Family doctor, social entrepreneur, international sailor, teacher, cyclist, radical activist.
Dr Austin O Carroll is an inner-city GP in Dublin since 1997. The focus of his career has been improving access for communities affected by marginalization or deprivation to quality primary healthcare.
He completed a Doctorate in ethnographic research into the health service usage behaviours of homeless people. He was a co-founding member of Northdoc. He received the Fiona Bradley Award; the Time & Tide Award for his work with migrants; the Healthcare professional of the Year Award 2015 and was awarded an Honorary membership of the RCPI the Doolin Award 2019; and Gertrude Ronan Award 2019. He was awarded the 5 Star Doctor Award from Wonca Europe in 2020. He participated in the 2016 Paralympics in sailing.
Among his many achievements, Austin has founded several initiatives:
Safetynet (2007) which provides GP services to over 6000 marginalized patients annually throughout Ireland. He initiated specialised services in several food halls/drop-ins/hostels; GP services for Roma community in two medical centres; a Mobile Health Unit for rough sleepers; a Mobile Health Screening Unit; He was Medical Director from 2007-2017.
GMQ, a primary care programme for homeless people which also specialises in addiction services (including methadone treatment and alcohol and benzodiazepine detoxes.
Partnership for Health Equity, a research, education, policy and service delivery collaboration.
GPCareforAll, a new social enterprise that creates new GP practices in areas of deprivation.
North Dublin City GP Training programme, the first programme internationally that trains GP’s to work in communities affected by deprivation or marginalization.
He set up the GP service for the McVerry Stabilization Centre in Barrymore House.
He was Dublin HSE Covid Lead for the Homeless Population between 2020 and 2022.
“…we have developed a health service that’s been designed for middle class people, who have routines in their lives, who are able to keep appointments, who are able to assert themselves in middle class ways that won’t get them kicked out, who value their health and who have hope of a future that they are looking forward. Therefore, that service we designed is for them because we know they will use our service. But that service isn’t designed for homeless people.”
Watch the video, listen to the podcast, read the transcript below
Discussing PhD at HRB Research meeting in Galway
How do you describe Austin? He’s a Family Doctor, a social entrepreneur, international sailor, teacher, cyclist, radical activist. But, actually, Austin you very nearly didn’t become a doctor. Tell us about that.
Austin O’Carroll. My background is that I was born with a disability. I have Thalidomide. My mother, interestingly, only took one tablet but one tablet was enough to cause a significant amount of destruction. So, I have a disability and I spent a lot of my time in hospital as a child. My disability affects my legs for walking and also my thumb. I’ve only a very rudimentary thumb so that affects my ability to use my hands. I decided I wanted to do medicine early on and, in fact, what I did was that I went to my own surgeon, and got advice from several doctors, and they all advised me that I wouldn’t be able to do medicine. First of all they said there’s a lot of walking involved in terms of going around hospitals but then, more importantly, they said they felt that because of my hands I wouldn’t be able to take bloods or to do put in IVs. So, I took it on the chin at the time and I decided to do law instead.
I went to Trinity College and in my first year in college I had the privilege of having Mary Robinson as my tutor and, in the second year she left and I was transferred to Mary McAleese. Both of them subsequently became Presidents of Ireland. Mary Robinson became President of Ireland and then she became the UN High Commissioner for Refugees and she’s the lead for the Council of the Elderly, the International Council of the Elderly. She’s a well recognized International player. And Mary McAleese is this wonderful woman who also went on to become President of Ireland.
What actually happened is that I was doing law and I fancied this girl who was doing medicine in a different college. We went traveling on our summer holidays and, as you do, you often end up together as a group and I happened to end up in the same group as this girl I fancied. I was in southern Italy, down below Sorrento, on the coast. I remember one very romantic evening, sitting outside on the edge of a cliff with her, overlooking the Mediterranean as the sun set. Unfortunately, nothing romantic happened, except that she said she thought it was ridiculous that I didn’t do medicine. So, I got on the train the next day went straight back to Dublin, went to Mary McAleese, and a week later I was standing in front of a group of men in a room showing them my hands and legs, and two days later I was in medicine.
Outside Trinity is one of the poorest areas in Dublin and I got very involved with youth work. In summers I ended working in playgrounds in the inner city and during the year we would bring kids out, got involved in also visiting old folk in their homes. … in a way, that set the template for where I was going to go for the rest of my career.
“she said she thought it was ridiculous that I didn’t do medicine. So, I got on the train the next day went straight back to Dublin, went to Mary McAleese, and a week later I was standing in front of a group of men in a room showing them my hands and legs, and two days later I was in medicine.”
From Tommy Tiernan Show on RTE
From Mental Health in Ireland.
DMacA: During your medical school time you became very socially active. You were involved in a lot of organizations…
AOC: In the two years I did law actually, that’s where I got involved. I always say I had two educations in college, one inside the walls of Trinity. Trinity is built with walls around it and it’s based on the concept of an island of learning, a haven of learning, within the toil and muck of the city. Outside Trinity is one of the poorest areas in Dublin and I got very involved with youth work. In summers I ended working in playgrounds in the inner city and during the year we would bring kids out, got involved in also visiting old folk in their homes. We used to do tutorials with people, local kids, visited work with people with disabilities and organizations. So, I got very involved in that type of work and I suppose that education was as important as my medical education because, in a way, that set the template for where I was going to go for the rest of my career.
DMacA: Lets fast- track on a little bit… the rest of your career is spent in inner city Dublin?
AOC: Yes, well, there’s a little interim which is interesting. When I was in Trinity and working with the Vincent de Paul, a fantastic organization, a charity, I learned the charitable approach. It was an interesting group because we did do things, for example, we brought people with disability in to show how inaccessible Trinity College was. We also ran an open day for the local community because, really interesting, while the local community walk all around Trinity, they never go inside the walls, even though it’s free access for everyone.
And then in the ’90s I got involved with disability activism. I went in with a slightly pompous attitude thinking that – ‘oh listen I’m a successful person with disability I’ve got plenty to teach’. In fact, I did more learning, much more learning, than teaching. Because I learned about the reality of what it was to be a person with a disability. But I also learned about a totally different approach which was the rights based approach and the complexity of a rights based approach. While I have great respect for people in charities, I founded two charities, still work in them, and I have great respect for people who come from that perspective. Ultimately, a charitable approach is about keeping people in the same position, it’s not about liberation or getting people out of that position. So, you go and you help them survive but, in a way, you’re not changing the system, you’re just helping people survive within the present system. A rights based approach is about change in the system and that probably defined my approach to health care from then on.
Then in 1997 I managed to get a GP practice in the inner city. Just to give you a flavour of what it was like – when I first started in the inner city, it was like shock therapy. I never realized how the drugs plague from the 80s had affected inner city Dublin. I ended up meeting families who had lost three or four kids to drugs. In my first four years I was attending a funeral at least once a month of a young person. I faced aggression on a daily basis from people looking for drugs. In fact, it was ironic that the aggression was so intense that I found myself, after six months, I’d have to take Valium at the weekend to relax down again because I’d be so stressed out by it.
“Outside Trinity is one of the poorest areas in Dublin and I got very involved with youth work. In summers I ended working in playgrounds in the inner city and during the year we would bring kids out, got involved in also visiting old folk in their homes. … in a way, that set the template for where I was going to go for the rest of my career”
From Tommy Tiernan Show on RTE
From Mental Health in Ireland.
DMacA: You’ve dealt very much with people on the margins of healthcare, people that other doctors shy away from, run away from, but you’ve tried to bring this mainstream and you’ve brought on a whole generation of people who are involved in healthcare on the margins. Tell us about that work.
AOC: I think that came from originally, as I said, a rights based approach. When I first started the practice I decided that we would take a vision, that vision being that we wanted everyone to have equal access to healthcare and we’d have a practice mission. It was just me and one receptionist. So, the mission was that we would provide healthcare to everyone irrespective of background and, as part of that, we decided that we would try and not bar people.
As I said, all those people were coming in, quite aggressive, and we actually managed to get them off ‘benzos’ without losing them as patients. So, from early on, we had this idea of trying to manage and I’ve since learned the whole theory of adverse childhood events and trauma informed care and, in a way, that’s what we were trying to do- not to lose the people who we felt were most disenfranchised. Because the people who you bar from practice are the ones who are most likely to end up dead while young and have significant healthcare needs.
What happened then, I suppose, was that I got a reputation for working in that area. They were setting up clinics for initially for migrants and I got involved in providing clinics for migrants. And then I got involved when setting up clinics for homeless people. They needed a clinic for homeless people in inner city Dublin and basically I started one in city centre Dublin and we’ve around 40 or so now around Dublin, and around others in Cork, Limerick, and Galway. So that was the start. Basically, what happened was that we started one clinic. Then they asked us for a second clinic, and a third clinic. Then I realized that there were all these different clinics providing services to homeless people but they were not connected so a homeless person could walk into my clinic one day and ask for certain drugs, go into another doctor the next day and get either the same drugs or different drugs that would interfere. So the first thing we did was that we set up a common database so that we could all see that if a patient goes into one clinic this is what they get and, then when they come to my clinic, I’m able to prescribe consistently with that. And that allowed us to do long-term care.
Once we got that running, we also decided to set up an organization to try and bring common protocols and procedures. We set up ‘Safety Net’ and that united all these clinics. Safety Net was then able to develop services where we felt there was gaps. So, for example, we developed all these drop-in services and we brought these services to hostels where homeless people were. Then, we realised that there was no service for rough sleepers so, we founded a mobile health unit for rough sleepers. Then, we saw that there was a lot of infectious diseases and we knew colleagues in the UK who were doing TB screening and bloodborne virus screening, so we brought them over once a year. Then, we realized that there was a lot of homeless people who were addicted to drugs and couldn’t get access to care so we developed an opioid substitution treatment and that expanded to provide benzodiazepine treatment and community alcohol detox.
We also now have two stabilization centres. We then developed a model for a step-up, step-down centre, and Intermediate Care Centre that’s been developed. Other things happened. People noticed there were a lot of Roma here, and because our services started to take Roma and we were using translators, we then had an expertise to provide the service to Roma, so then we provided a clinic for Roma. Then we saw there were a lot of non-documented migrants who couldn’t access health care so we provided that. Everything just mushroomed and now we have this quite extensive network for marginalized people in Dublin and across Ireland.
“Ultimately, a charitable approach is about keeping people in the same position, it’s not about liberation or getting people out of that position. So, you go and you help them survive but, in a way, you’re not changing the system, you’re just helping people survive within the present system. A rights based approach is about change in the system and that probably defined my approach to health care from then on.”
From Tommy Tiernan Show on RTE
Discussing the Special ICGP programme for teaching GP Trainees
DMacA: Let me bring you back to the homeless people because one of my favourite quotations is when you say “who ever thought it was a good idea to post out appointments to homeless people?” You developed all these services but it’s not just this development work because you did the PhD as well. Tell us about your PhD.
AOC: When I was developing these programs I learned that, when you’re developing proposals, you need to come from an evidence base and I felt that it would really augment my ability to develop proposals and develop services if I had this academic background. And, the second thing was that I also enjoyed research. I’m one of those people who thought I was terrible at research at college but then I discovered that it was all about finding what you want to research. And when I found out something I wanted to research, I found it really interesting. I got involved in research and then I found I’m more naturally a qualitative researcher than a quantitative researcher so I chose the area of exploring why homeless people don’t use health services and that was really relevant to my work. And it’s really interesting because, when you do a PhD you become a world expert in a very small area. And, obviously, because it was so central to what I did, a lot of it guided my work subsequently. But, it also gave me the ability to write good proposals when I was looking for further funding for other services, and you get the reputation as being an expert in the area. So, on several fronts it’s so well worth doing.
I did an ethnographic exploration of why homeless people don’t use health services. I’d sit out in the streets with rough sleepers, I’d sit in Drop-In centres, I’d sit in food halls and, what I found was, that homeless people don’t use Health Service in the way that everyone does. They wait. I saw someone last week who had a groin abscess that needed to be incised. I’ll say you need to go to the hospital and they say “oh I’ll be fine, I’ll be fine, just give me some antibiotics, I’ll be fine”. So, they’ll wait till they’re absolutely almost out on their legs, before they go into the hospital. Secondly, they’ll often default from treatment, they leave hospital before they’ve completed treatment, they leave the waiting room in the Emergency Department before they’re seen, they don’t keep hospital appointments. And, thirdly, they don’t attend GPs at all, they avoid general practice. They tend to be high users of Emergency Departments as a result and they tend to avoid Psychiatric Services. So, I wanted to understand why- when you consider they’re the sickest population you can think of and we know their mortality rates are far higher.
We know that in Dublin, for example, one in 20 have HIV, one in 20 have HepB, one in three have HepC, and they have very high rates of COPD, diabetes, and for the normal illnesses that are in the community, they have higher rates than everyone else. Of mental health problems, one in two has depression, two out of five have anxiety and, to show you the level, we know with depression that one in three in Dublin have attempted suicide at some stage in their lives, and one in five in the last six months. This is a really sick population who they don’t use Health Services. Why not?
I found what I called the external barriers and internalized barriers. Of external barriers, there are four different types. There were physical barriers and the obvious barrier was distance. You may have access to a GP but if your GP is five miles away and you don’t have bus fare you can’t get to it, and you may have a GP down the country but it’s way too far to get to. Then, administrative barriers, and the obvious one is appointments. I’m thinking of writing an article called four most stupid things in medicine, and the most stupid thing in medicine is going to be sending out appointments to homeless people because one, they don’t get the letters and two, even if they get the letters their lives are chaotic, they don’t have regular lifestyles, they don’t have diaries, they don’t have a regular routine to their day, they don’t have access to buses, to cars, to get to their appointments. It just doesn’t work. The third administrative barrier is forms. I always say that if you want a homeless person not to use your service, get them to fill in a form and, if you really don’t want them to use it, make that form as complex as possible. To access free primary health care in Ireland you have to go through a really complex form so it’s not surprising that 40% of homeless people have never filled out this form. A further administrative barrier was having to have strict rules. Now I understand having rules for safety but, the problem is that when you apply strict rules strictly to a population where rules were enforced with stick and fist when they were kids, they’re going to react the way they’ve learned as kids, through shouting, aggression etc. So it’s going to be no surprise that they get kicked out of the service or they’re excluded. Stigma was probably the biggest barrier.
The internalized barriers are barriers where you internalize external things. If you internalize stigma, it means you think that I’m not going to be treated if I go to that service so I won’t go. Some people internalize the idea that they’re going to die young so, what’s the point in taking care of their health. I call that a fatalistic cognition and, why do you think you’re going to die young? Because you see lots of young people dying, and lots of people do die in homelessness. Some people have a denial cognition saying, ” I’m going to be fine” and I think that comes from the idea that in homelessness, to survive homelessness, you need to be in denial because if you were to literally absorb the fact that you’ve been so abandoned by your family and society it would overwhelm you. A good way to survive homelessness is denial but it’s not a good way to manage your health. So, with all these things, I concluded basically that we have developed a health service that’s been designed for middle class people, who have routines in their lives, who are able to keep appointments, who are able to assert themselves in middle class ways that won’t get them kicked out, who value their health and who have hope of a future that they are looking forward. Therefore, that service we designed is for them because we know they will use our service. But that service isn’t designed for homeless people.
That work and that PhD transformed the way I understand our services, and the way we’re developing our services, and helped guide the directions for a lot of them.
“…, that’s what we were trying to do- not to lose the people who we felt were most disenfranchised. Because the people who you bar from practice are the ones who are most likely to end up dead while young and have significant healthcare needs.”
From Tommy Tiernan Show on RTE
DMacA: You have talked about so many different other people and how you’ve cared for so many other people, but I’d like to ask you about how you care for yourself…
AOC: I do work intensively but also, I’ve always been able to say that, if I finish at six o’clock, I’m finished. And I take time off, and I’m good at separating out. That’s the first thing. But then I go cycling a lot. There’s two parts to that. One is self care in terms of, I just love it. And two, it’s very good for your mental health. But three, because of my disability. Around 10 years ago, I thought I was going to be in a wheelchair by now because my walking had reduced from three miles when I was 21, to literally 50 yards, and I’d have to stop even in that 50 yards because of pain in my legs. So I lost 20 kg weight over a year and then intensively exercised. I started cycling a lot. The other one I started do, and it was great, was silent disco. I need to do impact exercise to prevent osteoporosis and someone said that dancing is great for impact. So, I go down twice a week with my cycling tights on, and I don’t wear a top, and I tell my kids don’t bring your friends in because you’ll be embarrassed. I put on my earphones and I do 40 minutes of silent disco. I can now walk up to 3K and so it’s hugely transformed me. I do all that. I love that. I go out and socialize. So, all those things are self care.
You mentioned the sailing. I just had an opportunity. I used to sail a lot years ago. I used to race a lot, but I got away from it. There was a disabled sailing competition in Ireland and they were short of a sailor. I ended up going on it and then ended up with someone saying “Oh listen, we’re looking for someone to do the Paralympics, will you do join us” I ended up doing Rio 2016 in the Paralympics Sailing which was an amazing experience. I’ve been okay about taking care of myself. Don’t worry. Life is good and I enjoy it.
DMacA: Austin, you’re a star. An Olympian, a family doctor, a role model for all of us. But, I thought we were going to have an exclusive interview this morning but you cheated on me because, you were on prime time national television on Saturday night! It’s been a fantastic pleasure talking to you. Thank you very much indeed, as always.
