Health and social care case studies

How do you encourage some of the most traumatised and disempowered people in the country to access healthcare? The Butterfly Project shows the way How can my team connect and work with the most marginalised people and communities in society? It’s a question that is asked repeatedly within the public sector.  And as we become increasingly aware of how inequality damages health and drives up pressure on public services, it is a question asked with ever greater urgency.  There is perhaps no more marginalised and ignored group than female prisoners. The vast majority have suffered layer upon layer of disempowerment. Many come from poor and excluded communities. Over half have experienced further disempowerment and trauma in the form of domestic violence, sexual violence, and abuse as a child. Then, of course, there is imprisonment itself which is very deliberately a form of marginalisation and disempowerment which has a disproportionately negative impact on women.  The proportion of female prisoners self-harming is seven times higher than male prisoners, while alcoholism and drug use is twice as high. In short, trauma, exclusion and distrust of authority are part of the everyday lives of female prisoners. This is not a group that is likely to engage positively with the state in any of its forms no matter how benign.  So, when a frontline innovation manages not only to engage but generate measurable positive outcomes with female prisoners, it is probably worth the rest of the public sector paying attention.   Releasing the Butterfly  That initiative is The Butterfly Project run by a social enterprise called Spectrum. The Butterfly Project set itself a simple but challenging goal: to increase the cervical screening rate to 90% for the 500 prisoners held at HMP Styal in Cheshire. This was ambitious. The screening rate at the prison was only 64% when the initiative began in 2020. The rate for the English population is not much higher at 69%. So, this would mean encouraging one of the most excluded groups in the country to massively exceed standard screening rates.   The Butterfly Project secured its goal. 92% of women at HMP Styal underwent cervical screening between 2020 and 2022. An achievement that has proved sustainable with a 91% rate by 2024.  So, how did The Butterfly Project do this? There are four key principles to their work. Principles that have wide applicability beyond engagement with prisoners.  1. Go where the people are  It may not sound radical but one major innovation was conducting cervical screenings at the prison itself. Most medical procedures occur outside the prison walls requiring prisoners to be escorted, often in handcuffs and prison vehicles, to a hospital or clinic accompanied by a prison officer. A process that reinforces stigma and inevitably adds considerably to the anxiety of any medical procedure. Conducting screenings in the prison eliminates that barrier.  This goes to the heart of an assumption underpinning much of public sector activity, namely that people should come to us. Vast swathes of the public sector’s work is conducted in buildings and places that suit the public sector rather than the people and communities they are serving. This inevitably creates an immediate barrier for engagement requiring people to invest time and money and to overcome mental and physical health barriers to interact with the public sector. It is telling, for example, that the Community Led Support initiative that has had such a positive impact on social care invests a great amount of time and energy into finding the right venue for their service.  Indeed, the principle has been taken a step further at another prison, HMP Low Newton, where a colposcopy unit has been set up so that any abnormalities identified during screening can be followed-up on site.  2. Let trusted people with relevant lived experience do the engagement  Peer mentors are at the heart of The Butterfly Project. These are prisoners who play a vital role not just in spreading the message about cervical health but also in discussing directly with those who may be anxious or doubtful about undergoing screening.   The mentors bring two vital aspects to the engagement. Firstly, they are far more likely to be a trusted source of advice and connection than a public service professional particularly when the population in question will have all been in conflict with the state and may have suffered mistreatment and discrimination at the hands of the public sector. Secondly, they bring an inherent and profound understanding of the lives of their fellow prisoners because they lead that life themselves.  There is clearly a lesson here for the public sector as a whole. Many public sector organisations assume that public sector staff or elected representatives are the best people to lead engagement. In fact, this assumption should be turned on its head in the case of marginalised groups by understanding that the public servant may well be the worst person to lead engagement. Instead, find those from the community who have the trust and shared experience of the community to act as connectors and conduits.   3. Take time to listen and understand  The role of The Butterfly Project’s peer mentors is not to meet targets or to push people into screening but to listen to their fellow prisoners and understand their fears and hopes. That can take a long time, particularly when working with people dealing with profound trauma. But it is time well spent for it enables trust to be built and allows mentors to develop a deep appreciation of the barriers preventing the women at HMP Styal accessing healthcare.  It’s an approach that extends to the Project’s medical personnel as well, who will often take considerable time to explain the screening procedure alongside the mentors and help address any concerns.  This is not an easy message for much of the public sector to hear. Time is a very scarce resource in a world shaped by constrained finances, rising demand and an obsession with top-down targets. The emphasis too often is on processing people as quickly as possible rather than taking time to listen and understand. But if any public sector body is serious about engaging with excluded individuals and groups, then ways must be found to carve out the time to build the necessary connection and trust.  4. Keep it friendly and welcoming throughout  Finally, and perhaps most obviously, The Butterfly Project places a premium on friendliness and providing care in a welcoming environment. Those who undergo screening often comment on the kindness of the doctors and nurses in the unit at HMP Styal. The necessity of this is obvious, particularly when engaging with people who may have suffered mistreatment and trauma. It is not only the most human approach but clearly it is the best way to ensure ongoing engagement and trust.    What The Butterfly Project teaches us is that with the right practices, enough time and a considerable dose of humility, it is possible to transform engagement with even with the most excluded people and communities. As health inequalities rise and demand pressures keep growing, this is a lesson the public sector needs to learn as quickly as possible.