Establishing GP clinic for marginalised groups in Limerick City
Dr Patrick O’Donnell
View of Limerick city from the St Vincent de Paul Clinic
Profile of the initiative
Name: Partnership for Health Equity (PHE) GP Clinics in Limerick City
Team Members: Dr Patrick O’Donnell
Commenced when: April 2014
Key stakeholders: St Vincent de Paul Drop-in Centre, Ana Liffey Drug Project Mid- West, HSE Homeless Action Team Limerick
Target Population: marginalised groups, those without medical cards or access to GP care, includes homeless people, drug users, migrants and asylum seekers
Funding: PHE (Health Service Executive, North Dublin City GP Training Scheme, University of Limerick Graduate Entry Medical School), Safetynet Ireland, EU RESTORE Project
The needs of marginalised groups in Limerick city
We know from national and international research that those who need healthcare most are least likely to access services that meet their needs. Limerick city is no exception, and access to primary healthcare for marginalised groups is a major issue in 2015. The Irish health system is under severe strain due to economic difficulties and many existing services are lacking the resources to meet the complex needs of marginalised service users e.g. homeless people, migrants, drug users and sex-workers.
The Partnership for Health Equity (PHE) was established in 2012 as a unique collaboration of clinicians, medical educators, social scientists and healthcare policy makers and planners from three organisations: the University of Limerick Graduate Entry Medical School (UL GEMS), the Health Service Executive (HSE) Primary Care and Social Inclusion offices and the North Dublin City General Practice Training scheme. This partnership focuses on a number of interrelated research, education and health service delivery projects. In this article I will describe one part of the service delivery work we do; the PHE GP clinics in Limerick city.
Firstly, a stakeholder consultation was carried out in Limerick city to inform the development of the planned clinic. The purpose of this was to consult all interested parties about gaps in existing services provided to marginalised groups. This took place from October to December 2013 and involved speaking to many people from marginalised groups, their families and the voluntary and statutory agencies in the city. We found that:
Many vulnerable people in Limerick city had poor access to basic medical care;
some do not have medical cards and others who do have medical cards face many barriers
to utilising their cards in existing services – Limerick city needed innovative Primary Care services to try to address this problem.
In response to this identified need, we worked with the Ana Liffey Drug Project Mid-West Service and the St Vincent dePaul Drop-in Centre in the city to come up with a way to improve basic primary care for marginalised groups. Both Ana Liffey and St Vincent dePaul have a history of advocacy and case working for vulnerable clients nationally, and in the Limerick area. The drop-in centre provides meals, washing facilities and advice on social and housing issues to many clients on a daily basis. Ana Liffey work closely with drug users in the city using the principles of harm reduction to assist clients to access drug treatment services and stabilise their lives. Each of these organisations now hosts a GP clinic one afternoon a week. These clinics were launched by the Mayor of Limerick Councillor Kathleen Leddin on April 4th 2014.
The clinic has been developed with the support of the Safetynet Primary Care Network. Safetynet provides support for doctors, nurses and voluntary agencies that provide primary health care to homeless people and other marginalised groups across the country. Safetynet has an online patient record system that means records for previous medical visits to affiliated services in Dublin or Cork are available at the time of consultation in Limerick. The clinic also relies on close working relationships with a number of key local statutory agencies and NGOs that work to improve the health and wellbeing of marginalised groups in the city (see box below). Collaboration with a variety of agencies and disciplines is necessary to try and begin to address the complex social and healthcare needs of the clients using the clinic.
Work to date
In the first ten months of clinical work over 180 patients have attended for over 400 consultations. The most common issues presenting are linked to intravenous drug use, benzodiazepine addiction and mental health problems. Blood borne virus testing, STI testing, Hepatitis A, B and influenza vaccination are all available. The clinics operate a low-threshold approach to care; meaning that a people are not denied access to the clinic, no matter how chaotic their situation is.
There is also flexibility around the clinic work in that it allows me to make calls to homeless hostels in the city if needed. Every effort is made to encourage the patients I see to apply for a medical card with a GP in the city, as engaging with mainstream primary care is crucial for the ongoing management of the health of these patients. The figure below from the European Monitoring Centre for Drugs and Drug Addiction (2011) highlights many of the values that we try to reflect in the work of the clinic.
Outcomes and impact
Many local services are now referring patients to the clinic and, most importantly, many patients are attending having heard of the clinic from other marginalised patients. The clinic has led to closer cooperation between many of the NGO and statutory services operating in the city. For example St Vincent de Paul and Ana Liffey have now share some staff training on issues of mutual interest, the HSE Limerick Drug Service now conducts a mobile needle exchange with Ana Liffey staff during one of the clinics, the HSE Homeless Action Team nurse will often follow up with visits to patients living in homeless hostels that I see in the clinic, and others.
Plans for the future
With any initiative like this when you start to address some gaps, you will always discover others. One possible avenue would be an evening clinic once a month for sex-workers in the city. Having engaged with NGOs who work specifically with this group, there is definitely a need for basic healthcare but the opening hours and possible language barriers currently act as a disincentive to attend. The PHE team at UL GEMS are in the process of arranging for medical students to sit-in on the clinics to try to learn more about caring for these marginalised groups.
For further information contact: Dr Patrick O'Donnell Patrick.E.ODonnell@ul.ie
The PHE Limerick clinics have been running for almost two years now and the Graduate Entry Medical School at UL recently published a short video describing the work that goes on there.
The video highlights the collaborative approach taken to running this low-threshold service.
Partnership for Health Equity Pilot Clinic Launch, April 4th 2014. Rachel Conway, Ana Liffey Drug Project.
Partnership for Health Equity Pilot Clinic Launch, April 4th 2014. Tom Flynn, St Vincent de Paul Drop-in Centre
News & Views
Examples of local services engaged with
Activity to date (02/04/14 – 05/02/2015)
Partnership for Health Equity Pilot Clinic Launch, April 4th 2014. L to R: Dr Patrick O’Donnell, UL GEMS; Diane Nurse, HSE Social Inclusion; Prof Anne MacFarlane, UL GEMS; Councillor Kathleen Leddin, Mayor of Limerick; Tony Quilty, HSE Social Inclusion.