In 1993, the ED of Medical Services at the WA Country Health Service, Dr Tony Robins, was a young flight doctor with the Australian Defence Force on active duty in Somalia. Part of that operation was humanitarian – to get food and medical supplies to a starving population, but what he saw there and what part he played has shaped his life and work ever since.
“I was taken to an orphanage as part of an advanced party with the army to see what support we could give. They had converted an empty generator shed, a concrete bunker really, into a makeshift health facility and it was full of children lying on straw contaminated with human and vermin waste. All the children had malaria whether it was their primary diagnosis or they had contracted it at the facility. There were three local nurses caring for these many children with no doctor,” Tony recalled.
“It was the middle of the day and it was hot, over 40C, and the nurses were trying to keep kids cool. I went to the senior nurse and suggested we could supply a mobile generator, fans and a fridge; we could supply liquid paracetamol and vaccines to help the children. Thankfully one of the nurses was bold enough to speak up because there is a cultural shyness for many when confronted with the ‘big western doctor’. However this nurse plucked up the courage to give me a dose of reality.”
“She thanked me but said a generator would be stolen within hours of us leaving. In any event they couldn’t get fuel to run it and same with the fridge. And as for the fans, they were desert people and the heat was not as big a problem as the sub-zero temperatures at night. Keeping the children warm especially with the rigours and tremors from the malaria was difficult.”
“What she asked us for was some secondhand army blankets, old army stretchers to get the children off the floor to stop infection spreading and paracetamol tablets that they could crush up and added to bottled water. Those things, she said, would do more for those children than any of our technology. I felt very humble. That person knew exactly what was needed to improve health outcomes in her community and it was not necessarily high-cost western solutions, but low-cost, easy to obtain and maintain practical solutions.”
“Listening is the key.”
Budgets and balance
As medical director of an organisation that is responsible for improving health outcomes over a vast area with vastly different demographics, listening, says Tony, is crucial to WACHS’ success. He believes his role is to represent the country in metropolitan board rooms and bring metro support and infrastructure to the bush – all balanced delicately within a constrained budget.
That budget, which for years had been underserviced, received a mighty kick from the Royalties for Regions program which has seen the refurbishment and rebuilding of country hospitals over the past decade. A showcase model is the Southern Inland Health Initiative (SIHI) which brought $500m to the table to “transform the health infrastructure” in the Great Southern, Wheatbelt, parts of the Mid-West and the Goldfields.
But it wasn’t just a bricks and mortar revolution. Crucial to the equation was a sustainable health workforce to use the facilities and keep communities healthy. This traditional hot potato has responded to extra cash but, perhaps, more importantly a blossoming culture of collaboration with other organisations such as Rural Health West, WAGPET and now the newly formed WAPHA.
WACHS employs 9500 people, 300 of whom are salaried doctors with a further 1000 on contract. Unlike the metropolitan health services, the system revolves around highly skilled GPs, either salaried to the hospital or contracted from private practices to provide services to local hospitals, which makes it doubly important to retain their services.
Miracle of SIHI
SIHI has delivered about 36 extra doctors to the region in the past five years – a feat which couldn’t have been achieved without the partnership with Rural Health West. Attracting and retaining GPs into those regions has required a concentrated effort.
“The better facilities have certainly made practice more attractive for GPs but research by Rural Health West has shown that doctors and their families need broad support – for practice, professional development, work-life balance, financial – to move, work and stay in the bush,” Tony said.
All this effort is to ensure as many people in rural and remote areas have the opportunity to see a doctor face-to-face, whether that it be in private practice or a hospital.
“Country people deserve to have that knowledge, experience and training; they need a doctor to see them, touch them and empathise and support them. This is WACHS’ preferred model of care that we aim to deliver to any community.”
“GPs in rural and remote areas have a long-standing reputation of service to their communities. They drop everything, day or night when needed so it’s vital not to let them burnout. That’s why we place such importance on providing locums and the Emergency Teleheath Service (ETS) also plays a part as a back-up when GPs are in or out of town.”
ETS is an adjunct
The ETS is now offered at 74 WACHS sites between 8am and 11pm.
“ETS is not a replacement for the local doctor, it’s a back-up and operates when the local doctor is not available and mostly used by nursing staff in hospitals. When the GP is in town, it is not called generally as a first-line response but it is a support and an extra hand in emergency situations, albeit virtual. No doctor is obliged to use it, nor is there any charge when it is used.”
Demand for ETS has been so great that a request to increase it to a 24/7 service, statewide, is being explored.
The need for a constant supply of doctors is an ongoing reality of Tony’s job. WA has moved on from its critical shortage of a decade ago eased by an influx of IMGs and an increased supply of local medical graduates. However, he believes we are far from being self-reliant in the health workforce.
A place for IMGs
“We still have a requirement for IMGs and like most people who work in remote Australia we recognise that we probably always will but our reliance has fallen.”
He said there were stereotypes in the past that IMGs were less qualified and too junior for solo roles but they were wrong.
“IMGs are highly trained, skilled doctors from medically competent countries and many, such as those from South Africa, are very experienced in remote and rural medicine. IMGs when they are well selected don’t just bring a doctor to a community but they add value to the health system and that fact is sometimes lost.”
The selection process has been refined and Tony said there was robust credentialing and monitoring systems in place so it was easier to pick the right people and keep them safe.
While the challenges remain, Tony is confident that two significant changes have sown seeds for a successful future.
“The investment into rural and remote medicine is significant in anybody’s language. The second is our inter-agency collaborations. We are able to keep patients closer to home and we can’t do that alone.”