17 July 2017

Back from the brink – reimagining rural health

General Practice Rural

The medical master builder who has pulled Queensland rural health services from the brink of ruin is being repaid in spades.

For Dr Denis Lennox, the reward is “sheer delight” at the growing momentum of the state’s rural generalist training program, started in 2006, and the turnaround in health services revitalised by its Australian-trained graduates and trainees.

“They said it couldn’t be done,” Dr Lennox said.

“The argument that was presented to us 15 years ago – that no self-respecting Australian medical graduates would find themselves in practice in rural and remote Queensland, and that we had to rely on an international workforce – has been proven untrue.”

Dr Lennox, who retired last month after a 40-year career at Queensland Health, has been made an honorary fellow of ACRRM and an adjunct professor at James Cook University in recognition of his achievements.

Presenting him with the AMA’s Excellence in Healthcare award in May, AMA President Michael Gannon said colleagues described Dr Lennox as a “visionary” who had produced tangible workforce and healthcare improvements in all parts of Queensland.

“He is the genesis point of the rural generalist pathway in Queensland, which is successfully delivering the committed, quality rural medical workforce that our communities both need and deserve.”

For a man who aspired to become a teacher but went into medicine after meeting a missionary from Africa, Dr Lennox has made an extraordinary public servant.

But if it weren’t for a career setback, however, his reimagining of his home state’s rural health system might never have happened.

Neither would the revival of rural generalism, lately championed by federal and some state authorities to promote new GP training with advanced and procedural skills.

The Queensland program was given the go-ahead in 2005, amid a scramble by Peter Beattie’s then State Labor government to respond to public outrage over patient deaths at the hands of Bundaberg Hospital surgeon Jayant Patel, and apparently slipshod assessment of international doctors’ credentials by the state authorities.

In fact, the case for change had been outlined some years before when Dr Lennox and others produced a report investigating concerns about the state’s heavy reliance on overseas-trained doctors.

“I was in this (workforce advisory) role from 1999 to 2002, and almost all of my work involved international graduates, because that was the only supply,” Dr Lennox told The Medical Republic.

“We realised there was trouble ahead, and we were commissioned by the general manager of Queensland Health to work with the AMA and the Medical Board to review the whole issue of international graduates and to work out a more systematic way of recruiting and supporting recruits.”

The report, produced in mid-2003, was at first greeted enthusiastically by the health department and the medical board, but then it was mysteriously buried.

Months later, as the Patel scandal broadened, a journalist was given a leaked copy of the Lennox Report and used it as the basis for news stories alleging overseas-trained doctors with inadequate qualifications were working in regional Queensland.  The department denied the report had been accepted, and Dr Lennox was falsely accused of being the source of the leak.

“I was reprimanded and had a disciplinary action recorded in my file for leaking this document. There was no investigation, not even asking me if I did it; it was just assumed that I did.  And, of course, that meant all my work on international graduates came to a halt.  I couldn’t do anything in that space,” he said.

Denis Lennox

Dr Denis Lennox

“I went back to Toowoomba and stared out the window and thought, what do I do now? The next question that came to mind was, have we seriously done all we could do to recruit Australian graduates into our rural and remote services?

“I started systematically then to develop the rural generalist program.”

Some evidence was already available, including a 2002 survey of some 80 Queensland generalist doctors who were the remnant of the old-fashioned country GPs with obstetrics, anaesthetics and surgical skills.

That led Dr Lennox and his team to believe a rebuilding of capacity would be possible, with a significant overhaul of training and workplace design to attract and keep the younger generation of doctors.

“This is an exemplar of the value of the state becoming actively involved in the development of the workforce that it needs for its communities, and not passively waiting for the output of medical schools to find its way,” he said.

Candidate selection is crucial; but another essential is understanding that rural and remote health services are inherently fragile. The smaller the workforce, the greater the risk that it will not meet the community’s needs or be able to provide full cover.  A larger group helps doctors stay resilient; they have support and are not constantly under the hammer.  Where a town is deemed too small to support a resident doctor, why not redraw the boundaries so it can?

“The next generation of doctors will not tolerate being 24/7 on call, they won’t tolerate a one-in-two roster; they will tolerate one-in-three if activity is not too hjgh, but preferably one-in-four,” Dr Lennox said.

“That infers, if you have a workforce smaller than four you are going to struggle, and if you have a birthing service, then you are going to have to maintain a roster for obstetrics and a separate roster for anaesthetics, which means you need a three for a three in one roster – so you need a headcount of six doctors.  Anything less is an unsustainable service.”

One example of sheer delight that proves the theory is Queensland’s Central West Health and Hospital Service.

In 2010, there were just five doctors resident in the district, supplemented by a costly churn of locums. Now, there are 24 rural generalist doctors and trainees, who work in general practice, secondary care, procedural medicine and a range of specialised skills.

“Interestingly for us, this is the confirmation of the original service plan we provided in 2010,” Dr Lennox said.

“Longreach (the regional centre) was on the brink of medical service collapse. The whole health service for the central west would have collapsed but for the services workforce
we designed.”

This vast region, which covers 23% of the state’s area and includes the towns of Muttaburra, Winton, Blackall and Barcaldine, no longer relies on external locums, and patient transfers have plunged.  The savings have far outweighed the extra cost of doctors; one key element of the Lennox design was paying generalist doctors more in recognition of their skills.

What’s more, positions are in demand.  Now, with doctors present in sufficient number to relieve each other, the medical workforce is more stable.

They are now facing the wonderful prospect of considering how they are going to retain training capacity – “which they are keen to do” – given they are such an attractive place for rural generalists to live.

“Tthey are thinking about the possibility of appointing some trainees only for the period of training and then releasing them, so they can bring others in,” Dr Lennox said.

“As you can imagine, this is absolute music to my ears.”

The 24 doctors operate as members of one medical practice.  The health services contracts with the practice to cover 60% of the doctors’ time in private practice.  Patients’ medical records are “joined up” and can be accessed from practice rooms or hospitals.

“This is the extent of the renaissance that is possible, and I don’t think we’ve come to an end. It is building momentum and I can’t envisage where it’s going, particularly given the intellectual capacity we have got working out there and coming through.  Our rural services will start leading the way for our urban services, I think.”

Dr Lennox said some rural areas were seeing a level of integrated access to care that not many urban areas had.

“There are some ways in which I believe the medical service in central west Queensland now exceeds the capacity I have to access medical services in Toowoomba.

“My response, when people raise their eyebrows to that, is that it should be so. We ought not to be settling for anything less than first-rate service for communities that have had access challenges.”

The impact is not confined to the outback.

Dr Michael Rice, a GP in Beaudesert, in the Gold Coast hinterland, said the new wave of rural generalist GPs with obstetrics skills allowed his local hospital’s birthing unit to reopen in 2014 after a 10-year closure.

“The availability of rural generalist training has attracted young, energetic, enthusiastic medical practitioners who might otherwise have been lost to metropolitan specialty practice,” Dr Rice, the immediate past president of the Rural Doctors Association Queensland, said.

“This is giving these procedurally interested doctors the opportunity to experience primary care as well.  They won’t necessarily spend all of their career in procedural practice, and a percentage of them will remain in rural areas in more traditional general practice.

“The work that Denis has done has laid the foundation for a pipeline, not just of rural generalists, but rural GPs more generally.”

To date, 130 rural generalists have graduated from the program, with 300 in the pipeline. Dr Lennox serves as director of Rural and Remote Medical Support.

On top of obstetrics, anaesthetics, and surgery, their advanced skills training has expanded to include adult medicine, indigenous health, emergency medicine, paediatrics, and mental health.

Professor Tarun Sen Gupta, head of medical education at James Cook University, said many of the university’s best and brightest medical graduates were attracted to the rural generalist pathway by its air of adventure and excitement.

“At James Cook University we talk about adventure, skills and impact,” Professor Sen Gupta says. “The rural generalist pathway has also captured that. They have adventure, they work in amazing parts of the world, they develop a set of skills and they see the impact they are able to have, so they end up having a very meaningful and fulfilling career.”

Fortuitously, the advent of the generalist training program, based at Toowoomba, came around the same time as the first cohort were graduating from James Cook medical school, founded in 2000. But the opportunity would have had little impact without the prospect of interesting jobs, Professor Sen Gupta said.

“The pathway is one pillar, but the service redesign is another thing, and valuing the practice and the work people do are others. In other words, it’s a lot more than just devising a training pathway.  If you had a pathway but no clear career plan, it would be a problem,” he said.

“Denis realised the need to redesign services to make the pathway attractive. He has provided wide advice and mentorship about directions and pieces of the jigsaw that needed fixing.

“And he also paid a lot of attention to relationships – with supervisors, hospitals and trainees.  You’ve got to remember, this is all about looking after people.  It’s that depth of thought, to be able to see through the issues. His counsel has been very wise. That has been very important, because you’ve got to consider all the things that had to be done.”

Leaders in rural health acknowledge that while many practitioners and academics were converging on agreement, back in the 1990s, that Australia needed GPs with a broader skill base, but no one else had the vision and the influence to bring off a whole-of-system solution.

“His ability to see opportunities in any situation is phenomenal,” said ACRRM President Dr Ruth Stewart. “It’s not just his achievements, he’s such a pleasure to work with and to work for. He has extraordinary intelligence and foresight, and quietly gets on with the job.”

Dr Lennox wants to see more doctors take leadership in the health system. But in his own case, he’s uncertain whether the generalist framework would have been fully realised without that abrupt setback.

“I’m not quite sure, if that hadn’t happened, if I ever would have done it. I was just forced by reality to think about what we hadn’t done for Australian graduates. I don’t think we were on any kind of trajectory to even contemplate that.”