What went wrong and what could be learned from the institutional and organizational Management of Care Homes during the Covid-19 pandemic in Spain

Eloísa del Pino, Francisco Javier Moreno-Fuentes, Gibrán Cruz-Martínez, Jorge Hernández-Moreno, Luis Moreno, Manuel Pereira-Puga, and Roberta Perna (2020) “Gestión Institucional y Organizativa de las Residencias de Personas Mayores y COVID-19: dificultades y aprendizajes”. Institute of Public Goods and Policies of the Spanish National Research Council (IPP-CSIC) Madrid.


This report is based on the Spanish case study of the McCovid19 research project, conducted by the Social Policies and Welfare State Research Group (IPP-CSIC). This project aims to analyse the challenges posed by the Covid-19 pandemic to the governance of the care homes sector, as well to the articulation of the health care and LTC sectors in the EU15.

According to all available data, Spain has been one of the European countries most seriously hit by the pandemic, experiencing dismaying figures regarding the number of deaths in care homes for older people. Between March and August 2020, at least half of the deceased due to the pandemic resided in care homes.

Although it is premature to establish the relative weight that the management of the care homes sector may have had in the death-toll rate vis-à-vis other factors, everything seems to indicate that had there been preventive measures and emergency plans in place that could have prevented the entry of the virus and its transmission within the nursing homes (or at least reduced its intensity), the number of deaths may have been sensibly smaller. To better understand what happened in these centres, and to facilitate policy learning, this study identifies the difficulties faced by institutional actors and nursing homes’ managers between January and August 2020.

The research team conducted 25 in-depth interviews with managers in care homes in Spain (directors, administrators, and medical supervisors) within eight different regions (Comunidades Autónomas). High-ranking officials responsible for social services and the public healthcare sector, both at the central and the regional levels, as well as representatives of trade unions and nursing homes associations were also interviewed. Documents issued by governmental and independent sources, together with the results of a survey elaborated by the Institute for the Older-age and Social Services (IMSERSO) of the Ministry of Social Affairs were examined. Furthermore, a survey on citizen’s attitudes toward public policies (7,175 respondents, conducted between the end of August and mid-September 2020 and including questions about citizen’s perception of the handling of the epidemic) was conducted and analysed for this research.

Lessons from our analysis

Residents in care homes live collectively, something which contributes to the spread of infections and diseases. Furthermore, their age, the frequent occurrence of concomitant chronic conditions, and the widespread lack of personal autonomy (implying the need for daily interaction with carer-givers), make this population especially vulnerable to Covid-19. Anticipating this scenario would have permitted to include these groups in national security strategies and emergency plans.

Crises are often elusive in their initial phases, when the intervention needs to be more effective. Consequently, plans and programs for this type of eventualities must be well known by the authorities, which has not been the case in this crisis. To this end, it is also indispensable, at the operational level, to train the health and care personnel on the protocols and measures that may allow them to minimize the risks emanating from a pandemic.

Moreover, distant threats should not be underestimated, while domestic capacities should not be overrated (especially after having gone through a huge economic crisis during the last decade that seriously affected the healthcare and Long-Term Care sectors).

Inter-sectoral coordination between healthcare and social services (which concerns ministries and Regional departments), as well as between care homes and healthcare centres, must be immediately activated in a pandemic. The relationship between the NHS and long term care has always been susceptible to improvement. The lack of coordination between these two sectors can be extremely damaging, as this research project confirmed in the case of Spain during the Covid-19.

After the 2009 swine flu (H1N1) pandemic, some countries re-evaluated which institutions should be responsible for managing a sanitary crisis given the overburden of the healthcare sector (whether it should be central ministries, or their equivalents at the regional level). Governmental responsibilities and tasks should be clearly established in advance. In the case of the care homes sector in Spain during the Covid-19 this coordination has been timid and scarce.

If crises are well-managed, they may become fruitful and positive for the ‘owner of the crisis.’ But if they are ill-handled, they can be extremely damaging for all stakeholders and the general public. In Spain, 73% of citizens believe that care homes have not been adequately managed during the pandemic. Specifically, 45% of respondents thought that the main responsible for the management of the nursing homes were the regions; 24% believed that it was a responsibility of the central government; and 28% thought that both government levels were equally responsible. It is important to underline that the politicization of the crisis by governments and political actors might have led citizens to doubt about how seriously they should take public health recommendations (in addition to delegitimizing the healthcare and social systems).

The health and social services systems have shown severe problems in terms of capabilities to secure resources, technology and professionals to manage the crisis. The insufficiency of data collection mechanisms, materials and tests highly conditioned public health responses.

Agreeing on a shared information system about care homes between different levels of government is crucial. Care homes must receive feedback on the data they provide to the system, which will be very useful for managing the current and future crises at the macro and micro levels.

All care homes should have contingency plans informed in situ, with inputs from Social Services and not just programmed at a distance by experts. The personnel in charge of implementing them ought to be trained according to their responsibilities. Health and sanitary protocols to be applied in care homes should not be designed without Social Services input. On several occasions, protocols call for actions that the care homes cannot implement due to their very architectural configuration, the organization of the way they work, and/or the specificities of the residents. In other occasions these instructions could be implemented, but at the cost of severely undermining the care functions of these centres or further aggravating the spread contagion.

Governmental authorities must anticipate the potential overload that the residential system might suffer due to the number of workers that will be on sick leave. In the first phase of this crisis, contagion, fear, and overly strict protocols (or the opposite) often overburdened nursing homes’ staff, which had to take on tasks they were unprepared for, including attending the health needs of their residents. As a consequence, the quality of healthcare received by these residents was clearly inadequate.

Likewise, it should be emphasized that the implication and commitment of the public healthcare system (public health, primary care, and hospitals) on the care homes sector during the first phase of the pandemic was clearly insufficient in some regions. In a context of severe crisis, the possibility of hospital overflow must be anticipated, and triage criteria must be ethically informed. Residents in geriatric centres should not be equated with terminally-ill patients.

Arrangements concerning deceased people in nursing homes need to be optimized to avoid the dramatic situations experienced by residents, their families and care homes personnel in the first stages of the pandemic.

One of the most effective practices for containing outbreaks has been transferring Covid-19 patients to other temporary centres, allowing healthy residents to keep living as close to normal as possible in their environments, which is very relevant to their physical and mental health.

Policy implications

The sometimes-poor management of the previously mentioned issues and factors can explain, at least partially, the poor results of Spain in this context. Although experts on crises recognize that even the best planning may not provide a perfect response to an emergency situation like the one provoked by Covid-19, the scientific literature explains and anticipates many of the management problems that emerged during this crisis.

Beyond the current crisis, it is necessary to rethink the future of the LTC sector in Spain. Fourteen years after the definition of the Spanish dependency system, and after the budget cuts introduced in the aftermath of the 2008 financial crisis, it seems crucial:

  • To secure quality LTC services for the older-age adults and for those who care for them. The entire society will benefit from the investment returns made to achieve this objective.
  • To avoid ‘medicalization’ of the care homes sector, exploring alternatives such as improving the coordination mechanisms between the healthcare and social services sectors.
  • To be attentive to proposals related to the future of the Social Services and LTC and its de-institutionalization.

It is still early to assess what the burden of managing the pandemic has been in the Covid-19 casualty count. Other factors, such as the moment in which the virus arrived in a country or region, the incidence in the territory, the type of healthcare system, the aging of the population, the population density, and other social and cultural determinants of health and social behaviours, can contribute in explaining the widespread impact of the pandemic in Western Europe in general, and in Spain in particular. However, the scientific literature on crisis management, following studies on governmental responses to the most different events (e.g. terrorism attacks, accidents, public health catastrophes, etc.), has identified various factors that hinder decision-making and the implementation of emergency responses in situations of maximum pressure. Many of them have been present in this crisis and should be carefully studied and addressed to plan our response to future sanitary emergencies.

Visit the McCovid website to learn more about the project.

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