Enhancing Access to Sexual Health Services for Underserved Communities in Salford
Becki Smee 20/9/22
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The Inclusion GP Service
Becki Smee 20/9/22
•
Our aim is to remove barriers to accessing health care; we can register patients
who have no fixed abode with links to Salford. This includes people who are
rough sleeping, sofa surfing, staying in emergency or temporary accommodation
such as hostels, hotels, B&Bs.
•
We do not ask for ID and immigration status does not matter.
•
We offer telephone consultations and face to face appointments in Eccles
Gateway, The Willow Tree surgery in Broughton and Salford Loaves and Fishes
in Pendleton. We will arrange Outreach and engagement visits where needed.
•
On a monthly basis, clinical members of the team join Salford Council Housing
Officers on a morning street walk to engage with rough sleepers bedding down
around the city. This provides opportunity for street engagement and immediate
and necessary street health intervention. It is also a fantastic opportunity to build
relationships with people who may be wary of accessing primary health care and
understand the barriers that people can face
Outreach and Engagement
We have held/hold Outreach sessions in:
•
Loaves and Fishes – flu vaccines, Covid-19 vaccines, wound clinics
•
Mustard Tree – registration opportunities
•
Answer Cancer weekend engagement and Smear clinics
•
Out Of Hospital Accommodation - City Gates – GP Provider
•
Hostels - flu vaccines, Covid-19 vaccines, registration opportunities
•
Women’s centre - flu vaccines, Covid-19 vaccines, registration opportunities
•
Street visits
•
In reach Service – Pathways – Salford Royal
•
Mobile clinic – St John’s ambulance (project now finished)
Becki Smee 20/9/22
MDT/ Partnership working/ holistic approach
A weekly MDT meeting is held to discuss patients and people of concern, it
provides opportunity for wrap around care for individuals. We also work closely
with the following teams:
•
Salford Council RSI/supported tenancies team
•
North Manchester BBV
•
Salford Homeless Mental Health Team
•
St Anne’s Hospice
•
Safeguarding
•
Secondary care
•
Hospital discharge team
•
Loaves and Fishes
•
DePaul charity
•
Mustard Tree
•
GP OOH EPIC
Becki Smee 20/9/22
Why Outreach and Engagement is so important…
Socially excluded people, including people experiencing homelessness, are 10 times
more likely to die early than the general population (Aldridge et al., 2018).
There are multiple barriers that prevent people experiencing homelessness from
accessing the healthcare they need, including inflexible registration and appointment
rules, negative attitudes of staff and competing priorities while surviving on the street
(Burrows et al., 2016; Rae and Rees, 2015). Of the 800 homeless deaths recorded in
the United Kingdom (UK) between October 2017 and March 2019, one third were
caused by treatable conditions (Bureau of Investigative Journalism, 2019)
Becki Smee 20/9/22
The aim of health related outreach/engagement is to bring healthcare directly to
the most underserved people, i.e those that other services fail to reach, and to
connect with hidden populations (Zlotnick et al., 2013; Szeintuch, 2015).
It is an assertive strategy to build relationships with people in their environment
and has been shown to increase engagement with sexual health, substance
misuse and psychological services (Dorney-Smith et al., 2018; Connolly and Joly,
2012).
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…
Becki Smee 20/9/22
Proposal submitted June 2022:
•
Our practice Nurse will be engaging with registered patients weekly on a
Saturday morning as an extra shift. She will initially call the patients and
discuss screening (cervical). The patients will be selected from our
registration process and will be of the appropriate age. She will look at any
previous screening either at our practice or previous practice. She will review
if screening is due or if no screening undertaken she will offer appointments.
•
Appointments will consist of education and health promotion and consent to
have the procedure taken.
Answer Cancer project
Becki Smee 20/9/22
•
She will follow up any results and action accordingly.
•
In order to capture people who may not be registered with a GP or from other
practices she will also offer engagement opportunities at a local charity
community hub where we share part of their premises (Salford Loaves and
Fishes). This would be one afternoon per week where she will offer advice
and education regarding the screening process for both cervical screening
and bowel screening.
•
She will offer verbal and written information to people attending the centre as
required.
•
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…
Becki Smee 20/9/22
Quarterly
progress
report:
Feedback from the
women involved has
included that they feel
more comfortable
coming for smear as
they have had time to
get to know staff and
ask questions. They
feel safer coming to the
surgery at the weekend
as it is quieter and that
they have appreciated
being given time to
digest information and
think about it before
attending appointment
.
Becki Smee 20/9/22
Case Study 1:
•
Married couple
•
Male (48y)
•
Veteran, PTSD, Cirrhosis of the liver, Hep C carrier, history of self-neglect
and rough sleeping
•
Female (47y)
•
Depressed mood, vary weary of strangers, history of self-neglect and
rough sleeping
•
Both victims of financial and domestic abuse by son
Case Studies – Outreach and engagement
Becki Smee 20/9/22
•
Both history of IVDU
•
Both were very cautious of meeting new people and did not want to
attend a surgery however agreed to registering with SPCT Inclusion.
•
Team had no previous medical details
•
Housing support worker chaperoned them to the mobile clinic
•
Couple able to sit with clinician together and discuss medical and
social history without time constraints
•
Both felt comfortable to have a new patient health check and
disclosed IVDU and Hep C diagnosis
•
BBV team on hand to support with neck bloods and referral into their
care – no time delay
Becki Smee 20/9/22
•
Referral to Achieve with support of Outreach worker
•
Partnership working with Protect team included further mobile
clinic and home visits before both attended surgery site
•
Prescriptions maintained with support
•
He completed Hep C treatment
•
Extra support given from BBV and St Anne’s Hospice in
regards to living with a chronic disease
•
She has gained weight and now more willing to attend
appointments and discuss health including menopause
•
Both maintained temporary accommodation and the plan is for
own tenancy to be assigned
Becki Smee 20/9/22
•
Male (71y)
•
Patient originally under mainstream GP care however due to temporary
accommodation was moved out of area and asked to re-register
elsewhere
•
HIV positive, undetectable load so deemed moderate risk for Covid-19
•
3 telephone appointments made and all 3 DNA
•
Picked up by Inclusion Service as more appropriate GP provider
•
Presented at Loaves and Fishes as phone no longer working and wanted
to see a clinician in person– stated both feet were swollen and warm
Case study 2:
Becki Smee 20/9/22
•
Advised to attend SJA Outreach that week – patient was aware of
area and agreed to plan
•
Full health check carried out on bus and medications reviewed, time
allowed for discussion with clinician
•
Blood results requested a repeat and noted Hba1c now in diabetic
range
•
Contacted via Loaves and Fishes to attend next Outreach SJA clinic
Becki Smee 20/9/22
•
Covid-19 vaccination arranged, transport booked
•
Results states new diabetic – management plan given
•
Trust built with patient, a new phone was given to him by support worker
and patient was now able to contact patient number when needed
•
Booked in at surgery with HCA for diabetic education and foot screen –
patient attended
•
Attended bowel screening appointment
•
Maintained prescriptions, engaged with reviews and has now been
transitioned to mainstream practice
Becki Smee 20/9/22
Patient’s name has been changed to Adam for anonymity*
Adam is in his 30s. He has been known to the local Housing and mental health
team over the last 5 years and had experienced homelessness due to his
excessive alcohol use in an attempt to numb child and adulthood traumas. When
the Salford Inclusion Pathways team met Adam, he had presented in ED after
spending some time out of area. He had disengaged from services, stopped his
medications, and was involved in a relationship which he described as toxic.
Adam presented tearful, unkempt, and covered in bruises, he stated he was
“desperate for help” and that his drinking was “ruining his life.”
“I had to leave the flat I was living in and was told I could not be housed as I had
no local connection, I used the last of my money to get a train to Manchester and
visit my sister. I knew I could not stay with her for long because of her children, it
would not be fair – I needed to stop drinking but I was scared.”
Case study 4 – In reach and hospital
engagement example
Becki Smee 20/9/22
Adam told the team he had children who he had lost contact with and had
increased his drinking to roughly 1 Litre of spirits a day since leaving the
army, 4 years ago. He wanted to detox but had had a seizure the last time he
tried. He agreed to accepting support from the Pathways team upon
discharge but did not have a phone; he consented to the team making
contact with his sister and providing her with a phone for him.
The team advocated for Adam with hospital staff and encouraged him to stay
in ED to be assessed. After spending some time on the medical admissions
ward, due to deranged Liver function tests, he was transferred to a RADAR
bed at local detox unit. The aim of the Service is to provide rapid access for
patients from acute hospitals across all general hospitals in Greater
Manchester presenting with alcohol dependence or acute alcohol withdrawals
who would otherwise require admission to an acute hospital bed.
Becki Smee 20/9/22
In the meantime, the team contacted the Salford Housing team to make an
application for accommodation. Adam was able to return to his property that
he occupied before leaving Salford and was linked back up with his
supported tenancies worker who specialises in supporting veterans, she
supported him in dealing with the rent arrears that had built up while he’d
been away and prevented eviction.
From the Detox unit, Adam contacted the team to check in and organise
support upon discharge, he was registered with the Inclusion GP service to
promote wrap around care, and during the weekly MDT he was discussed
with the local Drugs and Alcohol Community team who agreed to provide
Outreach support upon discharge.
Becki Smee 20/9/22
Weekly reviews allowed the team to monitor Adam’s progress and
support as and when needed.
There are ongoing challenges.
Adam
finds working with the Community Drugs and Alcohol team difficult and
he is also finding it hard to budget to meet his basic day-to day needs
but the team are on call to provide regular support to help him maintain
the progress made. He has abstained from alcohol since his detox.
During the last call, he shared that he had accepted a full-time job
which he is looking forward to starting to keep him busy. His long-term
plan is to reconnect with his children once he is more settled, he said
he feels like to he is on the road to a good place.
Becki Smee 20/9/22
These are just a handful of examples that we have that demonstrate that
Engagement and Outreach can benefit and have a positive impact on the
Underserved communities in Salford. This project is built on engagement – as
stated in the Women’s Health Strategy:
“This country’s health and care system
belongs to us all, and it must serve us all. However, sadly, 51% of the population
faces obstacles when it comes to getting the care they need.”
The women who we support and come into contact with deserve the opportunity to
be listened to and access information and education – enabling them to easily
equip themselves with accurate information and enable them to make informed
decisions regarding their health.
Please see the Women’s Health Strategy for further information.
Becki Smee 20/9/22
Engagement underpinning the project…
A word from
our Clinical
Lead, Dr
Yeung…
Becki Smee 20/9/22
Please see video:
https://vimeo.com/751825828
Improving engagement with sexual health services and increasing uptake in LARCs for underserved communities in Salford, including women experiencing homelessness, through the dedicated efforts of the Inclusion GP Service. They work tirelessly to remove barriers to accessing healthcare for individuals with no fixed abode, offering various consultation options and conducting outreach sessions at different locations. The collaborative approach, highlighted through MDT meetings and partnerships with various teams, ensures a holistic care model for those in need. Recognizing the importance of outreach and engagement, the service addresses the significant health disparities faced by socially excluded populations, working towards reducing early mortality rates among marginalized groups.
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Improving engagement with Sexual health services and increase uptake in LARCs for underserved communities in Salford including women experiencing homelessness Becki Smee 20/9/22
The Inclusion GP Service Our aim is to remove barriers to accessing health care; we can register patients who have no fixed abode with links to Salford. This includes people who are rough sleeping, sofa surfing, staying in emergency or temporary accommodation such as hostels, hotels, B&Bs. We do not ask for ID and immigration status does not matter. We offer telephone consultations and face to face appointments in Eccles Gateway, The Willow Tree surgery in Broughton and Salford Loaves and Fishes in Pendleton. We will arrange Outreach and engagement visits where needed. On a monthly basis, clinical members of the team join Salford Council Housing Officers on a morning street walk to engage with rough sleepers bedding down around the city. This provides opportunity for street engagement and immediate and necessary street health intervention. It is also a fantastic opportunity to build relationships with people who may be wary of accessing primary health care and understand the barriers that people can face Becki Smee 20/9/22
Outreach and Engagement We have held/hold Outreach sessions in: Loaves and Fishes flu vaccines, Covid-19 vaccines, wound clinics Mustard Tree registration opportunities Answer Cancer weekend engagement and Smear clinics Out Of Hospital Accommodation - City Gates GP Provider Hostels - flu vaccines, Covid-19 vaccines, registration opportunities Women s centre - flu vaccines, Covid-19 vaccines, registration opportunities Street visits In reach Service Pathways Salford Royal Mobile clinic St John s ambulance (project now finished) Becki Smee 20/9/22
MDT/ Partnership working/ holistic approach A weekly MDT meeting is held to discuss patients and people of concern, it provides opportunity for wrap around care for individuals. We also work closely with the following teams: Salford Council RSI/supported tenancies team North Manchester BBV Salford Homeless Mental Health Team St Anne s Hospice Safeguarding Secondary care Hospital discharge team Loaves and Fishes DePaul charity Mustard Tree GP OOH EPIC Becki Smee 20/9/22
Why Outreach and Engagement is so important Socially excluded people, including people experiencing homelessness, are 10 times more likely to die early than the general population (Aldridge et al., 2018). There are multiple barriers that prevent people experiencing homelessness from accessing the healthcare they need, including inflexible registration and appointment rules, negative attitudes of staff and competing priorities while surviving on the street (Burrows et al., 2016; Rae and Rees, 2015). Of the 800 homeless deaths recorded in the United Kingdom (UK) between October 2017 and March 2019, one third were caused by treatable conditions (Bureau of Investigative Journalism, 2019) Becki Smee 20/9/22
The aim of health related outreach/engagement is to bring healthcare directly to the most underserved people, i.e those that other services fail to reach, and to connect with hidden populations (Zlotnick et al., 2013; Szeintuch, 2015). It is an assertive strategy to build relationships with people in their environment and has been shown to increase engagement with sexual health, substance misuse and psychological services (Dorney-Smith et al., 2018; Connolly and Joly, 2012). We know that it works, here are some examples Becki Smee 20/9/22
Answer Cancer project Proposal submitted June 2022: Our practice Nurse will be engaging with registered patients weekly on a Saturday morning as an extra shift. She will initially call the patients and discuss screening (cervical). The patients will be selected from our registration process and will be of the appropriate age. She will look at any previous screening either at our practice or previous practice. She will review if screening is due or if no screening undertaken she will offer appointments. Appointments will consist of education and health promotion and consent to have the procedure taken. Becki Smee 20/9/22
She will follow up any results and action accordingly. In order to capture people who may not be registered with a GP or from other practices she will also offer engagement opportunities at a local charity community hub where we share part of their premises (Salford Loaves and Fishes). This would be one afternoon per week where she will offer advice and education regarding the screening process for both cervical screening and bowel screening. She will offer verbal and written information to people attending the centre as required. The proposal was accepted and work has begun Becki Smee 20/9/22
Quarterly progress report: Please summarise any Answer Cancer engagement events or activities you ve delivered or contributed to over the last 3 months. This could be an in-person event, a remote session (e.g. on ZOOM) or engagement through social media. Approx. number of people engaged 20 Description of event or activity Feedback from the women involved has included that they feel more comfortable coming for smear as they have had time to get to know staff and ask questions. They feel safer coming to the surgery at the weekend as it is quieter and that they have appreciated being given time to digest information and think about it before attending appointment. 3 Saturday clinics held for inclusion patients only Promotion of Cervical Screening and Q&A with females in Loaves and Fishes (unplanned drop-ins) 6 10 Discussion/education and engagement with people with a view to pre-book into up coming clinics 25 Outreach to hostels to discuss the procedure and explain the benefits Becki Smee 20/9/22
Case Studies Outreach and engagement Case Study 1: Married couple Male (48y) Veteran, PTSD, Cirrhosis of the liver, Hep C carrier, history of self-neglect and rough sleeping Female (47y) Depressed mood, vary weary of strangers, history of self-neglect and rough sleeping Both victims of financial and domestic abuse by son Becki Smee 20/9/22
Both history of IVDU Both were very cautious of meeting new people and did not want to attend a surgery however agreed to registering with SPCT Inclusion. Team had no previous medical details Housing support worker chaperoned them to the mobile clinic Couple able to sit with clinician together and discuss medical and social history without time constraints Both felt comfortable to have a new patient health check and disclosed IVDU and Hep C diagnosis BBV team on hand to support with neck bloods and referral into their care no time delay Becki Smee 20/9/22
Referral to Achieve with support of Outreach worker Partnership working with Protect team included further mobile clinic and home visits before both attended surgery site Prescriptions maintained with support He completed Hep C treatment Extra support given from BBV and St Anne s Hospice in regards to living with a chronic disease She has gained weight and now more willing to attend appointments and discuss health including menopause Both maintained temporary accommodation and the plan is for own tenancy to be assigned Becki Smee 20/9/22
Case study 2: Male (71y) Patient originally under mainstream GP care however due to temporary accommodation was moved out of area and asked to re-register elsewhere HIV positive, undetectable load so deemed moderate risk for Covid-19 3 telephone appointments made and all 3 DNA Picked up by Inclusion Service as more appropriate GP provider Presented at Loaves and Fishes as phone no longer working and wanted to see a clinician in person stated both feet were swollen and warm Becki Smee 20/9/22
Advised to attend SJA Outreach that week patient was aware of area and agreed to plan Full health check carried out on bus and medications reviewed, time allowed for discussion with clinician Blood results requested a repeat and noted Hba1c now in diabetic range Contacted via Loaves and Fishes to attend next Outreach SJA clinic Becki Smee 20/9/22
Covid-19 vaccination arranged, transport booked Results states new diabetic management plan given Trust built with patient, a new phone was given to him by support worker and patient was now able to contact patient number when needed Booked in at surgery with HCA for diabetic education and foot screen patient attended Attended bowel screening appointment Maintained prescriptions, engaged with reviews and has now been transitioned to mainstream practice Becki Smee 20/9/22
Case study 4 In reach and hospital engagement example Patient s name has been changed to Adam for anonymity* Adam is in his 30s. He has been known to the local Housing and mental health team over the last 5 years and had experienced homelessness due to his excessive alcohol use in an attempt to numb child and adulthood traumas. When the Salford Inclusion Pathways team met Adam, he had presented in ED after spending some time out of area. He had disengaged from services, stopped his medications, and was involved in a relationship which he described as toxic. Adam presented tearful, unkempt, and covered in bruises, he stated he was desperate for help and that his drinking was ruining his life. I had to leave the flat I was living in and was told I could not be housed as I had no local connection, I used the last of my money to get a train to Manchester and visit my sister. I knew I could not stay with her for long because of her children, it would not be fair I needed to stop drinking but I was scared. Becki Smee 20/9/22
Adam told the team he had children who he had lost contact with and had increased his drinking to roughly 1 Litre of spirits a day since leaving the army, 4 years ago. He wanted to detox but had had a seizure the last time he tried. He agreed to accepting support from the Pathways team upon discharge but did not have a phone; he consented to the team making contact with his sister and providing her with a phone for him. The team advocated for Adam with hospital staff and encouraged him to stay in ED to be assessed. After spending some time on the medical admissions ward, due to deranged Liver function tests, he was transferred to a RADAR bed at local detox unit. The aim of the Service is to provide rapid access for patients from acute hospitals across all general hospitals in Greater Manchester presenting with alcohol dependence or acute alcohol withdrawals who would otherwise require admission to an acute hospital bed. Becki Smee 20/9/22
In the meantime, the team contacted the Salford Housing team to make an application for accommodation. Adam was able to return to his property that he occupied before leaving Salford and was linked back up with his supported tenancies worker who specialises in supporting veterans, she supported him in dealing with the rent arrears that had built up while he d been away and prevented eviction. From the Detox unit, Adam contacted the team to check in and organise support upon discharge, he was registered with the Inclusion GP service to promote wrap around care, and during the weekly MDT he was discussed with the local Drugs and Alcohol Community team who agreed to provide Outreach support upon discharge. Becki Smee 20/9/22
Weekly reviews allowed the team to monitor Adams progress and support as and when needed. There are ongoing challenges. Adam finds working with the Community Drugs and Alcohol team difficult and he is also finding it hard to budget to meet his basic day-to day needs but the team are on call to provide regular support to help him maintain the progress made. He has abstained from alcohol since his detox. During the last call, he shared that he had accepted a full-time job which he is looking forward to starting to keep him busy. His long-term plan is to reconnect with his children once he is more settled, he said he feels like to he is on the road to a good place. Becki Smee 20/9/22
Engagement underpinning the project These are just a handful of examples that we have that demonstrate that Engagement and Outreach can benefit and have a positive impact on the Underserved communities in Salford. This project is built on engagement as stated in the Women s Health Strategy: This country s health and care system belongs to us all, and it must serve us all. However, sadly, 51% of the population faces obstacles when it comes to getting the care they need. The women who we support and come into contact with deserve the opportunity to be listened to and access information and education enabling them to easily equip themselves with accurate information and enable them to make informed decisions regarding their health. Please see the Women s Health Strategy for further information. Becki Smee 20/9/22
A word from our Clinical Lead, Dr Yeung Please see video: https://vimeo.com/751825828 Becki Smee 20/9/22
