Of the total sample, 83.5% of the interviewees were clinicians (mostly doctors and nurses) and 16.5% worked as managers within the institutions.
After completing the interviews, we identified three main themes relating to IM: access, notifying the authorities, and communication. We then compared services and countries. Countries were grouped according to the NowHereland categories: "no rights", "minimum rights, and "rights" [16
] [see Table for the classification of countries]. NowHereland categories were chosen as possible explanations for differences between countries.
Classification of European countries according to healthcare entitlement for irregular migrants a, b
Because of differences in the organisation and funding of health care systems across participating EUGATE countries, "access" could mean either entitlement or affordable care [21
All professionals in A&E departments, even in countries belonging to the "no rights" category, reported full access to IM (n = 48). However, for primary care, respondents in 16 services (n = 144) reported that no access was provided, either because of the absence of legal entitlement or due to financial barriers. Interviewees reported that treatment in A&E departments may be provided in emergency situations without clarification of the patient's entitlement to treatment being required. Furthermore, most A&E professionals reported no differences in delivering health care for IM and patients in a regular situation.
In mental health services, a quarter of respondents reported that it was unlikely for IM to come to their services for treatment. But they stated they would, nevertheless, provide care for an IM should they access the service.
Respondents in 24 A&E departments declared that they provide the same further treatment pathways for IM as for patients in a regular situation. Professionals in primary care and mental health services experienced more difficulties in performing further diagnostic and/or therapeutic interventions due to the restricted access IM face in health care. Prescribing drugs could be really difficult, as the IM patient could not afford it.
...because he is not health insured I will not give him a prescription - I cannot give him a prescription and I don't want to give him a private prescription, because he cannot afford it. That's why I actually always solve that problem by giving free medical samples and that works wonderfully...
ID7, primary care services, Austria
...I prescribe the medicines for my own name, if the patient has no money for it...
ID 146, primary care services, Hungary.
Difficulties in continuity of care occurred when supplementary treatment was arranged within the same service or when IM had to be referred to another service. This situation was reported even in countries where IM were guaranteed full rights.
If I have to refer him, it will be a hassle (I'm not saying it's not possible). So you can assume that a doctor will have a certain threshold for consulting a specialist. This is also to avoid getting the patient into trouble. For example, if I refer him to the emergency department, he could subsequently receive an 800 euro bill when there's nothing really wrong with him.
ID 206, primary care services, Netherlands
Where it gets complicated is if they need a referral to the hospital. That's where it gets complicated because, although we always do our bit, when they get to the hospital end, they may be charged. The situation at the hospital will be very different, because very different criteria are involved. We don't get involved in these situations. They may or may not be seen by a specialist, if that is what they need. It's not something we can control.
ID 312, primary care services, UK
Some professionals, especially in primary care, reported transferring IM between services or having to delay treatment while waiting for legal issues surrounding the patient's irregular status to be resolved.
An illegal patient would be received and treated illegally...such a patient is entitled to basic medical treatment only. And in theory - they should cover the treatment costs. If they had money, they could pay for the visit and receive a full range of services. And if not, emergency care and basic treatment only.... And perhaps, a doctor would arrange a check-up visit for them, without registering it...
ID 234, primary care services. Poland
Interviewees in primary care and mental health services also reported informing patients about services that provide free health care and administrative support or referring them directly to such services in order to bypass problems with access in their own service.
Notifying the authorities
Primary care and A&E departments were compared in terms of notifying public authorities, including the police, about IM being treated in their service. Most interviewees in both services reported that they would not inform the police about IM presenting at their service for treatment. Few would inform the police: 10 in primary care services (n = 144) and 5 in A&E departments (n = 48). In both types of service the tendency to inform the police was stronger in cases where the patient was suspected of being involved in criminal activities.
Conversely, some respondents reported informing the police to help IM or to protect them. Such scenarios included situations in which patients were considered a danger to themselves or to others. The need to identify the patient in critical situations would qualify as reason enough to inform the authorities.
No. For several reasons. There is no need for me to inform the police. If the individual was severely injured and he got so bad that you would need to get in touch with relatives or the like you would try through the police. Normally, we will contact the police if we are to get hold a relative we do not know about. If we have an actual identification problem and a need to inform relatives. That situation can arise if it is a catastrophic situation, but otherwise there is no need to contact the police.
ID40, A&E department, Denmark
By hook or by crook, we would find out who he is. Insurance, marital status, police, foreigners department.... No idea, we cannot take him into custody to move him into prison hospital.
ID 100, A&E department, Germany
Finally, although many of the interviewees would not inform the police, six primary care services and one A&E department did inform their own managerial staff. This was usually due to financial and organisational problems for which management would be responsible.
In primary care and mental health services, communication barriers were perceived as more problematic than in A&E departments. In A&E departments, staff emphasised difficulties in reaching a diagnosis due to language barriers, while professionals in primary care and mental health services reported communication difficulties being a more general problem. Interviewees from primary care services discussed issues associated with patients becoming more stressed as a result of not being able to express themselves to professionals.
Health professionals recommended or used professional face-to-face interpreters or telephone interpreting services when they had language barriers with their patients. However staff still reported little use of these interpreting services or not having full access to them. This was attributed to the administrative procedures involved, the lack of funding, or the poor quality of interpreting when available. Consequently, in practice, professionals, especially in primary care services, arranged alternative solutions such as asking children, families, friends, or bilingual employees to act as interpreters.
[...]So that's my Chinese I've told you about, an illegal immigrant. She was working illegally in a Chinese restaurant and I found another Chinese restaurant, and what happened is that they were able to communicate and the owner of that Chinese restaurant who was used to talk with her explained to her that she had appendicitis and that she had to be operated on. And when I told him "one should tell her that", he said "Oh appendicitis, I must look that up in a dictionary" not for the translation but to know what it was, he had never heard that word in French before so he looked the word up and told her she had to be operated on...
ID 32, Accident & Emergency Department, Belgium
Among non-major themes some interviewees reported problems related to culture, such as the refusal of care due to the health professional being of the opposite gender or due to cultural beliefs that hindered recovery. Two health professionals out of the whole sample reported different expectations about treatment leading to misunderstanding between health professionals and IM.
Despite variations in health care entitlement for IM, most of the countries investigated faced similar issues. No important differences in frequency were noted between countries in the "rights" category and those with only "minimum rights" for IM. In countries in the "no rights" category, communication problems and their consequences were the main theme. "Access problems and their consequences" were cited in all Swedish services while in Finnish services this theme was reported in only 2 services (n = 15).
Differences were found between countries regarding notifying the police about IM. In 5 of the 16 countries, interviewees considered informing the police about an IM treated in the service. Three of these countries are considered to provide "minimum rights", while the remaining two were classified as "no rights" countries [Table ]. Although they were classified in the "minimum rights" category, Germany and Lithuania were, during the data collection period, the two countries where there was an obligation of notifying IM to the police. However, only a few health professionals from both countries reported having done this.
Although we expected differences due to different legislation regarding access to health care, a quarter of the interviewees stated that there were no differences in the actual care provided for IM compared with patients in a regular situation in the host country.
Nevertheless, although in some countries IM were legally entitled to a wide range of health care services, professionals reported insufficiencies in the actual delivery of care. Where patients did have access to services, the quality of care was reported to be poor due to lack of funds, administrative requirements, and practices and procedures within the service. Consequently, some professionals reported transferring IM to other health care services with better human or material resources. Some professionals suggested that they would consider transferring patients, even when they were allowed to care for them or had the required funds to do so, to avoid the burden of IM on the service. Non-governmental organisations (NGOs) caring for IM were quoted as potential referral agencies, particularly in countries where IM do have access to care, such as Belgium or France.