RCPI Public Meeting Calls for Action on Inclusive Healthcare

"The gift I was given growing up poor is to challenge."

Professor Katriona O’Sullivan, author of the gripping Memoir Poor, has spent a lifetime challenging – challenging authority, challenging expectations, challenging broken systems that lock people out of their basic human rights.

Now an international, award-winning author and academic, Professor O’Sullivan’s powerful address at the RCPI Public Meeting – Every Voice, Every Body: Advancing Inclusive Healthcare – on Wednesday, 15 October, was a call to action to challenge and act upon the disadvantage inherent in our healthcare system.

Driven by a sense of responsibility to write her memoir Poor, Professor O’Sullivan reflected on the people who believed in her and the services she was able to access in Celtic Tiger Ireland in the late ‘90s.

She said: “Excellence is everywhere, but opportunity is not. I had some really inspiring people around me in childhood, and then I came to Ireland at a time when we were investing in poor people."

“Somebody saw and somebody helped – that is a theme throughout the book,” she said, insisting that she has “a lot of fractures” in her foundation, and was fortunate to be able to access the supports she needed.

Professor O’Sullivan spoke of being able to access services, treatment, mental health supports, housing and health, quickly and free of charge.

“Importantly,” she said, “these supports were not dependent on me being good or well behaved.”

Healthcare leaders – Mr Paul Merrigan, Dr Aoibhinn Walsh and Professor Brendan Kelly joined Professor O’Sullivan on stage for a panel discussion on inclusion healthcare, chaired by Dr Diarmuid O’Shea, RCPI President.

“The change happens when we reflect on why we see people in a certain way.”
 Mr Paul Merrigan

Mr Merrigan is the Person-Centred Addiction Lead in the first of its kind in Ireland Inclusion Health Team at St James’s Hospital. Drawing on his own lived experience with drug addiction, the social care system, and homelessness, Mr Merrigan supports vulnerable and marginalised patients, putting the care firmly at the centre of healthcare. His work uses a trauma-informed approach and advocates for equality of care. 

The inclusion health team focuses on psychosocial stressors, looking at the individual needs of the patient because as Mr Merrigan says, “one size doesn't fit all”. Many of the patients he sees have already been stigmatised and excluded from services because they don't tick the right boxes. 

He said: " I see what our patients are up against. People are treated differently because they don’t look the same, sound the same, and sometimes don’t smell the same as the patient in the bed beside them.  A patient might come in with nothing on their feet, so the first thing we do is go and get them a pair of runners. Our system needs to change to address the social needs of our patients."

In her address, Professor O’Sullivan explored the concept of success and how we measure success. “Sometimes,” she said, “it’s important to make people feel better – we shouldn’t just be focused on the final outcome.”

Mr Merrigan plays a key role in educating the doctors and nurses who rotate through the inclusion health team, supporting them to understand the needs of the individual patients and the challenges they face just to be there.

“When I see a trainee doctor or nurse come in, it’s like a blank canvas. Many of them wouldn’t have seen poverty or addiction.  I have an opportunity to show them.”  

Mr Merrigan also collaborates with established consultants to best support all patients who come through the doors of St James’s.  He said: “The education for me is about broadening the horizon of a doctor. The change happens when we reflect on why we see people in a certain way”.

Professor Brendan Kelly, Consultant Psychiatrist and RCPI Dun’s Librarian, echoed the importance of practical on-the-job education. Reflecting on his own first night on call at St James’s in 1999, he said: “My very first patient was a young man. He was just out of prison. He was homeless. He was addicted to multiple substances. He was HIV positive. I had never in my whole life seen anyone like this before. I had never even known this existed...I remember talking through his world with him, talking through mine. I didn’t know his world existed, and he didn’t know my world existed...His was a world of complete exclusion. I don’t think any amount of education in the classroom can match the gut punch I received that night.”

Professor O’Sullivan said that medical education has a key role to play. “[We need] Education that teaches people about inclusion – why people don’t “behave themselves”, don’t act the right way. Ethics in medicine and medical education is vital.”

The panel agreed that educating doctors on social barriers to care, trauma, and societal biases can improve awareness, skills and compassion, and is critical to advancing inclusion healthcare.

“The system is the issue, and what saved me were the people.”
Professor Katriona O’Sullivan

Dr Clíona Ni Cheallaigh, who leads the inclusion health team at St James’s, spoke from the audience about the basic human right to healthcare.

“If you walk in the doors of the hospital and you’re met with disgust, distain or judgement you’re not having your right to healthcare met,” she said.

“We need to change who is in the positions of power – someone like Paul [Merrigan] is so important to have there in a position of power and respect, to show the lads that they are respected and have a place there.”

Dr Aoibhinn Walsh, Consultant Paediatrician working in inclusion health, is an advocate for her patients and their families and argues that doctors have a responsibility beyond the medicine.

Many children and their families are not able to access healthcare – their basic human right – for a variety of reasons, from housing instability to familial addiction issues, language barriers or access to the right appointment at the right time.

 "'Did Not Attend' does not mean 'Does Not Need Care'."
Dr Aoibhinn Walsh

“Often the medical part is the easy part,” she continued. Digging deeper to understand the broader issues facing her patients, Dr Walsh said the service to support or treat them either doesn’t exist, isn’t in place, or has three-year waiting list.

“In that case, I don’t discharge the patient because I can be a point of vital continuity,” she said.

Paediatricians provide care at a crucial time in the physical, emotional and social growth of a child, while also working with and supporting their families.

She argued that being able to provide appropriate care for children who are marginalised, for whatever reason, has significant long-term impact on their individual health, their future health outcomes, and therefore impacts their lifetime dependency on the healthcare system.

“We can be really sympathetic to children, but that changes once they turn 18 – there is an othering and they become the problem.”

Professor O’Sullivan agreed: “My book is a call that we should not let people get to a point in adulthood where they are fractured, and they need to be really supported by the system.”

“The risk is that we see the systemic issues as too big,”
Professor Brendan Kelly

"We work within systems that are imperfect," Professor Kelly said. “We need to tell ourselves that our success will be partial. We can have a profound difference on an individual, but we can also slowly push to turn the big ship.”

Echoing Professor O’Sullivan’s urging not to look away, Professor Kelly continued: “A small thing can be a transformative thing, but also we have to have the strength to address the systemic issue.”

Dr Walsh discussed the importance of open dialogue to educate and inform change. “Creating spaces like this to openly discuss the barriers to care not only helps doctors to better understand their diverse patient base at an individual level but also helps the healthcare community to identify the systemic barriers to care.”

The panel agreed there are compelling moral arguments and economic arguments for improved healthcare that addresses the needs of marginalised communities and individuals.

Mr Merrigan shared his experience of watching young mothers die in addiction while on waiting lists. He said: “Their child then goes into care, and then we [in the Inclusion Health Team] take on the care of that individual – generational trauma is still being handed down.”

“We need to invest in the things we have stopped investing in,” Professor O’Sullivan said. “If I asked for help today, the services are gone, the grants are cut, or there is a significant waiting list.”

“When I got educated, my cognitive abilities changed,” Professor O’Sullivan said. “I wasn’t able to reflect – when my mind opened, I realised all these educated people have this gift and now look away - you’re destining people to die. By investing in people at a younger age, we are saving the government millions.”

"I need you to understand very clearly that poverty is a destiny,"
Professor Katriona O’Sullivan

Professor O’Sullivan shared five lessons for the audience to take away and reflect on.

Lesson 1: If you are working with people like me, educate yourself on poverty and adjust yourself for poor people.

Lesson 2: Always believe in a person’s ability to achieve excellence. Do not make it based on how they act.

Lesson 3: Go the extra mile for people and let them see you do it.

Lesson 4: Tell people they are good. Tell them they are amazing and tell them often.

Lesson 5: One bad teacher. All bad teachers. One bad doctor. All bad doctors.

“We’re so good at silence.

“We’re all responsible for making things fairer.”