Structural characteristics of the LTC system, impact of the pandemic, measures adopted and new reforms
This country profile brings together information on the experience of the long-term care sector (focussing on people who use and provide care) during the COVID-19 pandemic in Spain from a living international report on COVID-19 Long-Term Care. It also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in Spain.
Experts on COVID-19 and long-term care in Spain that have contributed to this report:
Living report: COVID-19 and the Long-Term Care system in Spain
PART 1 – Long-Term Care System characteristics and preparedness
- 1.01. Population size and ageing contextIn 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)
- 1.02. Brief description of the Long-Term Care system
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 national government has a key role in financing and defining minimum public coverage through the National Long-Term Care System (SAAD). The SAAD was established through the 2006 ‘Dependency Act’ which aimed to create new public national care coverage as the ‘fourth pillar of the welfare state’, aiming to improve personal autonomy and care for dependent people. The Act established two types of long-term care benefits: 1) in-kind services, and 2) those of an economic nature, 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.
- 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: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). 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: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-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 (source: LTCcovid-Spain-country-report-28-May-1.pdf).
- 1.04. 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 (source: CEQUA Spain Country report).
- 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.
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.
- 1.06. Approach to care provision, including sector of ownership
Due to limits in public spending on LTC, a number of public services are provided by private entities, both for and non-profit. In the care home sector. Although marketization has led to an increase in the available places, this has been at the expense of the quality of services, and 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 (source: LTCcovid-Spain-country-report-28-May-1.pdf).
- 1.07. Care coordination and personalization
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.
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, 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
- 1.09. Care home infrastructure
In 2020 three in every four LTCFs in Spain were privately run and many residents had some of their costs publicly funded. The fees received by the institutions had not changed for a long time, a result of years of austerity in Spain, and many private facilities had to make cuts to make a profit, whilst some lacked equipment even before the pandemic, many operated with minimum staff (source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241030).
- 1.10. 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)
- 1.11. Workforce conditions: pay, employment conditions, qualification levels, shortages
Low public spending on LTC, is related to low wages in the sector. The monthly cost per member of staff in the sector is 67% of the average wage per worker 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 (LTCcovid-Spain-country-report-28-May-1.pdf).
- 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).
PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
- 2.02. Deaths attributed to Covid-19 among people who use and provide Long-Term Care
Data on COVID-19 related mortality in care homes is reported on Spanish national television, which needs to be treated with caution because the methods and definitions used to gather the data from the regional governments are not homogeneous. According to this source, as of January 22, 2021, there have been 26,328 COVID-19 related deaths in care homes, which includes both the deaths of people who have been diagnosed with COVID-19 and the deaths of those with symptoms but who have not been diagnosed. Estimating the share of all COVID-19 deaths that the deaths of care home residents represent in Spain is complicated because the national estimates of COVID-19 deaths only include deaths of people with a confirmed diagnostic test, missing the deaths of people that were not tested at the beginning of the pandemic. The national estimate for (confirmed) COVID-19 deaths on January 22, 2021 was 56,563 (Source: https://cnecovid.isciii.es/covid19/#documentaci%C3%B3n-y-datos).
The Spanish National Institute of Older People and Social Services (IMSERSO) reported that, in the first part of the pandemic (up to July 2020), there had been 20,268 deaths of care home residents in care homes, of which 9,904 were of people who had not been tested. That report highlighted that the national estimate for total deaths linked to COVID-19 does not include people who have not been tested and recommended adding the number of suspected deaths in care homes to the current total of confirmed deaths nationally. Using a similar approach would bring the total of confirmed and suspected deaths in the whole population to 66,467 by January 22, 2021. This would suggest that 40% of all deaths linked to COVID-19 in Spain have been among care home residents. This figure is lower than the estimate of 47% produced by the Spanish National Institute of Older People and Social Services up to June 23, 2020. This suggests that, proportionally, care home residents have not been as badly impacted as the rest of the population, compared to the initial part of the pandemic. The most recent estimate suggests that there are 333,920 care home residents (Source: http://envejecimientoenred.es/nivel-de-ocupacion-en-residencias-de-personas-mayores/). Therefore, the total number of COVID-19 related care home deaths would represent 7.88% of this population.
The Spanish National Institute of Older People and Social Services also publishes a monthly report on the excess mortality for people registered with the Spanish public long-term care system. Between March and November 2020, there have been 45,665 excess deaths among those who had applied for (and or received) care benefits. This was 31.8% higher than expected. The highest number of deaths were among people receiving benefits for institutional care (22,718, representing 9.12% of all recipients of this benefit). About 72.6% of care home residents are estimated to be in receipt of care benefits, and these are expected to be those who are most frail (Source: https://www.imserso.es/InterPresent2/groups/imserso/documents/binario/gtcovid_residencias_vf.pdf). Among people receiving benefits for care at home, there were 17,612 excess deaths, amounting to 2.02% of recipients (the share was a bit lower for people receiving cash payments for family care, 1.41%, compared to people receiving benefits in kind, 2.62%).
- 2.04. Impacts of the pandemic on access to health and social care services (for people who use Long-term Care)
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 (Sources: https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf; https://ltccovid.org/wp-content/uploads/2020/10/LTCcovid-Spain-country-report-28-May-1.pdf).
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.
PART 3 -Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
- 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)
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
- 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).
- 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.
- 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).
- 3.06. Support for care sector staff and measures to ensure workforce availability
In Spain care workers without the required training certificates could be legally employed (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).
- 3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, training and implementation support
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, some care homes had not adopted any protocols until they had support from a primary health care centre in mid-April. Staff responsible for “quality reporting” were usually tasked with developing care home protocols and contingency plans but in some care homes that had medical support the protocols were developed by multidisciplinary teams. 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. Too many updates and changes in the guidance made it difficult to adopt them. Quite often guidance was difficult or impossible to implement because it did not reflect the reality of care homes, for example 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 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 (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).
- 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).
- 3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes
One of the most effective measures to contain outbreaks was the transfer of residents with COVID-19 to other temporary care settings, as well as preventing further spread, this practice was identified as positive for physical and mental wellbeing because it enabled the other residents to experience fewer constraints (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).
- 3.07.03. Care homes: visiting and unpaid carer policies
As of July 2021, care home residents are currently 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.
- 3.07.03. Care homes: visiting and unpaid carer policies
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).
- 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 (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).
- 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).
- 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).
PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies
- 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.
- 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).
Printable version of this country profile:
To cite this report:
TBC. LTCcovid country profile – Spain. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) International living report on COVID-19 and Long-Term Care users and providers: context, impacts, measures and lessons learnt. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. Available at: https://ltccovid.org/country-questions/
Ongoing research projects on COVID-19 and Long-Term Care in Spain:
Previous LTCcovid report on Spain (May 2020):
Acknowledgement and disclaimer
This report has been initially developed by the team working on the Social Care COVID Recovery and Resilience project and questions will be added to and validated by LTCCovid contributors who are experts on Long-Term Care in their respective countries. This study is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.