embedding these positions in larger regional centre and outer metro hospitals – not inner metro.

AMA and ASMOF have encountered instances where an IMG have been subject to disciplinary action simply because of ignorance about the culture or normal workplace expectations within the health service.

A common example encountered by AMA and ASMOF is where an IMG is alleged to be rude to nursing staff or other doctors either by speaking to them in what is perceived by the listener to be an abrupt manner or by appearing to ignore a staff member. In cases where this type of misconduct has been alleged against an IMG, it is our experience that it has subsequently become clear that the way IMGs interact with other staff in the countries in which they were trained or worked is very different to the way in which normal interactions occur in the Australian public health sector. Such incidents could have been avoided if the IMG had been given appropriate enculturation both before and during their employment in Victoria.

In one example, an IMG was subjected to disciplinary action for failing to use the Electronic Medical Record (EMR) system of a Health Service. The Health Service presumed that every doctor knew of the requirement to use the EMR. However, the Doctor was trained and had been working in a country where all medical records were maintained in a hardcopy format. Once the allegation of misconduct had been put to the doctor, the doctor immediately undertook to learn to use the EMR system.

A practical measure to provide professional development and collegiate support for IMGs in regional and rural health services where there may be only one or two doctors working in a particular speciality is to link departments in regional and rural hospitals with a larger department in a metropolitan-based health service.

General Practice and GP Registrars

While GPs are not the focus of this review, the current GP workforce crisis significantly impacts the public healthcare system. The lack of accessible primary healthcare is increasing pressure on emergency departments and health services statewide.

A single employer model for GP Registrar training offers a potential solution that is within the scope of health services and the Victorian Government. Clause 31 within the current DiT Agreement includes a mechanism that allows Health Services to employ GP Registrars and assign them rotations in General Practices.

Employing DiTs as GP Registrars within Health Services would create a 'single employer' model in Victoria and keep GP Registrars within the Public Health Sector and under the DiT Agreement, allowing doctors to choose to train as GP registrars without experiencing a pay cut, or loss of other conditions, including sick leave or parental leave that traditionally accompanies their departing the Public Health Sector. This would also mean that GP Registrars would have legally binding pay rates and employment conditions so that they would then fall under the DiT Agreement rather than the National Terms and Conditions for the Employment of Registrars (NTCER), which is neither registered nor enforceable. This would reduce the friction and soft ‘penalty’ of entering GP training particularly at a more senior level. Several single-employer model pilots are currently being run elsewhere in the country to initial positive reviews.
 

Appropriate resourcing levels for the Victorian public health system

There is a critical need for increased recurrent funding to Victorian public hospitals and to other entities operating within, or supporting, the Victorian public health and community health systems. This would enable public hospitals and these other entities to employ sufficient medical staff to meet the Victorian public’s needs and expectations and to offer and provide the remuneration and employment terms and conditions necessary to attract and retain high-quality medical staff.

The pressure on emergency departments due to bed block is another example of under resourcing of the system. Bed block is caused by a lack of places for patients to be transferred to once they are ready to leave the public system or to be moved to another part of the health service. This is both a function of physical space within the healthcare system, and the staff needed to ensure appropriate flow of patients through the healthcare system resources that we do have.

In addition, it appears that staffing models used by health services do not adequately consider the leave requirements of doctors. Leave is an essential right for doctors both from a recuperation perspective, but also for upskilling and being able to deliver high quality care at their health service. Health services should make sure that they have enough staff to cover all planned leave built into their rosters. They should also make every effort to have procedures in place to over any unplanned leave. We have had feedback from health services during enterprise bargaining that they are concerned by the number of hours of leave doctors have accumulated. Conversely, we often receive feedback from our members that their leave request is declined by those health services because they have no one to cover their shifts. Providing access to recreational leave (Annual and LSL) should be a priority if we are serious about attracting and retaining staff.

Long Service Leave (LSL)

While there have many improvements in long service leave arrangements for doctors through recent enterprise bargaining rounds, there is still room for further improvement, particularly regarding the recognition of service performed in other jurisdictions. The current DITs Agreement allows recognition of service performed in other jurisdictions where that service was with an ‘interstate government health service’, or otherwise was part of a Specialist training program accredited by a Specialist Medical College with an employer not covered by the DITs Agreement. Both scenarios are subject to some qualifiers. Service with an interstate government health service is qualified by when employment occurred (post 30 November 2008), and recognition of prior service is generally qualified by the length of breaks between periods of employment. The Specialists Agreement includes almost identical terms.

With respect to allowable lengths of break between otherwise recognisable periods of service, we would draw the Panel’s attention to an issue that we believe should be remedied; that is the issue where longer breaks between periods of employment occur due to lack of positions when a doctor is moving from a Doctor in Training role to a Specialist role. In this circumstance, the break between otherwise recognisable breaks in service can be beyond the doctor’s control and we do not believe the doctor should be penalised or disadvantaged in that situation.

Another issue that we would draw the Panel’s attention to and seek a correction to policy and approach relates to Specialists who hold two or more concurrent contracts of employment with different Victorian public hospital employers. The current long service leave arrangements in the Specialists Agreement do not allow Specialists to take long service leave at all concurrent health services once they entitled to access leave at one health service. We believe this is a matter impinging on fairness and equity, and a matter that has a disproportionate impact on female doctors as they are more likely to be Fractional due to carers' responsibilities.

Fractional Specialists who are concurrently employed by two or more Health Services are treated less favourably than full-time Specialists with respect to LSL.

The operation of the Victorian public Health Sector is dependent upon the engagement of Fractional Specialists and particularly on engaging the same Fractional Specialist concurrently by two or more Health Services. This allows Health Services to access a full range of Specialists even where the workload is insufficient to engage a full-time Specialist. It also encourages Specialists who do not want full-time employment with a single Health Service to work as a fractional Specialist at one or more Health Services.

The current approach to LSL in the Specialists Agreement (and which reflects the Full Bench decision) creates a positive disincentive to Fractional Specialists being concurrently employed by two or more Health Services.

The issue arises out of the wording used in the Specialists Agreement to describe the entitlement to LSL. There is no doubt about this issue as it was the subject of dispute which was taken to the FWC and the decisions of the FWC at first instance and on appeal were very clear. AMA/ASMOF v Alfred Health and others, [2022] FWCFB 7.

The effect of the FWC decisions is that continuity of service for LSL purposes for a Fractional Specialist who is concurrently employed at two or more Health Services is limited to only one of the Fractional Specialists current employers.

Both AMA and ASMOF sought to remove this barrier during bargaining for the current Specialists agreement but neither the Government nor the Health Services were willing to do so. This is a barrier to recruitment which has been deliberately maintained by the Government and the health Services. The barrier is easy to remove; all that is required is to amend the definition of Continuous Service in clause 55.3(a)(ii) so that instead of referring to “continuous service with the same Health Service”, it would instead refer to “continuous service with each current employing Health Service”.

We urge that the Panel address this issue in its deliberations and recommendations.
 

Second Term of Reference

Adequacy of existing classification structures and exploration of future clinical management roles, including the potential of expanding the utilisation of classifications such as Medical Officers.

Introduction

The landscape of medical staff classifications and remuneration in Victorian public hospitals has undergone significant transformation in past decades, particularly since the advent of 'enterprise bargaining' in 1995. This evolution has been marked by continual, often ad-hoc, revisions, influencing both DiT and Specialists. These changes encompass fluctuations in the number of incremental pay points and the introduction and phasing out of various classifications, reflecting efforts to streamline career structures, accelerate career progression, and align pay scales more closely with those in other Australian states. This complex history sets the stage for a critical examination of the current state and potential future directions of this system.

In recent times, efforts to simplify these structures have been met with varying degrees of success and reception among medical professionals. Our present focus lies in evaluating the merit of reintroducing some of the earlier classifications, especially concerning Medical Officers and Senior Medical Officers under the DiT agreement. The need for review and adjustment in this area is crucial, considering the evolving demands and expectations of the medical field.

A particular point of interest is the development of a distinct career path for Career Medical Officers, a role recognised in other Australian public health jurisdictions but less defined in Victoria. These officers, often experienced but not registered as Specialists in Australia, play a vital role in the public health system. Their current employment terms under either the DiT or Specialists Agreements do not fully reflect their unique position, leading to calls for a more structured and recognised career pathway.

Finally, we call for enhanced recognition and remuneration for Department Heads and high- performing Registrars, as well as Fellows in the medical field. Current classification structures, including those for Senior Registrars and Junior Specialists, are inadequate in addressing the needs of doctors who have completed their specialty training but are engaged in further training. This underscores the need for a thorough review and potential overhaul of the existing agreements.

Classification and Roles

The system of classifications, incremental pay points and salary ranges applying to medical staff directly employed by Victorian public hospitals has been subject to constant and ad-hoc revision over many decades, and particularly during the ‘enterprise bargaining’ era that commenced in Victoria in 1995.

Development of a Career Medical Officer stream

Most other public health jurisdictions specifically recognise and provide a discrete career path/structure for Career Medical Officers. These are doctors who are not (yet) recognised and registered as a Specialist in Australia, are not undertaking accredited training to achieve registration as a Specialist, but who are practising medicine in the public health system.

In Victoria, a doctor who is directly employed by a public hospital must be employed under either the DITs Agreement or the Specialists Agreement. While there is some flexibility in the definition of ‘Specialist’ in the Specialists Agreement that would allow a Victorian public hospital to employ a doctor as a Specialist even where they do not hold registration as such, we understand this to be a rare occurrence. This is true even where the doctor may have held equivalent registration as a Specialist overseas. Instead, Victorian public hospitals will typically employ such a doctor as a Medical Officer or a Senior Medical Officer under the DITs Agreement.

The Morey Review noted that there were “concerns about the lack of a career pathway and the lack of opportunity for continuing medical education for doctors who wish to remain in hospital practice without specialising”. The Morey Review further observed that these “concerns are not new and, despite a number of reviews nationally and in other states over the past two decades, little has changed”. We respectfully disagree with the Morey Review panel’s observations that little had changed in other states. The Awards and Enterprise Agreements in most other states and territories in Australia contain classifications and rates either specifically for Career Medical Officers, or otherwise recognise such doctors and provide classification/remuneration outcomes.
 

Recognition for Department Heads

As mentioned above, there have previously been classifications of Senior Specialist, Principal Specialist and Senior Principal Specialist available for the classification of both Full-time Specialists and Fractional Specialists employed by Victorian public hospitals. These classifications were rolled into the current Specialist and Executive Specialist classifications in the Specialists Agreement. This action of rolling together classifications was agreed between the negotiating parties for the purposes of achieving better remuneration outcomes for Specialist in general. However, that action created anomalies of classification that persist today, particularly regarding the appropriate classification, remuneration and recognition of Department Heads.

Department Heads have responsibilities that are generally greater than that of their Specialist colleagues who work within the same departments within Victorian public hospitals, and often report to other Specialists who are classified as Executive Specialists. We submit that these Department Heads should receive higher remuneration, to reflect their higher level of responsibilities.

To address this anomaly, the Panel should recommend either the creation of a Department Head classification, or the reintroduction of the Principal Specialist classification, with a remuneration level ten percent above the current maxima for both the Full-time Specialists and Fraction Specialists streams. The minimum pay of the remuneration band for Executive Specialists should be adjusted upwards such that it sits no less than five percent above the newly created pay rate for a Department Head/Principal Specialist.
 

Senior Registrar/Junior Specialist/Fellows

Existing classification structures are clearly inadequate. The existing classification structure in both the DiT and Specialists Agreements do not adequately provide for the following.

Doctors who have completed their training for a speciality and who have received membership of a Specialist College but who are still in training because of a need for post-Specialist training before they can practice their speciality.

These doctors are often employed with the job title of Fellow and are paid as Senior Registrars, which can be anywhere between a Registrar year 4 level and a Registrar Year 6 and thereafter level.

The reality is that these doctors are no longer covered by the DiT Agreement and as registered Specialists should be paid as Specialists. Even where the Doctor is undertaking further training, the Doctor is nevertheless a Specialist and will be working at the Specialist level whilst undertaking the further training.

The practical issue is that even though these “fellowed” doctors are Specialists, they are not being employed to fill the role of a Specialist but rather are engaged in a post-specialist training program to enable the ‘Specialist’ to develop skills in a sub-specialty.

If the term “Fellow” is to be used to describe a doctor with Specialist registration or a doctor who is entitled to Specialist registration and who is undertaking advanced training within a Specialty, then provision should be made within the Specialists Agreement with appropriate rates of pay and hours of work.

The specific inclusion of a “Fellow” classification within the Specialists Agreement and the specific exclusion of “Fellows” from the DiT Agreement would provide certainty to both Health Services and Doctors as to where and how “Fellows” fit into the system.

It would be inappropriate to include “Fellows” in the DiT Agreement as they are no longer involved in the Registrar training pathway and therefore the 43-hour week which applies specifically to Registrars is ill suited to being applied to Fellows. Further, even though the Fellow is undertaking post Speciality training they must nevertheless present themselves with the skills of Specialist and will be working as a Specialist for some or all their time as a Fellow.

The rate of pay for a Senior Registrar Year 6 and thereafter as of 1 September 2023 is $3,332.50 or $77.97 per hour for a 43-hour week.

The rate of pay for a Full time Specialist Year 1 as of 1 September 2023 is $4,917.44 or $129.41 per hour for a 38-hour week.

Health Services have put the argument to AMA/ASMOF that a Fellow is not worth the Specialist rate as the Fellow is not able to work independently as a Specialist given the need for training and supervision to be provided in training as a Fellow.

At its highest such an argument from a Health Service could (but not does not automatically) justify paying a Fellow less than the Specialist Year 1 rate of pay.

If any discount of the Specialist Year 1 rate was to be considered for Fellows, then the discount should be minor. The current forced discount of a minimum of $51 per hour is without justification or merit.

Unaccredited Registrars

The Victorian public health service has an undue reliance on Unaccredited Registrars (sometimes termed “service registrars”). An Unaccredited Registrar is a doctor who fills a Registrar position but without having been accepted into a College training program. Unaccredited Registrars do not get any recognition by the Colleges for any work performed as an Unaccredited Registrar, despite the job description and duties of the unaccredited and accredited registrars generally being the same. Health Services often use Unaccredited Registrars to fill in gaps or shortfalls in their Registrar workforce.

Unaccredited Registrars may but do not have to receive any of the same training required of a Registrar who is undertaking College accredited Registrar training. Unaccredited Registrars work the same hours as accredited Registrars and are paid the same rates.

The DiT Agreement specifically contemplates the concept and usage of Unaccredited Registrars as it defines a “Registrar” as follows:

“Registrar means a doctor who is either appointed to an accredited Specialist training position (refer subclause 42.7(c)) or who holds a position designated as such by the Health Service.”

Unaccredited registrars predominantly exist in specialties with in-demand, highly competitive entry, where it is common that doctors are not accepted onto the training program without first undertaking several years of work in the field. The positions can function as a means for DiT to gain experience in the field prior to applying to the specialty training program but can also function as a service pool of doctors who have no guarantee of career progression, and who work for years hoping to gain acceptance on a training program. Some Colleges place a ceiling of a maximum of three attempts to gain entry to a specific training program before the candidate becomes ineligible to make further applications, which blocks doctors from further efforts to pursue a specialty that they may have exclusively worked in for multiple years, effectively de-skilling them from other areas of medicine and effectively limiting their options for applying to other training pathways. These doctors are highly vulnerable to rostering exploitation, as the highly competitive entry of training programs can demand an exceptional standard of work and dedication from the unaccredited registrars, lest their supervisors and consultants provide a less than sterling reference in the annual application for the training programs occurs. Accredited registrars have protected training time which can include mandatory conferences and workshops; unaccredited registrars are expected to cover the unit workload during this time, and in most units the unaccredited registrar’s leave requests are secondary to the leave requests of the accredited registrar and the unit service demands. While unaccredited registrars are covered by the DiT agreement, their vulnerability is such that they risk their career progression (i.e. acceptance onto a training program) if they seek to object to unsafe rostering or failure of the health service to deliver on their entitlements.

AMA believes more needs to be done to protect the well-being and job satisfaction of Unaccredited Registrars and recommends health services be required to monitor the registrar roster to make sure that workloads are distributed fairly across both accredited and unaccredited registrars.
 

Third Term of Reference

Exploration of the barriers to recruitment and retention of ongoing medical staff arising from different modes of employment, such as fractional Specialists and full-time Specialists, and the impact of wage relativities between modes on attracting a stable medical workforce.

Introduction

Recruitment and retention of quality medical staff in Victorian public hospitals hinge critically on remuneration and employment conditions. While financial incentives are not the sole factor in a doctor's decision to work within this system, they undeniably play a significant role, especially for those at the outset of their medical careers. Beyond compensation, doctors also weigh a complex matrix of considerations in their career choices.

Work-life balance has emerged as a paramount concern in attracting and retaining doctors in the public sector. The changing face of the modern medical workforce is likely a factor in this. Particularly the increasingly inclusivity and participation of women, as well as doctors coming to the profession later in life due to post-graduate as opposed to undergraduate medical school, we are seeing a gravitation away from the gruelling work hours of the past in favour of more balanced lifestyles. This shift, along with the need for flexible work and training arrangements, particularly for those with caregiving responsibilities, underscores the evolving landscape of medical employment. These changes challenge traditional modes of employment and highlight the necessity of adaptable and supportive work environments.

Implementation of employment terms and conditions also plays a crucial role in staff retention. Innovative changes proposed in enterprise agreements are often met with resistance or inadequate support from health services, leading to implementation difficulties and gaps. Examples include parental leave inaccessibility and the failure to enforce mandated breaks post-shifts. The case of non-clinical time for Specialists further exemplifies the challenges in actualising contractual provisions. Failure to deliver entitlements to medical staff increases dissatisfaction and lowers morale.

The alignment of Specialist pay rates, employment mobility, and the intricacies of contract types such as zero-hour agreements present additional complexities in the Victorian public hospital system. These issues, coupled with the evolving dynamics of fee-for-service payments and market rate adjustments, reflect a healthcare environment in flux. The employment framework within Victorian public hospitals requires reform to ensure it is competitive, fair, and responsive to the changing needs and expectations of its medical staff.

Remuneration

It would be naïve to suggest that remuneration and employment terms and conditions are not front of mind for many doctors, particularly those starting their medical careers. That said, doctors will also look at matters such as camaraderie, prestige, access to and support for research, exposure and access to new and interesting technologies and diverse medical cases, opportunities to teach and to learn, the somewhat intangible concept of “job satisfaction”, travel time, parking, on-call rotas and the opportunity and ability to make a difference to the lives of patients and their families.

Work-life balance

Younger doctors overall are no longer seeking specialties with excessive workloads. 60–70 hour work weeks whilst once were deemed acceptable are now seen as excessive and a direct negative when considering future occupation choices. There is now the desire and expectation that work life balance, similar to what can be achieved in other white-collar jobs, is also attainable when working as a doctor.

Flexibility of work and training are also key to retention. Many DiT still report being told they need to consider the damage to their careers if they have children or consider requesting flexible or part time hours.

Too many doctors are lost to the speciality training pathways because they have carers responsibilities which are not accommodated by health services or Colleges.

Entitlements

Provision of entitlements has a significant impact on retention. At times health services spruik innovative changes that are designed to improve working life but then spend significant resources trying to avoid implementation or say they are not properly funded to allow implementation. Examples of this are the changes to parental leave clauses that removed gender-based terms to allow easier access to entitlements for whichever parent was to be the primary carer. Our experience remains that health services still have major barriers in place for the non-birthing parent to access leave.

We also note resistance to the introduction of the 10 hours break after a shift for DiT. Many health services claimed they could not implement this after it was a key improvement in the 2018 DiT Agreement. Some smaller sub specialities are still not implementing it.

20% non-clinical time (CST) for Specialists is also a condition that has not been fully implemented because health services say they are not funded for it.

While it is AMA/ASMOF who has the responsibility to enforce conditions, many doctors do not wish us to pursue their entitlements due to a lack of job security. Where we do successfully enforce conditions often it is a temporary fix until the new cohort of DiT come through, or the problems are only resolved for a single department or unit, with breaches continuing in other areas of the same health services. AMA/ASMOF resources are not sufficient to be able to monitor the implementation of every clause of the agreements in every hospital.

Alignment of Specialist pay rates.

That the pay rates set out in the Specialists Agreement for Fractional Specialists cannot be reconciled mathematically with those for Full-time Specialists – that is, that Fractional rates are not ‘pro-rata’ of Full-time rates and vice versa – is an artefact of Victorian industrial relations history. Prior to the Kennett Government’s seismic changes to industrial relations in 1992, separate State Awards existed for Specialists based on their mode of employment. At that time, Specialists employed in Victorian public hospitals on a full-time basis derived their pay and other terms and conditions of employment from the Hospital Specialists and Medical Administrators Award. Where Specialists were employed in Victorian public hospitals on a less than full-time basis, they derived their pay and other terms and conditions of employment from the Sessional Medical Officers Award.

Whilst there might have been some common nexus between the pay rates expressed in the former Hospital Specialists and Medical Administrators Award and the Sessional Medical Officers Award at some point in time, such knowledge is lost to history. The pay relativities between full-time and less than full-time Specialists were further affected firstly by the introduction of the ‘Fractional’ mode of employment pursuant to a recommendation of the Lochtenberg Review, and subsequently by adjustments to the Fractional pay rates recommended by the Wellington Review to address the diminution of take-home pay brought about by changes to Fringe Benefits Tax in 2000.

Whilst we recognise the historical reasons for the differing pay relativities between Full-time Specialists and Fractional Specialists, we believe that the inequity that this creates needs to be resolved. The longer it applies the worse the inequity becomes. We believe that all Specialists should be paid based on common rates of pay for each incremental point or range point for their classification, adjusted only for an individual Specialist’s time fraction. We believe the simplest way to achieve this is to apply the highest hourly rate currently available to Fractional Specialists at each incremental/range point and apply those hourly rates to all Specialists, regardless of their time fraction. That hourly rate would then be multiplied by the normal/contracted weekly hours of each Specialist to determine their weekly and annual base rates of pay.

If this approach is adopted, we would further recommend that the ‘Fractional’ designation for Specialists be retired, and a ‘Part-time’, or ‘pro-rata of Full-time’ designation be adopted for those Specialists who are employed by Victorian public hospitals on a less than full-time basis.

Casual employment and ‘zero-hours’ Contracts

The Specialists Agreement contemplates employment of Specialists on either a full-time or a Fractional basis. It does not allow employment of Specialists on a ‘casual’ basis, other than in the specific case of Internal Locums. Nonetheless, we are aware that many Victorian public hospitals offer casual employment contracts to Specialists who are not Internal Locums. While this is problematic in protecting the rights, terms and conditions and remuneration of Specialists, there has been a concerning variation on the casual employment approach that has arisen and spread across the Victorian public hospital system. This must be addressed.

The issue at hand is that several Victorian public hospitals have sought to circumvent the employment modes in the Specialists Agreement by offering ‘zero-hours’ casual employment contracts. A zero-hours contract is one whereby the Specialist is employed by a Victorian public hospital, but without any commitment by the public hospital to provide any minimum quantum of hours of work to the Specialist. Once employed, hours of work can be offered by the public hospital and can be accepted or rejected by the Specialist. A further variation on the theme of zero-hours contracts is where public hospitals offer a ‘one-hour’ contract to a Specialist, with that one hour being the only guaranteed hour of work offered to be worked anytime over the life of the contract.

We contend that a zero-hours contract cannot be offered under the coverage of the Specialists Agreement. Rather, any less than full-time employment must be by way of offering employment as a Fractional Specialist, and that there must at the very minimum be a requirement to perform some work under that contract given the schema of the Specialists Agreement.

A further, but not the only, disadvantage that attaches to Specialists offered and accepting a zero- hours contract arises in the context of accruals of paid leave entitlements and accrual of service for the purposes of qualifying for Long Service Leave; specifically, the treatment of such contracts when calculating service for the purposes of clause 55 of the Specialists Agreement. Illustrative of this was a dispute we raised on behalf of a Specialist engaged by a major metropolitan health service that had engaged a Specialist on a zero-hours contract. That major metropolitan health service adopted an interpretation and applied clause 55 of the Specialists Agreement such that as the Specialist did not perform any work during the period of the zero-hours contract, then the whole of the period of the zero-hours contract did not count as service. We contend that any period of employment that was offered as a zero-hours contract must count as service within the meaning of clause 55 of the Specialists Agreement as it would for a Fractional Specialist employed at least at the minimum weekly hours that can be offered and paid to Specialist employed as a Fractional Specialist.

We believe that a recommendation by the Panel that Victorian public hospitals cease offering zero- hours (and one-hour or similar) contracts, and to convert all such contracts that do exist to Fractional employment, with guaranteed minimum weekly hours of employment consistent with the schema of the Specialists Agreement, would improve the recruitment, retention and morale of Specialists.

Accreditation and “onboarding” processes

A major barrier to have a more flexible workforce across health services is the requirement that doctors comply with different onboarding and separate credentialling processes at each individual health service. It is often quoted to AMS/ASMOF as an annoyance and barrier to Victorian doctors being comfortable to work across multiple health services. This includes having to complete mandatory OHS courses like “hand washing” and advanced life support training at every health service. It would be far more efficient and therefore easier to fill gaps in rosters if the movement between health services was made seamless from an administrative/paperwork point of view. There would also be cost savings for the health services if each hospital did not need to employ staff who replicate compliance checks at each hospital. We believe there should be a statewide credentialing and mandatory training “hub” for the public system that manages all aspects, where practicable, of the recruitment and ongoing credentialing processes.

Fee for Service payments

A particular issue which needs exploration is in relation to the different modes of payment used by Health Services.

The Enterprise Agreements covering both Specialists and DiT are premised on employed doctors being paid an hourly or weekly wage rate. In other words, doctors are paid for time worked.

However, Health Services also use “fee for service” payment methods to pay doctors. In many cases fee for service payments are paid for work performed outside of the ordinary hours of work of the Doctor. In some cases, fee for service payments are paid as the only forms of payment when a Doctor is engaged on a short term basis.

The Specialists Agreement has a specific and limited exclusion for doctors in relation to fee for service payments.

Clause 4.2 provides as follows.

4.2 For the avoidance of any doubt, this Agreement does not cover any person in relation to ordinary work performed wholly on a fee for service or scheduled fee basis (including, by way of example only, the Commonwealth Medical Benefits Schedule (CMBS).

Clause 4.2 operates to exclude a Specialist from being covered by the Specialists Agreement whenever the Specialist is paid on a fee for service basis when performing “ordinary work”.

Whilst the term “ordinary work” is not defined in the Specialist Agreement the way in which this term is used in both clause 4.2 and in clause 29.5(a) suggests that “ordinary work” is meant to cover the ordinary hours of work of the Specialist.

Thus clause 4.2 operates so that a Specialist can move between being covered by the Specialists Agreement when the Specialist is paid an hourly rate for “ordinary work” and not being covered by the Agreement when the Specialist is paid on a fee for service basis or scheduled fee basis for “ordinary work”.

Given that clause 4.2 only provides an exception to coverage by the Specialists Agreement in relation to “ordinary work” it would appear that paying Specialists on a fee for service or scheduled fee basis for work performed outside of “ordinary work” does not result in the Specialist being removed from coverage by the Specialists Agreement.

A practical issue which arises from this is that clause 31 of the Specialists Agreement contains a general provision making it unlawful for a Specialist to ask for and for Health Services to agree to pay for work outside of “Ordinary work” on a fee for service or scheduled fee basis.

There is a significant history behind the practice of paying Specialists on a fee for service or scheduled fee basis, especially in relation to out of hours work or work that is not “ordinary work”.

The reality is that for some Craft Groups remuneration for work performed outside of ordinary hours has to be on a fee for service or scheduled fee basis if the Health Service wants the Craft Group to provide services outside of ordinary hours.

Anaesthetists have had a scheduled fee referred to as the Relative Value Guide (RVG) for many decades and payment of the RVG is simply part and parcel of getting an Anaesthetist to work out of ordinary hours. Similarly, Obstetricians are paid flat rates per day which are well above the Specialists Agreement rates for out of hours work.

Fee for Service or a Schedule of Fees generally remunerates a Specialist at a higher rate that the wage rates in the Specialists Agreement and is often reflective of market rates for the craft group.

Market Rates

In the 2018 Specialists Agreement recognition was given to the need to look at market rates for Specialists. Clause 63 of the 2018 Agreement established a Service Delivery Partnership Plan (SDPP) which had as one of its purposes the following:

“Establishment of a joint working party to undertake a review of the rates of pay (paper vs actual) and other conditions with a view to identifying conditions that more accurately reflect current practice and a method to move the current paper rates to actual/market rates for Full Time doctors.

Even though AMA and ASMOF were very keen to implement this aspect of the SDPP the Health Services through VHIA were not keen to do so and the matter was so dragged out that nothing occurred during the life of the 2018 Agreement.

What became obvious to AMA and ASMOF was that the Department of Health and the Victorian Government had no data on, or any actual knowledge of, the actual rates or remuneration methods paid by Health Services to Specialists. This information which is known to the Health Services has never been shared by them with Government or with AMA of ASMOF.

Fourth Term of Reference

Rostering practices that result in high levels of ad hoc overtime and on call that may impact the health, safety, and welfare of doctors and any alternative practices.

The fact that the public health system has been under increasing pressure for decades is widely understood. Population growth, aging population and an ever-increasing array of treatment options mean demand for hospital services has increased substantially. Waiting lists have continue to grow and COVID-19 has accelerated the problem. This has seen health services expanding operating hours into later nights and weekend shifts to try to maintain the required activity. The way in which Victoria’s public hospitals (attempt to) respond to this demand has significant implications for the medical workforce. One response has been the introduction of around-the-clock delivery of a broader range of medical services. The way in which Victoria’s public hospitals implement these extended hours arrangements have significant implications for the number of doctors - both DiT and Specialists – that need to be employed, and how they are rostered or otherwise allocated to duty.

Rostering Practices and Shift Lengths

Notice of and late changes to rosters for DiT is a constant source of frustration which has only worsened in recent years. Maximum shift lengths and the number of hours that a doctors can be rostered are well outside the WorkSafe guidelines and often create situations where doctors are working impaired. While progress has been made in this space under the 2022 Agreements, under those same agreements a DiT can still be rostered for up to 14 hours per day and be on call 6 times of up to 16-hour shifts in a row without needing to be rostered off. Fulltime Specialists have no restriction of the number of hours they can work and are required to stay on duty while there is a patient need. Clearly this contributes to burnout and a lack of work life balance.

The VAGO Report⁴ analysed the hours employees worked per week, with fatigue risk ratings based on Queensland Health’s Fatigue risk management systems implementation guideline. The report found that of all hospital staff, “doctors had the highest proportion of fortnights where they had a medium or high risk of fatigue (60.7 per cent). This was significantly higher than all other occupations. Nurses came in second at 36.9 per cent.”

Workload Management

Nurse-to-Patient Ratios and Midwife-to-Patient ratios (Ratios) were introduced in specified wards and units in Victorian Public Hospitals and Public Residential Aged Care Services (PSRACS) in 2001, based on recommendations arising from a consent arbitration decision in August 2000⁵. That the introduction of NPRs was beneficial to both patient care and the wellbeing of nurses and midwives is not disputed and is evidenced by the Victorian Government’s agreement to enhancements to Ratios in enterprise bargaining in 2004, 2008 and 2012, and the Victorian Government’s legislation of Ratios in 2015.⁶ That legislation has been subject to amendments, delivering further improvements to the Ratios contained therein. Further evidence of their value is that Ratios and similar workload management systems for (such as Nursing Hours per Patient Day) have been introduced by other jurisdictions in Australia, and in overseas countries.

As was the case for nurses and midwives before the introduction of Ratios as a workload management system, doctors in Victorian public hospitals and PSRACS face ever increasing workload demands in managing and treating patients. It is not uncommon for a Hospital Medical Officer (HMO) or a Registrar on an overnight shift in a large facility or campus to have immediate responsibility for the care of over 100 patients. This neither safe nor reasonable for either the doctor or the patients he or she is caring for. Inadequate staffing can also see on call registrars being responsible for patients across multiple health services or hospitals.

It would be in the further interests of patients and in the best interests of doctors if the Victorian Government were to commission a study into the design and introduction of an effective workload management system for doctors, complementing that already introduced for nurses and midwives. Ultimately, we feel it warranted that the Victorian Government introduce legislation supporting the workload of doctors as it has done for nurses and midwives. We would ask that the Panel recommend such a study as a pathway to the legislation of doctor-to-patient ratios in Victorian public hospitals and PSRACS.

We understand that the introduction of doctor-to-patient ratios or similar will require the employment of additional medical staff but believe this will prove a wise and productive investment by the Victorian Government.

Shift Loadings

Shift loadings should apply to all Specialists at the same rates and times as DiT. There is no justification for different rates for different cohorts’ unsociable hours are the same no matter whether you are an intern or consultant.

Fifth Term of Reference

Review the current Out of Hours arrangements for Specialists, particularly for Fractional doctors and Doctors in Training with emphasis on how technological advances may be changing the delivery of out of hours care.

Introduction

The management of out-of-hours work by medical Specialists, both full-time and fractional, is a significant challenge within the Victorian public health sector. This requires a nuanced understanding and strategic reform. The Specialists Agreement, which governs the terms of work for these professionals, has an insufficient framework for effectively managing out-of-hours work, leading to operational inefficiencies and discontent among medical staff. We need to redefine 'ordinary hours of work' for Specialists, clarify what constitutes 'out of hours' work and ensure fair compensation and work-life balance.

The concept of 'continuous duty' and the expectations of on-call work for doctors are central to this discussion. As delineated in the Specialists Agreement, continuous duty obliges Specialists to remain on duty during meal breaks and beyond their regular finishing time if patient needs demand it. This requirement often blurs the lines between regular and out-of-hours work, with 'patient needs' frequently cited as a reason for extended work hours. This ambiguous approach to defining work hours raises concerns about the actual implementation of meal breaks and rest periods, which, though theoretically provided for, are rarely realised in practice. The result is a workforce that often operates without significant breaks, impacting their well-being and the quality of patient care. This is highly detrimental for individuals who require breaks, including lactation breaks. Where breaks are not part of usual or accepted cultural practice there is significant pressure on individuals not to take breaks, regardless of whether this constitutes discriminatory behaviour, or breaches work health and safety laws.

Addressing out-of-hours work also requires a critical evaluation of the current overtime policies and their practical implications for both DiT and Specialists. The contentious nature of overtime compensation has been a source of industrial and practical disputes for decades, highlighting the need for a systemic overhaul. In this context, the ongoing challenges and frustrations of doctors, which affect their morale, job satisfaction, and even their health and well-being, must not be overlooked. The public health sector's approach to handling overtime, particularly considering changing practices like the introduction of electronic medical records (EMR) and at-home access to these, has significantly altered the dynamics of on-call duties, making them more complex and time-consuming.

The absence of a consistent and equitable system for on-call and recall across the Victorian public hospitals system has led to significant dissatisfaction and challenges for doctors. This situation is particularly acute for fractional Specialists who, without a centralised regulation since the abolition of the Sessional Medical Officers Award, face difficulties in being acknowledged and compensated adequately for their work outside normal duty hours. The need for a harmonised model that fairly compensates Specialists for on-call and recall duties is evident. Such reforms should not only align with best practices but also respect the unique needs and contributions of both full-time and fractional Specialists.

Out of hours work

Out of hours work by Specialists, both Full time and Fractional is poorly dealt with in the Specialists Agreement. This reflects the way in which out of hours work has evolved over a long period of time.

Out of Hours work should include all work which falls outside of the specific ordinary hours of work of a Specialist.

The first issue is defining the meaning of ordinary hours of work. This needs to be done so that all other hours become part of the out of hours period.

In the case of doctors employed in the public health sector two issues are presumed to be a normal expectation of a doctor: continuous duty and on-call.

Continuous Duty

The Continuous Duty (Clause 25 Specialist Agreement 2022-2026) requirement on doctors is set out in the Specialists Agreement as:

“All full time Doctors will remain on duty when patient needs require, notwithstanding the occurrence or normal meal breaks, conferences or the expiration of their normal hours…”

The Continuous Duty clause has the effect of requiring a Specialist to remain on duty as part of the ordinary hours of work of the Specialist during meal breaks and after the normal finishing time of the Specialist if patient needs require. The reference in the clause to “conferences” would appear to refer to a conference which is being held during the Specialists ordinary hours of work and at the Specialists ordinary place of work.

Meal Breaks

A traditional workplace relations/industrial relations approach to ordinary hours of work differentiates between ordinary hours which include a paid meal break and ordinary hours which allow for an unpaid meal break. In the traditional approach where the ordinary hours allows for an unpaid meal break work ceases and the employee is permitted to leave the workplace during the period of the unpaid meal break. In the traditional approach where ordinary hours includes a paid meal break then the employee is entitled to have a meal break but must do so at the workplace and must fit the meal break around work requirements.

AMA/ASMOF agree that the proper approach to be adopted in relation to Specialists is that their meal break is part of their paid ordinary hours of work.

The real issue for Specialists is that the nature of work in the public health sector invariably means that meal breaks are illusory – they exist on paper but do not exist in reality. The notion that a Specialist will take a meal break which is taken at times which do not interrupt the work of the Specialist is a notion that Health Services give lip service to but do not permit to happen in the workplace.

The very real reality for many Specialists is that they can work their full ordinary hours without any break, let alone a 20 minute or thirty-minute meal break.

In any consideration of out of hours work regard must be had to ensuring that Specialists are entitled to and do have access to meaningful meal breaks within ordinary hours.

The “Patient Needs” criterion

There appears to be an assumption that in the public health sector the ordinary hours of an employed doctor include work performed by a doctor which is continuous with the ordinary hours of the doctor and where the continuation of work is required to be performed by the doctor because “patient needs require” it.

There is an inherent looseness in the approach used in the public health sector to what are the ordinary hours of work which needs to be addressed as part of any consideration of the out of hours issue.

Firstly, the concept of “continuous duty” must be contained and limited so that it is not able to be used to require Specialists to continue working beyond the end of their ordinary hours. The notion that “patient needs” is sufficient to create an obligation on a Specialist to continue working must be significantly constrained. In a Public Health Service there will always be “patient needs” which require the attention of a Specialist. That is most certainly the case in the Victorian Public Health Sector where there is a shortage of Specialists and a lack of Government funding to enable Health Services to recruit the necessary number of Specialists.

The concept of “continuous duty” needs to be limited to instances where a Specialist is actively providing clinical treatment to a patient at the time that the Specialist is due to finish their ordinary hours of work.

Merely having a patient assigned to a Specialist should not be a sufficient reason to require the Specialist to continue working past the end of their ordinary hours.

The mere fact that there are patients waiting for clinical treatment should not be able to be used to require a Specialist to work beyond their ordinary hours of work. There will always be another patient waiting to be seen.

In the DiT Agreement has an entitlement for Doctors to have a 10 hour break between rostered shifts. Where this has been implemented properly it has seen a significant improvement in fatigue management. The 10 hour break should be extended to Specialists.

Overtime

The arrangements relating to, the loading rates applying to, and the payment (or non-payment) overtime have been matters of contention for both Specialists and DiT industrially and practically since the introduction of enterprise bargaining in the Victorian public hospitals system in 1995 (and possibly before that). It is a subject that has significant meaning and has engendered significant frustrations for doctors, impinging on their morale and job satisfaction, and on their health and wellbeing.

DiT

The Panel will be aware of the Class Action litigation initiated by ASMOF Vic on behalf of and in conjunction with over 2500 doctors over the non-payment of unrostered overtime by several Victorian public hospitals. Notwithstanding this litigation and the compensatory outcome(s) that might be awarded to affected doctors in the Class, there is an ongoing issue of non-compliance with the terms of the DIT Agreement, and inconsistent terms and application of local overtime payment policies and protocols that must be addressed. It is appropriate that the Department of Health intervene in this matter to direct Victorian public hospitals to comply with their statutory obligations. The Secretary of the Department of Health has the relevant and necessary powers of Direction for this purpose under section 42(1)(c) of the Health Services Act 1988 (Vic). We believe the Panel should recommend that course of action.

Specialists:

Specialists report that where they have historically had on-call obligations that were reasonable, unobtrusive and could be managed in a short discussion, that the advent of electronic medical records (EMR) with offsite access has made the nature of the calls far more complex and time consuming.

There is no common arrangement or entitlement in the Specialists Agreement for the payment of overtime to Specialist – Full-time or Fractional. However, such arrangements and entitlements⁷ were set out in earlier Certified Agreements⁸ made by individual public hospitals/health services and some or all of the Specialists they employed.

On-call and Recall

As with overtime arrangements and payment (or non-payment), the approach taken by Victorian public hospitals to the management of on-call and recall arrangements has engendered significant frustrations for doctors, impinging on their morale, job satisfaction, health, and wellbeing,

AMA/ASMOF observe that:

• On-call is grossly abused within the public health sector
• On-call is used by Health Services to cover shortfalls in staffing numbers. Rather than recruit new staff it is easier to require existing staff to do increased amounts of on-call.
• On-call is used by Health Services to cover ordinary work including ward rounds. Specialists:

On-call/recall payments for less than full-time Specialists have not been centrally regulated in Victoria since the abolition of the Sessional Medical Officers Award (Sessional Award) by the Kennett Government. However, many Certified Agreements made between 1999 and 2013 covering Fractional Specialists in Victorian public hospitals included provisions that replicated or improved the terms that had existed in that former Sessional Award. The Sessional Award provided that a Sessional Medical Officer (now Fractional Specialist), rostered on-call exclusively to a particular Victorian public hospital and expected to return to that hospital if recalled, would receive an ‘availability payment’ of 3.5 hours pay per on-call period (Exclusive On-call). If the Sessional Medical Officer was required only to be available for consultation during an on-call period, the payment per on-call period was one hour’s pay. Where the Sessional Medical Officer was recalled to duty at the hospital, he/she was provided with payment at 125% of their normal duty rate on weekdays and 150% of their normal duty rate on weekend days and public holidays. They were also paid one hour’s pay per recall for travelling time. A summary of those former Certified Agreement arrangements is provided in Appendix B – Comparison of out-of-hours remuneration for Fractional Specialists as of 1 January 2005.

In some cases, those (or other) Certified Agreements (or local/non-certified agreements) also included similar on-call/recall provisions for Full-time Specialists. Also, with respect to Full-time Specialists, we recognise that the base rates of pay in the Specialists Agreement incorporate a notional ten percent allowance for making themselves available to be placed ‘on-call’.

In the absence of the former Sessional Medical Officers Award, and since the replacement of those former Certified (and non-certified/local) Agreements, Fractional Specialists have faced difficulties in being properly compensated for the work they perform outside their normal duty hours. Full-time Specialists continue to face difficulties due to absent, or at least very mixed, recall arrangements and payments across the Victorian public hospitals system.

It is time for a common and consistent model and approach to on-call and recall. As a first step, definitions and arrangements (including payments) must be adopted across the Victorian public hospitals system for “exclusive” and “consultative” on-call. This can be informed by referencing provisions that are current practice at some health services for Fulltime and Fractional doctors to determine the ‘best practice’ arrangements.

We believe that the Panel should recommend adoption of the following minimum structure of payments should be payable to all Fractional Specialists:

• 3.5 hours’ pay at the Fractional Specialist’s normal rate of pay per on-call period for being exclusively on-call to a single Victorian public hospital.
• One hour’s pay at the Fractional Specialist’s normal rate of pay per on-call period for being available for consultation by telephone (or other form of electronic communication) per on- call period.
• payment at 125% of their normal duty rate on weekdays.
• payment at 150% of their normal duty rate on weekend days and public holidays; and
• One hour’s pay at the Fractional Specialist’s normal rate of pay for travelling time where the Fractional Specialist is recalled to perform duty at the hospital.

We believe the Panel should also consider and recommend an appropriate minimum recall provisions for Full-time Specialists. These payments should at least match those in the DiT agreement.

DiT:

While the DiT Agreement includes specific arrangements for on-call and recall, we believe these clauses need improvements to ensure that hours of on-call and recall work are safe and provide more appropriate compensation for DiT holding themselves available to be called back to work. Changes need to encourage improved rostering performance, reduce the reliance of on-call and better reflect the impact that on-call has on a doctor and the increased requirements to be available.

Sixth Term of Reference

Exploration of working arrangements, including part time and casual employment.

Introduction

The medical profession faces significant challenges in accommodating part-time and casual employment. Unlike factory production lines with straightforward duties, medical roles require specific skills and continuity of care, which can raise challenges in rostering doctors who work part- time or flexibly

Doctors often struggle to secure flexible work arrangements. While casual positions can offer diverse experiences and aid in balancing work-life, there is growing concern over their misuse. Health Services, at times, use casual contracts to avoid offering permanent roles and necessary support, placing undue pressure on regional and rural health services due to additional costs and workforce planning challenges.

There are various problematic employment models in medicine, notably the use of zero-hour contracts and the allocation of Effective Full Time (EFT) roles. AMA/ASMOF advocates permanent contracts for all doctors, especially those contributing through teaching or quality improvement projects. Ensuring adequate cover for leave is also crucial for the mental health of medical professionals.

Part-time workers face a disproportionate administrative burden, which varies across medical specialties and affects the implementation of part-time and job-sharing roles. AMA/ASMOF has observed a shift towards more flexible working arrangements and stresses the importance of accessible part-time roles for male doctors to achieve workplace equity. It calls for flexible working hours and pay parity between part- and full-time staff.

AMA/ASMOF receives many reports of instances where requests for flexible working were unjustly denied. Part-time work, which some practitioners elect to undertake in response to unmanageable full-time workloads, can adversely affect staff engagement and job satisfaction.

The difference in pay rates between Fractional and Full-Time doctors is no longer fit for purpose. What was introduced to incentivise sessional doctors to work in the public system has morphed in a quasi-part time arrangements that sees Fractional doctors paid a higher hourly rate than full timers for doing the same job. Under the Specialist Agreement Fractional doctors are entitled to set hours at the time of appointment that cannot be changed without the doctor’s agreement, however health services tend to ignore this entitlement. This has left these “part time” arrangements unregulated and open to abuse. The panel should recommend that pay rates be equalised and that the parties to the agreement should work towards introducing a more traditional form of part time employment at pro rata of the fulltime rates.

There is inherent tension between DiT seeking work-life balance and the requirements of Specialist training. There is a trend for colleges to permit flexible and part time training, but there is a paucity of flexible and part time positions for doctors in health services. To undertake flexible or standalone part time training a trainee requires both College permission, and a contract to work at a health service that has a flexible or part time accredited position. Job share models are a further option, but frequently the onus is put on the trainee to find a health service and unit who are willing to accept two doctors in a job share arrangement, and a job share partner. Health Services need more flexible approaches to part-time work, as exemplified by the lack of part-time options for internships. The insecure nature of employment for doctors often prevents them from asserting workplace rights or requesting different employment modes, making a career in medicine appear inaccessible to many, particularly women who step away from Specialist training.

Finally, we suggest that a thorough analysis is needed to identify opportunities for flexible work arrangements across all specialties, especially in subspecialties with limited doctor numbers. The evolution of fractional doctor roles, initially procedural and evolving into traditional part-time roles with additional responsibilities like on-call rosters and department meetings, is also highlighted.

AMA/ASMOF recommends a focus is on developing more flexible, fair, and sustainable employment models that can accommodate the diverse needs of the medical workforce, ensuring high-quality patient care and the well-being of medical professionals.

Seventh Term of Reference

Work design which may include task allocation and support.

There is an increasing administrative burden placed on medical staff. When cost-cutting measures reduce the number of administrative personnel, doctors are often required to undertake tasks outside their primary medical duties. This reduces the time that can be devoted to clinical care. At a time when Governments are increasingly calling for non-medical healthcare workers to be allowed to work at “top of scope” and increasing “scope creep” is seen where pharmacists and nurses are to be permitted to take on duties previously only performed by doctors, it is inappropriate to transfer administrative duties (e.g. sending faxes, typing letters) to doctors. This situation calls for a reassessment of staffing strategies, particularly the introduction of more administrative staff to support medical teams. The AMA/ASMOF emphasizes the importance of clearly defining job roles, especially for registrars and Specialists, to optimise efficiency and clarify responsibilities. Any moves to increase scope of practice by other healthcare workers should be conducted within doctor-led care teams if patient safety and quality care is to be maintained.

Job Roles

During bargaining of the 2022 Enterprise Agreements AMA/ASMOF sought to have job descriptions for registrars included into the documents. This was not accepted by health services. Having more clearly defined roles would benefit to both doctors and health services by. Job Descriptions particularly for Specialists should be reviewed across the system and be reviewed annually in consultation with doctors to make sure they are fit for purpose.

Conclusion

AMA/ASMOF observes that female doctors work within an industrial and cultural landscape that is 30 years behind the rest of society with regards to issues such as flexible work and career progression. Female doctors are still told that they must plan their pregnancy to suit the demands of medical training and that certain specialities are not suitable for individuals who wish to have children.

The insecure nature of employment and training of doctors from the start of their careers (1–2-year contracts) as DiT creates an environment where doctors are reluctant to speak out against breaches of employment conditions and bad behaviour. They fear not having their contract renewed or failing to enter or remain within college training programs if they do. This fear often continues well after the training years when many new consultants struggle to find full time work and are often offered zero-hour contracts (now “Internal locum” roles) and/or must take multiple fractional appointments. This particularly impacts on doctors with carer and other responsibilities outside the workplace, who are predominantly women.

While some doctors see “locuming” as a way to take back control of the working lives, AMA/ASMOF believe this has a detrimental effect on the profession and public health as locum contracts are often more costly to the system, can degrade the quality of care for patients and perpetuate further job insecurity. The panel should look at measures to improve access to flexible work while prioritising permanent employment for all doctors.

The gender balance of the workforce has normalised over the last 20 years, and in fact there are now more female medical graduates than male. Health services and senior doctors have not come to grips with the workforce impact of this and the changed nature of how doctors want/need to work. We see more and more doctors opting to locum or take short term contracts across Australia so that they can leave the role easily if they need to.

Poor workforce planning has also contributed to poor morale and short staffing, this in turn has created a reliance on IMG doctors to fill gaps in rosters. IMGs are the most vulnerable doctors in the system and health services often do not do enough to integrate them and protect them from bullying, harassment and, to be frank, racist behaviours. Employment of IMGs are and will continue to be necessary to fill shortages in the Victorian system but the Government and Health Services need to better support and educate these doctors before they start work and while they are establishing themselves in Victoria. We recommend a centrally controlled support be established by government, with the power to intervene in employment matters relating to IMG’s. It should be a requirement that all IMG’s employed in Victoria be given support and information to aide their transition to the Victorian system, including AMA/ASMOF contact information.

The disparities between conditions for Specialists in the Enterprise Agreement is having a negative impact on morale and productivity, e.g. the different rates of pay between Fulltime and Fractional doctors. As well, the lack of after-hours payments for recall and additional hours in the Specialists agreements has created a haves and have not situation for doctors within the same departments, health services and system, with some departments or specialties having negotiated after hours payments and others getting nothing for working the same hours in another department or health service. Minimum rates of pay must be set for on-call, recall and additional hours before the next agreement.

Health Services must do more to encourage work life balance and support doctors who wish to have flexible work conditions.

Appendices

Appendix A – Comparison of out-of-hours remuneration for Fractional Specialists as at 1 January 2005
 

References

¹ There was an earlier review of ‘salaries and terms and conditions of employment of medical officers employed in public hospitals’ (the ‘Dillon Review’) authorised in 1959 by the then Victorian Minister for Health. This review pre-dated the concept and practice of enterprise bargaining and offers fewer cues for the current Review.

² Specialists (including General Practitioners) directly employed by stand-alone Community Health Centres in Victoria.

³ Medical Deans Australia and New Zealand (2021) Inclusive Medical Education – guidance on applicants and students with a disability. Sydney, Australia)