Achieving health equity: A conversation with a sexual health nurse in homelessness

Sexual Health services have notable barriers to access, especially since the pandemic and especially for socially excluded groups. Yet we see a worrying increase in diagnoses of infections nationally. The QICN’s Homeless and Inclusion Health Lead Kirit Sehmbi met with a powerhouse who’s showing how things can be done differently and who many service leads and commissioners might want to take a lead from on their patch.

Meet Izzy Patrick, a Sexual Health nurse working with people experiencing homelessness. What does that look like, I hear you ask? Well, no two days are the same. This means, sometimes Izzy’s running a clinic in a day centre, other days doing street outreach and other times heading into other services to get the right support to vulnerable people who are often unable to access mainstream health services.

Mainstream services are difficult to access

This is a special role. Traditionally, Sexual health services sit within a fixed bricks and mortar facility which people have to access in-person or via an online system. This allows for access to clinical equipment and a lab to quickly turnaround samples and offer accurate results with treatment. But, what if your client group just doesn’t attend these places? As Izzy says: “The people I work with – a lot of them haven’t been to a sexual health clinic. They don’t go to GPs”.

There are many reasons why people might not attend Sexual Health services:

• Stigma associated with attending a Sexual Health clinic
• Perceived threat to safety (location + anonymity)
• Long wait times
• Digital exclusion
• Language barriers
• Perceived discrimination from staff
• Inconvenient opening hours
• Unaware of the services available

This was Izzy’s own experience years before becoming a nurse herself. As a university student who presented to a clinic, she was met with a negative and patronising attitude. This very experience kindled a strong desire to provide a service that gives people the respect they deserve.

A holistic service

Izzy’s role is an example of what it truly means to practice holistically. Not restricted by her speciality, and willing to problem-solve by reaching out to other specialists so that ultimately, she can offer her patient support in the moment they need it.

A person’s sexual health is only a part of their wellbeing. Although Izzy is not a specialist in wounds or diabetes, for example she knows who she can call on to advise her in the moment.

She tells me “There’s an element of having to know about general health…You might talk about a person’s mental health, substance use and need to follow it up instead of just signposting them to the GP.” It’s about “Providing an all-encompassing service.”

This doesn’t mean working outside of our scope or unsafely. But, too often we hear professionals say “That’s not my remit” and the issue isn’t addressed.

What helps is developing a team with varied skill sets and building a network of colleagues and specialists that you can call on. As Izzy explains, “The beauty of being in the HIT [Health Inclusion Team] – I can call someone in my team”.

But for Izzy, being holistic means so much more than having a generalist approach. It’s about meeting people where they’re at: “Going out to people gives them visibility. They feel seen.”

Thinking outside the box

Service policies, guidelines and SOPs are there to ensure safe practice. But the rigidity of these can often prevent creative and holistic care from being given. Izzy asks us to consider “What is better vs what is best practice.”

When mainstream guidelines and services don’t work, we need to take measured risks and make judgement calls on what the better option is for clients. This might look like meeting them in unconventional settings, not always being able to complete contact tracing, or understanding that lost-to-follow-up is unfortunately, a common occurrence.

Izzy now supports other services who are experiencing cuts and changes in policies. For example, she links in with the maternity services where they can no longer offer postpartum contraception, the local substance misuse services and inpatient mental health services who cannot offer contraception, STI treatment or PrEP and PEP. The reach of the service and gaps it plugs is such an accomplishment. However, we must consider why there is a need for it and where statutory services can reinstate and coordinate necessary services in-house.

Service sustainability

Services like Izzy’s are rare and don’t easily appear. They need the backing of forward-thinking leaders and managers. People who are comfortable with taking sensible risk and have a “why not?” attitude.

As Izzy tells me, she has the full support of her manager. It wasn’t easy though and a running theme I hear from practitioners in this line of work is that they often feel they have to justify the need for their services with commissioners: “Feeling constantly that I have to prove that the service is essential to carry on.”

Izzy explains that this role was initially funded for one year only through the Trust’s charity. However, through regular reporting and building case studies, they were able to showcase the need for the service as well as the cost-saving. The role is now permanent and based within a Health Inclusion Team rather than a Sexual Health service.

Undoing systemic failures

Something all practitioners I speak with in this sector have in common with each other is a resounding passion for their work. A clear take on justice, equity and care.

Understanding that many of the people they work with are in the situations they find themselves in because of systemic failure at some stage such as adverse childhood experiences, is what drives Izzy: “People are in this position because of the system we’re in. We owe it to them to do what we can to fix it.”

Recognising that institutional barriers can deter people from the very services they need, she explains “Devote yourself further to actually put help out there instead of expecting them to come to you.”

Finding meaning in numbers

While commissioners may need to be sold a service that has cost-saving ability, we talked about how it’s important for day-to-day work to focus on meaning over numbers. “There’s no chat about KPIs. The point is that you’re trying. It’s the nature of the role”, Izzy tells me.

She reminds us “If my job didn’t exist, it would be best in terms of budget, norm or how services historically got run. In the last 14 months, I’ve seen 222 patients. Many of them wouldn’t have been seen anywhere else.” And that’s the unmeasurable.

We’re often encouraged to present services in terms of cost-savings, but Izzy invites us to rethink this completely: “We need to reframe this to what the price of not being holistic is.” She reminds us “The people who we are seeing, their lives are overcome with trauma. That’s why so much money is being spent now.”

Job satisfaction and staff wellbeing

Izzy recognises the importance of a good team and supportive management in creating a healthy relationship with work. “I think the independence and autonomy that you’re given in that team is one of the most powerful things you can be given because it fuels you.” This, we discussed, is what allows a person to be creative in how they work.

Izzy has regular clinical supervision with a GP and has direct contact with the Trust’s mainstream Sexual Health service including consultants and health advisors. So, while most of her work is lone-working, she feels well-supported in her role.

We bring it to a close and it strikes me just how much passion and understanding Izzy has. At eight months pregnant, Izzy is still cycling her way around London to see her patients. Why? Because “No one else gets to wake up in the morning and do what I do”.

If this article has inspired you, Izzy is happy to be contacted at isabel.patrick@nhs.net.

Join the QICN’s Homeless & Inclusion Health Network

The QICN’s Homeless and Inclusion Health Network is a national network to improve the health of marginalised groups, particularly:

• People experiencing homelessness
• Gypsy, Roma and Traveller communities
• Boater and Showmen communities
• Vulnerable Migrants
• Sex Workers

Click here to find out more and sign up to the network.

Interested in working in Inclusion Health Nursing?

The QICN has recently published its updated guidance for those looking at a career in Inclusion Health. You can find out more and download the guidance here. 

If you would like to get in touch, please contact us at hih@qni.org.uk.