Marcel Slockers

17 General introduction kind of case manager, they help with various problems, especially when regular care seems absent or impossible. In addition, Rotterdam has an Urban Homeless Team, which consists of a street doctor, a street psychiatrist and a psychiatric nurse. They offer psychiatric care and treatment to rough sleepers and motivate them to accept healthcare. Unique to Rotterdam is the fact that this team also includes field workers and social workers. The overall picture shows big differences between local governments in policy, finance and organisation of social-medical care for homeless people. Based on surveys, the Dutch Street Doctor’s Group has shown a large variety in the number of consultancy hours. The 43 so-called centrumgemeentes, an inter-municipal cooperation between different munic- ipalities, receive state funding for social care. Of the 60% response rate, 25% reported not having any policy for social-medical care, while 65% had no policy for dental care for homeless people. 33 Other reports also showed shortcomings in social-medical care, as was the case in The Hague. 34 Reports on the approach of disoriented people indicate a lack of sufficient social-medical care for homeless people. 35,36 Likewise it was stated that disoriented, confused people become more confused by all the rules and regulations in society. The disoriented person loses grip on his or her situation, and therefore receives less rather than more care. Furthermore, the report mentions additional barriers to healthcare accessibility for people without an address, as they lose the right to insurance. 35 The report presents a proposal on how to organise and improve healthcare for disoriented persons, which includes possible cooperation between the police and street doctors. 37 In the Netherlands, important research has been conducted into end of life care for homeless people. During end of life care, palliative sedation with morphine and midazolam does not seem to work well for homeless people, who often have a history of using tranquilisers and opiates. 38,39 Other Dutch studies also detail the complexity of end of life care for homeless people. They describe an uncomfortable life, followed by an uncomfortable death. 40,41,42 In international publications and during conferences, people draw attention to inappro- priate and excessive use of the Accident & Emergency Departments (A&E) by homeless people. 16 The Rotterdam street doctors have been working together with one particular A&E-physician from the Erasmus MC, who also participates in their meetings. When homeless people can be directed from the A&E to the street doctors in the shelter, they receive more adequate healthcare, and it alleviates the pressure of inappropriate visits to the A&E. How is medical care for homeless people financed? Before the introduction of the Zorgverzekeringswet, the new Dutch Health Insurance Act, in 2006, there was a distinction between private patients and patients covered by