Table 5 Best practice guidance from participants

Partnership working and a range of provision:

• Outreach

• Provision in community spaces

• Network of agencies to provide holistic support

• Fast track appointments

• Seamless pathways between agencies

• Good communication between agencies

• the ideal would be for services to visit where sex workers feel most comfortable and then for assessment, referral and appointment booking all to be done in one hit. This would acknowledge how rare chances are that people feel ready to engage and would maximise the potential in those rare instances. (Support worker 7)

• Providing an in-house nurse/healthcare worker available specifically for sex workers- reduces stigma and judgements towards sex workers often arising from other services. (Support worker 5)

• In house GP presence in drop-in who have a good understanding and awareness of the needs and risks the women face. GP's link with other services to provide joined up approach. (Charity manager 13)

• offer of immediate care via quick interventions (eg on street medicine), take healthcare to them—some individuals will never / rarely access healthcare in a professional setting (Support worker 9)

• We work extensively with mental health colleagues, health inclusion nurses, addiction key workers, safeguarding midwives, voluntary sector to identify women with unmet needs and then work creatively and flexibly to meet them out in the community where they are (Charity manager 6)

• Strong relationships between key individuals in relevant agencies… means that despite system not being ideal, there is a good network of support for sex workers (Charity director 1)

• [Charity] run a service for sex workers and are willing to work jointly with Drug and Alcohol services—this can build up trust and encourage engagement (Drug and alcohol worker 1)

• Strong communication between different systems to avoid repetition of information (Charity director 1)

Organisation of health services:

• Drop-in availability

• Afternoon and out of hours provision

• Longer appointments

• Psychologically informed environment

• Flexible and responsive

• There are several afternoon sessions that people can access (Support worker 6)

• Easy access to GP support and prescriptions out of hours—most women we work with struggle during normal working hours to access support. (Charity director 2)

• Time to address several health needs at once. (Charity manager 10)

• Ensure the service was reactive, provide healthcare/ support when the person was ready not at an appointment 3 weeks away. (Charity manager 11)

• The service would need to be designed to allow for multiple consultations where there is no 'concrete' outcome—that the outcome is building trust and rapport. Commissioners need to understand that partial outcomes for our patients is progress. (Charity manager 6)

• A really nice environment where women would like to come and be. If they do have to wait, can the waiting room be lovely? Can there be things to do whilst they wait? Can they chat to a housing worker whilst they wait? A nice cup of tea? (Support worker 2)

• a more relaxed accessible drop-in to access treatment for dressings legs etc. At these appointments she has often requested a doctor to come and see them at the same time and refer them for other health needs whilst we have them there. (Charity manager 10)

• Our service does not discharge people for non-attendance. We will actively and creatively think of ways to engage. (Clinical lead 1)

Health professionals and staff- expertise and approach:

• Trauma-informed

• Specialist knowledge of substance misuse, mental health, domestic violence, homelessness

• Trusted relationships

• Non-judgemental

• Continuity of care

• Psychological support for staff

• they provide really good follow up, they link in with other services who work with the person, they have good awareness of how sexual trauma affects women when accessing something like a smear test (Support worker 6)

• Health care professionals understanding impact of complex trauma, not being dismissive of a SSW due to substance use and taking the time to let the individual be heard around their health. (Charity manager 4)

• Ability to address/treat mental health alongside substance misuse. (Charity manager 13)

• providing the right training to staff (trauma informed practice, borderline personalities training, a good understanding of the impact of ACE's and a good knowledge of health and gender inequalities. (Sexual health nurse 4)

• when these vulnerable women do access a service they are seen by a professional who is trained to support as fully as possible without having to go to another appointment/service. (Charity manager 6)

• Consistency of staff/staff who believe in what they are doing and understand the specific needs of SWs (Sexual health nurse 3)

• Really good mental health practitioners who are specifically trained to support this client group and who care about them. (Support worker 2)

• flexibility, non-judgmental healthcare professionals (no stigma!), confidence in confidentiality, compassion (Charity manager 10)

• Sex workers do not appreciate many different people as they find it difficult to trust and difficult to explain things multiple times. (Sexual health outreach worker 3)

• Psychological support for staff for reflective practice to consider transference and parallel process. (Clinical lead 1)

Case worker support:

• Holistic

• Advocacy

• Creative ways to engage and support

• assertive outreach that helps women to stay with treatment and advocates for women and accompanies them in their journeys. (Charity manager 1)

• We work in a person-centred way, supporting women 'where they are at' to achieve the goals that they have in mind. Often this leads to more in-depth interventions, support to access health care and substance use support. (Drug and alcohol worker 3)

Peer and volunteer involvement

• Peer mentor and volunteer support at [drug service] appears helpful for engagement (drug and alcohol worker 1)

• Many projects fail in this area because they do not involve sex workers in the planning and set up of any services. (Sexual health nurse 1)

• Peer led works really well (Practice nurse 2)

Gender sensitivity

• It would have workers well trained/experienced in the specific needs of sex workers (including trans sex workers) who are non-judgemental (Support worker 6)

• Female only settings (Charity manager 13)