Developing health service and training pathways for health equity in Ireland with Dr Austin O'Carroll Artwork

Community, Health and Capital @ 19 Hills

A podcast series exploring new approaches to primary care, public health and public service delivery, supporting the 19 Hills Wellbeing Centre and community activities in Ringland, a small area in the east of Newport in south east Wales.

We talk to colleagues and partners around the UK and beyond on how shifting to prevention, prioritising action on the Social Determinants of health and community-owned models of service delivery could change lives - and give staff a better job and purpose.

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Community, Health and Capital @ 19 Hills

Developing health service and training pathways for health equity in Ireland with Dr Austin O'Carroll

May 20, 2024 • Dr Jonny Currie • Season 1 • Episode 4

0:00 | 29:04

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In this 4th podcast episode of the series we interview Austin O'Carroll, an inner city GP in Dublin since 1997, founder of Safety Net Ireland, a charity working to improve healthcare access for people who are homeless, and co-founder of the North Dublin City GP Training programme aiming to recruit and train GPs to practice inner-city medicine.

Listen to the episode for how flexible access arrangements, a social model for health and patient empowerment (and more) could help us better tackle health inequalities through local services.

Get in touch via podcasts@19hills.org if you have any feedback or would like to feature on an upcoming podcast of ours.

OK. Hello and welcome to the 4th episode of the Community Health and Capital podcast series that we're developing and delivering to help the delivery of the 19 hills well-being centre in Newport today. I've got Austin Carroll with me. Hi, Austin.

Hi, Johnny. Nice to see you.

Nice to see you too, Austin. Thanks for coming along. Austin is a GP across the water in Dublin. He's got a long term experience in primary care and health inequalities and. Yeah, so we're here to invite people, as I said, to talk about different approaches to prevention, primary care service, collaboration. And what do you introduce yourself and tell us about yourself first?

OK. Just in case, maybe I'll give you the best way to choose was to give you my story of when I first started and I first started in inner city practise 1997. There was no Georgian building area deprivation, quite a shock coming into it actually for me because I had worked in the inner city when I was a young person with children. Just before the heroin epidemic came into our into Dublin and then I had sort of disappeared. And when I came along, I came to this community where there was a huge amount. Of you know, there was a huge disease burden. There was a huge amount of young death. I had a lot of people and families who lost three or four kids to drug addiction. I was going to funeral once every month and I was coming into an area where there was huge pressure on us to manage drug addiction with very few resources as well as the whole.

Effects of poverty. On top of that, so it was quite a baptism of fire. Anyway. I set up the practise in 1997 and it was myself and one receptionist, and we gradually grew and. We eventually hired other doctors and I was a lot of the people I worked with. I mean, in fact, around 19 the late 90s, there was a flood of migrants came into Ireland and through asylum seeking processes and next thing they couldn't get doctors to work with them. And there's a lot in as as. Is. Normal the because properties cheap in areas of deprivation. That's where they get the the accommodation for them. So suddenly they needed to have a service.

Got into developing services for migrants and asylum seekers. And then because we had done that, we also discovered there was a large homeless population in our area. And it's funny, I know. I know. In the UK homeless services and GP services tend to be separated, whereas interestingly and I I I I query whether that's the right way to go about it. Because for me, homelessness is just the far end to poverty. So I'll often see patients in my own practise and actually they disappear and. I've since started homeless practises and I meet them in the homeless practise the following week and I said what are you doing here? And I said I'd arrived my mom and then I'll be in homeless for a number of months and suddenly they appear disappear for homeless and then to back in my practise. So what happened was because we had developed service for migrants, they asked me to develop services for homeless people. So we started to develop and it started with one clinic and one nurse and uh. But then the homelessness was really rapidly expanding. And Dublin. So then I I started to to develop other clinics and I recruited other doctors. And then I realised with all these clinics with different doctors and you know, a homeless person could go into one clinic, get medication, go into another clinic the next day and get different medication. So then we set up safety net, which is an organisation that coordinates. So now we have a common database for anyone who goes into any clinic around Ireland actually. So you can go into clinic in one place.

And we'll see that you got that medication, but also that then allowed us to develop Miss Systems of following chronic care. So we could see that your blood pressure was done two weeks ago and was raised and you need to get a repeated and maybe you need medication change. You need blood tests followed up. So certainly start to develop all these possibilities anyway. It was from there on I was still running my practise in Mount Joy. And and then at the same time developing these homeless services. And they just grew exponentially because homelessness grew exponentially. So now we have, like, around we have safety Nets in reach. And so around 1010 different homeless hostels, we have around four different drop in centres. We have a a methadone treatment service that is over 500 people on it. We have a mobile outreach unit that goes out to homeless people in the streets. We have mobile health and screening service that does X-ray screening, blood virus screen and we have we run 2 stabilisation centres. The detox centre. We also run a HIV stabilisation unit. Step up. Step down service like and we also developed extra services for migrants so. All this was happening, but at the same time I was also one of the GP practise. Now I suppose the last bit of the puzzle was that, you know, we were finding it difficult to recruit GPS into both the services for the homelessness as well as our own practise. And I there's no GP training service in North Dublin, even though it's a huge area of deprivation in our leafy South side. There, there's less, much less deprivation. There is 3GP training schemes. So then I developed a GP training scheme in 2009 to train GP's to work in areas of deprivation and. Marginalisation. And that was hugely successful. Almost all our graduates end up working in deprivation, are with marginalisation. And in fact, we have a second note in here and I think after we started the Glasgow Pioneers started and then the Trailblazer started and then the HEFT programme started in the UK. So we're now across Ireland, UK. There's a large number of GP's who are specifically trained to working as deprivation and interestingly, just to fit whole thing is now we have no problems. Recruit and GPS in our practise are in the homeless services, so actually. And and I was in Manchester recently where a similar scheme was opened up by Laura Nielsen and she said that they had difficulties recruiting GPS, but now they don't in their area, deprivation. So it's sort. Of. Completed the. The puzzle of providing healthcare to areas of deprivation in north Dublin. Sorry.

It's really interesting. Because obviously we're keen to develop the service model, but I think there's a lot to do about kind of teaching something different really there. So definitely round and come back to that. You you you've obviously. Thrown yourself a lot about all these services and what you've set up and expanded where where does that passion come from, Austin?

I suppose just to give you a little bit of background, I have little mine. I don't know you know the my mother took glutamine and I have shortened limbs and significant disabilities and I got involved with the disability movement rights movement or even go back further the 1980s my my family would have been very much involved in charities. And when I got into college. Even though I'm agnostic, I joined the Vincent Nepal and I always say I had two educations, one inside the leafy glades within the walls of Trinity College and then outside that walls was the thriving, you know, human debris to be. Of. Of deprivation and very interesting. They actually got involved in providing Youth Services all around inner city Dublin. I had working my summers and playgrounds in north in the. Inner city Dublin. And then I discovered that it was really. And that, you know, people who are living in their 60s and 70s in the community, that Trinity College was was based, had never been in Trinity College. The only people from the community who ever went into Trinity were the local, the cleaners. So I got. I developed a very much a charitable ethos there. However, then when I got.

Later on in the 90s, I got involved with the rights movements and that made me realise that even though I have great respect for people involved in charity, charity is actually ultimately about disempowering the individual the concept. And I learned a more human rights. Approach. So when I actually got the start to the practise and went. Joy. Straight I suppose I'll give you a story and. I inherited a huge amount, a huge problem with benzodiazepines. And uh, like I I people are on 6 so it's up to 60 milligrammes of days upon a week and some massive amounts about a week a day. So I basically had to reduce all this down. And that meant that, you know, I was having a lot of arguments. And I remember, ironically, that I ended up taking days of pain at the end of the weekends. I was so stressed out. But I sort of decided that I wanted to manage this and bring them off. But in a way that would not lose them because I believed that they had a right to healthcare. So I took a decision. Early on that my mission was to address the effect of health and equality and that actually ever since then, I believe are have a big believer in vision. Vision is the way you see the you see, you would like the. Able to be and the mission is what you're going to do to try and achieve that. So it sort of developed a vision and. Mission. With my then single administrator, our receptionist and the two of us, and she had a similar ethos. To be fair as well, and therefore we managed to get them all off the benzodiazepines. And actually maintain them all as patients as well. No, some of them left because they go to the doctors would give them, but we didn't put them off the list. So we've always held that ethos. And then I think in later years, the concept of trauma informed care has sort of incident, you know, neatly fitted in. It's given the language. The way I instinctively was going from a rights based approach. So I'm a big fan of trauma informed care. So trauma from care is a way of understanding.

That people behave and it allows us to ensure that those people who are most on the margins have the right to health care, maintained and fulfil.

It can. It can really help. I think help people understand the different ways people behave really can to it really, because I think we can take quite an antagonistic approach to. When people are acting in a certain way, presenting in a certain way, but there's a huge background to keep the relationship going, isn't there?

I I find it's just instinctively, you know, I mean you you understanding the whole impact of that child of diversity is really from a cognitive point of view is, is is fantastic. It gives you a language and and you know it gives you the statistical. Understanding. But the simple intuitive understanding is that if I see someone in my waiting room, so for example there's a while back, there was a a, a young couple coming in for a benzodiazepine detox. We did do those and the UM, this is in my homeless service and their child was in the waiting room and the child starts to do something. And the father said, Ohh, stop doing that and someone else in the waiting room said he's doing no harm. Leave him alone and the father just lost it. He absolutely lost it and he went tearing for the other guy. And two of my staff managed to hold him back, managed to put him outside. He kicked in the door. He taunted someone at the pavement. They brought some. He then went across the paper to talk to someone else, and the guards picked. Him up. And brought him in. Now when I look at that guy, you know, I see a child having a tantrum. Never learned the skills to manage that and probably when he attentions as a child was reacted to with violence and aggression. So that's my intuitive understanding and I was really delighted because my staff came back to me and we've trained them up in trauma from care. And they came in to me one day and like I was saying, does not come not bringing him back and expose him to the staff. The staff came in and said, actually we we think we can deal with them. So we brought him in out of after the surgery was closed and we actually completed his benzo detox and in fact, by the end he was fine and he come in during the day and he. Knew that he couldn't act like that again. So.

That's really interesting.

What are the some of the things that you've led the staff to learn in that trauma informed training?

I think you see I I I what I think is that I I've got local staff, a lot of them from the area. So a lot of them have sympathy for these people because these are people from their own area.

So I think they had an intuitive understanding themselves. And again, when I gave them when you give them the, the, the, the to me is true, you're you're you're never transformed. It's a process. It's not a state. You know the process of constantly being.

Where? So we do training and Roman forms and give them the, you know the the the the data on the impact of childhood adversity and then we talk about how we manage people who are going to have challenging behaviours in a way because they're the ones who are most likely to end up dead, you know, because you know, they're the ones who end up. We see for example. Food addiction as a self treatment for the impact of trauma. Irvine Welsh, you know the guy who wrote Trainspotting. I was listening to on the radio recently and he said something really interesting. He was saying that he he used to use heroin and the interviewer said to him you kind of offer.

Doing and, Irving said. Oh yeah, he said I got off here and said I just used used heroin for fun. He said it's easy to get off heroin. He says the people who stay on heroin, he says they're the ones who are using it to treat whatever happens to them as kids. And that's the way I we see drug addiction as as the self managing of trauma. So the people who are most chaotic are the ones most likely to drug use. And most likely to die. Yeah. So. And I also think is there's this thing about if you have a vision and mission and actually motivate you and keep your passion, you know.

Yeah, yeah, yeah.

Burnout is such an issue in general practise and I'm I mean, I'm not saying I I go through periods where I feel burnt out and the good thing. I think a key issue is knowing to recognise when your parents house, so I go in some days and I know how to go through the motions. Say oh God, that's terrible. And how are you? And that's awful. So I can look empathic, but don't really give a damn on those days. And and I think you get away with that for so long, the patients eventually.

Upon, if you stay in that, so when you learn to recognise that you take action, and then there's, I mean, in general, I go in and I do feel.

The empathy, and I feel the sorrow with. And the happiness? So. But I think a big part of keeping that empathy and that uhm, avoiding burnout, is having a clear vision and mission. You know, you know. You're clearly what you're doing to help people, and I have found that hugely powerful in helping me go into my life.

So thinking through all of the work that you've done before and where your passion lies us and if if you were to kind of have a role in shaping what we could do with our centre, you know, 1620 thousand people in the area, what what are some of the kind of principles or approaches you might take?

Well, I think the the first thing is it sounds obviously like you're there is obviously to have a clear vision and mission in what you're doing. And I think it's to get all the staff. And then when I right down to the cleaners, get them involved in that vision and mission because I think and you know, so for example, the management of challenging behaviours for example is. Key that the reception staff know how to do that and they have to buy into the model so that I think that's the first thing I would do, I think.

Is that something you found easy with staff over the years?

I think it's a question of part of its recruitment and I do think doesn't have to be local staff, but having a lot of staff or staff from a background in those areas they it does help, but it doesn't have to be that. But I so but I think so. I think that's part of it. But then I think the training is so yeah, if you're someone who is you know it's recruitment. When you're recruiting someone, I'm looking for someone who has a passion or who I think. Has a. Leaning towards that so and there's times you get someone who doesn't feel that in event it's a bad fit and it's about working together for you both to. Realise it doesn't. Fit and move them on. So I do think getting the right team is key and if someone doesn't visit to the team I think you need to be a bit ruthless. And say you know, because you can, you can end up wasting their time because they get frustrated because they're involved in some. That really doesn't feel right to them. So that's the first thing. And then so yeah. So and then the training, once you have the right team, then it's about the training and it's about, you know, rewarding them. And when you know you manage a staff for a person really well, it's about saying that was really good and we go out and celebrate often and we every time we have achievements. We, like we follow our figures and we get we we we feed that back and we celebrate a lot. So we took out a celebration which was great fun and.

Teams in primary care to often come together enough. To do that, really do there the, the the jobs were busy, everybody's looking to clock off. Everybody is quite burnt out, really aren't and can be quite lonely as well.

I think so, and I think those those, those celebrations are key in developing and maintaining your vision and mission. And you know, because you realise that you know when you celebrate together, it's actually bonds you're together. And also I think it makes you feel appreciated. And I do think if I was to be fair, I said my staff would say. They feel appreciated. By the the work by my management. So I think I think that's key. And then in other things is, I do think you know when you're running a practise, the key issue is about having systems that allow your run. So you know appointment systems, admin systems. But then I think in an area deprivation and I suppose this is particularly obviously for homeless people, is they don't fit into systems. And and I think.

Like I I originated research at the graphic research into why homeless people don't use health services, and I concluded it's because health services are designed for non homeless people. So homeless people, you know, ideally it's drop in clinics and areas of deprivation. There's a lot to be said for, some appear to. Drop in.

While more flexibility.

Yeah. So I think it's about getting that flexibility. And so you want a system that helps us, you know, has helps your own properly, but you need flexibility as well. And I mean. In Ireland, I think it's different than England. I think specialised services are separated away from the primary care, which I think it's like pity. In Ireland we have this connection still that a lot of the services are run by. Primary care centres. Primary care services and and I I think that that that connection is really useful because we often transfer patients from our homeless practise into our primary care. But if you do are developing services for those groups of people, I do think as they tend to keep away from UM from from the mainstream services. Very interesting simple things like some homeless people know that they smell or look different and they feel embarrassed and they're not comfortable in that space.

I apologise, I do loads of stories but like I remember I was doing my research and I was in the emergency department in the hospital. And everybody is waiting for ages, but they're all chatting and at the back. Suddenly I saw the the door open and came to those two people and they're obviously either drug users are homeless and the whole room went silent and the two drug users are homeless, started talking very aggressively and angrily. And they sort of crept around the side of the wall. And then they went into the toilet and then sort of relaxed. And then they came out again. Everybody tensed up again and went silent. And they. Crawled and they talked loudly but and then they went out. When they went out, everybody relaxed. So I followed the two lads out the back and went down and found them sitting with four others and they're all drinking and it was like being at a party. It was great crack. We're all sharing stories and I realised that we have two different spaces. You know, the homeless people, stroke drug users were comfortable in the space of the steps outside and uncomfortable.

And the way they expect their discomfort was to talk aggressively. Mainstream people. So that's why I do think and I don't like the term specialised services because it sounds like we're making a special effort for them. It's not. It's just developing services that are suitable for that one. So just the same way as we develop and we care centres to be suitable for the House population, so.

I think if you need to get to those service communities, you need to develop that type of service. That is more outreach and gets out there.

Yeah, yeah, yeah. OK. And you've obviously had a lot of success with the teaching and training side. What what are some of the kind of unique things that? You think staff? Or GP's need to know, working in the areas where the patient groups. That we're talking about.

1st I have to study is a motivation. It's really interesting. When I first started, as everyone said to me, don't call it. GP trains came to train GPS to recognise deprivation. A marginalisation, I said. Why is it too long? And they said no. They said no one will apply. And we have had probably the highest rate of application since we started and I'd love love to say it's they were fantastic, but I think it's now it's that young people actually.

Do want to make. A difference just to provide them the opportunity. So that was the first thing and actually the first thing is just getting that group of people together. The second thing is you have to train them as high quality GPS you want.

High quality, cheap.

In. Your area deprivation, so. You know that's not for negotiation. You know, they have to get the same quality of training as everyone else. What we do on top of that is we do a social medicine module. So we teach them in, uh, you know, health and equalities. But we also teach them about UM, you know, working with marginalisation, trauma, informed care, etcetera. We also do an arts based programme and this I think is about interesting is it's it's it's much more valuable than people realise. The reason I use the art space is you know the way you consider a group of doctors down and we can sit and talk about real life cases that are really sad and in a case conference and discuss it. And you know, we're fine that night we'll go to a fictional film and we'll be all crying in the Isles. And what is it? I mean, it's probably a good thing that we're not crying at these meetings.

Yeah. Can extend. Yeah, yeah.

And then I. An educational point of view, it's good to be able to access those feelings and work with them because they're the feelings that keep you motivated, going. And so we go to a lot of plays like we were at the play last week, which was set in the inner city. About the 1918 flu pandemic and its effect on our local Rotunda hospital and we got the theatre director came and talked to us. We were at, we go to art galleries where there's exhibitions. So it's relevant to social medicine.

Night out. It's actually great fun to go for a pint after and, but it allows to explore these ideas and I suppose what I'm trying to get people to understand is that general practise is much richer than just biomedicine, and you can learn about it from all aspects. You can learn about it from books. You can learn about it from theatre.

Film and from a social medicine point of view. Obviously you're exploring aspects you know other than the cognitive you're exploring the impact of the emotional impact when you go. To. Theatre. So we do an arts based programme, we do a change management programme because we. Want them to change the world?

And and in their 4th year, they spent four months for a day a week working in homeless services, four months for a day, a week working in drug services and four months for a day a week working in prisons in the morning and migrant service in the afternoon. And now we have other components. We have a self-care module as well, which we do in life is based stress reduction. We teach them yoga and we talk about how we manage self-care. And again we celebrate again and that and that's partly to model that we enjoy celebrating, we enjoy so.

These are all the things we also like we do theatre with your press and the thing. And so we do other different things so.

Sounds fantastic. I wish I had a chance to go on it. Looking back at it, Andrew, it's the time to get people, really, isn't it? You know, if you can.

Engage somebody at that point of their career when they're still forming their ideas and direction. You know the opportunities to, to reorient, to to a different direction. There's huge and transformative. It isn't it.

I think that's The thing is, it's really interesting. It's about you're you're you're mixing your normal everyday teaching, you know, uh, knowledge based teaching with transformative learning because I think that's what it is you're trying to transform their worldview and. And it's it's interesting. I was only talking to a Chinese last weeks and she's. I want more work, you know, sessions on liver function tests and and cardiac stuff. And I understand that she's very pragmatic and she's a brilliant doctor and she's very devoted to The thing is the scheme where sometimes we do more transformative type stuff and some people and you know. Different people react to it in different ways, but I think in general we've we've got. Responses to it.

I mean, just imagine if you know the state of training across a whole country was similar schemes, maybe not always tailored to specific services such as homelessness really, but to kind of teach primary care with. That. Mindset would be would be massive, really, wouldn't it?

Well, see, I I think it's interesting. I think that's sort of the way they developed GP training is it's. Sort of done. On oh, we're producing doctors that can work anywhere. Now I've always said is you need a national curriculum which meets the needs of, you know, the high quality doctors. But you need to develop a local curriculum that addresses the local needs of the community.

So it doesn't matter if it's a well off community, there are local needs there and you know by uh teaching people to address them that locally and you know, so that means people who are going to stay in those areas and most people stay in the areas they're trying to are more geared are more geared up to working in that area.

And again, going back to that idea. I I think we we've medicines become way too biomedical and so as to use those other methods to try and understand, go back to the rich concept of general practise. We're rooted in a community, a member of the community, and we helped people through illness. You know, they didn't necessarily have to have disease. They might have just come in with symptoms that couldn't be.

We couldn't find the cause for loneliness. You know, we don't have to classify loneliness as depression to help them so as to give a much. Your idea of what we workers do as GPS.

And get into the source programme. I just wondered, Austin, you said you'd learn so much from the disability movement and that kind of empowerment agenda. We're not always good in healthcare or the NHS, at least in Wales and England in terms of. Inviting people in to kind of really challenges, you know, whether it be from patient participation groups or to any other kind of way. You know how how do you see us doing that different and involving local people in in what it is that we're doing?

Well, I'm a big fan of of local involvements. I think it's it's really key. And also I think it's a key to get peer workers working. So we're developing peer working programmes and our homeless services. In terms of I have for example in training in terms of disability rights, uh, like the social meds, the model of medicine is such a challenge to the medical model and that transforms the way I see the world. So the social model is basically saying is that, you know the the the medical model of disability is that there's a problem with the person. So you know, they have an impairment and that's.

You know, we have to give them medical services, so a person of wheelchair needs medical services, the social models. Personal wheelchair needs to get buildings that don't have steps in them and needs to get employment opportunities and needs to get training and not rehab. They need training in the normal college and to get all the barriers that prevent them participation in society and that social model has transformed. So for example, people with disabilities now. Would not go into nursing homes where nurses control their lives. They recruit their own personal assistants and train them in how to help them be independent, and that may include nursing duties. But it may include being into the pub or to their work. So I totally agree with you. We need to bring in these other concepts on our Community development, disability rights, social medicine model and traveller's rights and other cultures because they they can challenge our biomedical paradigm. I'm not don't get me wrong, I'm not antibiotics.

Hugely important. Just.

You know, I think we we have overtime developed a restrictive worldview restricted to biomedicine and these.

And a steep hierarchy with it really isn't a I think really that is quite impervious to challenge. OK. Well, Austin, it's been an absolute inspiration talking to you, I I think it's really. Noble and audible, what you've developed over there over the years and thank you so much for sharing it with us today. This was the 4th episode of Community Health and Capital podcast. If you've got any ideas for future podcast, let us know. Thanks to Austin for joining and we look forward to coming together with interview in the weeks to come.

Thanks very much, Johnny.