Using the candidacy framework to explore access to NHS healthcare for street sex workers in Sheffield: an ethnography and art-based research project

Background: Street sex workers (SSWs) experience some of the highest levels of health inequality in the UK, yet face persistent barriers to accessing NHS healthcare. These barriers are shaped by structural disadvantage, stigma, and the complex realities of their lives. Despite significant health needs, engagement with services remains low, and existing models of care often fail to accommodate the lived experiences of this population.

Aims: This study explores how SSWs access, experience, and navigate NHS healthcare. It aims to understand the barriers and enablers of access, identify areas for improvement, and offer recommendations to inform the development of more inclusive service provision.

Methods: An ethnographic approach was undertaken within a South Yorkshire charitable organisation. Data collection involved participant observation and an arts-based scrapbook intended to facilitate trauma-informed, flexible engagement. Thematic analysis was used to analyse the data, organised around a dynamic, processual approach using the candidacy framework.

Findings: Barriers to care were present across all stages of healthcare engagement, including minimisation of health needs, administrative exclusion, lack of continuity, and stigma from professionals. Participants frequently described systems as inaccessible. Key enablers included supportive organisational staff and consistent, trusted relationships with specific providers.

Areas for Improvement and Recommendations: Findings highlight the need to simplify registration processes, provide in-person options, and reduce reliance on digital communication. Greater continuity of care and gender-sensitive, trauma-informed approaches were consistently requested. Services should not be evaluated solely by uptake but by how well they accommodate marginalised users. Healthcare settings that prioritise safety, trust, and consistency were shown to improve engagement. SWs spoke of the work of accessing care, which for many was too hard to gain.

Conclusions: SSWs are not disengaged from healthcare but are routinely excluded by systems that fail to meet their needs. Service redesign must begin from the realities of those who are most marginalised, through co-production, to reduce health inequity and build meaningful access.