Healthcare equity – A call to action

A recent RCPI masterclass discussed how to achieve greater equity of access for marginalised communities

“I will believe in you, until you believe in yourself.”

This powerful statement was shared by Mr Paul Merrigan, Case Manager in the Inclusion Health Team in St James’s Hospital, Dublin, during the RCPI’s recent masterclass on healthcare equity.

Hearing this promise from a healthcare worker marked a turning point in Mr Merrigan’s life, a point at which his own self-worth was his greatest barrier to getting the care and support he needed.

“Access to care is about so much more than getting an appointment,” said Prof Trevor Duffy, RCPI Director of Healthcare Leadership, who facilitated the masterclass.

“It was so important to us in designing this masterclass that we brought together the right mix of people to explore the prevailing and complex issue of healthcare equity. In practice, none of us have all the answers. But by working with our colleagues, community, Government agencies, and key workers, we can have a profound impact in addressing the societal and systemic issues of access to care for individuals and for populations.” 

Breaking the cycle

Sharing his lived experience of intergenerational poverty and drug addiction, Mr Merrigan demonstrated how, with the right supports, it is possible to break the cycle. Now an integral part of the Inclusion Health team in St James’s, he works every day with people facing some of the same issues he once did.

Mr Merrigan’s parents were addicted to heroin and he had to be detoxed when he was born. Mr Merrigan was put into State care where he always felt abandoned and rejected. He struggled with school. Treated as a problem, he was continually excluded from the classroom. He left school at 12.

Mr Merrigan reconnected with his mother as a teenager. She was still using.

“She couldn’t show love,” Mr Merrigan explained. “The only way she could show love was to show me how to shoot up.”

Mr Merrigan was stabbed. He was struggling to breathe and his vision was blurry. He knew his life was in danger. He took a bus to the hospital.

“When I got to the hospital, they asked me if I came in an ambulance. I said ‘no’. A taxi? ‘No.’ I thought my life was at risk, but I got public transport to the hospital. I didn’t think my life was worth calling an ambulance.

“People don’t feel they are worthy which is why we have a high death rate in our society. You have to feel you’re worth looking after to care for your own health.

“I have seen in hospitals where people wouldn’t even make eye contact with me. I understand why many people in my situation wouldn’t go in.”

Mr Merrigan’s repeated trauma defined his self-worth, but, with help, he was able to begin believing in himself. He went to college, he is doing his Masters now, and with Inclusion Health he is saving lives.

“Our patients – I call them the lads, because they are no different to me – I try to give them what was given to me when that person told me ‘I will believe in you until you believe in yourself’.”

Dr Clíona Ní Cheallaigh works alongside Mr Merrigan as Clinical Lead of the Inclusion Health Team in St James’s. She explained that many of the patients she sees are afraid of accessing care because of their experiences in the past. Some feel shame and fear, they will be greeted with judgement rather than care and compassion. 

Dr Ní Cheallaigh explained that she learned about the physical consequences of addiction during her medical training, but through her work she has come to understand that the psychological consequences, including stigmatisation and prejudice from healthcare workers, run far deeper. 

“What I’ve really come to appreciate is that when a person presents with an addiction, how suddenly they can change in our eyes from a good and deserving patient to a ‘bad’ person who if they just got their act together… wouldn’t be wasting our time,” she said.

“I think that reflects a lack of emphasis in our education of understanding addiction and what drives it. And systemically, the rules and regulations in hospitals, such as being banned for using drugs – while I understand why that happens – reflect significant barriers to health equity.”

Disadvantages

Dr Ní Cheallaigh and other panelists spoke of how the system disadvantages those already starting from a place of disadvantage. For example, sending an appointment letter in the usual manner to someone who is experiencing housing insecurity or suffers from illiteracy may not be appropriate.

“A lot of suffering we see is preventable,” she said.

Dr Ní Cheallaigh explained how poverty is significantly associated with dying at a younger age. And, when combined with one or more intersecting factors, such as gender, race, sexual orientation, homelessness, and/or addiction, can significantly increase morbidity.

“It’s up to us as a society how easy we make it for people to break out of this cycle of adversity.”

Just as Mr Merrigan described people avoiding eye contact with him and being excluded from class, avoidance has become a way to deal with adversity, but such strategies only exacerbate social exclusion, creating a more entrenched problem.

“The slightest act of kindness or care you give, means so much and it is so important,” said Mr Merrgian.

Dr Aoibhinn Walsh, a Consultant Pediatrician with special interest in inclusion health, reflected on how many of Dr Ní Cheallaigh’s patients are also parents. She explained that it is hard, even with the best supports in place, to be a good parent, admitting to missing a doctor’s appointment for her own child despite having better knowledge than most of the system.

“Our healthcare system needs to be easier to navigate,” Dr Walsh said. “Even trying to navigate the maze of hospital corridors when you’re there for the first time can seem impossible.”

This challenge is even more pronounced for families who aren’t native English speakers.

Migrant families

Dr Walsh works closely with migrant children and their families, a growing group who face significant barriers to accessing appropriate healthcare.

In January 2023, there were 3,431 children registered as homeless in emergency accommodation and 4,096 children with refugee status or seeking international protection in direct provision in Ireland. Inflation rates are consistently high, so more families are struggling with the basics.

“We have to act now to address this growing issue or it will be too late for the families we work with,” she said, explaining how the social determinants of health directly impact clinical care and outcomes.

“When dealing with nutrition and a picky eater, I’m a big advocate for sensory play. But food is expensive and I’m telling people to throw it around. And what about if you’re in a hotel and not your own home – making a mess might not sit very well. We have to be aware of these contexts and ask the tough questions.”

From her experience working with vulnerable families, Dr Walsh shared her ‘playbook’ for trauma-informed care to tackle health equality as more than the provision of healthcare.

Time: It is not only about the medical diagnosis and treatment. It is about asking hard questions, about building a relationship of trust.

Historical context: We have to consider the individual intergenerational context, but also community-based historical contexts; for example, the Roma community have unique and predominantly negative experiences of healthcare.

Education: We are talking about literacy and language, but also numeracy to be able to administer the correct dose, and understanding basic health concepts that we often assume parents and caregivers are familiar with. There is an onus on us to understand what the limitations might be and tailor our questions to this.

Signposting: We need to investigate what supports are available for the problems we uncover and be able to point to freely available local and national or global resources.

Empowerment: Any treatment plan should be flexible and work for the family we’re treating. That could be as simple as providing appointment times that can feasibly fit into an already stretched lifestyle.

Recognition: Working with these children and their families represents an opportunity to break the cycle and recognising they have a right to be involved in the creation of a service designed to suit their needs.

Dr Douglas Hamilton from the National Social Inclusion Office, HSE, brought the public health perspective to the discussion. He drew attention to the unique experiences, environmental factors, and stability once in Ireland for our migrant populations.

“We need to understand the unique challenges of people fleeing war trauma, or civil conflict, for example, in order to understand the potential barriers to care,” Dr Hamilton said.

“How we communicate with these groups is important – what social platforms are they using? How can visuals/graphics support our message with people who do not speak English?”

Healthcare equity requires bespoke and targeted interventions. The HSE has a suite of resources to support cultural awareness and understanding. Such resources can help us to identify the questions we need to ask to identify the challenges or limitations our patients might be facing.

Similarly, the Sláintecare healthy communities programme provides area-based, peer-led approaches, which are evidence-based, to support vulnerable communities in accessing care appropriate to their needs and circumstances.

A multifaceted approach to community healthcare in Ireland is vital in addressing healthcare equity according to Prof Duffy. And, there is important work already underway.

“The RCPI is committed to tackling this huge and growing challenge of healthcare equity, but we need your help,” he said.

To get involved, email policy@rcpi.ie.

This article was produced by the RCPI.