Fiona O’Reilly has a handy phrase for describing her career in healthcare: “I like working in areas where most people don’t,” she says, simply. As Chief Executive Officer of Safetynet Primary Care, a Dublin-based medical charity that delivers free quality care to marginalised people in society, Fiona is right at the frontline of the health service in Ireland.
On a typical day, Safetynet’s patients include homeless people, drug users, migrants and displaced people, and members of the Traveller and Roma communities. Unlike clinic-based colleagues, the Safetynet medical staff see patients in hostels and emergency accommodation, at open-access clinics and even in a kitted-out truck that includes consultation rooms and a mobile chest X-ray.
“Thankfully, the people who are attracted to work at Safetynet are a bit like me – they won’t be happy if they’re not at the very front of the frontline,” says Fiona. “It’s exciting and it’s challenging.”
Fiona trained as a general and paediatric nurse against the backdrop of famine in Ethiopia and elsewhere. “I wanted to go overseas and change the world,” she recalls. “I was affronted by the injustices in the world and wanted to put some of my effort into making it a more just place.”
A year after qualifying, she went overseas and worked in humanitarian crisis zones for about five years. She worked primarily in Sudan, Ethiopia and Somalia, and also spent time in Zambia and Afghanistan. Engaged mainly on food and nutrition issues, Fiona found there was often a gap between the theory and practice of helping people, a recurring theme in her work.
“Everyone goes out to do their best but I found myself in situations going ‘what do you do here?’ For example, we know that breastfeeding is best but what if the mother has been shot?”
Returning home, she spent some time working with the World Health Organisation (WHO) and its subcommittee on nutrition. She also did a Master’s in Community Health at Trinity College Dublin and established a campus company, the Emergency Nutrition Network, in 1997. She spent seven years with the venture, which focuses on building institutional memory among NGOs on issues around food insecurity and malnutrition. It still exists as a charity based in Oxford in the UK.
After starting a family and opting not to go overseas again, Fiona began a PhD looking at the problems of inequality in Ireland, including homelessness and drug use. She worked with Dr Austin O’Carroll, who had set up Safetynet Ireland in 2009 to help connect medics and other professionals working with homeless people in a more coordinated way.
“I could see that the system didn’t really work for homeless people and people on the margins,” says Fiona. “They don’t have one care provider; you go there for your drug problem, you go there for your diabetes, you go there to see the public health nurse. Having one system was obviously seen as a benefit.”
In 2016, Safetynet changed its name and mandate to become Safetynet Primary Care, a primary healthcare provider, and Fiona became its first chief executive. She was the only employee of the charity, which now has 50 employees – including doctors, nurses and support staff – and a multimillion euro annual budget, funded predominantly by the HSE.
Safetynet quickly established its Homeless Primary Care Team with an inreach/outreach model, operating clinics in homeless accommodation and also using mobile services to reach people on the street. The Mobile Health and Screening Unit, manned by GP trainees, was boosted by the donation of a medically-equipped truck from a UK service, Find & Treat. The first nurse that Fiona employed, Sinead Grogan, is still with Safetynet, running the mobile health unit.
Since its inception, the organisation has used an electronic patient record system from Dublin-headquartered Clanwilliam – previously known as Helix Health. Having centralised records for its cohort of transient patients meant that clinical staff had up-to-date information and reduced the risk of duplicate prescribing, says Fiona.
Safetynet’s other early priorities included a response to the Syrian crisis, when Ireland took in about 4,000 Syrian refugees, mainly to provincial or rural towns. Safetynet was funded by the HSE National Social Inclusion Office to provide on-the-ground health checks to the new arrivals and progress them into mainstream health services.
“We’re always looking for the gaps between what the health system provides and what’s required on the ground,” says Fiona. “The idea is that we go in and provide something within that gap. Then the services develop and pick that up – and we go and do something else.”
Safetynet got its first premises – a former health centre in Summerhill, Dublin – in 2019, allowing it to establish an Inclusion Health Hub that patients can visit. It now runs open access clinics in several locations in Dublin, as well as providing medical staff and resources to a Step Up Step Down facility operated by Dublin Simon Community for people post-hospital discharge.
“That’s for people who are too sick to be in hostels but not sick enough for hospital,” Fiona explains. “The Americans call them ‘hoptels’, a cross between a hospital and a hostel.”
The Covid-19 pandemic was a challenging time for Safetynet, given the danger of the disease in congregated settings such as homeless hotels and halting sites. “The whole advice for the population was ‘go to your room and isolate’. What if you don’t have a room?” Fiona asks.
Safetynet set up a Covid rapid response unit, including a freephone number for hostels to call if they had residents with symptoms. After phone triage, doctors were dispatched to test the individual. Typically tenacious, Fiona got her hands on a GeneXpert machine to give rapid results of Covid PCR tests. “That speed of identifying [Covid] and isolating meant we could stop the spread,” she says.
The Safetynet staff had barely taken a breath after Covid when Russia invaded Ukraine, prompting over 100,000 Ukrainians to flee to Ireland. The charity was drafted in to provide primary care clinics on-site at emergency accommodation and the national transit hub. Safetynet still works closely with International Protection Accommodation Services (IPAS), which offers accommodation and other services to people in the asylum process.
During an unexpected freezing weather event in Dublin earlier this year, it was Fiona and her colleagues at Safetynet – working in conjunction with IPAS and the HSE – who got 150 people out of tents and into temporary accommodation. “I hired the coaches because the Department couldn’t get any transport,” she says. “It was like being back in Africa.”
While Safetynet is funded to provide primary care services, service provision is just one of its pillars, alongside network, advocacy and research, Fiona points out. “First you provide the services. Then you look critically at what you’re doing, and that goes into research. Then you find out what works best, and that goes into the advocacy.”
The charity counts ‘innovation’ as one of its values and Fiona says its relatively small size allows it to be agile and try new things. Its patient services are anchored by Clanwilliam’s Socrates web-based medical record system, with licences donated to the charity. The system manages detailed patient records that can be accessed even by staff on the mobile units.
“The record follows the person,” explains Fiona. “During Covid, we were moving people all over the place, in and out of isolation, and the doctor could still get in and see their charts and medical history. It’s actually very rare that we meet someone who isn’t on the system already.”
This year, Safetynet is getting a new premises in central Dublin that can house all its staff under one roof, marking the next phase of its development. Fiona, who is preparing to move on from the charity after seven years at the helm, says that resources and infrastructure, whether physical or technical, are critical for its future resilience.
“The type of infrastructure that Socrates has given us, for example, means we’re able to provide not just healthcare for people on the margins, but quality healthcare. It’s not poor care for poor people. It’s the best care for those who need it most.”
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