By Miguel Ángel Manzano, independent researcher and editor of the blog Llei d’Engel

There is growing evidence that COVID19 is having an enormous impact on the long-term care system in Spain. Older people’s services are particularly affected, although the impact also extends to other services and groups.

There are no official statistics on the numbers of people who have tested positive for, or died from, COVID19 in care homes. Analysis by Vanessa Davey, based on figures published in newspapers, estimates that by the 26th of March there had been 1,548 deaths in care homes in Spain. Newspaper reports about care homes calling on the army or fire service to help due to staff shortages and the overwhelming numbers of deaths, provide further proof of the catastrophic nature of the outbreak.

A number of problems have emerged:

• The collapse of care provision due to staff shortages and large number of deaths. Reports of the mayor of a village and other local politicians stepping in to provide care in local residential homes and the statement from the Defence Minister concerning the army finding dead residents in care homes, have had an enormous social impact.
• The systemic lack of care staff, which has been exacerbated by the impact of COVID19 on rates of sick leave. Although data is being collected on the number of health system staff affected by the illness, but there is no equivalent data collection for social services staff.
• Poor working conditions that make it more difficult to deal with the outbreak. There has been no widespread testing yet and as of the 29th of March, personal protection equipment was about to be distributed in some parts of Catalonia.

Some of these issues stem from long-standing systemic dysfunctionalities in the long-term care system that have become fully apparent during this emergency. The system relies on care within the family, with or without formal support, and care homes. This has resulted in both a large number of care homes, and of older people who live in intergenerational families.

The care home sector is increasingly dominated by private for profit providers, and there are longstanding concerns about decreasing quality standards as a result of efforts to contain costs. The same issues are faced by public sector facilities that are managed by private providers. These factors may be behind the lack of preparedness to face a pandemic, which shows that most care homes are lacking infection control protocols, contingency planning for staff absences and the ability to procure personal protection equipment.

The COVID19 crisis has  also brought to the surface systemic problems in relation to human resource management. Professional profiles are poorly developed in terms of competences and training, and working conditions are less than ideal. In contrast with the health care system’s response to COVID19, there has been a clear lack of leadership in the response to the crisis.The logic of the residencial and domicilary care models respond more to organisational convenience than to person-centered care. This makes the transition between different forms of care, as advocated by Fernando Fantova as one of the responses to the COVID19 challenge, very difficult. This is made even more difficult by lack of capacity of community-based care services

The governance of the Spanish long-term care system involves all three levels of government (central, regional and local), which makes the system very unwieldy (see Manuel Aguilar Hendrikson, p. 28). This complicated governance makes it very difficult to adopt and implement ambitious measures and it has created legal difficulties in relation to, for example, purchasing equipment and re-organizing the workforce in response to the pandemic.

Measures to respond to the COVID19 crisis in long-term care:

• Given this background, it is perhaps unsurprising that the main policy decisions taken in response to the pandemic have been reactive and very different regionally and locally. Key measures include:

• Social funding: The central government has approved an  Extraordinary Social Fund of 300 million euros for regional governments to use for emergency social spending, including funds to strengthen the long-term care systems. It has also granted permission for local councils to allocate an additional 300 million for social care from their budgets.
• Organisational measures: both the central and the regional governments have new legal powers enabling them to:
  • require that social care staff provide additional services
  • recruit additional staff by temporarily suspending the accreditation requirements
  • facilitate the hiring of staff without the minimum qualification requirements.
• Technical support: different administrations, professional groups and non-governmental organisations (NGOs) have developed protocols and guidelines to  help social services respond to the pandemic. A compilation of these resources is available at  SiiS, Centro de documentación y estudios, including a selection of technical documents at: #covid19 ServiciosSociales.

The public administrations and care providers have also adopted many contingency measures, including:

• Using new facilities for isolation.
• Adapting hotels to care for older people who have COVID-19.
• The evacuation of care homes that are no longer viable.
• Increasing staff numbers by launching a recruitment drive.
• Mass purchasing of personal protection equipment.

On the 29th April, news have emerged of a new agreement by the Barcelona City Council that changes profoundly the crisis management of care homes. The City Council will be able to deploy all their human resources (over 4,000 home care staff) to replace staff from the 255 care homes in the city if they go on sick leave, or if additional support is required. This decision removes governance barriers that according to which care homes were the responsibility of the regional government.

Suggested citation: Manzano M.A. (2020) Report: COVID-19 and long-term care in Spain: impact, underlying problems and initial measures. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE.