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
- 1.00. Brief overview of the Long-Term Care systemAccording 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. Each autonomous community has legislated and designed its own care and social services systems. The 2006 ‘Dependency Act’ (law 39/2006) 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). This is carried out with the collaboration and participation of all public administrations, and the central government guarantees minimum common rights for all citizens in any part of the territory of the Spanish State. The Act established two types of long-term care benefits: 1) in-kind services, and 2) economic benefits, and gives priority to the former. All benefits and services established in the law are integrated into the social services provided through the autonomous regions (Guillen et al. 2017). The catalogue of services and economic benefits of the Law is as follows: Services : a) Services for the prevention of situations of dependency and those for the promotion of personal autonomy . b) Telecare Service. c) Home Help Service (help with home tasks and personal care);:
- Attention to the needs of the home.
- Personal care.
- Day Centres for the older people.
- Day Centres for those under 65 years of age .
- Specialized Day Care Centres.
- Night Centres.
- Residential care for the older people in a situation of dependency .
- Care centres for people in a situation of dependency, due to the different types of disability.
- 1.01. Population size and ageing context
The population in Spain, as in the rest of Western societies, is going through a marked and continuous process of ageing of its population, due to social, health and cultural factors. According to the latest data from the INE (Institute of National Statistics. Data provisional as of July 1, 2021), Spain has a total population of 47,326,687 people, of which 9,444,037 are aged 65 or older (which represents 19.95% of the total); with 1,597,298 people aged 85 or older (3.38%). In addition, this ageing is noticeable in women, who account for 56.48% of the total number of people aged 65 or over, and 65.79% of people aged 85 or over.
In addition, and in relation to the population at risk of relying upon care from others, it is estimated that there is a total of 6,044,675 people (that is, 12.77% of the total population) who can be considered as “potentially dependent” (based on factors such as age or recognized disability).
On the other hand, there is a gradual decrease in women of childbearing age and, 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).
ReferencesMartínez-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/
- 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)
- 1.02. Long-Term Care system governance
As responsibility for administering social assistance has been assumed by all the autonomous communities, the governance of the System for Autonomy and Dependency Care (SAAD) falls into the hands of the bodies established within the framework of the different social service systems. This is dependent upon the structure of each of the autonomous communities. The responsibility of the management of SAAD (both the reception of the application, assessment of the applicant, and the recognition of the situation of dependency and the benefits that can be recognized to each person), corresponds to each autonomous community. The sole exceptions to this is the management of SAAD in the Autonomous Cities of Ceuta and Melilla, which is assumed by the General State Administration through the Institute for the Elderly and Social Services.
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)
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).
- 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).
The Dependency Law includes a specific financing system, which differs from a tax-based system, that establishes the participation of both the public administrations (mainly the General State Administration and the Autonomous Communities) and beneficiaries of the benefits. This is carried out via means tested co-payment systems (source: Joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-2019-update_en). The financing system established in the Dependency Law is based on the existence of three levels of protection:
- The minimum level of protection provided, must be paid in full by the General State Administration (AGE). This depends on the number of people who rely on care from others who are receiving a benefit.
- The agreed level of protection is based upon the conclusion of the corresponding collaboration agreements between the AGE and the autonomous communities. The financing of the AGE of this level of protection is based on the annual distribution of money, which is distributed among the autonomous communities based upon a series of variables and predefined criteria.
- The implementation of the final level of protection is optional for autonomous communities, and they are responsible for its financing.
In a global study, recent calculations estimate that spending on care for people who rely on care from others is around 0.7% of the national GDP, although the improvement in the financing of the system will mean an increase in this amount.
Likewise, the AGE has been financing social security contributions associated with the special agreements that could be signed by non-professional caregivers of people in a situation of dependency. This helps ensure that no additional costs are incurred. It also ensures that non-professional caregivers (the vast majority of whom are women) benefit from this type of agreement, with a view to accruing future pensions (retirement, death and survival).
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
- 1.04. Approach to care provision, including sector of ownership
In Spain, 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 (with most 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.
The Dependency Law
The Dependency Law states that an attempt should be made to provide adequate care for a person in a situation of dependency. If this is not possible, then money/cash will be provided to pay for care. The law also states that official/recognised benefits and services should be integrated into the Social Services Network of Autonomous Communities.
Within this starting framework, the Law itself also states that:
- Recognised benefits and services are integrated into the social services network of the respective Autonomous Communities.
- The network of centres will be made up of the public centres of the Autonomous Communities; the state centres for the promotion of personal autonomy and care of situations of dependency; and accredited private centres.
In short, some of the services The Dependency Law recognises are provided by public administrations aside from the autonomous communities, and by privately run centres that are regulated by the Autonomous Communities.
Non-subsidized private centres and services that provide services for people who rely on care from others must also have the proper accreditation from the corresponding Autonomous Community.
In conclusion, the services that are recognized within the framework of the Dependency Law must be provided through public or publicly funded places in private care homes . In cases where this is not possible, cash benefits can be provided for an accredited private centre to provide the service.
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
- 1.05. Quality and regulation in Long-term care
The Spanish LTC system (System for Autonomy and Care for Dependency or SAAD) has three instruments to ensure quality: 1) a national and regional regulatory system; 2) formal quality controls; and 3) good practices. The responsibility for periodically inspecting and evaluating SAAD, along with ensuring that LTC Centres and service providers meet quality standards regarding the rights of service users, lie with the autonomous communities. They are also responsible for sanctioning any organisations that do not comply with quality standards.
The Territorial Council of Social Services and the System for Autonomy and Dependency Care (CTSAAD), formed by representatives of the central and the territorial governments, is responsible for setting common criteria for the accreditation of centres. It is also responsible for setting the common criteria for homecare and residential care quality plans. This is carried out within the general quality framework of the General State Administration. CTSAAD is also required to agree on quality and safety criteria for centres and services, by establishing indicators for evaluation, continuous improvement and comparative analysis of the System’s centres and services. CTSAAD is responsible for issuing guides for good practice, and for services portfolios, ensuring they are adapted to the specific conditions for people with care needs, under the principles of non-discrimination and accessibility.
CTSAAD is required by law to ensure the coherent application of social policies by working with the General State Administration and the Autonomous Communities. This is carried out by the exchange of points of view and the joint examination of any problems that may arise, along with proposing appropriate measures to solve them.
Accredited centres can be inspected at the request of recipients of publicly funded subsidies, or randomly by the autonomous community. The formal quality controls of 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, CTSAAD 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).
On June 28, 2022, CTSAAD approved a new Agreement on Common Criteria for accreditation and quality of the centres and services of the System for Autonomy and Dependency Care (SAAD), which replaces the previous agreement adopted in 2008.
This new text regulates the accreditation processes through which the Autonomous Communities authorize care centres and services to be a part of the SAAD network, after verification of compliance with the established requirements.
Accredited centres and services will be subject to adequate inspection, control and monitoring, performed by inspection services to ensure continued compliance with the requirements.
Specific criteria are also included to ensure quality in employment, and to address the professional qualification and skills of both first and second level direct care staff, along with the continuous training of care staff. Other areas that are covered by the criteria include common hiring criteria, occupational health, or coordination for social and health care, among other aspects related to quality in the SAAD network.
It is worth noting that 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. 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).
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
- 1.08. Care home infrastructure
According to the IMSERSO report Social services aimed at older people in Spain (December, 2020), care homes are considered as Residential Care Services. They offer accommodation and support to older people on a permanent or temporary basis. Residential Centres are classed as social facilities that offer accommodation and specialized care to elderly people who, due to their family, economic and social situation, as well as their personal autonomy limitations, cannot be cared for at home.
The weekly IMSERSO report on the impact of Covid-19 in residential centres, states that care homes can be classed in the following ways:
- Residential centres for the elderly
- Residential centres for people with disabilities
- Other permanent accommodation for social services aimed at the above groups.
Autonomous Communities have responsibility for care homes, and this contributes to the care home sector being remarkably heterogeneous and complex. This is due to the differences in each autonomous community’s criteria about what constitutes a care home for older people or people who are eligible for public care (Abellán García et al., 2019).
In Spain, there are 5,529 centres (1,451 publicly owned, and 4,078 privately owned) with a total of 389,677 beds, of which a total of 246,303 (63.2%) have public funding. The remaining 143,734 (26.8%) are privately financed. In general terms, the coverage index for all centres is 4.19 (number of places/population>=65)*100). Of this, 2.65 corresponds to public centres, and 1.54 to privately financed centres.
The weekly IMSERSO Report noted that as of 3rd June 2022 there are a total of 353,823 people living in residential centres, with 85.8% living in residences for the elderly. The remaining 14.2% live in residential centres for people with disabilities, and other permanent social services accommodation. The report also noted that 71% of care home residents are women, and 79.3% are over 80 years old. The annual public price of a place in a residential centre is estimated at €18,839.62, of which the beneficiaries contribute around €8,020.13 (42.6% of the total price).
The Community of Madrid has 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 fifty beds prevailed (Comas-d’Argemir et al., 2021).
In 2020 three in every four long term care facilities in Spain were privately run and the fees for many residents were publicly funded. Mas Romero et al (2020) noted 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. They also identify this as a factor that may have affected the ability of care homes to respond to the challenges of COVID-19.
Despite concerns about 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 one hundred beds (compared to 17% in Catalonia and 16% in the Basque Country) (Abellán García et al., 2021). There are seventeen care homes that exceed three hundred 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).
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
- 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:
- Older people:
- Assisted residence for the older people on a temporary or permanent basis.
- Sheltered housing for the older people on a temporary or permanent basis.
- Temporary or permanent home for the older people
- People with disabilities:
- Residences and Homes Residences for people with intellectual disabilities.
- Residences and Homes Residences for people with physical disabilities.
- People with mental illness and / or addictions:
- Residences for people with mental illness.
- Homes Residences for people with mental illness.
- Therapeutic communities and reintegration flats for the care of people with drug addictions.
- Residences for Children and Adolescents with Autism Spectrum Disorder.
- Child under custody:
- Educational Residential Centers.
- Residential Center for Intensive Education Action.
- Reception Centers.
- 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).
CAMFIC & AIFICC (2016) Model d’atencio sanitaria a les residencies de Catalunya.
- Older people:
- 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).
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
- 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 people with care needs.
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).
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 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).
To facilitate taking care of disabled people or people with care needs, many women abandon their careers. They consequently not only lose the opportunity to develop as a person, but also as a worker who contributes to the labour market. They also lose the right to accrue possible benefits from the Social Security System, as it would be impossible to comply with the requirements of the system’s contributory benefits.
Measures to support unpaid carers
The Dependency Law, via a series of measures designed for non-professional caregivers (who are largely women), includes a measure that allows them to accrue social security benefits while caring for family members. This is financed by the Spanish General State Administration (AGE) and requires that non-professional caregivers of people with care needs sign an agreement to prevent them incurring any economic cost. Essentially, this allows non-professional carers to accrue benefits for retirement and if they find themselves suffering from permanent disability.
As of 31st January 2022, there are a total of 67,249 special agreements signed by non-professional caregivers (88.6% of which are women). The payment of the special agreements for non-professional carers by the AGE has meant a total expense of €1,639,881,600.61 since the Dependency Law came into force (although it must be taken into consideration that this measure was on hold between 2012 and April 2019).
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).
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.
- 1.14. Pandemic preparedness of the Long-term care sector
At the beginning of the COVID-19 pandemic, the protection of care home residents was a global priority. This included preparing clear and efficient action protocols, especially in the face of worsening scenarios.
However, in a study of the institutional and organisational management of the COVID-19 pandemic in Spanish care homes, Del Pino and colleagues identify lack of preparedness, as well as lack of protection resources, as key factors in the slow response. Consequently, the pandemic had especially serious and tragic effects for residents of nursing homes, especially during the first wave.
Prior to COVID-19, the Spanish Ministry of Health had developed a plan in response 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 these 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 infrastructure”, as most people living in these centres have no other housing alternative.
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. This was compounded by the experience of having “over-prepared” for flu pandemics in the past. There was a lack of recognition of the increased risk COVID-19 posed to care home residents in particular, despite awareness of the impact of flu among the older population (source: DIGITAL.CSIC).
On December 2, 2020, the final report of the COVID-19 and residences working group was released. The report compiled the lessons learned in the field of residential care during the first wave of the pandemic, along with some of the work carried out in previous months in conjunction with the autonomous communities. These included:
- A common framework for the application in the field of social services of the Early Response Plan (Annex I).
- A common checklist for contingency plans (Annex II).
- A compilation and systematization of the measures adopted to ensure socio-health coordination in the different autonomous territories (ANNEX III).
- Proposal for the systematization of information and adaptation to the European Centre for Disease Prevention and Control (ECDC) (Annex IV).
The report highlighted the factors that helped increase the impact of Covid-19 in residential centres:
- The pathogen SARS-CoV-2 and the disease COVID-19.
- The residents of residential centres and their characteristics.
- Infrastructure, activity and access to means of protection.
- Care staff and human resources of residential centres.
- The policies and strategies of isolation and confinement.
- Intersectoral governance between different administrations.
- Ageism, ethical dilemmas and legal problems.
The report also provided a table of available evidence, lessons learned and possible measures to help contain, mitigate or annul the above factors. This was compiled through the examination of action plans developed by all the autonomous communities. Many of these measures, if not all, had been adopted by the release of the report.
Improving the response to the pandemic in care homes, involves deciding where there is capacity to act immediately and in the medium term. This is combined with clearly identifying tasks, resources, timings and responsibilities.
It is crucial to learn from what happened in care homes in the first wave of the pandemic, and to implementing improvements. The resulting measures should be adopted in care homes and maintained in the long term, regardless of the efficacy of vaccines.
- 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)
- 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.
PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
- 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)
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.
- 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 6th of February 2022) is 32,639. The total number of deaths in the whole population (confirmed through testing) is 95,163 up to 9th 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 22nd 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 22nd 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 1st 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 6th 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.
- 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.
Del Pino E., Moreno-Fuentes F.J. , Cruz-Marti?nez G., et al. (2020) Informe Gestio?n Institucional y Organizativa de las Residencias de Personas Mayores y COVID-19: dificultades y aprendizajes. Instituto de Poli?ticas y Bienes Pu?blicos (IPP-CSIC) Madrid. http://dx.doi.org/10.20350/digitalCSIC/12636
Zalakain, J. Davey, V. & Sua?rez-Gonza?lez, A. The impact of COVID-19 on users of Long-Term Care services in Spain. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. https://ltccovid.org/wp-content/uploads/2020/10/LTCcovid-Spain-country-report-28-May-1.pdf
- 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).
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
- 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.
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/
- 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).
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/
- 2.09. Impact of the pandemic on workforce shortages in the Long-Term Care sector
In December 2020, It was agreed by the Territorial Council of Social Services (TCSS) and the System for Autonomy and Care for Dependency (SAAD), that weekly IMERSO reports would be published for the duration of the pandemic. These reports contain information about how residential centres are coping during the pandemic.
The reports show that during the peak of each wave of the pandemic, the number of staff infected with Covid-19 was lower than the number of infected residents of the centres. This was not the case in the last weeks of December 2021 and first week of 2022, where the number of infected care home staff exceeded that of residents.
To guarantee services for people who rely on care from others during the pandemic, the TCSS and SAAD decided in March and October 2020 (and again in December 2021) that care home staff could be exempted from holding a professional qualification for the duration of the pandemic.
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.
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
On December 2, 2020, the Territorial Council of Social Services and the System for Autonomy and Dependency Care, agreed to prepare and publish weekly statistics and reports regarding the situation of residential centres during the Covid-19 pandemic.
The report is published on the Institute for the Elderly and Social Services (IMSERSO) website, and is prepared with each autonomous communities aggregate data concerning the situation of residential centres in their territory. The report includes information on residential centres for the elderly (R1), residential centres for people with disabilities (R2) and other permanent social services accommodation for both elderly and disabled people (R3).
The collection and systematization of statistics is conducted by IMSERSO, the Ministry of Health’s Coordination Centre for Health Alerts and Emergencies (CCAES) and the Ministry of Science and Innovation’s Institute of Health Carlos III (ISCIII). Data is submitted by ISCIII for weekly updates which can be found at https://covid19-country-overviews.ecdc.europa.eu/.
The data is always provisional and is updated weekly by the Autonomous Communities, and consequently, the structure of the report may vary. The report can be found on the IMSERSO website, and it is also possible to download the data that forms each weekly report.
The reports’ meet the parameters of the European Centre for Disease Prevention and Control’s (ECDC) protocol for epidemiological surveillance of residential centres in EU / EEA countries. The ECDC’s metadata has been implemented into the European Surveillance system (TESSy) since January 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).
- 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.
- 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).
Del Pino E., Moreno-Fuentes F.J., et al. (2020) Informe Gestio?n Institucional y Organizativa de las Residencias de Personas Mayores y COVID-19: dificultades y aprendizajes. Instituto de Poli?ticas y Bienes Pu?blicos (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.
- 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
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).
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
- 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.
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
- 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).
- 3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector
The “Report of the Covid 19 and residences working group ” highlighted the difficulties care homes encountered sourcing effective PPE for their staff during the first wave of the Covid-19 pandemic; especially between March and mid-April 2020. 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. At the time, there were reports of plastic bags being used instead and of the sharing of masks between staff (Del Pino et al., 2020). The lack of supply from abroad was due to the global lack of resources.
However, 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).
While massive global demand for PPE is difficult to manage, especially if sufficient stock has not already been procured, the report recommends that an essential part of contingency planning is to ensure a sufficient stock of PPE that should last at least one month. This includes PPE for residents, care home staff and family members in the event of an outbreak that affects large numbers of residents.
The report also recommends offering training about COVID-19 and its transmission to all care home care home staff, as well as training in the use of PPE. The report also states that it is especially important for care home staff to be provided with PPE when treating infected residents
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.
- 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
On January 15th 2021, a Shock Plan was approved by the Territorial Council of Social Services and the System for Autonomy and Care for Dependency (SAAD). The aim of the Shock Plan is to ensure adequate working conditions for people who work in the SAAD, along with improvements in services and benefits to guarantee adequate care for dependents.
The plan includes a series of objectives and measures regarding the development and management of the SAAD. The issues that are addressed by the plan include the need to carry out an evaluation of the SAAD, the reduction of administrative obstacles, the simplification of the procedures for awarding benefits, the reduction of waiting lists, and the recognition of telecare as a subjective right.
Improving the financing of SAAD is one of the main aims of the Shock Plan, and is achieved by an increase in contributions from the General State Administration (AGE). The two areas that have seen increase are in the minimum levels of protection and the agreed level of protection.
In 2021 and 2022 the funding for both areas increased significantly. The increase in minimum levels of protection have been enshrined in the General State Budgets for the year 2022, and can be seen in the table below:
Degree Previous amounts (€/month) New amounts (€/month) Increase Grade III Large Dependency €235.00 €250.00 6.38% Grade II Severe Dependence €94.00 €125.00 32.98% Grade I Moderate Dependence €60.00 €67.00 11.67%
The agreed levels of protection increased from €283,197,420 in 2021 to €483,197,420 in 2022. In 2021 the overall financing of the SAAD increased by 40.53% to €563 million and is expected to increase significantly in 2022.
- 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).
This means that, people who can prove they are a non-professional caregiver and meet the conditions necessary to receive a cash benefit for caring for a family member, will be able to apply for social security credits without incurring any financial penalty. Instead, it will be the General State Administration that will pick up the cost of paying for the benefits.
As of January 2022, 67,249 special agreements have been signed by non-professional caregivers (of which 88.6% correspond to women, and the remaining 11.4% to men). The total cost of special agreements for the General State Administration since the signing of the Dependency Law, is €1,639,881,600.61. However, this measure was suspended between 2012 and April 2019.
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.