WESTMEAD – from early days to the present

History… is not the arrangement of what happens, in sequence and in truth, but a fabulous arrangement of surmises and guesses held up by a banner against the assault of withering truth.

Roseanne McNulty in Sebastian Barry’s The Secret Scripture

Brutal concrete

Westmead Hospital is a fine example of brutalist concrete architecture. It was designed by Chic Campbell, a manic Canadian architect, after the first team of project developers were fired in about 1972.

McMaster University in Hamilton, Ontario, built around that time has striking similarities in design. Both used bold colours on doors, have (or had) carpeted corridors as wide as freeways and an unmatched sense of interior space. Both were designed to foster collaboration among clinicians of various stripes and to make it easy to integrate clinical service, research and education.

Brutal concrete conveys a message of strength and defiance against inimical environmental forces – an appropriate defence against the wild west. The land on which Westmead stands was once a stock-car racing track and dumping ground for asbestos waste from Hardies, a fibro manufacturer.

The pasture was more genteel in the days when sheep belonging to Government House at Parramatta grazed there – on the ‘west meadow’. We know nothing of its utility during the Dreamtime. Down the road was the habitat for Aboriginal people during Macquarie’s time – known as Black Town; now, Blacktown has only the Australian average of Indigenous people (9000) or 2.9% of the population.

With time, as with all hospitals, Westmead has sprouted small buildings and sheds, panels of ritzy cladding, with lightwells filled to hold clinics and bureaucratic document files. 

First contact

My association with Westmead began in 1972 when, concurrently completing my PhD at USyd, I worked two days a week with Bernie Amos. Bernie, the project overlord, was a man for whom I already had great respect and affection from our shared experiences at Royal North Shore Hospital. He was a loyal friend, supporting my headstrong departure, after two years’ internship, for an interim year in the highlands of Papua-New Guinea. That year alerted me to the importance of public health. I abandoned plans for a career in experimental neuroscience – an outgrowth of my BSc(Med) experience with John Pollard in 1963 – and, with Bernie’s support, returned to RNSH in 1969,  completing my MRACP in 1970.

The details of the luminous ‘functional brief’, written by the late respiratory professor John Read, were being interpreted and turned into policy. The brief contained sections devoted to every clinical discipline, the crucial role of education and research and much about the desired ethos. Page after page reveals a strong awareness of, and responsiveness to, the local community. Each section had been produced by academics, with the USyd front and centre. The then NSW Health Commission also featured strongly – especially through the work of several of its eminent commissioners who had joined the clinical working parties.  

The thrilling awareness of the opportunity to create an entirely new and different teaching hospital is palpable throughout John Read’s brief. This awareness energised and motivated many of the original clinical appointments. Whereas the other USyd clinical schools were grafted onto existing hospital stock, with the problems of antiquarian halls and theatres, antiquated governance and musty, desiccated traditions, Westmead could, by contrast, be big, bold and above all, NEW!

I don’t know the origin of the spark which set ablaze the enthusiasm for so bold a venture as Westmead. Health Minister Harry Jago was crucial; surgical Professor John Loewenthal and John Read were academic champions. The vice-chancellor, John Ward, was a strong supporter. I know little of the pre-history, stumbling onto the scene only in 1972. This period, which I call the Westmead pre-Anthropocene, would make a fine topic for a scholarly history.

The role of the Commonwealth was substantial. When Gough Whitlam addressed Westmead’s thirtieth anniversary celebrations he said, with a flourish of humility, “There was a point when they [the NSW govt] said they would not fund it, so I said, ‘We will’!  And do you know what, suddenly they declared that they would fund it!”

Community Medicine at Westmead

In 1973, Bernie asked me to write an implementation expansion of the brief concerning Community and Geriatric Medicine. I worked on this two days a week. I was also completing my PhD on factors affecting the lung function of 12,000 Sydney schoolchildren. My colleagues were Ann Woolcock, Ruthven Blackburn and epidemiologist Godfrey Scott in the Department of Medicine in the Blackburn Building and the School of Public Health.

The HQ of the Westmead Project Planning Team was the old Preventicare building on the north-western corner of Missenden and Parramatta Road. Chic Campbell arrived on the scene (I think) towards the end of that year.

I was no expert in Community Medicine, which might explain why my paper was well received!  John Loewenthal breezed into my office one morning to say that, after having read it, he at last understood what Community Medicine was. I considered asking for an explanation because I was, I confess, none too certain myself. Loewenthal was a great encourager of the Westmead people. Rob Griffin, the first Director of Medical Services and one of many imports from the RNSH (including John Dowsett), told me how JL would drop into his office weekly “just to see how I was going.”

The ambitious plan was to combine hospital community outreach (the community health program was still in its infancy) with geriatric inpatient, outpatient and community-based care, and to offer a general practice clinic. 

The first Westmead property – now gone!

To give visibility to the Community Medicine concept, we bought the house on the corner of Railway Parade and Hawkesbury Avenue and labelled it Department of Community Medicine, Westmead Hospital. It served as the base for the recently-formed community nursing group – the forerunner of Whitlam’s ‘community health centres’ – and we accommodated a local branch of the Family Life Movement (now Relationships Australia). The cottage remains the property of the Western Sydney Local Health District.   Community health centres, different from the original model, persist. The cottage was demolished recently to make way for the new Parramatta to Westmead light rail.

The Community Health Program, funded by the federal government in 1972, was a major initiative in the newly created Western Sydney Health Region (similar, but not identical, to the current WSLHD) , developed by the NSW Health Commission and directed by Gary Andrews, later Founding Professor of Community and Geriatric Medicine at Westmead. The teams of nurses were commissioned with due ceremony, at Lidcombe (I think). As they filed onto the stage to receive their badges from the Minister for Health, several had arms in slings or were supported on crutches. They had been equipped with fault-ridden Leyland’s Marina cars! This was an inauspicious start for an idealistic service built on the concept of health beyond the reach of clinical medicine.

I gained a good feel for Western Sydney, driving around with Bernie in his Holden Statesman (he was a superb driver) stopping for Chinese lunch. He considered it important to have an idea of the community we were proposing to serve. We attended the opening of the Mt Druitt polyclinic, with Health Minister, Kevin Stewart, where we were accosted by a disappointed local resident who told Kevin, in stern words, that the local citizens wanted a hospital, not a clinic with one bed! I met her again in 2016 – at Mt Druitt Hospital – when the WSLHD Board was visiting – and we shared happy memories.

My life in the late 1970s and early 1980s

In 1974, our family moved to London for me to pursue an NHMRC post-doctoral fellowship in clinical epidemiology at St Thomas’s Hospital in Lambeth with Walter Holland, the father of British epidemiology, and Charles Florey, son of the prince of penicillin. That was a splendid, rich 18 months of cultural and academic experience of unparalleled depth. I often felt that I had come ‘home’ – my paternal grandparents had come from a farm in Thaxted in Essex – where I met another Stephen Leeder, much my age!

The AUD was so buoyant that my salary exceeded that of Walter Holland. While consuming a dreadful coffee and bun in the pre-war cafeteria, I recall watching snow beat up the Thames. Bomb damage was still visible in sections of the hospital building and weeds grew in the cracks. At various points, rationing occurred – butter for example. The Brits thrived on this nostalgia. One day, walking to St Thomas’s, I encountered a 50-metre queue outside a small store. I asked a happily humming man what he was queuing for. “I don’t know!” he said, “but it’s such fun!” he replied, resuming his tune. There was a little corner store near St Thomas’s where I bought lunch occasionally. This was 1974. On one occasion, a woman was asking for butter. “I have only German butter,” the proprietor told her. “I’ll leave it then” was her disgusted reply.

The McMaster epiphany

In 1975 we moved to McMaster University in Canada for a year. I was intrigued by David Sackett, one of the progenitors of clinical epidemiology and subsequently of evidence-based medicine. He had been at St. Thomas’s while I was there. He had made clinical epidemiology educationally interesting. Most prior public health education I had encountered had been dry and eminently forgettable. Sackett was an educational magician. By integrating epidemiology with clinical practice and making it the foundation for quantitative research he achieved the impossible! No major research activity or educational development at Mac was devoid of a clinical epidemiological contribution and collaboration. 

Everything about McMaster was stimulating, from the architecture to the happy and creative atmosphere (including the massive cafeteria where everyone was expected to turn up for lunch).  Moran Campbell, a dazzling respiratory physiologist, was a major intellectual force: he co-authored a Lancet paper ‘What is the probability of a committee meeting?’ He and his co-author compared the turn-up at formally organised meetings (laborious) and at a spontaneous gathering of the same group at lunchtime! Lunch won!

The design of the McMaster University Medical Centre favoured flexibility in the future use of space.  There were no internal structural walls, so that rooms could be demolished and reinvented without much effort, according to desire. To enable repurposing, enough space was left between floors for workers to walk about, moving utilities to fit – plumbing and electrical outlets, for example. 

The McMaster year showed me how truly integrated research and education could work, how the combination could be clinically relevant, and how much fun working in a collegial environment could be. It was also a revelation as to how medical education could be changed from conventional didactic boredom into an exciting activity in self-directed learning. The course lasted three years. There was no formal assessment. Students defined their own learning and used the faculty as resources. They integrated with the various departments and research programs in the medical centre.

The Newcastle years

From McMaster, we returned to Newcastle. David Maddison had recruited me as the foundation Professor of Community Medicine. That, too, was exciting – a completely new venture where we had the opportunity of introducing new methods of medical education akin, but not identical, to what had been pioneered at McMaster.

In Newcastle, with its accessible and contained Hunter Region community, its own media and politics, I had an active decade undertaking population-based NHMRC- and Cancer Council- supported research with colleagues from the Faculty of Mathematics (Annette Dobson and Bob Gibberd) in cardiovascular disease (the WHO MONICA project), an RCT of school-based smoking prevention and more. I was deeply involved in developing the entirely new curriculum and was put in charge of assessment.

The new medical school was community-focused, treated the students as adults, emphasised the importance of clinical problems as the basis of medical education, assisted students to learn how to work in teams and to direct their own learning, and assessed their progress in terms of acquired skills.  Communication skills were strongly emphasised.

These were also years when I had extensive international engagement. Because of my McMaster contacts, I became the founding director of the Rockefeller-funded Asian and Pacific Centre for Clinical Epidemiology and Biostatistics. This trained top-flight young clinicians from Thailand, Indonesia and other countries in these dark arts. This centre was a part of an international training network – INCLEN – including training units in hospitals in SE Asia and major resource centres at Pennsylvania, McMaster and Newcastle.   

Newcastle was also where I formed a close relationship with Denis Butler, the deputy editor of The Newcastle Herald. He encouraged me to write (heavily and instructively edited) op-eds, including a series after Laurie Brereton decided in1981 to cancel the construction of a combined clinical school and cancer centre at the Newcastle Mater Hospital. Huge community pressure reversed that decision.

Denis also supported my writing Saturday book reviews. His friend, Tom Naisby, the poetry editor, did likewise with my poetic efforts. They were wild men in their own ways and added to the rich diversity of Newcastle’s cultural life. After David Maddison, a heavy smoker, died suddenly in late 1981, much changed. That was a great sadness and a terrible disruption.

Westmead revisited

In early 1985, I considered that ten years in any place was long enough and took on the directorship of the Westmead position in the hope that experience gained in Newcastle would help develop the department about which I had written in 1973. I started there the same day that Andrew Wilson commenced as my first Registrar.

It was not a happy scene. We soon lost the geriatricians who felt we were not medically kosher and who detested the rehabilitation physicians. General practice was always restive in their department and increasingly identified with the ED.

In their place, we established strengths in health economics (Jane Hall and the Centre for Health Economics and Evaluation, now a thriving unit at UTS) clinical epidemiology, health promotion, statistics, and related disciplines. Andrew Wilson, Bob Cumming, Ross Lazarus, Karen Webb, Penny Hawe, Simon Chapman, Bin Jalaludin, Allen Sheill, Stephen Jan, Beth Stickney, Jason Grossman and Vicky Flood passed through the department and went on to assume major academic and managerial positions in ageing, nutrition, environmental health and more.  

My national commitments continued over this period, serving on the Better Health Commission, the Health Goals and Targets committee and various other groups with the strong support of the then federal health minister, Neal Blewett and the secretary of the Department of Health, Bernie Mackay. These appointments led to the first set of goals and targets for Australia’s health. NSW counterparts also took my time and energy. During this time, when Medicare was established, Blewett also set up the then Australian Institute of Health – to gather statistics as we could not easily identify these when we needed them for the Better Health Commission.  He also commissioned a review of public health education and research in Australia with Kerr White from the Rockefeller Foundation and Johns Hopkins University.  Kerr White had founded INCLEN. One of his suggestions was that the school of public health at USyd should be wound down and the resources applied at Westmead – a highly provocative suggestion that led to fury at Camperdown!

During this period the Public Health Association was reinvigorated and given federal support for a secretariat. I became the first national president. The enthusiasm was palpable.  

In Community Medicine we led the development of the intranet within Westmead with the help of Ross Lazarus. Deirdre Degeling led major health promotion community programs such as Healthy Hearts West and Karen Webb, with Penny Hawe, did excellent work with the Penrith City Council developing a ‘healthy city’ program. The department provided methodological support for many clinical researchers. We developed applied public health research and had a team of over 30 by the time I left ten years later.

But Western Sydney had been a totally different ballgame from Newcastle – huge diversity, much larger, complex economically and socially. I had had culture shock for months. I wrote this poem about the experience:

HEADING WEST

In the hinterland of life

west of the coast

by 25km of traffic

dense as dust we must

confront the size

of the problem.

My brown shoes

have lost their shine

and their soles worn –

urban, ethnic, aged,

alcohol-obliviated,

club-dominated,

fast-food saturated,

Diet Coke burpurated:

is it any wonder?

Suburbs built without amenities

create misunderstandings,

offend sensitivities;

concrete poured and walls built

in haste against imaginary winds

provide no rhyme, no reason

nor do random roads and rusting gates,

yet Map 241, F13 still marks

the Mt Druitt of my soul,

and public transport is crap.

I moved to the USyd Camperdown campus in 1986, first as head of the School of Public Health and then as dean of the Faculty of Medicine in the era of the new curriculum and the devolution of authority to the clinical schools. The Westmead department of community medicine, which could have come into its own in the current era of community re-orientation and integrated care, was slowly wound up.

During my USyd career, I chaired the Health Advisory Committee of NHMRC for three years when Michael Wooldridge was health minister. I served on the Senate as a staff representative for eight years. I learned a lot about politics in academe! I continued my involvement at Westmead, serving on the board and assisting with the Respiratory Ambulatory Care Service run by Mary Roberts and John Wheatley at Blacktown Hospital. That gave me a deep understanding of home care for people with serious and continuing illness. Brilliant. I was also on the SWAHS Board at that time.

Craig Knowles as state minister for health did many constructive things to bring clinical perspectives into health district management, including establishing an advisory group chaired by John Menadue, former head of Prime Minister and Cabinet with Whitlam. That committee developed and fostered the idea of research Hubs, and we pushed that concept with great success in western Sydney, building on the initial work of Tony Cunningham and others.

After a little over five years I finished being dean. I then had 18 months at the Earth Institute with Jeffrey Sachs at Columbia University, and the Mailman School of Public Health, with colleagues Susan Raymond and Hank Greenberg. We worked on the economic impact of cardiovascular disease on low- and middle- income countries. On my return to USyd, I directed the Menzies Centre for Health Policy, initiated by Michael Frommer and colleagues and now headed up by Andrew Wilson. 

At the end of this interval, I returned to Westmead, chairing the WSLHD, editing the Medical Journal of Australia, and directing, with Helene Abouyanni’s superb support, the WSLHD Research and Education Network. It has grown include about 700 researchers and educators: we are a network, not a department. We are more a ‘community of interest’ than a bureaucratic structure. The difference is profound.

Many of our members are researchers and educators, helping manage education and research, research and governance oversight of research, financial management, intellectual property development, and statistical and support with writing papers and grant applications throughout the WSLHD. We assisted in establishing conjoint chairs in pharmacy, nursing, clinical education, allied health and preventive public health practice. We oversaw the development of a strategic plan for nursing research and, most recently, a statement of strategic intent for research and education. This was endorsed enthusiastically by the WSLHD board in March. The recent arrival from the UK of Peter Hockey, professor and director of education, ushers in a range of new options in our educational efforts.

In my most recent incarnation as Chair of the WSLHD Board, we saw great things planned through the commitment of Health Minister Jillian Skinner – leading to the redevelopment of Westmead and Blacktown/Mt Druitt Hospitals.  During my term (the past ten years) as director of the Research and Education Network, we began by having to sort out terrible financial tangles in the support of research and to re-energise the relations between the local health authority and the research community. 

It has been exciting to watch the amazing achievements of Tony Cunningham and colleagues in establishing the Westmead Research Institute and, with Jeremy Chapman, consolidating the unique and special relationships with all research entities in the precinct in the Westmead Research Hub. 

This is the year I retire. I do so after much happy experience, the joy of knowing and having worked with splendid people and having seen many achievements. We are still, as a hospital and a district, yet to fully accept our mandate to contribute to enhancing the health of the community, but that is growing.

I leave to others to describe and assess the massive redevelopments. That is a whole other story, bursting with exciting potential, and only just beginning!

A new age is dawning. Westmead – make the most of it!