Table 5 Sample responses from healthcare professionals

Personal resources

Cognitive capacity, healthcare culture and understanding of the system

(1) P.18 “Some people have a medical card and some don’t; normally they don’t have an assigned doctor and they have to be registered as city residents and fill out a series of papers, something they understand as us not wanting to attend to them. This is an important barrier.”

(2) P.19 “For homeless people everything is too bureaucratic, so they get the idea that no one wants to help them in the health centers, and they leave.”

(3) P.24 “Many of them have no documents, because their documents have been stolen, or lost, and they never replaced them. Many don’t care about it, because they prefer to die.”

(4) P.20 “The fact that a homeless person ventures into a clinic or emergency room or has a medical card does not imply good access. I think access is deplorable.”

(5) P.25 “Normally, these people tend to make occasional or extreme use of health services, they only go to emergency care and then there is no continuity, among other things.”

(6) P.26 “The situation is that this population has no territorial links, so they don’t go to their local clinics for care, because they don’t know which one they have been assigned to.”

Mobility, personal autonomy and social assistance

(7) P.20 “On the 061 Emergency line they are really arrogant. When I call them to come for a user who is in alcohol or drug crisis and cannot move, I get answers like, ‘and you’re calling us about this?’

(8) P.24 “My perception of the people who are in the street is that they don’t really care about their situation and logically the same thing happens on the healthcare side also, it’s not their priority and they don’t seek care until the symptoms of the illness they are suffering from become unbearable.”

(9) P.25 “From the healthcare side it’s a situation where you try to give medical and pharmaceutical treatment… but the person also needs a bath, lodgings, etc. Health services can’t provide that, it’s a social services issue. Once there is minimal social processing, then they can see the doctor, but if the social side is not addressed, it’s impossible to do anything there.”

(10) P.26 “Healthcare displaces social [issues], social displaces healthcare.”

(11) P.22 “This population thinks that doctors represent a society that has rejected them and which they do not trust, so the solution is to go to them [the homeless], not to wait for them to come.”

(12) P.27 “The main problem? There are no resources designated to this population.”

(13) P.28 “The doctors are very aware that homeless people do not follow the treatments prescribed to them and so have the sensation that they are wasting their time on them. This may be why they don’t pay much attention to them.”

(14) P.21 “The case of a man with respiratory problems. Hostels and shelters don’t allow oxygen cylinders and these people go from one to another.”

(15) P.22 “As professionals we are not sufficiently prepared, nor do we have the resources, to attend to this population.”

(16) P.21 “It is heroic when homeless people manage to see a doctor, they have had to overcome numerous obstacles.”

(17) P.28 “The health system is very rigid about access for these people, it’s difficult for them to understand all this bureaucracy.”

(18) P.27 “What happens is that homeless individuals do not easily access the healthcare system, precisely because of how they live.”

(19) P.29 “A homeless person comes to our center and the first thing they encounter is an admin person who doesn’t stop asking questions: are you a registered resident? Do you have an assigned doctor? Do you have a medical card? …”

(20) P.20 “The situation sometimes depends a lot on the good will of the medical worker. Me, for example, when someone like this comes in, I ask that they be assigned to me, because otherwise, since they have no address, no one can be assigned to them.”

(21) P.31 “There are a lot of administrative hang-ups that slow down care, then when you finally manage to see the person and give them the immediate treatment they need and get them an appointment with the social worker, the person has already left, without medication, without the smallest chance of follow-up.”

(22) P.29 “The system has been reducing the obstacles to access and today it is practically universal, but even so, there are some populations with special characteristics who do not come in, you have to go find them. And in this group, we find the homeless.”

(23) P.18 “There need to be units that go to them. The role of the street educators is essential.”

(24) P.30 “Often time is the issue: we have seven minutes to address medical problems, social problems, relational and communication problems… You feel powerless, you see the situation is unresolvable and no matter what you do it’s not worth the effort and they won’t follow your instructions, because they can’t.”

(25) P.28 “I believe the problem is that there is no coordination, no integrated effort that covers everything. The problem is not the nursing staff, the doctors, or the social workers; the problem is [lack of] coordination.”

(26) P. 30 “Coordination is shoddy because there are no standards for this population and they always end up looking to see who is on call, to see if they can send them the cases or not”.

The role of healthcare professionals

External appearance of the user and attitudes of professionals

(27) P.32 “The main problem for the homeless population in accessing health care is that it is heavily influenced by their outward appearance. Both users and professionals are aware that their outward appearance has a lot to do with access conditions and standard treatment.”

(28) P.31 “You encounter a man who smells terrible sitting in the waiting room, at a moment when you have forty visits and five minutes for each one; the people waiting begin to grumble that the man is bothersome… then, after a while, you get him into the room and you find a person who is difficult to understand, whom you know nothing about because it’s the first visit. Then, when you say ‘undress’, you have to make a massive effort at professional discipline to get close and not vomit.”

(29) P.27 “There’s a whole range of prejudices on the part of the medical professional that make it so that the homeless patient always ends up getting worse treatment: because they drink alcohol, because they have mental problems, because of their drug addictions, because of their physical appearance… In these cases, the professional examines them from a meter away. Dirtiness is always a factor in care discrimination, in fact, there are auxiliary staff who wash them up so that the doctor will treat them like anyone else and not be discriminatory.”

(30) P.26 “Sometimes they are even treated first just so that their physical appearance and smell do not bother the other patients who are waiting.”

(31) P.21 “Sometimes people arrive lice-ridden, filthy, drunk, malnourished… For special cases, there are two closed examination cubicles and they are left there to wait, away from the others.”

Information provided by the system and medical professionals

(32) P.25 “Homeless people are checked, but the doctors don´t speak to them, they always speak to the person accompanying them.”

(33) P.19 “Sometimes homeless people find that they have seen many different doctors who have told them completely different and contradictory things in a very short time.”

(34) P.30 “I think that apart from all the problems with social services and difficulties with networking care, there is a part that we (healthcare workers) should try to facilitate.”

(35) P.32 “Doctors are not concerned with the personal situation of the users, they attend to them, admit them to hospital if necessary, and the rest are problems for the administrative staff.”

Attitudes and habits related to health

Following protocols and continuity of care

(36) P.29 “The problem is, how can you ask a street person to follow a prescribed treatment, when they live day to day? People living on the streets can’t care for themselves.”

(37) P.19 “Sometimes they have so many problems… not just a housing problem. Sometimes they are homeless, but also illegal residents, they have mental health issues, they are alcoholics or addicts… Then you look at them and you think ‘where do I start?’”

(38) P.24 “I think that subconsciously, medical professionals avoid the homeless a bit. They [health workers] know their habits and that they won’t follow treatments, so they [the homeless] are relegated and end up being treated differently”.

(39) P.31 “We have to deal with the real situation that we have: taking a person’s blood pressure, when you know there will be no follow-up if you treat them for hypertension, is a waste of time.”

(40) P.32 “With the homeless, the idea is: ‘whatever they have, don’t put yourself out, there’s no solution and in the end we all have to die’. They are relegated in treatments, they wait longer, because they don’t complain and ‘we’re doing them a favor’ by seeing them at all.”

(41) P.30 “There is no follow-up, it’s really difficult.”

(42) P.23 “The argument goes like this: what’s the point of solving their health problem, if no one can ensure that they will follow the prescribed treatment? The result is that they get patchwork answers rather than solutions for their real problems.”

(43) P.18 “Without a medical card, we sent them to Fundación Trueta. The problem is that this population often present mental health problems and that entity does not provide medications for them.

(44) P.27 “They have difficulties in accessing primary care and therefore they also don’t have access to a more ongoing treatment path”.

(45) P.23 “Another problem is the follow-up for these people. Because any person, when you finish treating them in an emergency service, you say, ‘all done, now go home and finish recovering’, but these people don’t have a home to recover in. And I don’t think this is due to the poor functioning of healthcare, but because this population are not taken into account.”