Deep End, Down Under
A Family Doctor who believes in the traditional values of general practice…Once described as “A valiant but unfortunate captain [in the health system] going down with the ship despite [his] best efforts to avoid a disaster.”
Dr Tim Senior is a GP who works in Aboriginal Community Control in South West Sydney. He teaches and works in policy and advocacy relating to Aboriginal and Torres Strait Islander health and writes on general practice and health equity. He recently returned from a Churchill Fellowship visiting various Deep End GP groups in England, Ireland and Scotland, hoping to bring these ideas back to Australia.
Dr Tim Senior lives and works on land traditionally owned by the Dharawal people. He acknowledges the traditional owners, and notes that sovereignty has never been ceded.
Watch the video here or on YouTube
Listen to the Podcast here or on Spotify
“Alice Springs and the Northern Territory was what I knew about Australia then and so my feeling then was that as a doctor, Aboriginal health was part of what you do- “
Let’s bring you back to the very beginning. What started your interest in medicine?
Tim Senior: There were two things I wanted to do when I was a child. One was be an actor. Imagine playing James Bond and being in movies like that although I don’t think I was ever a very good actor. The only other thing that came to me was doing medicine, and I was really lucky because I was gradually drawn to the idea of medicine and being a doctor and that really fitted with what I wanted to do. I think I was very lucky in deciding that I wanted to do that from quite a young age.
DMacA: So where did you go and how was it for you?
TS: I went to a state comprehensive, what they call a public school in Australia. And from there to medical school where I did my pre-clinical years at Cambridge University and my clinical years at Oxford University, which was an amazing experience. I spent my whole first year looking around at these beautiful old buildings thinking, wow! I’m actually here. And I don’t think I did very much work. I threw myself into all sorts of extracurricular activities- did quite a bit of acting, did some writing, performing comedy and I did lots of music. My Director of Studies said at the time, and admitted it several years afterwards, that he thought I was doing way too much outside medicine, but I got my degree and I was very happy with that.
DMacA: So your career progressed, and what did you do then?
TS: After that I did my house officer jobs in Winchester and in Bath, beautiful places. In Australia they are called intern jobs. And after that, because I’d gone to university straight from school, I knew that if I didn’t travel then, I never would. I’d get on a career path and that would be it. So I thought I’d take the opportunity to take a gap year. I applied to one of the Australian locum agencies that were, at the time, placing junior doctors in hospitals mostly in Queensland. They came over and interviewed a whole group of us. At the interview they said, ‘Oh, you sound like an adventurous type. How would you like to go to Northern Territory?’ I didn’t know the difference between Queensland and the Northern Territory, so I thought about it and said, ‘Yes, that sounds good.’
As a result, I spent six months in Alice Springs and six months in Darwin. And that was that was pretty much life changing. It changed the direction of my whole career from that point and led to me to what I’m doing here. That was for just over a year, and I gained experience in Alice Springs Emergency Department, and had a brief stint in Tennant Creek, a tiny place about 500km north of Alice Springs, doing remote district medical officer work across what’s called the Barkly Tablelands, beautiful cattle pastoral country. To learn more about this area see https://northernterritory.com/gb/en/tennant-creek-and-barkly-region/destinations/barkly-tableland
I was providing clinics across that area until the Medical Board in the Northern Territory time got wind that this really junior doctor was doing District Medical Officer work and they called me back to Alice Springs. We had a great time and there were no catastrophes.
DMacA: I couldn’t imagine a greater contrast between the Northern Territories and what you did next…
TS: Together with another doctor, a good friend who’s also still working in Australia, we worked out that between us, two recent graduates from the UK at the two emergency departments in Alice Springs and Tennant Creek, we were covering an area the size of the United Kingdom, albeit with a tiny population. It was a hugely different experience but it taught me emergency skills really well so that when I went back to the UK and I did some locum work in Emergency departments before getting on to a GP training scheme in Sheffield. It was an incredible experience, it was really formative. Being immersed in a different culture, because there was a lot of Aboriginal health in those times, you really start to notice the differences between cultures that you’re working in.
DMacA: Its interesting to look at that now, with so much discussion in this part of world about the number of junior doctors going to Australia, is it something you would recommend?
TS: I would. A lot of the publicity makes it look like a sort of tourist video – going to the beach, barbecues, sunshine, and beautiful landscapes. And that’s all absolutely true. But I’ve found that my work in Australia, and I really feel I’ve found my niche working in Aboriginal health, that’s there is a life of a different sort, doing really important medicine. That’s not quite the sort of beaches and barbecues image that’s often portrayed but I think that’s important to appreciate for UK doctors coming over. What’s happening in the NHS at the moment is probably the Australia’s best recruitment strategy but there are particular restrictions for graduates from other countries working in Australia, so it’s unlikely that people end up in Sydney. They’ll quite frequently end up in beautiful rural and remote areas of Australia.
DMacA: You’ve completed your vocational training and then you went into practice. Tell us about that…
TS:. I did GP training in Sheffield, I loved it, and that was really where I really started to enjoy my medicine. I very much enjoyed emergency medicine but general practice training was where medicine aligned with what I wanted to do and made me realize the sort of doctor I wanted to be. That was quite important to me and the training was very much with like minded GP’s. I look back on that, having been taught by really excellent GP’s, that it gave me a really good foundation. After that I met the woman who was to be my wife, we got married and we went back to Australia and, initially, to Alice Springs again. I worked in Alice Springs as a GP for a year, working part time in a general practice in the town centre, and part time as district medical officer flying in and out to Aputula, a remote Aboriginal community about 400km south of Alice Springs. And again, the experience of flying to work in an airplane and staying in a community was an incredible experience. It gave me the sensation of being this little boy on the other side of the world having these fantastic experiences and it made me realize what a great passport a medical degree with GP training is, in terms of allowing you to be welcomed into communities, not just as a tourist but, with some initial wariness, where you can be of real service and make a difference in communities. So, that was another year in Alice Springs and doing Aboriginal health there.
Alice Springs and the Northern Territory was what I knew about Australia then and so my feeling then was that as a doctor, Aboriginal health was part of what you do- if you’re in the fire brigade, you go and put out fires and I just thought that, if you’re a GP in Australia, you do Aboriginal health, it’s really important.
We had twins in Alice Springs and so we needed to be closer to family to help with looking after the twins. But, it wasn’t until we moved down to south west Sydney that I suddenly realized that Aboriginal health was seen as this sort of niche in Australia and not seen as a routine part of work. And that was that was a bit of a surprise to me.
When we moved down to south west Sydney, I actually phoned up the local Aboriginal Medical service and asked “ Do you have any work going?” And they said, “ Did you see the job advert for a GP.” I said, “No… can I apply?” And so I applied, got that job, and that’s where I’ve been working ever since 2005.
DMacA: You need to tell us a little bit more about that because, for us, Aboriginal Health and Sydney, don’t seem to fit.
TS: The largest Aboriginal population in Australia is in west and south west Sydney. The proportion is lower because the overall population is so much higher. But actually the numbers are very high. If you work in a remote area the Aboriginal people are much more visible but there’s certainly a significant population in western South Sydney. The service I work in is an Aboriginal community controlled health service, which means that it’s owned and run by the local Aboriginal community, a sort of population co-operative model. I’m employed there, as a GP on a salary, which is a very unusual way of being employed in Australia. Most GP’s in Australia are independent contractors or practice owners and that model, set up in the centre of Sydney, in Redfern, just west of the central business district, was the first of those community control models. And they’ve just celebrated their 50th birthday. That model was quite successful and is really well liked by Aboriginal people. They didn’t feel well-served by mainstream health services and felt comfortable going there. Now, there are well over 150 Aboriginal community controlled health services all over Australia. That’s the model that I work in and I’ve found myself really committed to that model. It’s Australia’s version of primary care, as Barbara Starfield would understand it, and it’s definitely done with an Australian flavour. Lots of health services and systems can learn from the Aboriginal community control model.
Tim is a keen writer and communicator. He has written a range of wonderful articles in BJGP. You find these by searching the BJGP database and his BJGP and other academic writing listed here on Google Scholar.
DMacA: You’ve done lots of other really interesting things, so let me go through a few of them. One of the things that caught my eye is that you did a leadership course.
TS: That was back in 2010. I tend to be a little sceptical of leadership courses, they all look the same, and reading things on LinkedIn, they all sound AI generated. The course I did was about social leadership, by an organization that doesn’t exist now, called Social Leadership Australia. They took people across all different sectors wanting to be leaders including the community and the not-for- profit sector. So it wasn’t just about how ‘corporates’ do leadership. It wasn’t about importing those ideas into social organizations, because they recognized that leadership in those areas was quite complex because what you were trying to do was much more complex than just making biscuits!
And a few of the things that really appealed to me about that course was that they used a model called ‘adaptive leadership’, which is the idea that technical challenges are easy problems to solve because you just apply a formula. You do the science and it sorts it out. But adaptive leadership problems are those where you keep coming back and revisiting the same problems, and they never get solved. And so there are ways of managing those complex problems. And one of the important things that I took out of that was the idea of ‘exercising’ leadership. It wasn’t about people being leaders, it was about leadership as an activity.
I’ve never thought of myself as a leader. I’ve always seen people in charge of organizations and thought, that looks difficult, but I can now see leadership as an activity that anyone can do. Wherever you are in an organization or within a complex system, you’re able to exercise leadership. And one of the other important things that it taught me was the idea of orchestrating productive conflict. I was always very uncomfortable with conflict but the idea is that you can turn up the heat just enough that you generate ideas and discussion, where people are passionate about things, not so much that people begin hating each other and blowing things apart, but not so little that everyone’s really comfortable. The idea that conflict can be quite productive, that you can disagree with people, and that can move things along. And as someone who’d been fearful of conflict, that was actually really significant for me.
DMacA: This idea of leadership, challenges, and conflict, fits with something else I want to ask you about, and which I greatly admire, and that your interest in communication, throwing out those ideas, and challenging people with your writing.
TS: I’ve always been struck that what we do in general practice is actually really complex. We’re always making these, ‘in the moment’ decisions about how we’re relate to someone, what the dynamics are about, who’s in the waiting room. People who look at that from outside think it’s really easy. They say, ‘Well, that’s really simple. Look, they’ve just written a prescription’. And this constantly happens. So, I think that I came to it from the idea that, as a profession, we’re just not very good at describing what we do and telling people what we do. But, we’ve nothing to fear from lifting up the bonnet, and explaining the workings of what we do and the way we approach decision making. That can actually be really useful for people in understanding how they make decisions and patient centered care.
There are people who’ve written well about general practice and, although there aren’t that many around, I’ve always admired people who do that. Iona Heath is one prime example because she writes really beautifully about what it is we do as GP’s. The idea of witnessing people’s distress, that it’s not just a purely mechanistic biological system, the ideas around the different models we use in consultations, that are able to move us away from just a purely biological model so that we can actually handle people’s suffering and take a different approach to move people on in their lives.
Patients, often without being able to name it, recognize what’s happened, that there is someone that is listening to them, that sees their viewpoints as important. And I do think it’s really important to be able to describe to ourselves as a profession, to policymakers, and politicians, and funders, and to our patients, that these are the things that we’re doing when we see patients, and the reasons why it’s really important, and that there’s clear evidence that its gets better outcomes for people than just a purely biological system.
If you are interested to read more about the Churchill Fellowship, Tim been writing for an Australian health website and those articles can be found here: https://www.croakey.org/
DMacA: Let me ask you about something else. You’ve been described, with respect to general practice, as the heroic captain of a sinking ship. You have just come back from the UK on a Churchill fellowship. Are you still the captain of a sinking ship?
TS: Going back to the Sydney leadership thing, I’m not the captain but I might be exercising ‘Captainship’, and I’ve been really inspired by the GP’s I’ve met.
So, let me explain: The Churchill Fellowship is an opportunity, funded by Winston Churchill Trust, to allow people in Australia to travel overseas to investigate a topic in some depth, and bring back that learning to Australia.
One of the things I realized, while working in Aboriginal health, was that we have this idea in Australia that all our health problems are related to being rural and remote, or focused on Aboriginal and Torres Islander health. And then I read the work of the ‘GP’s at the Deep End’, serving the 100 most deprived communities in Scotland, and it seemed they were describing exactly the work I was doing. It opened this way thinking to me that actually, we haven’t got this poverty lens on health in Australia, so it means that we don’t see that as a problem.
I visited different ‘GP’s at the deep end groups in the UK; in Plymouth, in London, in Sheffield, in Glasgow, and in Dublin as well. These were GP’s working with communities and people who were traditionally disengaged from health services, where health services said they were difficult to reach. But, actually, for those people, it’s the health services that are difficult to reach for patients, not the health service having difficulty reaching out the patients. And I found the GPs doing really extraordinary work that was very familiar, quite inspirational, and often not seen by people. So, I’ve had this opportunity to see their amazing work, I’ve been inspired by it, and I hope, coming back saying this is really important.
Both in the UK and in Australia, there are real challenges around health policy, particularly seeing health as being this transactional thing that happens between a doctor and a patient or between other health professionals and a patient, and that’s where the threat lies. Going back and being able to say that really important health care only works when it’s relational, when people feel engaged with a human being providing their health care- these are the core values of general practice. Celebrating that is really important, and being able to describe that to other people is really important. I don’t think our ship is necessarily sinking. I’m optimistic, but I think we have to be loud and proud about our profession, that general practice has a real contribution to make, and that the people I see doing it are highly skilled experts. We lose that at our peril.
DMacA: Finally, let me ask you about something completely different and that’s your interest in music. And, its not just your interest in music, but you’ve also commissioned a piece of music…
TS: Yes, I did. I’m a very keen amateur viola player. And, one of the best things I’ve done is that I’ve managed to maintain that through my career, because there’s nothing quite like playing music, of being in a big orchestra, for re-grounding you when things are difficult.
When the Covid 19 lockdowns hit in Australia, I was looking at what was happening and thinking, this is coming, I’m going to get Covid and I’m going to be shut in my house for two weeks without anything to do. I’ve got friends who are musicians and involved in the arts and we all depended on the arts completely during our lockdowns. We were making music. We were watching Netflix. That’s what sustained us.
But the work of all the artistic people that I knew had just disappeared overnight. It was a real struggle for them. I heard an idea from a composer that I know who presents a radio show on, on Radio National, the UK Radio 4 equivalent in Australia, who talked about how we need to support the arts. And so I thought, why don’t I commission a solo viola piece to practice when I’m in lockdown. And I did that and he wrote this beautiful piece called “In My Solitude” based on a song by Purcell, an English composer of three centuries ago, about being inside on his own. He wrote this beautiful music, which was subsequently performed beautifully on video by a violist called Katie Yap. (Click on the video below)
And so, the idea of having a piece of music, created because of the Covid lockdown, that people can that can play, and I go back to play, is actually one of the special things that I’ve done that I’m actually quite proud of. It’s very different. And it’s something that would I do again. As it happened, I didn’t end up getting Covid during that time, but I did manage to find time to practice and play the piece.
DMacA: Its been an absolute pleasure talking to you. Thank you very much for sharing so much of your life, your profession and all your other interests. We really appreciate it. Thank you.
