LTCcovid Country Profile – Printable Version

1.00. Brief overview of the Long-Term Care system

According to the Spanish Constitution, responsibility for Long-Term Care in Spain is mainly at the regional level (Autonomous Communities), although provincial and local authorities also have a role in care provision.

The 2006 ‘Dependency Act’ (law 39/2006) which aimed to create new public national care coverage as the ‘fourth pillar of the welfare state’. The Act aims to guarantee the rights of citizens to personal autonomy and care to people in a situation of dependency through the creation of the System for Autonomy and Dependency Care (SAAD), with the collaboration and participation of all public administrations and the guarantee, by the central government, of a minimum common rights for all citizens.

The Act established two types of long-term care benefits: 1) in-kind services, and 2) economic benefits, and it gave the former a priority. The law lists social services which contribute to long-term care:  services for averting dependency and enabling personal independence; tele-assistance services; home care services (help with home tasks and personal care); day and night care centres; residential services. All benefits and services established in the law are integrated in the social services provided through the autonomous regions (Guillen et al. 2017).

References:

Montserrat Guillen, Ramon Alemany, Manuela Alcañiz, Mercedes Ayuso, Catalina Bolancé, Helena Chuliá, Ana M. Pérez-Marín, and Miguel Santolino (2017). Country Report: Spain. Retrieved from European Network on LTC (CEQUA).

Update for: Spain   Last updated: April 29th, 2022   Contributors: Sara Ulla Díez  |  Esther Pérez de Vargas Bonilla  |  

1.01. Population size and ageing context

In Spain, the share of the population aged 65 and over was 19.6% in 2020 and is expected to reach 26.5% in 15 years. Two trends are emerging, on the one hand, the ageing of the oldest-old,  with a notable increase in the numbers of people over 100 years old (from 12,550 in 2020 to 49,730 in 2035). On the other hand, there is a gradual decrease in women of childbearing age since, if current demographic trends continue, the population loss in the next decade will be concentrated in the age groups of 30-49 years, with this group decreasing by 2.8 million (Martínez-Buján, et al, 2021).

References

Update for: Spain   Last updated: March 10th, 2022   Contributors: Carlos Chirinos  |  

1.01. Population size and ageing context

In 2019, the total population in Catalonia was estimated to be 7.619.494, of which 51% were women and 49% were men. Like most European regions, Catalonia has an ageing population, with 18,9% of the population aged 65 or older, and 6% of the population aged 80 or older. These figures follow an increasing tendency over the last decades and are expected to continue to do so (22,3% of the population is expected to be aged 65 or older in 2030 according to mid-range scenario projections). (Source: https://www.idescat.cat/pub/?id=aec&n=253&t=2010)

Update for: Catalonia (Spain)   Last updated: February 10th, 2022   Contributors: Gemma Drou-Roget  |  

1.02. Long-Term Care system governance

Generally speaking, LTC services are under regional administrations. Delegating the provision of LTC services and benefits to the regions has entailed differences in the access to benefits in different regions. Even though social services are managed, regulated and promoted by the autonomous regions, there are some programmes promoted by the central state, for example  vacations programmes for older people which are partly subsidised by the state (Guillen et al. 2017).

References:

Montserrat Guillen, Ramon Alemany, Manuela Alcañiz, Mercedes Ayuso, Catalina Bolancé, Helena Chuliá, Ana M. Pérez-Marín, and Miguel Santolino (2017). Country Report: Spain. Quality and cost-effectiveness in long-term care and dependency prevention. CEQUA LTC Network. Retrieved from European Network on LTC (CEQUA).

Update for: Spain   Last updated: February 10th, 2022

1.03. Long-term care financing arrangements and coverage

In 2016 public LTC expenditure in Spain was estimated to represent 0.9% of Gross Domestic Product (source: European Commission: The 2018 Ageing Report). Spain has a tax-based long-term care financing system, with national eligibility criteria and defined benefits, run at regional level and financed by national, regional and local funding. National funding aims to take into account differences in population need (equalization function). Co-payments are means-tested (source: Joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-2019-update_en). Overall, funding and coverage of LTC services in Spain is considered to be highly inadequate to meet people’s needs, and long waiting lists to receive services are a pressing issue nationwide and at a regional level (Zalakain et al. 2020).

References:

Zalakain, J. Davey, V. & Suárez-González, A. (2020). ‘The COVID-19 on users of Long-Term Care services in Spain’. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

Update for: Spain   Last updated: February 10th, 2022

1.04. Approach to care provision, including sector of ownership

A number of public services are provided by private entities, both for and non-profit. In the care home sector, although marketisation has led to an increase in the available places, this is considered to have been at the expense of the quality of services, Public administrations have difficulties in terms of inspecting and evaluating services. Additionally, migrant workers, often without an official contract, provide a share of home care in Spain (Zalakain et al. 2020).

Data on the social care workforce in different settings:

Looking at the settings in which the social care workforce is employed gives a good indication of the scale of different types of care in Spain. Analysis by Martinez-Bujan et al (2021) shows that in 2020 there were estimated 684,949 people working in social care (based on data from the EPA survey), representing 3.7% of the total number of employed persons in Spain. 

66.3% of social care workers were employed in private households, either as home carers (17.7%) or as domestic workers (82.3%).

Carers working in care homes represented 19.9% of the total care workforce (most them  employed as nursing assistants), and carers in social services without accommodation (mostly home help services, usually referred to as SAD) represent 13.9% of the care workforce.

References:

Martínez-Buján, R.; Jabbaz, M. and Soronellas, M. (2021) El cuidado de mayores y dependientes en España ¿En qué contexto irrumpe la covid?. In Comas-d’Argemir, D. and Bofill-Poch, S. (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Zalakain, J. Davey, V. & Suárez-González, A. (2020). The COVID-19 on users of Long-Term Care services in Spain. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

Update for: Spain   Last updated: March 10th, 2022   Contributors: Carlos Chirinos  |  

1.05. Quality and regulation in Long-term care

The Spanish LTC system has three instruments to ensure quality: 1) a national and regional regulatory system; 2) formal quality controls; and 3) good practices. The regulation of quality in terms of services and the training of professionals and carers is developed through the Council of the System for Autonomy and Care for Dependency (CISAAD) which sets the minimum criteria for the whole state with respect to minimum carer-to-recipient ratios, staff qualifications, and resources/equipment/documentation applied to all accredited care centres. The CISAAD also establishes essential quality standards for homecare and residential care. Accredited centres can be inspected at the request of a dependent user or randomly by the autonomous community. The formal quality controls of the LTC system (the SAAD) are based on the accreditation systems established by each regional authority. Although there is a common denominator among them, each region has its own specific regulation and quality plan. With regard to good practices, the CISAAD agreed on common criteria to define, develop, and evaluate good practices in 2011, however most regions have not developed tools to evaluate good practice (Rodriguez Cabrero et al, 2018).

Leon and colleagues have identified a weak and fragmented regulatory system as one of the factors that contributed to delays in the implementation of measures to prevent COVID-19 in care homes in Spain.

References:

León, M., Arlotti, M., Palomera, D., & Ranci, C. (2021). Trapped in a Blind Spot: The Covid-19 Crisis in Nursing Homes in Italy and Spain. Social Policy and Society, 1-20. doi:10.1017/S147474642100066X

Rodriguez Cabrero G, Montserrat Codorniu J, Arriba Gonzalez de Durana A, Marban Gallego V and Moreno Fuentes FJ (2018) European Social Policy Network Thematic Report on Challenges in Long-Term Care, Spain. European Commission, Brussels.

Update for: Spain   Last updated: November 23rd, 2021

1.06. Care coordination

The provision of LTC in Spain is fragmented, due to the intervention of many agents and the differences between the autonomic regions. There have been several initiatives to improve care coordination through: the creation of social and healthcare coordination structures, the implementation of shared information systems, improving the comprehensive assistance in social centres and promoting the creation of hospital assistance units of continuity (Guillen et al., 2017).

A published study aimed to analyse the residential care crisis in Spain in the context of the COVID-19 pandemic and its impact on high mortality and abandonment of the user population. The theoretical focus of the analysis was the comprehensive and person-centred care (CPCC) model based on the autonomy of people and the centrality of their rights. The study concludes by proposing a comprehensive reform of long-term care that includes both a change in residential care in the form of small cohabitation units and reinforcement of care in the home and the community as a growing preference for the elderly population. An optimal combination of residential and home care is the basic proposal of this work (Gallego et al., 2021).

References:

Gallego, V. M., Codorniu, J. M., & Cabrero, G. R. (2021, January 1). The impact of COVID-19 on the elderly dependent population in spain with special reference to the residential care sector. Ciencia e Saude Coletiva. Associacao Brasileira de Pos – Graduacao em Saude Coletiva. https://doi.org/10.1590/1413-81232020261.33872020

Guillen M. et al. (2017) Country Report – Spain. Quality and cost-effectiveness in long-term care and dependency prevention. CEQUA LTC Network.

Update for: Spain   Last updated: February 10th, 2022   Contributors: William Byrd  |  

1.08. Care home infrastructure

In February 2022 there were 352,227 people living in care homes in Spain, according to the Spanish National Institute of Older People and Social Services (IMSERSO). Of these, 86.2% were living in care homes for older people.

In 2020 three in every four LTCFs in Spain are privately run and the fees for many residents are publicly funded. Mas Romero et al (2020) identify as a factor that may have affected the ability of care homes to respond to the challenges of COVID-19 that the fees received by the care homes have not increased for a long time, a result of austerity measures, resulting in many private facilities making cuts to maintain their profits, for example by operating with minimum staff (Mas Romero et al., 2020).

Autonomous Communities have responsibility for care homes, which contributes to the care home sector being remarkably heterogeneous and complex, with differences in criteria on what constitutes a care home for the older people or people with dependency by each autonomous community (Abellán García et al., 2019). In Spain, 5,542 care homes have some 389,031 places to care for older people. Most of these centres, 4,107 (74.1%), are private, while 1,435 are public (25.9%) (Comas-d’Argemir et al., 2021). The Community of Madrid is the one with the highest proportion of private care homes (86.8%), followed by Catalonia (85.1%) and the Basque Country (74.1%) (IMSERSO, 2020). The average number of beds in care homes in Spain is 70.2, representing a notable increase compared to 2009 when centres with fewer than 50 beds prevailed (Comas-d’Argemir et al., 2021).

Despite concerns about of large care homes (IMSERSO, 2009), the macro-residence model has been implemented especially in the Community of Madrid, where 41.9% of the centres have more than 100 beds (compared to 17% in Catalonia and 16% in the Basque Country) (Abellán García et al., 2021). There are 17 care homes that exceed 300 places, and the largest has no less than 604 places. That is the case in public and privately-owned centres (Comas-d’Argemir et al., 2021).

References:

Abellán García, Antonio; Aceituno Nieto, María del Pilar y Ramiro Fariñas, Diego (2019): Estadísticas sobre residencias: distribución de centros y plazas residenciales por provincia. Datos de julio de 2019, Informes Envejecimiento en red nº 24, Enlace.

Abellán García, Antonio; Aceituno Nieto, María del Pilar; Fernández Morales, Isabel y Ramiro Fariñas, Diego (2020): Una estimación de la población que vive en residencias de mayores, Informes Envejecimiento en red, Enlace.

Comas-d’Argemir, Dolors; Legarreta, Matxalen y García Sainz, Cristina (2021), Residencias, las grandes olvidadas, en en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

IMSERSO (2009): Servicios sociales para personas mayores en España. Enero 2009, Boletín sobre Envejecimiento. Perfiles y Tendencias, 43. Enlace.

IMSERSO (2020): Servicios sociales dirigidos a personas mayores en España (Datos a 31/12/2019), Ministerio de Derechos Sociales y Agenda 2020, Enlace.

Mas Romero M, Avendaño Céspedes A, Tabernero Sahuquillo MT, Cortés Zamora EB, Gómez Ballesteros C, et al. (2020) COVID-19 outbreak in long-term care facilities from Spain. Many lessons to learn. PLOS ONE 15(10): e0241030. https://doi.org/10.1371/journal.pone.0241030

Update for: Spain   Last updated: March 10th, 2022   Contributors: Carlos Chirinos  |  Adelina Comas-Herrera  |  

1.08. Care home infrastructure

In Catalonia, according to data from 2016, people living in an assisted living facilities, compared to the entire population over the age of 64, have greater dependence and clinical complexity and are on average 10 years older than those who do not live there (85.7 years vs. 75.7 years). The average age of patients admitted to a nursing home increases every year, with women being admitted on average almost 3 years older than men. However, people in assisted living facilities have more associated pathology, with dementia being up to 10 times higher than for people over the age of 64 in the general population (CAMFIC & AIFICC, 2016).

Catalan Long-Term Care facilities can have public, private or subsidized places. The facilities that are part of the Catalan Social Services System (public and private ownership), that is, that have been authorized by the DTASF or the DS (in the case of drug addiction therapeutic communities) are intended for 4 large groups of people and various residential resources are identified for:

1. Older people:
   1. Assisted residence for the older people on a temporary or permanent basis.
   2. Sheltered housing for the older people on a temporary or permanent basis.
   3. Temporary or permanent home for the older people
2. People with disabilities:
   1. Residences and Homes Residences for people with intellectual disabilities.
   2. Residences and Homes Residences for people with physical disabilities.
3. People with mental illness and / or addictions:
   1. Residences for people with mental illness.
   2. Homes Residences for people with mental illness.
   3. Therapeutic communities and reintegration flats for the care of people with drug addictions.
   4. Residences for Children and Adolescents with Autism Spectrum Disorder.
4. Child under custody:
   1. Educational Residential Centers.
   2. Residential Center for Intensive Education Action.
   3. Reception Centers.
   4. First Aid and Emergency Services.

According to 2019 data published by the Consejo Superior de Investigaciones Científicas (CSIC) in Catalonia, there were a total of 62,015 places for the older people in facilities, 12,601 (20.3%) publicly owned and 49,414 privately owned (79.7 %). (CAMFIC &AIFICC, 2016).

References: 

CAMFIC & AIFICC (2016) Model d’atencio sanitaria a les residencies de Catalunya.

Update for: Catalonia (Spain)   Last updated: March 10th, 2022   Contributors: Cèlia Estruch  |  

1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages

Low public spending on LTC, is related to low wages in the sector, for example, the monthly cost per LTC employee is 67% of the average wage in Spain. Poor working conditions are the norm in a sector where women are the majority. In care homes, staff ratios vary markedly between regions and are generally inadequate (Zalakain et al. 2020).

A mostly female and migrant workforce

In 2020 there were 684,949 people working in social care (based on data from the EPA survey), representing 3.7% of the total number of employed persons in Spain. 66.3% of social care workers were employed in private households, either as home carers (17.7%) or as domestic workers (82.3%). Carers working in care homes represented 19.9% of the total care workforce (most them  employed as nursing assistants), and carers in social services without accommodation (mostly home help services, usually referred to as SAD) represent 13.9% of the care workforce.

In all occupations women exceed 90% of the workforce, specially among domestic services, where 98.3% are female. Migrant workers represent 62.2% of domestic workers, 49.2% of home carers and 25.6% of nursing assistants (Roca et al., 2021).

Improving the working conditions of female workers is essential to ensure the quality of care. This is no a homogenous sector since it is very different to work in a care home, in a Home Help Service [SAD], or as a home and care worker (Martínez-Buján, 2011; Moré, 2015; Roca, 2017). But there are some common characteristics among care workers since they all share precarious working conditions. They also share that they are feminized and poorly qualified jobs, converted into a labour niche for foreign migrants with little recognition. Domestic workers have the worst working conditions and suffer from an evident lack of rights (Comas-d’Argemir and Martínez-Buján, 2021).

Female care workers face various obstacles to professionalization. One of them is related to the persistence of a family model of care that links care to the home (preference to grow old at home), where an individualizing logic predominates and where the figure of the family caregiver extends into that of the paid caregiver (Moreno-Colom et al., 2016). The other obstacle is that little or no qualifications are required to do this job, based on the naturalisation of expertise considered unique to women, which justifies the low salaries (Recio Cáceres et al., 2015). That weakens the capacity for collective action and increases the insecurity and vulnerability of these workers (Cañada, 2021). Job insecurity is the enemy of quality care. Low wages, part-time work and temporary employment generate a high turnover of female workers, especially the youngest, who can access more qualified qualifications and easily leave the sector searching for better-paid jobs. Or they go to the health sector, where there are better salaries. The lack of specific training to treat certain pathologies also affects the quality of care (Comas-d’Argemir and Martínez-Buján, 2021). The dichotomy is clear: either the costs of care are assumed socially so that it is carried out in decent conditions, or women continue to be exploited, either as unpaid family caregivers or as cheap labour. That is the current model in the Spanish context (Comas-d’Argemir and Martínez-Buján, 2021).

References:

Cañada, Ernest (2021) Cuidadoras. Historias de trabajadoras del hogar, del servicio de atención domiciliaria y de residencias, Barcelona, Icaria.

Comas-d’Argemir, Dolors y Martínez-Buján, Raquel (2021), Hacia un modelo alternativo de cuidados, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Martínez-Buján, Raquel (2011) La reorganización de los cuidados familiares en un contexto de migración internacional, Cuadernos de Relaciones Laborales, 29, 1, 93–123.

Moré, Paloma (2015) Cuidados a personas mayores en Madrid y París: la trastienda de la investigación, Sociología del Trabajo, 84, 85-105.

Moreno-Colom, Sara; Recio Cáceres, Carolina; Borràs Català, Vincent y Torns Martín, Teresa (2016) Significados e imaginarios de los cuidados de larga duración en España. Una aproximación cualitativa desde el discurso de las cuidadoras, Papeles del CEIC, 145, 1-28.

Roca, Mireia (2017): Tensiones y ambivalencias durante el trabajo de cuidados. Estudio de caso de un Servicio de Ayuda a Domicilio en la provincia de Barcelona, Cuadernos de Relaciones Laborales, 35, 2, 371-391.

Roca, Mireia, Bañéz, Tomasa y Hernández, Ana Lucía (2021), Trabajadoras en servicios de cuidado. Servicios sociales básicos, centros de día, asistencia domiciliaria y asistencia personal, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas.www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Recio Cáceres, Carolina; Moreno-Colom, Sara; Borràs Català, Vincent y Torns Martín, Teresa (2015) La profesionalización del sector de los cuidados, Zerbitzuan, 60, 179-193.

Zalakain, J. Davey, V. & Suárez-González, A. (2020). ‘The COVID-19 on users of Long-Term Care services in Spain’. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

Update for: Spain   Last updated: March 10th, 2022   Contributors: Joanna Marczak  |  Carlos Chirinos  |  

1.11. Role of unpaid carers and policies to support them

In Spain, the family continues to be an essential resource in care provision. Despite numerous public and private care resources that make up a complex care system, the family continues to be assigned by society the task of caring for its members. Virtually no family caregivers carry out care activities entirely alone (Soronellas & Jabbaz, 2021). Family care is carried out progressively, fitting together different resources provided by the care diamond agents: family, state, market, and community (Razavi, 2007). We will refer to this with the expression: mosaic of care resources, that is, the set of aids and services that are used to care for people in long-term care situations (Soronellas and Comas-d’Argemir, 2017). In Spain, the weakness of public policies and the lack of incorporation of men fragments care among the different provider agents, overloads women and makes it difficult for families to manage care for dependent people. In the analysis of the mosaic of care, we must consider the factors that condition access to formal care resources that we will mention: (1) Having a certain degree of dependency. (2) Have the economic capacity to finance the private outsourcing of care. (3) Living in an urban area with a great diversity of institutional resources or low public and private resources in a rural area. (4) Be willing to accept the possibility of sharing care (Soronellas & Jabbaz, 2021).

Prevalence

The Spanish LTC system is family-based often relying on women.  In 2016, 13.3 % of women and  9.5 % of men provided unpaid care. Moreover, over 50 % of informal carers provided more than 20 hours of care weekly (EC, 2021).

Impact of caring

A recent paper shows that informal carers experience significant problems due to their caring responsibilities, although the impact is greater on women than men.  It has been estimated that informal care duties pose a significant obstacles for female carers’ participation in the paid workforce, as well as reporting less time for social activities and to care for themselves. Both men and female carers’ face financial difficulties due to their caring (Peña-Longobardo, et al. 2021).

Measures to support unpaid carers

Overall, services for informal carers are considered to be scarce and vary between the autonomous communities (EC, 2021). The law however promotes support for unpaid carers, such as training programmes, information and respite care. Carers may also pay social security on a voluntary basis (Guillen et al. 2017).

References:

European Commission, EC (2021) 2021 Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Joint Report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL)

Peña-Longobardo, L.M.; Río-Lozano, M.D.; Oliva-Moreno, J.; Larrañaga-Padilla, I.; García- Calvente, M. (2021). Health, Work, and Social Problems in Spanish Informal Caregivers: Does Gender Matter? Int. J. Environ. Res. Public Health 2021, 18,7332. https://doi.org/10.3390/ijerph18147332

Guillen, M. et al. (2017). Spain. Country Report. CEQUA LTC Network 

Razavi, Shahra (2007): The political and social economy of care in a development context. Conceptual issues, research questions and policy options, United Nations Institute for Social Development, Enlace.

Soronellas, Montserrat y Jabbaz, Marcela (2021), Cuidadoras familiares, antes y depues de la pandemia, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Soronellas, Montserrat y Comas-d’Argemir, Dolors (2017): Hombres cuidadores de personas adultas dependientes. ¿Estrategias ante la crisis o nuevos agentes de cuidado?, en María Rosa Herrera y German Jaraiz (eds.), Pactar el Futuro. Debates para un nuevo consenso en torno al bienestar, Sevilla, Universidad Pablo de Olavide, 2221-2239.

Update for: Spain   Last updated: March 10th, 2022   Contributors: Joanna Marczak  |  Carlos Chirinos  |  

1.14. Pandemic preparedness of the Long-term care sector

In a study of the institutional and organisational management of the COVID-19 pandemic in care homes, Del Pino and colleagues identify lack of preparedness in care homes, as well as lack of protection resources, as key factors in the slow response. Prior to COVID-19, the Spanish Ministry of Health had a plan in place that had developed to respond to Influenza (H5N1), which was used in 2009 during the H1N1 outbreak. There were also plans in place to respond to Ebola, Dengue and Zika, and one for MERS-CoV. The study found that people responsible for regional responses were not aware of those plans, potentially because they had not been in post for long. None of the plans in place had any provision for interventions in care homes (or any other collective living establishments). Although, in principle, these establishments should form part of the “critical infrastructures”, as for most people living in these centres there is no other housing alternative and these centres are needed to maintain basic social, health and wellbeing of the people living there. The fact that Spain ranked very highly in the Global Health Security Index in 2019 may have generated over-confidence in the ability of the health care system to respond, coupled with the experience of having “over-prepared” for the flu pandemic in the past. There was a lack of recognition of the increased risk this virus posed to care home residents in particular, despite awareness of the impact of flu among the older population (source: DIGITAL.CSIC).

Update for: Spain   Last updated: February 10th, 2022

1.09. Community-based care infrastructure

Spain characterises insufficient community support for people with moderate of sever needs who live in their own homes, moreover there are visible inter-regional disparities regarding the quality, coverage or funding of services, which creates unequal access to services. A high number of people with LTC needs receive cash allowances to family caregivers in lieu of services, which heightened the responsibility of families in providing care. Migrant care workers, often hired with no legal contract, often provide private care at home (source: CEQUA Spain Country report (filesusr.com)

Update for: Spain   Last updated: January 6th, 2022

2.00. Overview impacts of the Covid-19 pandemic on people who use and provide Long-Term Care

In Spain, the covid crisis has revealed the fragility of the long-term care system and has had a significant impact on the men and women who provide care, both in families (unpaid) and paid. In the social care sector, carers include family caregivers, care service workers and domestic workers. In all these cases, there is a strong predominance of women, many of whom have experienced the effects of the pandemic with great vulnerability and precariousness (Comas-d’Argemir et al., 2021).

The social care sector was practically ignored at the beginning of the pandemic until the extreme situation in care homes triggered a new crisis within the health emergency. This neglect had severe consequences for older people and people with disabilities and carers. The delay in supplying protective equipment to the workers facilitated contagion between the staff and the residents. There was also a strong impact of covid in care homes in other European countries, but Spain is one of those that suffered it most virulently (see the LTCcovid compilation of data here). Social, political, and cultural factors that give little value to social care, older people and people with disabilities, explain this neglect and the deficits of the social care system (Daly, 2020). The underfunding of the dependency care system also had an impact: historical lack of investment, setbacks in applying the Dependency Law, insufficient staff in the services, and precarious working conditions (Costa-Font et al., 2021; Navarro and Pazos, 2020). The coronavirus crisis has highlighted all of these problems and, at the same time, has given visibility to the importance and essential role of care in maintaining life and for the functioning of the economy and society (Bahn et al., 2020).

In part due to the urgency of the pandemic, the role of women in health crises has tended to be ignored (Smith, 2019), and this has also happened in Spain with the coronavirus pandemic. While the government assumed the health part of the pandemic, it placed the rest of the responsibility to fight the pandemic with households. The confinement and the measures adopted with the declaration of the state of alarm, which lasted for months, led to an increase in care tasks at home and required an extraordinary effort, especially from women (Comas-d’Argemir and Bofill -Poch, 2021). The family has been the pillar of the response to the pandemic, without this being explicitly acknowledged. The pandemic has redistributed social functions (due to the closure of day centres, educational centres, a saturation of health services, etc.) which have been assumed fundamentally by the women of the family. In parallel, the impact of covid on health and social care personnel, who have had to work without adequate protection materials and in unsafe working conditions, has also been cause for concern. The pandemic has confronted workers with unprecedented, high-tension situations that are emotionally difficult to deal with (related to illness and death, fear, isolation…), which in many cases have left profound consequences on their physical and psychological health. Women have been working on the front lines of the pandemic, and although the health sector has received social recognition for its work, this has not been the case with nursing home or care service workers (Comas-d’Argemir et al., 2021).

Video accounts of the experience of providing care in Spain during the pandemic (in Spanish)

These videos were made for the project CUMADE: El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19 (Comas-d’Argemir y Bofill-Poch, 2021).

Conxita and Rafael: family carers

Participants: Rafael Hervás (Castellon), who is carer to his wife and Conxita Vallès (Barcelona), who is a carer to her mother.

Iñaki: functional diversity support

Participant: Iñaki Martínez (Barcelona), who is a personal assistant and President of the Asociación Profesional de Asistencia Personal.

Ruth and Janire: Care professionals in care homes

Participants: Ruth González (L’Ametlla del Vallès), who is a geriatric assistant at the Fundació Antònia Roura care home, and Janire Diaz (Bilbao) who is a trade unionist, responsible for the socio-health area of Gipuzkoa in the Syndicate Eusko Langileen Alkartasuna- Solidarity of Basque Workers (ELA).

Patricia and Carolina: home care workers

Participants: Carolina Elías (Madrid), President of the association Servicio Doméstico Activo (SEDOAC) and Patricia Zapata (L’Hospitalet de Llobregat), Domestic and care worker, member of the association Mujeres Unidas entre Tierras (MUET)

Marina: Community initiatives

Participant: Marina García (Granada) Promoter of the Albaicín Town Hall Care Group, Granada

Caring in the pandemic (ALL PARTICIPANTS)

References

Bahn, Kate; Cohen, Jennifer y Van del Meulen Rodgers, Yana (2020): “A feminist perspective on COVID-19 and the value of care work globally”, Gender Work Organization, 27, 695-699.

Comas -d’Argemir, Dolors y Bofill-Poch, Sílvia (2021): “Entrevista a María Ángeles Durán ‘Pandemia y Cuidados’”, en Dolors Comas-d’Argemir y Sílvia Bofill-Poch (eds.), El cuidado de mayores y dependientes. Avanzando hacia la igualdad de género y la justicia social, Barcelona, Icaria, 35-54.

Comas-d’Argemir, Dolors; Legarreta, Matxalen y García Sainz, Cristina (2021), “Residencias, las grandes olvidadas”, en en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Costa-Font, Joan; Jiménez Martin, Sergi y Viola, Analía (2012): “Fatal underfunding? Explaining COVID-19 mortality in Spanish nursing homes”, Journal of Aging and Health, 33, 7-8, 607-617.

Daly, Mary (2020): “COVID?19 and care homes in England: What happened and why?”, Social Policy & Administration, 54, 7, 985-998.

Navarro, Vicenç y Pazos, María (2020): El cuarto pilar del Estado del Bienestar. Propuesta para cubrir necesidades esenciales de cuidado, crear empleo y avanzar hacia la igualdad de género. Propuestas presentadas en el Grupo de Trabajo de Políticas Sociales y Sistema de Cuidados de la Comisión para la Reconstrucción social y económica del Congreso de los Diputados (15 de junio), Enlace.

Update for: Spain   Last updated: March 21st, 2022   Contributors: Carlos Chirinos  |  

2.02. Deaths attributed to COVID-19 among people using long-term care

The Spanish National Institute of Older People and Social Services (IMSERSO) publishes weekly reports  on deaths linked to COVID-19 in care homes, collecting data from all regions and including care homes for younger people. The data is collected in line with The European Surveillance System (TESSy) of the European Centre for Disease Prevention and Control (ECDC).

Cumulative estimated number of deaths linked to COVID-19 among care home residents:

So far, the total number of deaths linked to COVID-19 among care home residents (until the 6^th of February 2022) is 32,639. The total number of deaths in the whole population (confirmed through testing) is 95,163 up to 9^th February, 2022. Adding the suspected cases among care home residents in the first wave (10,546, see above) would bring this to 105,531. The estimated share of all deaths (confirmed and suspected) linked to COVID-19 who were care home residents in the whole period would be 30.9%. Comparing the number of deaths with the estimated number of residents in 2019, 333,920 (estimate by Envejecimiento en Red) suggests that the number of deaths linked to COVID so far represents 9.77% of the number of care home residents at the beginning of the pandemic.

First wave: difficulties estimating the number of deaths linked to COVID-19

Due to lack of testing at the beginning of the pandemic, there is some uncertainly about the number of people who had a COVID-19 infection and died in that period. IMSERSO estimates that, until 22^nd June 2020, there were 27,411 deaths from all causes among care home residents. Of these, 9,753 had COVID infections confirmed through testing, and 10,546 had symptoms compatible with COVID. So the total number of care home residents who died with either a COVID-19 infection or compatible symptoms (suspected COVID) were 20,299. In the total population, official data shows that, during the same period, the total number of people who died with confirmed COVID infections was 29,692, there is no national estimate of the numbers of people who died with suspected COVID in the population. To estimate the total number of people who died linked to COVID in Spain during the first wave (up to 22^nd June) we can add the number of suspected COVID deaths among care home residents to the total number of official deaths in the population, resulting in an estimate of 40,238 COVID-related deaths. Based on this, the share of COVID deaths that would have been care home residents would be 50.4% in the first wave.

2020: Estimated number of deaths linked to COVID-19 among care home residents

In total in the year 2020 there were 26,335 deaths among care home residents linked to COVID-19 (confirmed and suspected).

2021: Estimated number of deaths linked to COVID-19 among care home residents

During 2021 there were 5,205 deaths of care home residents who had tested positive for COVID-19, of these, 3,686 took place before the 1^st of March, the date when the initial COVID-19 vaccination of care home residents was completed. There were 1,519 deaths in the period post-vaccination until the end of year.

2022 so far: Estimated number of deaths linked to COVID-19 among care home residents

As of the 6^th February there have been 1,099 deaths of care home residents who had tested positive for COVID-19.

Excess mortality among people registered with the public LTC system:

IMSERSO also publishes a monthly report on excess mortality among people registered with the Spanish System for Autonomy and Dependency Support (SAAD). Between March 2020 and December 2021 there 71,539 excess deaths (compared to average in previous five years) among people in the SAAD register (19.7% more than expected), affecting 3.77% of people registered with the system. 78.9% of those whose death is counted as “in excess” were aged 80 and over (56,411 people).

Excess mortality was much higher among people who receive their SAAD benefits through residential care, amounting to 29,435 (11.8% of all recipients), among those receiving benefits for community or home-based care there were 44,977 excess deaths, representing 5.2% of recipients.

Update for: Spain   Last updated: February 14th, 2022

2.04. Impacts of the pandemic on access to care for people who use Long-Term Care

Access to health care for people living in care homes

In Spain, in the early part of the pandemic, there were widespread difficulties for care home residents to access health care services, including at primary care level. There were many instances of hospital admissions being denied on the basis of where a person lived (a care home) or their type of disability (for example dementia), without consideration of the individual’s situation and potential to benefit from treatment. This generated great controversy and concern about human rights violations (see for example Del Pino et al., 2020 and Zalakain et al., 2020).

Access to long-term care in the community

A report from May 2020 outlines that day care centres were closed to reduce the risk of infection. In addition, many ‘light’ home care services were cancelled by local and municipal authorities. Recommendations issued in March 2020 by the Ministry of Social Rights envisaged that social services departments would have to ensure continuity of services where private providers suspended home care services. The recommendations also emphasised a continuation of services for people with personal care needs and people requiring support with other activities of daily living (e.g. shopping, accompanying people outside the house). The guidelines also recommended a greater combination of services than usually permitted, to reduce administrative barriers when taking on new clients, and encouraged service providers to alert social services departments if cases of people with particular needs were identified.

References:

Update for: Spain   Last updated: January 14th, 2022

2.05. Impacts of the pandemic on the health and wellbeing of people who use Long-Term Care

A study in a care home in Galicia aimed to measure the decline in cognitive, functional and affective status among 98 older people living in the care home after a period of lockdown during the first wave of the pandemic (July to September 2020) and compared this to previous measures collected at three different time points to determine whether the decline had accelerated. The study also collected data on frequency of social contact.

The study found lower cognitive and functional scores and higher depression scores after the lockdown but these were not different to the decline that would be expected compared to the previous measurements, suggesting that decline had accelerated during the lockdown. Changes in depression scores were strongly associated with mental health and functional measures, suggesting that social contact is a strong protector against adverse effects (Pereiro et al., 2021).

References:

Pereiro, A.X.; Dosil-Díaz, C.; Mouriz-Corbelle, R.; Pereira-Rodríguez, S.; Nieto-Vieites, A.; Pinazo-Hernandis, S.; Pinazo-Clapés, C.; Facal, D. (2021) Impact of the COVID-19 Lockdown on a Long-Term Care Facility: The Role of Social Contact. Brain Sci. 11, 986. https://doi.org/10.3390/brainsci11080986

Update for: Spain   Last updated: March 21st, 2022   Contributors: Adelina Comas-Herrera  |  Carlos Chirinos  |  

1.06. Care coordination

The Catalan Government Plan for the XII legislature, approved on September 25, 2018, highlighted the need to deploy a unique strategy of integrated social and health care due to the health and social needs of the population, especially for those people who are older or have complex needs. It was agreed to redefine the Interdepartmental Plan for Social and Health Care and Interaction (PIAISS), which was replaced by the new Integrated Social and Health Care Plan (PAISS).
The aim was, in short, to create a model of integrated care for health and social services, drawing up a work plan that would help to generate a model of coordinated global intervention, with the same overall vision, which would place the person at the center.

Update for: Catalonia (Spain)   Last updated: March 3rd, 2022   Contributors: Cèlia Estruch  |  

2.07. Impacts of the pandemic on unpaid carers

The impact on families and, specifically on women, has been intense and, in some cases, devastating due to the loss of support and essential social networks for care, disrupting the process of extension and externalization of care. This has caused the reorganization of care and a change in the mosaic of care (Soronellas and Comas-d’Argemir, 2017). The closure of day centres, the crisis in residences, the reduction of Home Help Service (SAD), the loss of some paid workers, the fear of contagion and the strict home confinement of older people have transferred care responsibilities to households. As a result, care has been refamiliarised, and, with it, women have absorbed much of the impact of the pandemic (Soronellas and Jabbaz, 2021).

The pandemic removed the option of residential care and day centres, with extended family networks and the community needing to take more care on. While some day centres carried out home visits, this was not enough to replace the support they used to provide, particularly in terms of physiotherapy and other therapeutic inputs (Soronellas and Jabbaz, 2021).

Family carers of medium and high socio-economic groups have suffered the economic consequences of the pandemic to a lesser extent. They have been able to hire paid carers to absorb the work overload caused by the closure or reduction of services. In contrast, care has been entirely within the family among carers from lower socioeconomic groups (Soronellas and Jabbaz, 2021).

A study by Del Rio-Lozano et al (2022), consisting of a cross-sectional survey carried out in two regions in Spain, found that the pandemic has exacerbated gender differences in unpaid care provision. They found that male unpaid carers experienced fewer reductions in informal support during the pandemic. Linked to this, female unpaid carers were more likely to have experienced increases in caring intensity and burden and deterioration of self-perceived health, compared to male unpaid carers. These differences in self-perceived health, however did not hold for men who provide high intensity of care.

References:

Del Río-Lozano M, García-Calvente M, Elizalde-Sagardia B, Maroto-Navarro G. (2022) Caregiving and Caregiver Health 1 Year into the COVID-19 Pandemic (CUIDAR-SE Study): A Gender Analysis. International Journal of Environmental Research and Public Health;19(3). https://doi.org/10.3390/ijerph19031653

Soronellas, Montserrat y Comas-d’Argemir, Dolors (2017): “Hombres cuidadores de personas adultas dependientes. ¿Estrategias ante la crisis o nuevos agentes de cuidado?”, en María Rosa Herrera y German Jaraiz (eds.), Pactar el Futuro. Debates para un nuevo consenso en torno al bienestar, Sevilla, Universidad Pablo de Olavide, 2221-2239.

Soronellas, Montserrat y Jabbaz, Marcela (2021), “Cuidadoras familiares, antes y depues de la pandemia”, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Update for: Spain   Last updated: March 21st, 2022   Contributors: Adelina Comas-Herrera  |  Carlos Chirinos  |  

2.08.01. Impacts of the pandemic on migrant Long-Term Care workers

The CUMADE project (Care matters. Gender impact on caregivers of elderly and dependent persons in times of COVID-19) carried out interviews with care workers, including those employed privately (often informally) in domestic settings, the majority of whom were migrant women).

A first consequence of the pandemic has been the dismissal of many female workers, accompanied by a drop in hiring. The reasons that explain the temporary or permanent suspension of jobs are diverse. However, apart from the deaths caused by the covid, the pandemic changes in the employment and economic situations of the employing families (teleworking, loss of jobs) temporarily dispensing with the worker and sometimes taking direct responsibility for the care of their family members. The pandemic also involves changes in the composition of households: older people with dependency moving in with their children, and children who move into their parents’ homes. These situations that can lead families to do without the worker. The fear of contagion and the perception of risk within households have also caused the temporary suspension of contracts or dismissals (Offenhenden and Bofill-Poch, 2021).

However, the impact varied according to the hiring regime of migrant caregivers. For example, the new conditions generated by the pandemic (economic precariousness, restricted mobility, restricted access to services) have increased the demand for live-in female workers. One of the characteristics that usually stands out in live-in work is the claim of the total availability of the worker’s time. In general terms, the increase in the working day has not been remunerated. Likewise, female workers have seen their mobility restricted, giving greater control to their employers and seeing their privacy and rest times reduced (Offenhenden and Bofill-Poch, 2021).

The labour changes caused by the pandemic and confinement have made it even more difficult for workers with family responsibilities to reconcile work and family. Strategies have ranged from delegating care to older sisters to quitting work. For some workers who have gone from the external to the internal (live-in) regime, confinement has meant not being able to attend to the care needs of their children. That has generated deep discomfort in the workers, who have not been able to care for their children at a challenging time due to home confinement (Offenhenden and Bofill-Poch, 2021).

On the other hand, those workers who did not have savings or alternative income, faced with the loss of employment or the drastic reduction of their working hours, have had to resort to mutual aid groups, social assistance entities and religious organisations to cover basic needs (accommodation and food). Moreover, the pandemic also affected the ability to send remittances and take care of his family’s costs from a distance. To send remittances (apart from the fact that the closing of call shops made it enormously difficult), women have reduced their daily expenses and prioritised costs in their countries of origin. In some cases, this leads to debts being generated in the families of origin due to the impossibility of sending money during confinement (Offenhenden and Bofill-Poch, 2021).

References

Offenhenden, María y Bofill-Poch, Sílvia (2021), “Trabajadoras de hogar y cuidados”, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas. www.antropologia.urv.cat/es/investigacion/proyectos/cumade/

Update for: Spain   Last updated: March 21st, 2022   Contributors: Carlos Chirinos  |  

2.09. Impact of the pandemic on workforce shortages in the Long-Term Care sector

Survey data suggests that the number of long-term care (LTC) workers in Spain increased by 7% during the first wave of the pandemic. The increase was driven by the private sector recruiting female temporary staff; mostly part-time. Conversely, in Navarre, Spain, over 24% of workers in LTC facilities took at least one medical leave and three-quarters of LTC facilities had at least one employee who took leave during the first wave.  Leave in context of staff shortages limited the capacity to respond effectively to the pandemic (Source: OECD paper). More recently, concerns have been voiced around staff shortages linked to the spread of the Omicron variant (Source: Territorial Council for Social Services, 2021).

According to a recent report (February 2022) by The Federation of European Social Employers, Spain has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

Update for: Spain   Last updated: February 5th, 2022   Contributors: Daisy Pharoah  |  

3.02. Governance of the Long-Term Care sector's pandemic response

In Spain, in principle, 4 different ministries were tasked with responding to the pandemic, but in practice the Ministry of Health had the most visible role (this was also the case at regional level. The governance of the pandemic in relation to the Long-Term Care system has varied by region and in the different phases of the pandemic. Local governments were also involved, specifically with regards to logistical support and in rural areas. There was also support from the army, civil protection volunteers, police, the fire service, and NGOs. A report on the organisation and governance of the pandemic response in care homes concluded that being better prepared would have reduced the reaction time, which has been identified as a key factor in the impact of the pandemic on the Spanish care home population. There was also a lack of clarity over responsibility, where 45% of the population thought that responsibility of the pandemic response in care homes was with the regional governments, 24% with the central government, and 28% with both (Del Pino et al, 2021).

The delay in adopting (and having enough resources to implement) preventative measures in care homes, compared to in health care services has been attributed to policy legacies resulting in nursing homes lacking recognition and visibility and being seen as a marginal part of the Long-Term Care system (Leon et al, 2021)

References:

Del Pino, E., Moreno Fuentes, F. J., Cruz-Martínez, G., Hernández-Moreno, J., Moreno, L., Pereira-Puga, M. and Perna, R. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Spain’, MC COVID-19 working paper 13/2021. http://dx.doi.org/10.20350/digitalCSIC/13688

León, M., Arlotti, M., Palomera, D., & Ranci, C. (2021). Trapped in a Blind Spot: The Covid-19 Crisis in Nursing Homes in Italy and Spain. Social Policy and Society, 1-20. doi:10.1017/S147474642100066X

Update for: Spain   Last updated: November 23rd, 2021

3.02.02. Measures to improve coordination between Health and Social Care in response to the pandemic

In the earlier parts of the pandemic, there was lack of clarity in governance, which resulted, in some instances, in care homes being given contradictory guidance from the regional Departments of Health and by Social Services. This improved in later phases of the pandemic. To improve coordination, in some regions joint working groups were established, whereas in others the Department of Health took control. (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Update for: Spain   Last updated: September 9th, 2021

3.03. Monitoring Covid-19 impacts in the Long-Term Care sector: data and information systems

Until [check date] there was no national information system available to track the impact of the pandemic in the LTC system. Each region collected their own data but using different methodologies (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf). Since [check] data is collected and published regularly using European Centre of Disease Prevention and Control guidance.

Update for: Spain   Last updated: November 23rd, 2021

3.05. Long-Term Care oversight and regulation functions during the pandemic

There has been little oversight, at most reviews of written documents, which care home managers have found to be very onerous (Source: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Update for: Spain   Last updated: September 10th, 2021

3.06. Support for care sector staff and measures to ensure workforce availability 

In response to concerns about availability staffing linked to the spread of the Omicron variant, on the 30th December 2021 the Territorial Council for Social Services approved a provisional relaxation of the criteria required to recruit social care staff.

Update for: Spain   Last updated: January 13th, 2022   Contributors: Sara Ulla Díez  |  

3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, support and implementation

Care home experiences

According to a study of the experience of care home managers and local officials, lack of information and guidance at the beginning of the pandemic resulted in chaos and uncertainty and made it difficult to develop adequate responses. While some care homes were able to react quickly, others had not adopted any protocols until they had support from a primary health care centre in mid-April. Care homes were fearful of legal repercussions if they did not get things right. All care homes were required to develop contingency plans to fight the pandemic in June 2020 and were supported by the regional governments in developing these. However, numerous updates and changes proved to be a barrier to adoption: guidance was often difficult to implement because it did not reflect the reality of the care home environment: for example, the physical layout of care homes, staffing constraints, or the characteristics of residents. Early protocols did not account for the possibility of asymptomatic transmission. Care homes reported that they would have found it helpful to have some support with checking their plans, as well as the monitoring of implementation. Care homes found it very difficult to train staff to reflect changes in guidance, in part because many members of staff were new and had had little training or relevant experience (Del Pino et al., 2020).

There were examples of collaboration between hospitals and local care homes, for example Saez-Lopez and Arrendondo (2021) describe how a multidisciplinary team from a hospital supported four local care homes, not only through medical support, but also through training in Infection Prevention and Control (IPC) and implementation support, which included the hospital providing Personal Protection Equipment from their own stocks to the care homes.

Intervention by Medicines Sans Frontiers (MSF)

While supporting the public health system in Spain to overcome the most acute period of the COVID-19 outbreak in early 2020, MSF turned their attention to care homes in Spain to provide physical and emotional support to residents and staff. A key element of their intervention across over 500 care homes was to provide training (in person and remote) to enable staff to carry out their tasks safely. The organisation also set up a website with documents and videos on protocols, infection control, control tracing, and the use of PPE (source: MSF, 2020).

References:

Update for: Spain   Last updated: February 22nd, 2022   Contributors: Daisy Pharoah  |  

3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings

In the early part of the pandemic residents returning to a care home, without a test, from a hospital stay for some other reason where suspected to be a main source of COVID-19 outbreaks. On the other hand, there were many instances where care homes were not able to access any health care support, from either primary care or hospitals. There were examples of hospitals that were systematically restricting admissions from care homes (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Update for: Spain   Last updated: September 9th, 2021

3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes

Evidence on using a cohorting algorithm to separate infected, exposed, and unexposed residents

This study describes the implementation of a cohort classification algorithm to prevent the spread of COVID-19 in nursing homes in Spain. This algorithm helps to classify residents in order to separate them into three different areas. The approach was designed in the surge of the COVID-19 outbreak when PCR tests could not be performed for all nursing home residents.

The first step is to perform a chromatographic immunoassay to detect antibodies in all residents in the nursing home using rapid point-of-care test. Residents with a positive result would be placed in the ‘red zone’. Residents with a negative result would initially be located in the ‘green zone’. Early detection of cases of COVID-19 in this area must be performed either by identification of close contact to confirmed cases or through daily surveillance of symptoms. Residents considered suspicious of being infected should be immediately transferred to the ‘yellow zone’, where further study must be undertaken. The intervention was implemented on April 24, 2020, and it has been held in 17 nursing homes. The study reports that, after the intervention, 94% of nursing homes had made an improvement in sectorisation (Gonzalez de Villaumbrosia et al. 2020).

References:

Gonzalez de Villaumbrosia, C., Martinez Peromingo, J., Ortiz Imedio, J., Alvarez de Espejo Montiel, T., Garcia-Puente Suarez, L., Navas Clemente, I., Morales Cubo, S., Cotano Abad, L. E., Suarez Sanchez, Y., Torras Cortada, S., Onoro Algar, C., Palicio Martinez, C., Plaza Nohales, C., & Barba Martin, R. (2020). Implementation of an Algorithm of Cohort Classification to Prevent the Spread of COVID-19 in Nursing Homes. Journal of the American Medical Directors Association, 21(12), 1811–1814. https://doi.org/10.1016/j.jamda.2020.10.023

Update for: Spain   Last updated: January 12th, 2022   Contributors: William Byrd  |  

3.07.03. Visiting and unpaid carer policies in care homes

Visiting in care homes has been severely restricted between March 2020 and February 2021, although many care homes maintained very restrictive regimes for longer (Zunzunegui, 2022)

The recommendations from the Ministry of Health on care home visits have not been adopted uniformly in the different Autonomous Communities, with some being more restrictive. In practice care homes have developed and applied their own policies, as long as these were also more restrictive than the national or regional policy.

As of July 2021, in principle, care home residents are able to receive visitors and are able to themselves go on outings, always with appropriate protective measures. Before vaccination, visits were restricted. However, following vaccination there have been efforts to recover normal visitation schedules that have not been observed since before the pandemic. Both short and long outings are allowed.

References:

Zununegui M.V. (2022) COVID-19 en centros residenciales de personas mayores: la equidad sera necesaria para evitar nuevas catastrofes. Gaceta Sanitaria 36(1): 3-5 DOI: 10.1016/j.gaceta.2021.06.009

Update for: Spain   Last updated: January 21st, 2022

3.07.03. Visiting and unpaid carer policies in care homes

In June 2021, care home residents are able to receive visitors and are able to themselves go on outings, always with appropriate protective measures. Before vaccination, visits were restricted. However, following vaccination there have been efforts to recover normal visitation schedules that have not been observed since before the pandemic. Both short and long outings are allowed (https://canalsalut.gencat.cat/web/.content/_A-Z/C/coronavirus-2019-ncov/material-divulgatiu/gestio-infeccio-coronavirus-ambit-residencial.pdf).

Update for: Catalonia (Spain)   Last updated: November 6th, 2021   Contributors: Gemma Drou-Roget  |  

3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector

During the first wave, care homes that did not purchase PPE in January or early February at the latest, were unable to obtain PPE afterwards, with example of use of plastic bags or sharing of masks between staff (Del Pino et al., 2020).

There are examples of hospitals providing some of their own PPE to local care homes in the early part of the pandemic (Saez-Lopez, 2021).

References:

Del Pino E., Moreno-Fuentes F.J., et al. (2020) Informe Gestion Institucional y Organizativa de las Residencias de Personas Mayores y COVID-19: dificultades y aprendizajes. Instituto de Politicas y Bienes Publicos (IPP-CSIC) Madrid.

Sáez-López P, Arredondo-Provecho AB. (2021) Experiencia de colaboración entre hospital y centros sociosanitarios para la atención de pacientes con COVID-19. Rev Esp Salud Pública. 95: 14 de abril e202104053.

Update for: Spain   Last updated: February 22nd, 2022

3.11. Vaccination policies for people using and providing Long-Term Care

Spain’s vaccination programme began in early January 2021, with nursing home and long-term care facility residents in the highest prioritization group alongside frontline healthcare workers. Vaccination campaign responsibilities fall to the individual regions.

In Spain, like with any other vaccine, vaccination for COVID-19 is voluntary for all the citizens, including workers from the health sector and the long-term care sector. Workers from the health and the long-term care sector have been prioritized groups in the COVID-19 vaccination strategy, but vaccination is not compulsory (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion6_EstrategiaVacunacion.pdf).

Update for: Spain   Last updated: September 7th, 2021

3.12. Measures to support unpaid carers

The Mecudia plan (initiated 18 March 2020) enables people with work and care responsibilities to request an adjustment or reduction of their working arrangement to support the person with care needs. In addition, people who are financially vulnerable, including unpaid carers who experience a substantial loss of income can apply for a mortgage debt moratorium. Some municipal governments have also produced information material, helplines or phone counselling. NGOs have also provided information and support (https://ltccovid.org/wp-content/uploads/2020/10/LTCcovid-Spain-country-report-28-May-1.pdf). In addition, resources to support unpaid carers have been developed (https://ltccovid.org/wp-content/uploads/2020/06/International-measures-to-support-unpaid-carers-in-manage-the-COVID19-situation-17-June.pdf).

Update for: Spain   Last updated: September 7th, 2021

4.02. Reforms to the Long-term care financing system

An EU report noted that a Dependency Shock Plan 2021 was approved in Spain which, among other things, increased financing to the LTC, the increase in funding is supposed to be dedicated to the adoption of specific SAAD (System for Promotion of Personal Autonomy and Assistance for Persons in a Situation of Dependency) improvement measures including ensuring adequate working conditions for people who work in the SAAD and improvements in services and benefits to guarantee adequate care for dependents.

Update for: Spain   Last updated: September 7th, 2021

4.06. Reforms to improve support for unpaid carers

In 2019 Spain reinstated the payment of social protection credits by the state for informal carers who were recognised as care-givers in an individualised care plan (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Update for: Spain   Last updated: November 23rd, 2021