A qualitative descriptive-interpretative and exploratory study was conducted to analyse the phenomenon of study —changes in perceived quality of care provided to immigrants during the economic crisis— from the main social actors’ perspective. The study population was made up of health professionals and users of Moroccan and Bolivian origin in two counties of Catalonia: Baix Empordà and Barcelona, semi-rural and urban areas with a high proportion of immigrants (19.1% and 14.2% respectively). These countries of origin were chosen because they are amongst the largest groups 20.8% and 3.4% respectively, (first and sixth -but first of Latin America- groups of the foreign population in Catalonia28) and differ in relevant characteristics such as language, culture, etc. Fieldwork took place from November 2014 to September 2015.

A theoretical sample was selected through a two-stage process. In the first stage, the contexts, primary care centres with the greatest proportion of immigrants and their referral hospitals were selected. In the second stage, informants were selected according to the following criteria in order to ensure variety in discourses: a) health professionals: medical and administrative personnel, from primary and secondary care, with different job profiles and more than 10 years’ work experience in the national health system, and b) users from Morocco or Bolivia with and without an individual healthcare card (IHC) and with at least 5 years’ residence in Spain. Reaching immigrants without IHCs proved more difficult than anticipated. In order to increase the recruitment chances, different strategies were applied: expansion of the study areas in Barcelona; collaboration with hospitals’ mediators; contacting NGOs and immigrants’ associations; direct recruitment by the first author in local stores, bars and consulates; posting announcements in public places; and snowballing. Due to the limited success, being without IHC was converted into a variation criterion. The final sample was determined by saturation (Tables 1 and 2). A member of the research team in most facilities (and a collaborator for SC in Barcelona) applying the defined criteria would select professionals and contact them for participation. Most users were identified by NGOs (when not directly by the first author). The first author then contacted those who agreed on participating to ensure that they complied with the criteria and to agree on the time and day for the interview.

Individual, semi-structured interviews were carried out using a topic guide. The explored topics included perceived quality of health care provided to immigrants in general and of its technical and interpersonal components, resolution capacity; changes perceived during the crisis, and the attributed causes and mechanisms. Topics were addressed with open-ended and probing questions and were discussed as they came up during the interview. Interviews were conducted in places convenient to informants: with health personnel, in the health facilities, and with users their homes or community centres. They lasted between 40-80minutes, were audio-recorded and transcribed verbatim. An Arabic interpreter was needed in four interviews.

Thematic analysis was carried out using the Atlas-ti software. Data was segmented by areas and type of informants. Categories of analysis were generated through a process of mixing those from the topic guide with those emerging from the data. Themes were identified, coded, re-coded and classified in order to identify common patterns by looking at regularities, convergences and divergences in data in a process of constant comparison, going back and forth between the data and the conceptual framework. Quality was ensured through triangulation, by comparing different areas and groups of informants. Three analysts with different backgrounds and a good knowledge of the context participated in the analysis.

To identify the informants producing the discourse, a set of abbreviations is used: a) type of informant: medical professional (MP), administrative professional (AP), immigrant users (U); b) area: Barcelona (B), Baix Empordà (BE); and c) healthcare level: primary care (PC) or secondary care (SC); followed by a serial number.

This study was approved by the Ethical Committee for Clinical Research of the Municipal Health Institute of Barcelona (2014/5708/I) and the Jordi Gol and Gurina Foundation (P14/159). Written consent was obtained from every participant prior to interview. Confidentiality and anonymity were guaranteed.

A deterioration in the diagnostic process emerged: while medical professionals refer to a potential increase in diagnostic errors and superficial anamneses, immigrants report superficial examinations and non-specific diagnoses and treatments. Both groups attribute these to a reduction in the time available per patient, which professionals considered insufficient and forces them to work quickly (“I can’t work as well as I’d like to [APBE02PC]”) (Table 4 a, b). Moreover, they highlight difficulties in producing a good anamnesis, especially for patients with a language barrier or cultural differences when reporting pain/discomfort. According to some professionals it makes caring for a patient a more “laborious” process (Table 4 c-e) and aggravates the pressure they are under as it prolongs consultation and waiting times. Immigrant users described superficial physical examinations and non-specific diagnoses and treatments: “[…need] to examine her more closely (…) I want to know what the problem is” (UB05) (Table 4 f, g). Both professionals and users attribute the reduction in consultation times to staff cutbacks leading to an increase in assigned patients. Some immigrant users in Barcelona attribute mistakes in procedures to the employment of young and inexperienced professionals (Table 4h, i).

Secondly, professionals and users report the inadequate use of diagnostic tests and limitations to treatments. Some professionals point out that they are unable to request all the necessary tests or they substitute them for more invasive procedures in order to avoid the additional bureaucracy involved in getting the most suitable tests performed (Table 4 j, k). According to immigrants, the professionals “avoid” requesting diagnostic tests due to cutbacks in spending during the crisis (Table 4 l, m): “They avoid doing tests (…) We’re in times of crisis (…) they don’t generate more costs” (UB06). However, a PC doctor considered that restricting tests had allowed them to go back to being a complement to physical examination and anamnesis (Table 4 n). Professionals also point out restrictions on treatments (those considered non-first choice), hence they are not always able to adapt them to the patient's individual needs, and they attribute this to increased controls on spending since the economic crisis: “They control you more. Resources have been severely limited (…) what isn’t in the [clinical] guidelines as the first choice (…) you have to justify” (MPBE07PC). Users report the prescription of non-specific treatments (analgesics), with no alternatives offered when the health problem is not resolved (Table 4 o).

Some SC doctors in Barcelona highlight difficulties in making more precise diagnoses because the technology used is obsolete or does not work properly, which they attribute to a lack of investment due to budget restrictions (Table 4 p).

Professionals and users generally perceived that the relationship between professional-patient has deteriorated in recent years. Medical professionals indicate that less empathetic responses on their part are more common (Table 5 a, b), whilst immigrants, in addition to perceiving they are treated worse, report worse communication because medical staff do not allow them to ask questions or provide explanations “they don’t listen like they used to” (UB09) (Table 5 c). Both groups attribute this to tiredness due to the increasing work overload and worse working conditions of professionals, but also to a change in the attitude of both professionals and users (Table 5 d, e). According to medical professionals, although some users are more understanding because of the crisis, others are more demanding and insist on immediate solutions. According to administrative professionals, this leads mostly immigrant users to perceive they are being treated poorly when they are asked to present paperwork in order to access care: “We’re not out to screw the patient over (…) I can’t [give them access]” (APB06PC). Nevertheless, some users perceive that they are treated as if they were “worth nothing” (UBE08) and they attribute this to their situation of exclusion from the system (Table 5 f, g).

In the discourse of medical professionals and immigrant users, a reduction in the resolution capacity of the health services emerges marginally, in both care levels but especially in primary care. PC doctors report the repetition of consultations for patients waiting to receive SC (surgery or diagnostic tests) which, in addition to not resolving the problem, reduces accessibility to PC (Table 6 a) and leads some medical professionals to mark requests for ordinary tests as priority/urgent (Table 6 b). In SC, medical professionals highlight inappropriate responses or a failure to respond to problems of low complexity because they prioritise the most severe/urgent cases (Table 6 c). “Our main (…) priority is severity (…) low complexity problems (…) you don’t give them any answers” (MPB06SC). Likewise, some young immigrants perceive that their problems are relegated in the face of more complex cases and that they are treated as “secondary” (UB06) (Table 6 d).

Lastly, some social workers in Barcelona point out delays in the discharge from hospital of patients who are clinically stable but have social problems (mostly immigrants), since this hinders the appropriate use of hospital beds (Table 6 e).

The results point to a deterioration in technical quality related to the reduction in consultation times, also described in previous studies15,29 and restrictions on diagnostic tests and treatments, attributed to cutbacks in resources, especially health personnel. This suggests that diagnostic errors may have increased during the crisis, due to superficial anamnesis and examinations and an inappropriate use of tests. Further research is required on medical errors to contrast these results.

These problems appear to affect immigrant users more acutely. Some are consistent with problems described in immigrant care prior to the crisis, in this30 and other contexts,19 but seem to have become more acute. Allowing enough time is particularly relevant for immigrant patients when making a diagnosis, because of the communication difficulties that often arise due to linguistic/cultural barriers and which may be further complicated by the reduction in mediation staff.

Furthermore, the inappropriate use of tests and treatments due to restrictions, although it affects the whole population, could translate into an increase in the inequities described in previous studies showing that immigrants undergo less diagnostic testing and experience longer waiting times for appointments in SC.25,31

Professionals and users coincide in reporting that treatment to patients had got worse and they attributed this to a deterioration in the working conditions of professionals and a change in the attitude of patients. This result is in contrast with available indicators according to which the personal treatment received from professionals remained highly rated in Catalonia and Spain (1995-2015),17 although this difference may be because the data is not disaggregated by the origin of the user.

Professionals attribute this not only to the work overload but also to a more demanding attitude of patients because of the economic crisis, although in previous studies professionals associated this attitude (more aggressive or demanding) with certain groups of immigrants,32 so this may be reflecting the professionals prejudice rather than the actual situation of crisis. Users report worse treatment from administrative staff towards the most vulnerable (particularly, those without IHC) which may indicate variability in their responses. Receiving an inadequate treatment is especially relevant because it can have a dissuasive effect on immigrants’ use of the health services.27

Although our study does not allow us to evaluate the effectiveness of interventions, the results appear to indicate a reduction in the resolution capacity of the health services, in both care levels but especially in PC, due to cutbacks in human resources and a consequent increase in waiting times for SC. These results are consistent with the increase in average waiting times for basic specialties,16 or worsening of some quality indicators such as avoidable hospital admissions for congestive heart failure (CHF) in adults that increased by 1.8% over the period 2008-2013.33

Delays in hospital discharges for socially vulnerable patients, apart from contributing to a reduction in the effectiveness of the services, is evidence that the health system is containing problems that should be addressed by other sectors, such as social services, which have also been affected by policies adopted in the context of the crisis.

The deterioration in working conditions of the health professionals due to increasing workloads emerges as a reason for the drop in technical and interpersonal quality of care. During the crisis, policies were designed that affected the pay of NHS staff (RDL 08/2010; RDL 20/2012; Ley 2/2012), although their implementation has varied among the autonomous region. The data is difficult to access, but available studies indicate a generalized reduction in variable bonus payments over the period 2009-2014 and they have disappeared altogether in some regions.34 Moreover, health professionals without a permanent position work on average 5.73 contracts per year, of a duration of less than six months or part time.35 Furthermore, the presence of young, inexperienced professionals, which users relate to a loss of care quality, could be an indication of a lack of staff to oversee training due to retired professionals not being replaced.

As reaching migrants without IHCs was more difficult than expected, identified changes in perceived quality of care might be worse than our results suggested. Results are based on main actor's opinions, hence further studies are needed to deepen the analysis and establish the size of the problem.