MC COVID-19 Governmental Response to the COVID-19 Pandemic in Long-Term Care Residences for Older People: Preparedness, Responses and Challenges for the Future

MC COVID-19 Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future

Spain Eloísa del Pino, Francisco Javier Moreno Fuentes, Gibrán Cruz-Martínez, Jorge Hernández-Moreno, Luis Moreno, Manuel Pereira-Puga, Roberta Perna Institute of Public Goods and Policies (IPP-CSIC)

MC COVID-19 WORKING PAPER 13/2021 Contents

1. DESCRIPTION AND ANALYSIS OF THE ROLE OF THE RESIDENTIAL CARE SECTOR FOR THE OLDER-AGE POPULATION (PRE-COVID19) 3 1.1. Trajectory of LTC until the most recent model 3 1.2. Current arrangements in LTC 4 1.3. Debates around the development of a LTC system 5 1.4. LTC governance 6 1.5. General functioning of the residential care system 8 2. DESCRIPTION OF THE EVOLUTION OF THE PANDEMIC IN SOCIETY AT LARGE, AND IN THE RESIDENTIAL CARE AND HEALTHCARE SECTORS MORE SPECIFICALLY 10 2.1. Evolution of the epidemic 10 2.2. The effects of the epidemic on the healthcare system 14 2.3. The epidemic in the public and political debates 18 3. DESCRIPTION AND ANALYSIS OF THE MEASURES ADOPTED TO ADDRESS THE IMPACT OF THE PANDEMIC ON THE RESIDENTIAL CARE SECTOR FOR THE OLDER-AGE POPULATION 21 3.1. Background of preparedness for the Crisis 21 3.2. General Impact of the Epidemic on the Residential Care Sector and Policy Responses 25 3.3. Ensuring quality healthcare in nursing homes 34 3.4. The recovery of activity and the future of the residential sector 41 REFERENCES 43

MC-COVID19 text of institutionalized older-age care (age Project Coordinators: Coordination mechanisms in Corona- group that appears particularly vulnerable Eloisa del Pino Matute virus management between different in this epidemic context), in Spain as well Francisco Javier Moreno-Fuentes levels of government and public policy as in the rest of the EU-15. This study fo- sectors in 15 European countries cuses on the articulation of resources be- Research Team: tween health and social policies, and aim Gibrán Cruz-Martínez The political and administrative manage- to contribute to improve the effectiveness Jorge Hernández-Moreno ment of the healthcare crisis provoked by of the decision-making process and cru- Luis Moreno the COVID 19 is a key issue in preventing cial aspects in the fight against the pan- Manuel Pereira-Puga the spread of the disease. The Mc-COVID demic. Findings also aim to be useful to Roberta Perna 19 project is set to analyse the socio-san- inform other public policy sectors involved itary co-ordination procedures in the con- in crisis-related situations. https://www.mc-covid.csic.es/

How to cite this publication: 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 Eloísa del Pino 1. DESCRIPTION AND ANALYSIS OF THE ROLE OF THE RESIDENTIAL Institute of Public Goods CARE SECTOR FOR THE OLDER-AGE POPULATION (PRE-COVID19)1 and Policies (IPP-CSIC) [email protected] 1.1. Trajectory of LTC until the most recent model Francisco Javier Moreno Fuentes Institute of Public Goods The response to Long-Term Care (LTC) needs in Spain has been traditionally and Policies (IPP-CSIC) characterized by a low level of public involvement and a central role of the [email protected] family in the provision and financing of care. Up to 2006, the residual state Gibrán Cruz-Martínez intervention in this domain was structured around two basic programs: a Institute of Public Goods social insurance scheme (granting relatively small amount cash-transfers) and Policies (IPP-CSIC) for workers with LTC needs deriving from accidents at the workplace; and a [email protected] poorly developed system of personal social services run by municipalities Jorge Hernández-Moreno and regional governments, characterized by the deployment of means-test- Institute of Public Goods ed programs targeted to the most disfranchised groups (notably older de- and Policies (IPP-CSIC) pendents without resources or substantive family support networks), and [email protected] fundamentally focused in funding the provision of institutionalized residential care. Luis Moreno Institute of Public Goods and Policies (IPP-CSIC) This highly selective public LTC system, characterized by the extreme heter- [email protected] ogeneity of the level of coverage, as well as of the nature of the services provided across the territory, served only a small proportion of the dependent Manuel Pereira-Puga population. It actually depended on the considerable ability of family net- Institute of Public Goods and Policies (IPP-CSIC) works to absorb and internalize the functions of care of its members. The [email protected] responsibility for the care of dependent relatives fell mainly on women within households, a situation that had a considerable impact on the participa- Roberta Perna tion of women in the labor market, and most notably on their personal and Institute of Public Goods professional life opportunities when they assumed the role of caregivers. and Policies (IPP-CSIC) [email protected] The increasing incorporation of women into the formal labor market chal- lenged the Mediterranean welfare regime, notably the central role assigned to women in the provision of care within the household. In this context, the use of undocumented migrant workers (women for the most part) allowed families to set up financially affordable solutions (given the low salaries paid to these women) to the care needs of its members. The implications of this informal market’s substantial growth in recent years contributed to the ques- tioning of the traditionally weak role of public policies in the domain of LTC 1 (Da Roit and Moreno-Fuentes, 2019). Nevertheless, and despite the limita- This series of reports is one of the tions of this situation (unequal treatment to different sectors of the popula- research results of the Mc-COVID-19 project, “MC-COVID19: Coordination tion, low levels of assistance to those in need, precarious working conditions mechanisms in Coronavirus of care providers, poor quality of care due to the lack of qualifications of care management between different levels providers, or strong economic and functional pressures on families espe- of government and public policy sectors in 15 European countries”, cially for those women trapped in the role of caregivers), the inclusion of this funded by the Spanish National topic in public and political agendas did not occur until recent years. Research Council (CSIC) within the CSIC-COVID-19 programme, as well as In the early 2000s, the need to strengthen formal care structures became of the GoWPER project, “Restructuring the Governance of the Welfare State: pressing as informal care-provision structures were increasingly less able Political Determinants and Implications to face the growing LTC demands of an ageing population (e.g. chronic and for the (De)Commodification of Risks”, degenerative illnesses, mental health issues), the growth of the dependent CSO2017-85598-R Plan Estatal de older population, and the changes in the size and structure of the tradition- Investigación Científica y Técnica y de Innovación. al caregiving population. The perception of the inadequate nature of the

3 4 ℅ MC COVID-19 institutional and financial frameworks dealing with LTC needs in Spain implied increasing pressures for change in public policies in this domain. The urgent demands arising from these socio-demographic changes set the stage for a substantial reform of this relatively undeveloped welfare area.

1.2. Current arrangements in LTC

The 39/2006 Law on the Promotion of Personal Autonomy and Care for Dependent Persons (generally known as the “Dependency Law”) came into force in 2007, establishing the System of Autonomy and Dependency Care (SAAD). This national LTC system recognized the subjective right to social protection for all those who, regardless of their age, can provide proof of a stable residence in Spain for at least five years and who are recognized one of the degrees of dependency established in the Act (Moderate -Degree I-, Severe -Degree II-, and High Dependence -Degree III-). It broadened the scope of the public network of social services, defining a more coherent governance structure for the LTC system, improving the level of cooperation between social and health services in the domain of care for dependent people, and promoting the formalization of employment in the care sector.

Although the system is supposed to be mainly service-oriented, it also pro- vides cash benefits to informal caregivers and for personal support. The ideal preference for services was, in fact, soon confronted with the reality of pre-existing and profoundly heterogeneous social services schemes set up by regional and local governments. The strong path-dependency linked to those regional and local care systems strongly contributed to the shape that the SAAD took in every region and city. Those systems were often characterized by a close cooperation with private (often non-profit) operators in the care market focused on residential services and a fragile development of public care services. A consequence of that state of affairs was an evident lack of professionalization of care-providers and a weak development of a labor market niche linked to care. Financial restrictions experienced by regional governments, ideological preferences of regional policy-makers, and the social and institutional inclination for cash benefits also contributed to a systematic deviation of the reality from the SAAD’s initial design as a system mostly based on the direct provision of services. Thus, in practice, the SAAD operates as a hybrid system that combines the provision of services with cash transfers and informal care in households (heavily dependent on women, who account for more than 60% of the caregiving population in Spain) (Rodriguez Cabrero and Marbán, 2013).

The system is financed jointly by the central government, with a certain level of co-payments directly assumed by beneficiaries. Public funding com- prises the “minimum level” financed by the central government (aimed at guaranteeing the common basic coverage of a similar minimum level of benefits in the whole country), the “supplementary agreed level” (aimed at granting territorial redistribution in accordance to criteria of territorial dispersion, population size and number of users, jointly financed by the central government and the regions), and the “additional level” (voluntarily funded by the regions from their budgets). Accordingly, each regional government

◂ back to table of contents SPAIN ℅ 5 may establish a more comprehensive set of benefits for its residents beyond the standard basic coverage. In the original design, the national government was expected to pay for about a third of the system’s total costs, with regions assuming an additional third. The last third of the costs to fund the LTC system was supposed to be generated through co-payments by the beneficiaries, in accordance with their relative levels of income and wealth.

1.3. Debates around the development of a LTC system

Following the economic crisis that hit Europe in the early 2010s, and in the context of the strong pressures to reduce public deficits and to cut public expenditure, a series of measures were adopted by the Spanish government to scale down the implementation of the “Dependency Law”. This resulted in a significant reduction of its financial contribution to the funding of the LTC system, and in a significant delay in the calendar of deployment of this policy initiative. Specifically, the central government’s contribution to the financing of the “minimum” level of benefits was significantly reduced, and its contribution to the “agreed” fund was also eliminated, decreasing its total contribution towards the financing of the SAAD system well below the third of the total budget that had originally been established. The share not paid by the central government was assumed by the regions (which became responsible for around 60% of the total costs of the System) and by the beneficiaries themselves (with co-payments increasing to nearly 20% of the total costs). This state of affairs had, of course, significant consequences for the LTC system. For the regions, it implied a very heavy financial burden in a context in which they were also required to reduce their budget deficits. For the beneficiaries of the system, it implied having to devote a higher share of their revenues (often coming from their retirement pensions) to finance the services they received. For the SAAD itself, this situation implied a virtual freeze of its implementation, with a clearly negative effect on its range of coverage, the intensity of the protection it provided and the quality of its benefits, especially in relation to community services and cash benefits.

A key debate regarding the SAAD delves into the financial sustainability of this system. A wide-spectrum political agreement was reached in De- cember 2016 to reverse the financial cutbacks introduced at the peak of the financial crisis and to establish a Commission for the Analysis of the Situation of Dependency in Spain. Commission conclusions pointed at the need to reform and to improve the funding of the system, including a review of the funds provided by each level of the state administration, as well as a redefinition of co-payments (currently very heterogeneous between the different regions and with a regressive nature –beneficiaries with lower incomes contribute a greater proportion of their income than those with medium-high incomes).

A second debate that contributed to shaping the functioning of the SAAD is the extent to which care in the community (at home and/or with relatives supported by public care systems) should be promoted as an alternative to the institutionalization of dependent people. The idea that they should continue living in the same physical and social environment where they

◂ back to table of contents 6 ℅ MC COVID-19 lived before losing autonomy has gradually gained ground among care professionals, coinciding with the preferences of a vast majority of the population who wish to live in their home, maybe with the help of their families while receiving the necessary institutional support. The implications of this discussion are quite significant in a country in which informal care structures staffed by women relatives have traditionally characterized the care provision schemes.

A third debate influencing this policy was the idea that the personal services sector constitutes a niche of potential employment if the already existing care-related jobs - often functioning within the sphere of domestic repro- duction (with families assuming those tasks as non-reattributed functions) or in informal markets (care providers hired in the underground economy without social rights or contributions to social insurance schemes) - would emerge. Thus, the “Dependency Law” was born with the explicit objective of creating/emerging jobs in the care sector. Particular attention should be placed in this respect to the segmentation of the market of care provision by nationality, where immigrant caregivers (often undocumented and working irregularly) have constituted an informal and relatively cheap market response to the care needs of Spanish families. In addition to the conveni- ence of liberating women (human capital) from their caring responsibilities so that they can join the labor market and develop their own professional trajectories without limitations, issues related to the working conditions of those involved in the domain of care (full or part-time, salary levels, etc..), the skills that should be required from them depending on the tasks they are supposed to perform (personal assistance, healthcare, housework, etc.), and the career paths of caregivers, constitute key aspects in the analysis of the implementation of LTC policies. Since one of the objectives of the “Dependency Law” was to improve the quality of the care provided to dependent people, the choices made by regional and local authorities between the direct provision of services or cash transfers, and the potential role of immigration in this informal niche of the labor market, deserve special attention, particularly in relation to the role that checks and/or direct cash benefits may have in creating and sustaining informal care markets.

A final debate is related to the quality of the services and benefits provided by the SAAD, with a strong emphasis being placed on the persistence of waiting lists to access the system by persons whose eligibility to social protection has already been recognized, the characteristics of certain employment positions within social services, the excessive differences in coverage among the autonomous communities, and the shortfalls in the development of institutional coordination between social and health services in the field of dependency.

1.4. LTC governance

Before the passing of the “Dependency Law”, the Spanish central government largely abstained from intervening in this area of policy. The tradi- tional LTC system, which in origin was grounded on a limited set of Social Security benefits combined with some residual schemes run by regional

◂ back to table of contents SPAIN ℅ 7 governments and municipalities, evolved towards a model that imitates the basic traits of the “social-democratic” model (financed via general taxation, and granting access to a universalistic and basic –limited– protection in the form of a package of services and/or cash transfers). Thus, the SAAD is structured as a universal coverage LTC system based on cooperation between the central administration and the autonomous communities, integrated within the network of regional and municipal social services.

In this institutional equilibrium, the central government regulates the basic conditions that guarantee the equal exercise of the right to LTC nationwide and is also responsible for the Information System of the System for Auton- omy and Care for Dependency (SISAAD). The regions represent the operational structure of the system, as they are directly responsible for the actual management of the LTC system. They are in charge of handling the register of providers, the inspection and evaluation of dependency degrees according to the official evaluation scale, and the recognition of the right to LTC services and benefits. Local authorities also take part in the SISAAD and may complement the package of benefits to their constituencies (mainly by financing community services), although, in practice, they play a relatively subordinate role in the whole system.

The governance of the new LTC system is based on a structure of shared powers between the central government and the autonomous communities through the decisions adopted in the Consejo Interterritorial del SAAD. Both the central government and the regions are represented in this body, which defines the main traits of the functioning of the system, the intensity of the services provided, the terms and amounts of economic benefits, the criteria for co-payments by beneficiaries, and the scale for the recognition of dependency in the whole country.

The inter-institutional balances that characterize this area of policy deter- mine the powers and responsibilities of each level of government in caring for dependent people based on a logic of intergovernmental cooperation, which has profound implications with regards to the role of the different political actors involved in the process of development and reform of this policy domain (political mobilization, level of inter-institutional cooperation/ competition, nature and composition of financial flows, evaluation of the implementation of the system, etc.).

Several aspects of the functioning of the multi-level governance structure of the LTC system constitute potential sources of tension between the different levels of government involved in this area of policy. The first one has to do with the ideological opposition that often exists between the central and regional governments, which makes cooperation and information sharing a complex process. The poor articulation of the participation of municipalities in the functioning of the SAAD and the different level of political compromise of the regional authorities with the implementation of the “Depend- ency Law” also contribute to the emergence of potential difficulties in the coordination of the LTC system. If the different regions embraced the implementation of the SAAD with varying intensity and degree of compromise,

◂ back to table of contents 8 ℅ MC COVID-19 a similar situation can be observed in the application of the restrictive measures established by the central government regarding the LTC system after the fiscal consolidation measures applied in the early 2010s. Thus, certain regional governments pioneered the cost containment efforts in this domain, while others appeared to be considerably more reluctant in the implementation of those cuts (Rodríguez Cabrero et al., 2018). The consequence of this has been not only a system lacking internal coherence but, very particularly, the emergence of considerable inequalities between the treatments received by citizens depending on their region of residence.

1.5. General functioning of the residential care system

The residential care sector in Spain is highly heterogeneous and diverse. This is the case in relation to key characteristics such as the care homes’ ownership, its financing, their coverage and occupancy rates, the area where they are located (rural vs urban), as well as their size and infrastruc- tural characteristics (type of rooms, capacity to sectorize and isolate residents, etc.). In addition, nursing homes in Spain differ quite markedly in relation to the degree of healthcare they are capable of providing, or the degree of professionalization of their management. These differences play a very important role in the planning of a response to health-related crises like the current pandemic.

There is no official registry of care homes in Spain, so it is not easy to provide precise figures about the number of residences for older adults in the country. As it has been stated, the competences in this field are transferred to the regions, and there is a great disparity of criteria among them in the definition of the concept of care home (Abellán García et al., 2019). These potential differences around what is considered a care home imply a series of limitations when trying to obtain an accurate image of the residential care sector at the national level or developing comparisons between different regions.

According to data provided by the Institute for the Older-age and Social Services (IMSERSO) (2019), there are about 5,457 residential centers for older people in Spain, 4,063 of them (74.5%) privately owned, and 1,394 (25.5%) public care homes (Table 1). In total, they add up 381,158 places, representing a coverage rate of 4.21% (which varies significantly between a 7.6% coverage in Castilla y León, and 1.42% in the region of Murcia). Al- though the ownership of these centers is mainly private, most places within them (almost 6 out of 10), are financed through public funds (59.8%), with notable differences between regions.2

The average size of those residences is 69.8 places, although there is also a large dispersion across regions and between centers. According to IMSER- SO data (as of December 31, 2018), the occupation of the sector would 2 be around 72.6%. Regarding the number of residents, the CSIC “Envejec- This information refers to residential imiento en red” portal3 recently published some figures that estimate the care centers and does not include total number of older people residing in this type of residences at around assisted housing schemes. 333,920 people (60 years and older) (Abellán García et al. 2020). For its 3 part, IMSERSO (2019), in the absence of data in 4 regions, estimates in http://envejecimiento.csic.es/.

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Table 1. Characteristics of residences of older people by region

Average number Number of places Number of centers of places by center by type of funding % Coverage ratio (type of funding)

Region Total Public Private Total Public Private Total Public Private

Andalusia 658 150 508 67.3 44,255 62.4 37.6 3.07 1.92 1.16

Aragon 277 73 204 64.8 17,939 30.1 69.9 6.28 1.89 4.39

Asturias 247 46 201 59.9 14,788 51.4 48.6 5.62 2.89 2.73

Balearic Islands 68 28 40 95.2 6,472 51.7 48.3 3.62 1.87 1.75

Canary Islands 198 69 129 48.8 9,665 40.1 59.9 2.84 1.14 1.70

Cantabria 63 10 53 96.2 6,060 69.3 30.7 4.78 3.31 1.47

Castile and Leon 702 195 507 68.1 47,798 77.4 22.6 7.86 6.08 1.77

Castile-La Mancha 343 135 208 77.3 26,498 71.0 29.0 6.86 4.87 1.99

Catalonia 1,157 170 987 55.4 64,093 71.4 28.6 4.44 3.17 1.27

Valencian Community 331 69 262 82.6 27,327 47.7 52.3 2.84 1.35 1.48

Extremadura 289 211 78 49.7 14,352 64.2 35.8 6.49 4.17 2.32

Galicia 215 52 163 89.0 19,128 40.7 59.3 2.81 1.15 1.67

Madrid 473 63 410 109.1 51,582 41.9 58.1 4.37 1.83 2.54

Region of Murcia* 55 11 44 60.1 3,304 100.0 0.0 1.42 1.42 0.00

Navarre 74 28 46 77.7 5,749 56.1 43.9 4.48 2.51 1.96

Basque Country 270 73 197 68.6 18,522 75.5 24.5 3.77 2.84 0.92

La Rioja 31 9 22 103.5 3,210 53.3 46.7 4.85 2.58 2.26

Ceuta 4 1 3 49.0 196 94.4 5.6 1.97 1.86 0.11

Melilla 2 1 1 110.0 220 59.1 40.9 2.48 1.46 1.01

Spain 5,457 1,394 4,063 69.8 381,158 59.8 40.2 4.21 2.52 1.69

Source: IMSERSO (2019): SERVICIOS SOCIALES DIRIGIDOS A LAS PERSONAS MAYORES EN ESPAÑA. With data from the regions. *Data for the region of Murcia include assisted living for older persons.

276,924 the number of people (in this case, 65 years and older) residing in these centers, of which 70.4% are women, and 29.6% are men. The average age of the residents is quite high (81.8% are 80 or older), which helps to explain the vulnerability of this social group to a health threat such as the SARS-CoV-2 virus.

According to Jiménez-Martín and Viola (2020), with estimates based on data from the Active Population Survey (EPA), the residential care sector employs around 320,000 people, representing 1.7% of the total workforce. It is a clearly feminized sector (83% of women), and most of the positions are in the private sector (80%). In fact, the growth experienced by employment in this sector in recent years is mainly due to jobs created in the

◂ back to table of contents 10 ℅ MC COVID-19 private sector. As it has been the case in other sectors, employment has rebounded since 2015, but to a large extent, it has done so at the expense of lower wages than in other sectors. The level of precariousness in this sector has increased because indefinite employment fell while temporary and part-time employment increased (Jiménez-Martín & Viola, 2020).

2. DESCRIPTION OF THE EVOLUTION OF THE PANDEMIC IN SOCIETY AT LARGE, AND IN THE RESIDENTIAL CARE AND HEALTHCARE SECTORS MORE SPECIFICALLY

2.1. Evolution of the epidemic

Spain was the second European country to heavily suffer the impact of the coronavirus (Table 2). According to several experts4 consulted during this research, there was considerable scepticism in Spain about both the information provided by China about the epidemic and its capacity to deal with it, which might have led to an underestimation of the actual scope of the risk. Similarly, some interviewees stated that the great effort of preparation and expenditure made in Spain in the case of influenza A virus some years before, which then had only a modest incidence, acted as a deterrent to adopt stricter preparatory and preventive measures. It was thought that, on this occasion, something similar could happen. Besides, the scope of decisions that were expected to be taken throughout the crisis was of great salience not only in terms of health, but also in social and economic terms. It is quite plausible to think that authorities felt overwhelmed when they had to take harsh decisions with huge socio-economic implications.

On January 30, 2020, the World Health Organization (WHO) announced the outbreak of the new coronavirus pandemic. Numerous media articles

Table 2. Diagnosed people (PCR) and deaths in Spain (December 2020)

Diagnosed people Deaths 4 The POSEB research team collected World 67.087.071 1.536.255 primary and secondary data to support United States 14.760.626 282.312 the arguments developed in this working paper. The research team India 9.677.203 140.573 conducted 25 in-depth interviews with nursing homes’ managers Brazil 6.603.540 176.941 (directors, administrators, and medical Russia 2.439.163 42.675 supervisors) in various Spanish regions between July and August France 2.345.648 55.247 2020. The team also interviewed high-ranking officials responsible Europe 19.392.429 440.379 for the public healthcare and social Spain* 1.684.647 46.252 services at the central and regional levels of government. Furthermore, the team examined documents from *The data for Spain only include those cases confirmed by PCR. The data on confirmed governmental and independent cases are cumulative figures and include recoveries. Source: El País. sources, along with the results of a https://elpais.com/sociedad/2020/07/27/actualidad/1595838623_808240.html survey elaborated by IMSERSO.

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Table 3. Cases of coronavirus in Spain by region

Region Confirmed cases New cases Deaths 14-day cumulative incidence

Madrid 354326 1058 11426 224,03

Catalonia 310141 693 8126 208,54

Castile and Leon 123433 8 4647 295,06

Andalusia 238783 293 4296 229,94

Castile-La Mancha 87956 102 3825 250,88

Basque Country 99716 438 2568 342,06

Valencian Community 108586 194 2444 232,64

Aragon 74534 250 2360 302,66

Galicia 51557 344 1246 199,96

Asturias 24175 229 1073 344,35

Extremadura 29461 145 971 202,96

Navarre 40032 82 893 233,26

Region of Murcia 55116 60 623 192,72

Balearic Islands 25288 116 425 204,88

Canary Islands 21753 152 346 86,38

Cantabria 15903 151 324 302,54

Ceuta 2854 7 55 227,66

Melilla 4152 9 43 344,56

La Rioja 16881 41 561 340,91

Spain 1684647 4372 46252 231,11

Source: Ministerio de Sanidad, December 4, 2020.

speculated on the seriousness of the virus and its possible spread throughout Europe. On January 31, the first official case of COVID-19 was confirmed in Spain. On February 28, the WHO recommended drastic containment measures to halt the spread of the disease. At the national level, on March 1, some containment measures began to be taken (for example, holding all professional sports competitions behind closed doors, or requesting health professionals not to attend congresses), but these measures were not generally widespread. Some cities in the autonomous communities of La Rio- ja and Catalonia took more drastic measures. Madrid closed its older-age care centers to prevent new infections due to the death of an older adult and because 16 users tested positive to the virus. On March 8, massive public events were held, such as the Women’s Day demonstrations with thousands of participants, including several ministers (some of whom later tested positive for COVID-19) or the VOX party congress in the Vista Ale- gre arena (Madrid). Following notifications from various other autonomous communities (Madrid alone had 469 cases), the central government assumed the existence of community transmission on March 9.

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Figure 1. Death estimates by weeks (2020) Source: INE (accessed December 2020)

Figure 2. Excess mortality in Spain in 2020 Source: https://www.euromomo.eu/graphs-and-maps/#

On March 11, the WHO formally declared the existence of a pandemic. On March 14, the Spanish government declared the state of alarm throughout the national territory and empowered the Minister of Health as the delegated competent authority to take all measures it deemed appropriate to strengthen the national health system (Sistema Nacional de Salud –SNS–). On March 15, the first Conference of Presidents (gathering the Spanish Prime Minister and the Presidents of the autonomous communities) was con- vened. Between March 30 and April 9, a severe lockdown was implemented, and all non-essential economic activity in the country was paralyzed.

The Ministry of Health confirmed 46,200 deaths caused by COVID-19 from the start of the pandemic until the end of November 2020 (Table 3). How- ever, the National Institute of Statistics (INE) has also confirmed an excess death rate of nearly 80,000 (i.e. around this number of people had died in comparison to the average in the same period in the previous five years). Among the deceased, there would certainly be COVID-19 patients and would possibly be other non-COVID-19 patients who did not receive the same attention from the health system.

A very important percentage of deaths, about 50-60 per cent, were older people living in nursing homes. In some regions, there were problems in

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Figure 3. Seroprevalence of SARS-CoV-2 by province providing care for the older adults, both in primary care services and in hospitals (for further details, see the analysis below). This development caused a great deal of consternation in the country. Since the end of April 2020, the virus incidence decreased.

A nationwide population-based study aiming to estimate the seroprevalence of SARS-CoV-2 infection in Spain at the national and regional level was carried out between April 27, and May 11 (Pollán et al. 2020: 535 ff.). The findings of that study indicate that the prevalence of IgG antibodies against coronavirus at that time was around 5% in Spain. Marked regional differences could be observed (Figure 3): “The prevalence in hotspot areas such as Madrid was more than five times higher than that observed in low- risk regions such as most provinces and territories along the coasts”. The main findings indicated that prevalence:

“… remain low and are clearly insufficient to provide herd immunity. This cannot be achieved without accepting the collateral damage of many deaths in the susceptible population and overburdening of health systems. In this situation, social distance measures and efforts to identify and isolate new cases and their contacts are imperative for future epidemic control.”

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2.2. The effects of the epidemic on the healthcare system

The SNS has gradually been universalized since 1986 to cover all Spanish citizens and registered foreigners. Since 2002, management for healthcare was decentralized to the seventeen autonomous communities, while the central government is responsible for the regulation of the right to healthcare and the establishment of the basic elements of the organization, coordination and financing of the SNS (it also holds responsibilities in foreign health, design of training plans for health personnel, pharmaceutical policy, and high inspection of the system). This multilevel healthcare policy decision-making equilibrium is governed by the Inter-territorial Council of the SNS (Consejo Interterritorial del Sistema Nacional de Salud –CISNS–), which brings together the regional and national healthcare ministries. Autonomous communities’ management of the regional health systems amounts to about 40 per cent of their regional spending.

Constitutionally, the general coordination of health policy is the responsibility of the national Ministry of Health. Within the Ministry, the Center for the Coordination of Health Alerts and Emergencies (CCAES), created in 2004, is in charge of setting up preparedness and response plans to deal with public health threats. The CCAES must also carry out a survey of the national capacity requirements set out in the International Health Regulations (2005), and it is to coordinate along the regions to ensure their implementation.

On February 4, 2020, the Ministry of Health held the first special meeting of the SNS governance intergovernmental body (the Inter-territorial Council of the SNS –CISNS–) to address the pandemic, and it established an In- ter-Ministerial Coordination Committee. As of March 9, a second phase in the managing of the pandemic began, when the central government took the leading role in handling the crisis. The Ministry of Health held bilateral meetings with all the autonomous communities and within the multilateral CISNS, and proposed to take further action. The Spanish Prime Minister announced that a group of experts were working in 4 areas (health, social, economic, and international) to prepare all the issues that had to be considered when designing policy responses in the pandemic’s context. In the health domain, group members came from the Ministry of Health, while the autonomous communities did not formally participate. Therefore, it lacked a very relevant perspective on the functioning of the SNS. This lim- itation was evident in the group’s recommendations, which focused on the SNS’s reactive capacity and overshadowed contagion’s prevention measures, raising no little criticism. One of the main critiques was the scarce role given to primary care to detect and monitor cases of coronavirus (the 13,000 health centers and clinics distributed throughout the country are the centerpiece of the SNS system). The group identified several problems, the most important being the lack of precision in the data about COVID-19 incidence and the system’s operative capacities.

On April 2, in the middle of the first wave of the pandemic, the maximum number of hospital admissions because of COVID-19 was 47,035 patients.

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Figure 4. Daily admissions to hospitals with coronavirus in Spain

Figure 5. Daily ICU admissions with coronavirus in Spain Source: Red Nacional de Vigilancia Epidemiológica

The peak of ICU occupancy was reached on April 5 (6,576 ICU beds). Many autonomous communities reached their maximum ICU capacity, especially Catalonia and Madrid and the autonomous communities nearby. Some autonomous communities had to build temporary field hospitals.

Figures 4 and 5 focus on the first wave of the COVID-19, which extended from March 2020 to June 2020. At the end of this period, the curve was considered to have been flattened. However, well before the end of the summer, there was a new upturn in the number of cases, and in Septem- ber, it was taken for granted that Spain was already facing a second wave of the pandemic. The peak of this second wave did not reach the proportions of the first, probably due to the early adoption of restrictive measures of

◂ back to table of contents 16 ℅ MC COVID-19 mobility and social interaction. In December 2020, the number of cases was declining, although there was a great concern about the arrival of the Christmas holidays and its effects on social interactions and the spread of the disease.

Nearly 58% of patients hospitalized with coronavirus in Spain are men suffering from hypertension (50%) and diabetes (22%), the most frequent previous associated pathologies. Fever is the main clinical manifested symptom in 40% of cases, and the most common complications are related to pneumonia (40% severe and 53% mild), and respiratory distress syndrome (20%). The intra-hospital mortality rate is 18%. One out of three patients with COVID-19 who went to the hospitals during the first months of the pandemic needed oxygen since their arrival to the intensive care in emergency rooms (ER), and more than 80% were admitted with pneumonia, many of them in severe or critical conditions.

According to the Ministry of Health, another side effect provoked by the pandemic has been the increase in waiting times for surgery. In June 2020, people on the list waited an average of 170 days for surgery, almost two months longer than was expected in the previous year. The number of surgery interventions also fell by 36% in the first half of 2020, as compared to the same period in 2019. Likewise, the number of people on waiting lists (691,508) was slightly smaller. This has been due to the suspension of consultations and diagnostic tests that prevented more people from entering the waiting lists. All of these developments have made health professionals be concerned about the aggravation of pathologies that could have been treated more easily otherwise.

As early as January 23, 2020, experts from the Ministry of Health and the autonomous communities adopted the first protocol in the event of possible suspicious cases of COVID-19 (which would be modified at least three times over the following month). Since then, the Ministry of Health implemented numerous measures to contain and fight against the pandemic. It drew up protocols for professionals and tried to make resources available to the autonomous communities, mobilising 81,000 health professionals, students and private health resources and providing financial support. Likewise, it implemented a centralised purchase process for healthcare equipment (PPE and respirators, among others). Such a course of action was one of the most criticised decisions for four reasons: (1) the Ministry lacked the administrative capacity to deal with the purchasing processes because of the lack of funds and the decapitalisation experienced by the Ministry of Health over previous years (there was an implicit belief that, due to decentralisation, the Ministry was no longer relevant); (2) the Ministry did not foresee the saturation of international markets; (3) some private companies slowed down the acquisition of health equipment in the expec- tation that it would be taken up by the central government; (4) the media continued to project images of healthcare workers inadequately protected.

On April 7, the Ministry of Health established a group of experts who prepared a technical report on “Health Recommendations for the Transition

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Strategy” with general recommendations concerning healthcare, epidemiological surveillance, identification, and containment of sources of infection and collective protection measures. The central government approved on April 20 a new plan for de-escalation with four phases (0, I, II and III) to reach the so-called “new normality”. The change of phase of individual regions was to be decided by the Ministry of Health based on epidemiological criteria and, in principle, each phase would last two weeks.

On May 6 the Carlos III Health Institute (ISCIII), through the National Net- work of Epidemiological Surveillance (RENAVE), published the “Report on the situation of COVID-19 in health personnel in Spain”. During the first wave of the pandemic, healthcare workers had to fight the disease inadequately protected, which resulted in a disease incidence rate among healthcare professionals twice as high as among the general population. Between March and May 4, 30,660 health workers got infected: 89% did not need hospitalization, 16.5% developed pneumonia, 1.2% required admission to ICU, and 0.1% died. Over three quarters of these health professionals were women, with an average age of 46. In November 2020, the number of infected healthcare workers was already 86,028, and the group’s death toll reached 65.

Formally, the central government and the autonomous communities carried out an impressive coordination effort in the field of health. This did not occur in other sectors such as social services, despite it was legally possible for the Vice Presidency for Social Rights to assume a role similar to that of the Minister of Health to respond to the huge problems occurring in nursing homes (Galán and Roig, 2020). Throughout that period, two intergovernmental political fora of great importance were significantly active: (1) the CISNS, which, until July 2020, met around 40 times, and (2) the Conference of Presidents, which during that period had already met 14 times. In addition, 68 bilateral meetings of the central government with the autonomous communities were held up to June 25. The CISNS technical committees were also very active, with around 70 meetings during the same period (only 6 CISNS meetings were held in 2019, between 2012 and 2016, there were three per year, and between 2004 and 2017, there were only 6 Conferences of Presidents).

Despite these coordination efforts, criticism of the central government’s initiatives were voiced with arguments such as: not including the autonomous communities timely in the decision-making process (for example, the Prime Minister used to announce measures at a press conference before discussing them with the Regional Presidents); the opacity of the criteria in the decision-making during the process of de-escalation, as well as about the identity of the experts who participated in that process; the lack of presence of autonomous communities in different groups of experts ad- vising the Ministry; assuming responsibilities without having sufficient administrative capacity, thus delaying the regional management; or making health recommendations without knowing the different regional realities. Since the end of health decentralisation, the Ministry had, in fact, lost part of its expertise, and the autonomous communities had organised their own

◂ back to table of contents 18 ℅ MC COVID-19 healthcare systems in diverse manners. In addition, some autonomous communities, among them Madrid and Catalonia, with different political colouring in their executives from that of the central government, showed an aggressive attitude against the central authorities that some media sources found unfair or inappropriate during the hard times imposed by the pandemic (Mattei and Del Pino, 2021).

Several factors forced the central government to start shifting its involvement towards the third phase in which the autonomous communities would have more room for autonomous decisions, such as: (1) to some extent the central government assumed some of the criticisms made by the regions, for example the poorer knowledge of the SNS; (2) the central government seemed to increasingly acknowledge that it was much more practical to share management responsibilities with the autonomous communities; (3) the central government had increasing difficulties in obtaining “automatic” approval of the legislative validation by Parliament for the required exten- sion of the state of alarm every 15 days (in fact, in exchange for the support of the regional nationalist parties in parliament, the central government agreed that once phase III of the de-escalation plan was reached, the autonomous communities would be the competent authority to manage the pandemic); and (4) at the end of this period, the central government was better valued by the public opinion because it had managed to flatten the curve and had left the responsibility for what could happen afterwards in the hands of the autonomous communities. These would also be account- able for their policies in citizens’ eyes.

On June 10, a regulation approved the conditions for the so-called “new normality”. A few days later, the COVID-19 Fund (Royal Decree-Law 22/2020) was passed with an extraordinary credit of 16,000 million euros to face the consequences of the pandemic. This extraordinary fund of a budgetary non-refundable nature, which aims at providing additional financial resources to the autonomous communities to meet the budgetary impact of the crisis caused by the COVID-19 Pandemic, led to a significant increase in health spending (around 0.8 points of GDP in 2020), most of which has been met by the autonomous communities (0.7 points) and financed by this extraordinary fund. It is expected that by 2021, a significant portion of health spending will need to be maintained, around 0.4 points of the GDP (AIREF, 2020: 73).

After 6 extensions validated by Parliament, on June 21 the state of alarm ceased and, with it, the measures established by the central government. From then on, the autonomous communities were to manage their territories according to their own plans and approaches to deal with the pandemic.

2.3. The epidemic in the public and political debates

2.3.1. Politics and COVID-19 in Spain

Unlike other European countries, the politics in Spain during the first months of the pandemic were characterized by political confrontation and conflict.

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One of the major issues during the first wave was the management of the crisis. On March 14, the central government declared the state of alarm which would be in place until June 21. The state of alarm provided the progressive coalition government (Partido Socialista Obrero Español –PSOE–, and Unidas Podemos –UP–) with the legal framework to implement a number of measures that could not be applied otherwise, such as mobility restrictions and closures of businesses, bars and restaurants, among others.

Over that period there were significant disagreements between the central government, the opposition, and some regional authorities over whether or not the state of alarm was the correct instrument to effectively manage the pandemic, and which level of government should be in charge of what. The main opposition party, the conservative Partido Popular (PP), repeat- edly accused the central government of poorly managing the crisis, using the state of alarm to take powers away from the regional governments, and even lying to the public about the number of cases and death tolls. On its side, the far-right party Vox (the third biggest group in the Spanish parliament) insisted that the coalition government was using the state of alarm to replace democracy with a totalitarian regime.

There were also conflicts between the central government and the governments of the regions where PP is in office. Here, it is worth highlighting the continuous disputes between the central government and the regional government of Madrid, with President Isabel Díaz Ayuso (PP) accusing Prime Minister Pedro Sánchez of taking decision aimed at “ruining” Madrid.

2.3.2. COVID-19 and the public

Given such a heated political context and taking into account that Spain was one of the worst-affected countries in Europe during the first wave of the pandemic, it is not surprising that COVID-19 was (and still is) a major concern for Spaniards. According to a survey conducted by Centro de In- vestigaciones Sociológicas (CIS) in early September, 93.9% of Spaniards were very (51.2%) or fairly (42.7%) concerned about the coronavirus.5 Apart from the health crisis, Spanish citizens expressed their concern about the consequences of the pandemic over employment and the economy. 38.8% of Spaniards were as concerned about the economy and employment, as about the health situation; and almost one in four (24.1%) were more 5 concerned about the economy and employment than about health issues. Estudio nº 3292. Available at: http:// Spaniards were also pessimistic about the future, at least over the short datos.cis.es/pdf/Es3292marMT_A.pdf. term. A survey published by FUNCAS in September showed that almost 6 three out of four Spaniards (73%) thought that Spain will come out of the https://www.funcas.es/boletines/ economic crisis later than most European countries.6 encuesta-funcas-sobre-el-coronavirus- seis-meses-bajo-la-pandemia/. Regarding the political situation, Spaniards’ trust in the central govern- 7 ment’s management of the crisis is low overall and has been declining In April, 10,5% thought that governments’ over time. In September, only 6% said that governments’ decisions could decisions could be totally trusted and be totally trusted, and 25% that could be fairly trusted.7 As expected, trust 36% that could be fairly trusted. Estudio 3279. Available at: http://datos.cis.es/ in central government’s decisions is strongly associated to political behav- pdf/Es3279mar_A.pdf. ior: 55.7% of PSOE, and 70.8% of Unidas Podemos voters thought that

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Government’s decisions could be totally or fairly trusted; while only 4% of PP and 1.1% of Vox voters trust the government.8

In relation to citizens’ preferences for the level of government that should be in charge of managing the crisis, in September 73% thought that the central government and regional authorities should manage the crisis co- ordinately, while 15.8% thought that the crisis should be handled by the central government, and 4.9 were favorable to the regional governments. The main cleavage here is not the left-right, but the support for nationalist vs non nationalist parties.

2.3.3. COVID-19 and nursing homes in the media

Regarding the crisis in care homes, the high salience of these centers in the total death toll of COVID-19 in Spain implied that there has been an extensive media coverage of the coronavirus crisis in nursing homes. In order to analyze the media coverage of COVID-19 and LTC, two of the major Spanish daily newspapers have been selected: El País (center-left), and ABC (right). From March to August 2020, almost six hundred pieces of news on COVID-19 and nursing homes were published by these two newspapers: 301 by El País, and 275 by ABC. The media coverage included a range of topics. The most remarkable ones were related to new cases of infections and deaths of older people in nursing homes; the measures taken by the central and regional governments; the investigations carried out by the general and provincial prosecutors’ offices (Fiscalía General del Estado and fiscalías provinciales, respectively); court decisions and possible legal consequences of the crisis; and the political confrontation related to the measures taken to reduce the impact of the virus in nursing homes.

Regarding the latter, political dispute has been reported to take place at three different levels:

1. Media systematically reported political confrontation between the progressive coalition government and the autonomous governments managed by the PP. Such confrontation may to a large extent be un- derstood as blame-avoidance dynamics. Conservative regional governments have blamed the central government for the high impact of the virus in nursing homes arguing that the central government was responsible of managing the crisis in the LTC sector after the decla- ration of the state of alarm. Simultaneously, the central government insisted that powers in residences remained in the hands of the au- 8 tonomous communities. Estudio nº 3292. Available at: http:// datos.cis.es/pdf/Es3292rei_A.pdf. 2. The previously mentioned political struggle between the central gov- 9 ernment and some of the opposition parties, especially PP and far- “This social-communist government right party Vox, also reached the nursing homes. Here it is interesting wanted to introduce a regulation how the latter used a strategy of fueling conspiracy theories in order on euthanasia in Spain; and, to discredit the government. For example, the spokeswoman of Vox in unfortunately, and by way of facts, it has applied it in the most ferocious Parliament said in an interview that the central government had used way (in nursing homes)” (Los the COVID-19 as a method of euthanasia in nursing homes.9 desayunos, La 1, April 13, 2020).

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3. Media also reported political conflicts within some regional (coalition) governments. It must be highlighted in particular the conflict in the Region of Madrid between the regional minister of Social Policy, Alberto Reyero (member of the liberal party Ciudadanos [Citizens]), and the regional minister of Health, Enrique Ruiz Escudero (PP). At the height of the conflict, Alberto Reyero stated in Madrid Parliament (Asamblea de Madrid) that the regional protocol for transferring infected persons from nursing homes to hospitals was “unethical and, probably, illegal”. Allegedly, the criteria for allowing older persons infected from COVID-19 in nursing homes to receive hospital care were far too restrictive in several autonomous communities during the early stages of the pandemic.

3. DESCRIPTION AND ANALYSIS OF THE MEASURES ADOPTED TO ADDRESS THE IMPACT OF THE PANDEMIC ON THE RESIDENTIAL CARE SECTOR FOR THE OLDER-AGE POPULATION

3.1. Background of preparedness for the Crisis

In 2002, Spain participated in some pandemic simulations organized by the European Commission. The Preparedness Plans of Spain and other countries to deal with respiratory viruses derived from MERS-CoV were re- viewed by the European Center for Disease Control in 2015 (ECDC, 2015). The report drafted following that initiative made a number of recommendations for each of the three countries included in that analysis (Greece, Unit- ed Kingdom and Spain). The recommendations included: (a) strengthening public health capacities through training, exercises and evaluation; (b) ensuring the provision of human and technical resources; (c) analysing the challenges of implementing the plans, especially when the designer is not the one implementing it; (d) improving public communication; (e) strengthening collaboration with other countries; and, (f) the need for cross-sectoral collaboration. In the case of Spain, and concerning what the report called “vulnerabilities” (pp. 21 and 22), a series of red flags were signalled, including the lack of public health resources; the need to improve communication between actors; the absence of emergency response exercises, which are generally perceived as a “waste of time”; and the substantial differences between the autonomous communities, differences which are not necessarily due to the particular conditions of each one. Attention was drawn to the deficient intersectoral coordination between health and other areas of public policy programming and implementation.

Before the arrival of this coronavirus pandemic, the Ministry of Health had Preparedness plans which were developed to deal with the H5N1 influenza virus (updated in 2009). In line with this planning, the autonomous communities also had regional Preparedness and Response Plans. There was also a protocol for action in suspected cases of Ebola (updated in January 2020), and a National Plan against vector-borne diseases (Dengue and Zika). In 2017, the Ministry drafted the first protocol for health professionals to deal with a potential outbreak of Mers-CoV. The central government

◂ back to table of contents 22 ℅ MC COVID-19 was also organizing the first national preparedness exercise, which should have taken place in April 2020 in accordance with the National Security Strategy, although the reality of the pandemic forced its postponement.

Neither the more general plans at the central government level, nor the preparedness plans existing in the Ministry of Health for cases of influenza and Ebola anticipated the scope of an epidemic like the COVID-19. The content or scope and consequences of the decisions that had to be taken in a crisis, or the procedures, public policy instruments, and/or type of rules through which the decisions had to be taken, were actually not anticipated. The regional Public Health Director Generals interviewed for this research were actually not aware of the existence of the emergency plans that had been made by the central government with respect to other health threats in previous years.

The required intergovernmental and intersectoral coordination arrangements necessary to deal with the disease were especially complex to articulate once the pandemic hit. Likewise, the administrative and health capacity needed to deal with a crisis of this magnitude (very poorly effective in the case of social services and other policy sectors) took the authorities by surprise. For instance, previous plans foresaw individual but not territorial confinements. Furthermore, the existing preparedness plans or protocols contained very little information on how the health system as a whole should relate to other public policy sectors such as the regionalized social services. The latter had been greatly affected by the budgetary cuts introduced after the 2007-08 economic crisis and did not have the resources and/or the expertise to confront the critical situation produced by the Coronavirus pandemic.

Social and health authorities may have also been overconfident about their capacities because the Spanish healthcare system was ranked among the best in the world by several international organizations in the years prior to the pandemic (e.g. The Lancet Ranking). The Spanish SNS was considered to be the most efficient healthcare system in Europe, and the third most efficient in the world (Bloomberg Index). Spain also scored reasonably well in the Global Health Security Index (2019), which measures, among other things, the ability to detect pandemics and epidemics.

The reality is that the Spanish health system had also suffered the strong impact of the budgetary cuts made during the Great Recession (about 10- 12% reduction in healthcare spending), and by 2017 it had not yet fully re- covered the pre-crisis levels of spending (Del Pino, 2020). Among experts, the view that public health activities and epidemiological surveillance had been left behind was generally shared and often mentioned.

3.1.1. Preparedness Plans in care homes

Neither the National Strategies, nor the Preparedness and Response Plans of the Spanish Ministry of Health provided guidelines for interventions in collective housing (including residential care homes for older-age adults)

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prior to the pandemic, despite this type of centers might even fit the definition of “critical infrastructure” since they constitute the only alternative for many older-age adults. Residential care homes are necessary for the maintenance of essential social functions, the health, safety, social and economic welfare of citizens, and the effective functioning of the public sector, as defined in the framework of the National Security System.

Residential care homes for older-age adults accommodate individuals living collectively, thus facilitating the spread of the virus. Moreover, they contain three mutually reinforcing elements of vulnerability: the older-age of their residents, the presence of a multiplicity of chronic diseases, and the fact that caring for residents implies very intensive daily human contact. Even though it may have been possible to anticipate that these centers could suffer quite severely from the consequences of this type of pandemic due to their particular characteristics, the preparation to intervene in them was clearly not anticipated and planned.

The existing preparedness plans stipulate the direct participation of both the autonomous communities and authorities linked to social services in the committees that draw up these types of documents, but the pre-pandemic plans - drawn up at the initiative of the Ministry of Health - did not specify how to act in residential care homes.

3.1.2. Protocols and contingency plans at the organisational level

The regulations governing the field of care homes for older-age adults con- template situations of risk and emergency. A number of rules require care homes to have an emergency plan.10 The company (in case of private care homes) has to guarantee the safety and health of its personnel in all aspects related to work and, if necessary, provide them with a protocol of action to avoid occupational risks.

The coronavirus crisis forced care homes’ managers and the government to update and adapt the contingency plans and protocols rapidly and re- 10 peatedly. In the specific context of the COVID-19 crisis, care homes for old- These included the resolution of the er-age adults have been urged to draw up contingency plans to combat the 2nd December 2008, by the State pandemic (see “Royal Decree Law 21/2020 of 9 June for a list of urgent Secretariat for Social Policy, Families and Care for Dependency and prevention, containment and coordination measures to deal with the health Disability. The resolution published the crisis caused by COVID-19”). At the regional level, the autonomous com- Agreement of the ‘Territorial Council munities produced various documents and guidelines to lead residences of the System for Autonomy and in the preparation of their contingency plans (for example, see those of the Care for Dependency’, with common accreditation criteria to guarantee the regional government of Aragon, or the Community of Madrid). quality of the centers and services of the ‘System for the Autonomy and Care Directors and workers of the residential care homes claim that the lack for Dependency’, and, in addition, the resolution of April 25, 2012, by the of information and protocols to respond to the spread of the virus initially Directorate General of Employment, caused chaos and uncertainty. Moreover, it prevented a harmonised and which registered and published the VI standardised response. It was not clear who had to be contacted, what State Collective Agreement Framework tasks were to be carried out by whom, there was no adequate stock of per- on services for care of dependent population and the development of the sonal protective equipment which would have been easy to store and could promotion of personal autonomy. have prevented the spread of the virus in many residential care homes.

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Informants also noted that the role of the central and regional administra- tions to supervise and regulate the response to the pandemic was totally insufficient.

Some residential care homes formalised their first protocol in February 2020. In other cases, the protocols were drawn up as late as mid-April. Dur- ing the evolution of the pandemic, protocols and Preparedness and Contin- gency Plans drafted at the different levels (from the central government to the residences, passing by the autonomous communities health and social services authorities) were continuously modified as new information and instructions were made available from various organisations and health authorities. Residences’ protocols were also adjusted to incorporate their own experiences in responding to the health emergency in their facilities.

Thus, when protocols started to arrive at the residential care homes, they did so from a multiplicity of local, regional and central actors, as well as from governmental and non-governmental ones. The lack of coordination in the development and publication of protocols meant that the residential care homes were overloaded with regulation that they had to carefully study to ensure they implemented/updated the measures required.

Although every care home contacted for the drafting of this report made a considerable effort to elaborate and adapt their protocols, the availability of specific professional profiles among the residence staff facilitated the task for some of them. While in some cases the responsibility was initially assumed by a single person, in others a multiplicity of actors worked on the development of those protocols (the geriatric doctor, the nursing coordina- tor, the director of the residential care homes, the quality-assurance manager, the head of maintenance and even representatives of the residential care homes’ owners -ARTECAM for its acronym in Spanish-).

In several autonomous communities, employees at the residential care homes came together in mutual help groups using technological applica- tions to learn from each other about the best way to respond to the pandemic. Also, workers were seen in fora where they collaborated with the regional or central government.

• The analysis of the situation in a series of care homes allows us to highlight that:

• The initial lack of knowledge about the characteristics of the virus led to the drafting of recommendations for the management of residents or asymptomatic staff which clearly contributed to the spread of the disease inside the centers.

• COVID-19 protocols have often been insufficiently sensitive to the architectural and spatial reality of the residential care homes. A large number of the residential care homes do not have enough space for proper sectorization. This issue must be taken into consideration when planning a possible evacuation of those infected or suspected

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of being infected with the virus. In many residential care homes, for instance, most of the rooms are of double occupancy, which makes isolation very difficult. Common areas or even transit areas were used for sectorization, but this meant the closure of common spaces in several parts of the buildings.

• Protocols did not elaborate with sufficient detail how services were to be organized. For instance, some professional profiles (like doctors, nurses, or physiotherapists) were unique to residential care homes and, for at least the first few weeks of the pandemic, they had to care for both healthy and infected residents. This may also have contributed to the spreading of the virus.

• The same applies to residents’ living arrangements. During the pandemic, residents’ care has been organized according to epidemiological criteria, while traditionally their cohabitation had been organized according to their degree of dependency or other criteria. The new organisation in times of a pandemic can make cohabitation and attention to residents’ needs very difficult.

• Some residential care homes developed their first protocols internal- ly. These centers studied and updated previous protocols for other contagious diseases (although not all residential care homes had developed an infectious disease protocol before). For example, one nursing home reported having a protocol based on their previous experience with the SARS crisis, while another nursing home just had protocols for gastroenteritis and common flu. Most of the residential care homes with a protocol for contagious diseases in place came from the time of the Avian Flu. The problem is that these protocols, for the most part, had not been implemented, were not adequately studied, or adapted to respond to a virus like SARS-CoV-2.

• The development and implementation of protocols require on-site supervision of each nursing home and intersectoral collaboration, mainly between the Health Department and Social Services.

3.2. General Impact of the Epidemic on the Residential Care Sector and Policy Responses

3.2.1. The difficult intersectoral and intergovernmental coordination to respond to the COVID-19 in residential care homes

Intergovernmental coordination

A large part of the public discussion about the response to the pandemic has been focused on issues related to the intergovernmental coordination. However, the functioning of this coordination is actually difficult to assess, due to the noise generated by the blame avoidance strategies deployed by the different actors involved in the multi-level governance of the response to the disease.

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In the first phase of the crisis, the central government was criticized for the excessive centralization of decisions. Once the first curve flattened out in the summer 2020, the central government was accused of a lack of involvement and intergovernmental coordination. Some autonomous communities have been criticized for being vague in their opinion about which tier of government should be primarily responsible for the management of the crisis. This was regarded as a strategy for electoral gains. In addition, some autonomous communities were also criticized for not complying with the requirements established by the central government with the support of the interterritorial commission to manage the de-escalation, something which may have contributed to a resurgence of the virus earlier than expected after the summer.

Coordination with the Ministry of Health has taken place in formal terms, judging by the number of meetings of the SNS governance bodies where the issue of residential care homes was discussed. However, it is unclear whether it had been dealt with sufficient depth. By the end of the summer, the SNS governance bodies had met more than a hundred times. Especially in the first part of the crisis, the Vice President for Social Rights had been less active in the coordination. This is confirmed by examining the limited meetings (4) between formal bodies of the intergovernmental relations of this policy domain (the SAAD Territorial Council and its commissions). Prob- ably this was due to the fact that the team taking responsibility for Social Rights had just taken office right before the outbreak of the pandemic.

The Ministry of Health designed protocols to help guide the actions of the regional governments of the autonomous communities in the care sector. Still, those protocols did not always arrive on time due to dissemination problems. In other occasions they needed to coordinate the protocols with those already developed by the autonomous communities, or even by the residential care homes themselves. Numerous measures had been agreed upon during lockdown, de-escalation and the so-called “new normality”. These measures were related to the staff to be mobilized, the resources available or the studies to be conducted. In the case of social services, there had been different initiatives to facilitate the management of the autonomous communities in relation to the residential care homes. For example, by providing financial resources and modifying the regulations on staff recruitment. Late in the crisis, several measures were put in place to collect information and review what had happened in the residential care homes. However, recurrent complaints have been made underlining that these initiatives should have been initiated earlier.

The intergovernmental management of health data, and in particular data on residential care homes, was problematic and incomplete in monitoring the epidemic. The two main Ministries involved were (and to a large extent still are) urged to play a greater role in coordinating initiatives, especially those which, for political and electoral reasons, are particularly difficult to adopt in a single AC. The central government was also requested to take measures related to data collection and information sharing, including the dissemination of international and regional good practices. The residential care homes have had the Regional Ministries as their main reference

◂ back to table of contents SPAIN ℅ 27 bodies for intervention. In some cases, the regional Social Services and Health ministers also participated, but the involvement of the central government Ministries did not take place with the same intensity because of the territorial division of competences and power.

Cross-sectoral coordination

In many autonomous communities, the Regional Ministries of Social Ser- vices were the first authorities to reach out to residential care homes. The Social Services were responsible for restructuring the system because of the perceived inaction of the Ministry of Social Rights and the lack of understanding of its problems by the Ministry of Health. In some autonomous communities, the Regional Ministries of Social Services describe themselves as powerless. They had harsh encounters with the health sector (both at regional and central levels) because the latter “did not understand the risk in the care homes sphere”.

At times it was extremely complex to get access even to basic healthcare in primary care centers, which claimed to be collapsed with the general population, and even more so in hospitals, which in certain instances received restrictive instructions about attending patients coming from care homes. The relationship of the Regional Ministries of Health and Social Services with the residential care homes has not been standardized due to the territorial internal diversity of the autonomous communities, and the different impacts of the different phases of the pandemic. In some autonomous communities, the Regional Ministries of Social Services have had what could be described as an “administrative relationship” with residential care homes, leaving the operational relationship to the regional health system.

During the interviews, some managers of residential care homes empha- sized that, after several weeks, a joint work dynamic between the Social Services and Health regional ministries had already developed. In several autonomous communities, plans for social and health coordination have subsequently been launched, for example in Castile-La Mancha and Aragon. Likewise, the autonomous communities organised healthcare with different measures that, within the same autonomous communities, may have varied over time. In some, public health services have played a more prominent role, creating and providing residential care homes with detec- tion and diagnosis devices. In others, the relationship and coordination with residential care homes has been carried out mainly with hospitals through the geriatric service (as in the regions of Madrid or Valencia) or, alternative- ly, through primary care (as in Catalonia or Asturias).

One of the cases where the epidemic was better controlled in the first wave of the pandemic was Asturias. One interviewee in this region attributed the initial success in controlling the spread of the disease to the following factors: the distance from regions like Madrid, where the outbreak was quite virulent in the first stages of the pandemic; the time margin with which they were able to prepare for the arrival of the first cases of the illness to the region; the good functioning of primary care and public health services; good

◂ back to table of contents 28 ℅ MC COVID-19 home care; the tracking system; responsible citizenship; leadership (political and technical); team work; fast health and social coordination from the beginning; and the system of Reinforced Surveillance in Residential care homes. All these factors and actions resulted in a rapid intervention in the residential care homes. As soon as there was a positive case, the health system intervened and put a nurse in place to review protocols and practices in the residence involved. In some autonomous communities, the appropriateness of having the Regional Health Ministries in control of the response to the pandemic has been debated and questioned.

In the case of Asturias, and as a result of the cooperation and collaboration between the Regional Ministry of Social Rights and Welfare, and the Regional Ministry of Health, the COVID-19 Surveillance and Early Warning System in Residential Social Services Centers (SisVAT-COVID-19) was established on March 16, 2020. This is a system for collecting and analyzing a broad set of indicators designed to monitor the situation of the centers (residents and staff) on a daily basis. Using an online platform, the directors of residential care homes (both public and private) transfer the daily situation of their center to the Directorate General for Planning, Organisation and Adaptation to Social Change. The ultimate goal is to facilitate decision-making in an agile and informed way, as well as the establishment of concrete measures by the public authority according to the evolution of the crisis at each moment. The development of this system was very well received by those responsible for the residential care homes themselves, as it unified data collection, provided transparency, and simplified the management and information process: “At first they provided data to Social Services Planning and Epidemiological Monitoring. Later this was unified into a single survey that was managed by Social Services which passed it on to Health” (EN:16).

Thanks to the “Common Framework for the application of the Early Response Plan in a scenario of control of the COVID-19 pandemic in the area of residential social centers” (August 2020), a wide range of mechanisms were put in place to make this coordination effective. The common framework was drawn up by the central government and those autonomous communities with a more committed participation of the Regional Ministries of Social Ser- vices. The measures have pursued five main objectives: (1) the identification and reporting of COVID-19 cases from the residential care homes to the SNS; (2) the specific care of COVID-19 patients by the SNS in SAAD centers and services; (3) the establishment of protocols for the referral of SAAD beneficiaries to the SNS; (4) the supervision of the care of dependent persons in SAAD centers; and (5) the provision of the health and social resources required to care for dependent persons living in residential care homes.

In addition to the Regional Ministries, the residential care homes have also been in contact with the local authorities who often provided logis- tical support and took an interest in the situation of the centers. This has been particularly important in rural areas. The residential care homes have also been linked to the armed forces (notably through the Military Emer- gency Unit –UME–), the Civil Guard, Local Police, Civil Protection, Fire Bri- gades and NGOs. These organizations collaborated in sterilizing, providing

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Table 4. Measures implemented by different autonomous communities on data collection and dissemination

Autonomous community Implemented policies

Balearic Islands • Creation of a database with daily information provided by residential care homes. • Elaboration of a report with the information included in the database from the health and social coordination team to monitor the evolution of the pandemic.

Canary Islands • Creation of a database for the monitoring of the epidemiological situation of all residential centers. • Drafting of daily or weekly reports on the epidemiological situation of these centers based on the data collected. • Periodical transmission of the database to the competent body of the Regional Ministry in charge of the supply of materials to the centers. • Periodical transmission of the database to the Public Health department to coordinate actions, including the screenings (PRC and serological tests) of care homes’ residents and personnel. • Periodical transmission of the database to the regional police force to coordinate actions the latter carried out in residential homes.

Navarre • Creation of a “Coronavirus Monitoring” platform where the residential care homes provide data on the incidence and prevalence of COVID-19 in residents and staff.

Basque Country • Use of existing daily registration procedures in residential care homes to collect data on cases, cohorts and deaths. • This register is shared with the Health Ministry to confirm official status and with the Public Prosecutor’s Office (weekly) to report positive COVID-19 cases, along with COVID-19 and non COVID-19 deaths.

Source: Ministry of Social Rights and 2030 Agenda (2020)

protocols on issues such as managing the removal of corpses, moral support and solidarity. The Public Prosecutor’s Office also kept, and continues to keep, a relationship with the residential care homes during the crisis.

3.2.2. Monitoring systems in the residential care sector

Data management during the pandemic has been and remains highly con- troversial in the residential care sector. Some of the difficulties decision-makers and managers had to confront derived from pre-existing problems, and particularly from insufficient information concerning the residential care sector, including the number of residential care homes, their location and characteristics (e.g., the number of beds, the profile of residents and staff, etc.). This structural lack of information made it very complex to collect information quickly and systematically from the beginning of the pandemic. The Ministry of Health urged the autonomous communities to provide information concerning the residential care homes before April 8 and, since then, to update such information twice a week. However, at the end of Novem- ber 2020, data about deaths due to COVID-19, or with symptoms compat- ible with the disease, in the residential care sector had not been yet made publicly available by the central government. The lack of available data had been justified due to inconsistency in the data reported by the autonomous communities and the residential care homes. In turn, such inconsistency had been justified by the non-user-friendly nature of the platform developed to this end, and the ambiguous definition of indicators to be provided.

Although many autonomous communities made a substantial effort to collect information, data have not always been reported or timely publicised.

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Despite these difficulties, autonomous communities put in place numerous initiatives to collect data (some examples are listed in Table 4), which helped monitoring the evolution of the pandemic.

During the pandemic, residential care homes have had to report data to a variety of actors and institutions, in some cases to as many as five different institutions on the same day. As in the case of any other notifiable disease, data must be reported to the Autonomous Community, which then passes it on to the special surveillance system. In the case of COVID-19, however, our interviewees highlighted a diversity of actors involved, including the Min- istry of Social Services, the Ministry of Health (Inspection, Public Health, Health Area Management), the competent hospital corresponding to the location of the residential care home, the Public Prosecutor’s Office, the Municipality, the nursing staff of the corresponding primary care center, the Civil Guard and/or the police.

3.2.3. Strengthening the staff: numbers, training and working conditions

In Spain, the problems the sector faces in terms of professional resources have long been known. The poor implementation of the 2006 Dependency Law, due to the 2008 economic crisis and the policies of fiscal consolidation that followed, and blockages in the central administration, together with other problems of the LTC sector (analysed in section 1 of this report), have all aggravated the situation.

Current staffing levels are clearly insufficient to care for increasingly older residents. Moreover, in many cases, the staff is poorly trained, and much of the employment in this sector is precarious, with low salaries, and unwant- ed temporary or part-time contracts (Hernández-Moreno and Pereira-Puga 2021).

In the context of the COVID-19 crisis, many additional difficulties have aris- en. One of the main problems has been the lack of personnel, which has not always been covered during the pandemic. Sick leaves in the residential care homes were mainly due to: (a) contagion among the staff; (b) the need to comply with isolation measures after being in contact with infected persons; or (c) having some personal health risk factor. Staff members also left their jobs out of fear of a possible infection, family pressures or trauma. All these factors were associated to the pandemic and the vulnerable situation in which workers in the care homes sector found themselves.

However, the situation of sick-related leaves in residential homes varied. In some cases, they did not occur, mainly in those centers where there were no COVID-19 infections, while other centers were confronted with 75% of staff on leave. As a medical director pointed out, there were not sufficient available tests at the beginning of the outbreak. Sometimes, staff leaves of absence extended beyond 15 days, although in many cases they turned out not to be COVID-19 infections (what has been subsequently called “false positives”). For those who tested positive to COVID-19, the leave could last for up to a month, as it was complex to carry out a second PCR due to the

◂ back to table of contents SPAIN ℅ 31 scarcity of tests, a necessary condition for the reincorporation of the worker to its job. As described by one interviewee, a serological study involving a large number of personnel in residential homes in his Autonomous Com- munity revealed that about 30% of the staff had developed antibodies.

The scarcity of personnel has proved to be heterogeneous in its characteristics and evolution as well. Larger urban centers with multiple functions (e.g., including day-care centers), or those residential care homes belong- ing to bigger companies, found it easier to maintain their staff levels. By closing the day-care centers, they could redirect workers to residential care homes in need of staff. In other centers, this was actually not the case, with some residential care homes operating at minimum staff requirements (and sometimes without medical personnel).

To deal with these shortcomings, the different autonomous communities put in place similar initiatives. For instance, the Aragonese Social Service Institute (Instituto Aragonés de Servicios Sociales) created two dedicated “job centers” (bolsas de trabajo) for people willing to work in the sector during the pandemic (one with professional accreditation requirements). This measure resulted in two lists, each one including around 2,500 appli- cations, 1,500 CVs of which were provided to the residential care homes for staff recruitment (Survey IMSERSO YEAR). Similarly, available health workers from other public services which at that time were not operational, such as in the education sector, were made available to residential homes in need of personnel. In some autonomous communities, however, the lists providing for prospective workers were already exhausted when the residential care homes relied on the bolsas de trabajo to deal with staff shortages. At times, the situation about staff resources was so complex that in certain areas, residential care homes had to resort to advertising job offers on popular internet sales sites.

Other than numbers and data statistics, our interviewees often mentioned the difficulties residential care homes encountered in training new staff members during the pandemic, particularly in the case of non-professional workers, or people with insufficient skills. Consequently, public administra- tions and the residential homes themselves produced training materials. In this process, technology played a fundamental role to facilitate the sharing of information, instructions and training in the face of the plurality of actors involved and the continuous updating of protocols.

Another significant problem related to staff concerned overloading of the workload, tasks and responsibilities. Residential care homes adopted several measures to ease such burden, including workers’ rotation and the concentration of working hours on fewer shifts. This strategy not only reduced turnover, but also had the advantage of allowing more time to potential COVID-19 symptoms to appear in workers before the next work shift.

In some cases, workers isolated themselves with residents, while others decided to rent shared flats for fear of infecting their families.

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In a large number of residential homes, the staff was also sectorized to avoid vulnerable workers coming into contact with residents with COVID-19, as well as to reduce the mobility within, and so the diffusion of potential contagion in, the centers.

3.2.4. Diagnostic and protective measures

The majority of residential homes had very scarce initial stocks of protective materials at the beginning of the COVID-19 pandemic. The little they had was actually limited to gloves and face masks. The prioritization of healthcare structures for the allocation of Personal Protective Equipment (PPE), and the problems related to concentration of the demand of such materials in the international market, greatly conditioned the adoption of certain basic public health measures of protection in Spain in general, and in residential homes for older-age adults in particular.

Some larger residential care homes had anticipated purchases of protective materials already in January 2020. This was largely due to the lessons learnt from dealing with the SARS-CoV-2 epidemic, when the system suffered from supply problems as well. Others had to buy these materials at very high prices, reuse and recycle them beyond technical specifications, or even to rely on self-made materials, such as non-approved PPE.

Concerning diagnostic measures, the lack of availability of reliable tests (PCRs in particular), and the delay in the arrival of test results (especially in the first months of the pandemic), have been one of the main problems in the management of the crisis. Our interviewees generally agreed on the fact that the time passed between the request for PCR tests and the possibility of carrying them out was generally too long, from several days to more than a week (especially in March and until mid-April 2020), and with significant differences across autonomous communities.

Complaints about the shortage of tests for care homes residents and staff during the first few weeks of the pandemic, or about the delay in obtaining test results were widespread. As new information about the virus became available, health authorities changed the criteria for testing. For example, tests were not applied to asymptomatic people at the beginning of the pandemic. Nationwide, for example, the “Guidelines for the use of rapid antibody tests for COVID-19” of the Ministry of Health of April 7, 2020 stated that, in the case of residential care homes, only those with symptoms should be given rapid tests. In the event of a single resident resulting positive for COVID-19, no further tests ought to be performed, assuming that all residents were infected (unlike other out-of-hospital centers and institutions, where it was established that symptomatic and 11 11 Ministry of Health, Guidelines for asymptomatic patients should be tested). According to some observ- the use of rapid antibody tests ers, this approach “…is too restrictive, it shows a complete lack of knowl- for COVID-19, last update: 07.04. edge about how our centers work, and a clear disregard for the older-age 2020. Available at: https://www. adults, treating them indiscriminately and, more seriously, this lack of areasaludbadajoz.com/docencia_ investigacion/biblioteca/Guia_test_ testing can increase rather than decrease infections” (Federation FED, diagnosticos_serologicos_20200407. 2020). pdf. Accessed on: 06.09.2020.

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Table 5. Closing of residential care homes: indications from employers’ organizations and Autonomic instructions

First communication Autonomous Community Employers’ organization Instruction from the competent authority from the employers’ organization

Catalonia ACRA February 25 March 12

Castile-La Mancha ARTECAM February 26 March 14

Aragon ARADE February 25 March 16

Valencian Community AERTE February 25 March 18

Castile and León ACALERTE March 1 March 13

Madrid AMADE March 6 March 15

Andalusia CECUA March 11 March 14

Source: CEAPs, 2020

A study carried out by the trade union Comisiones Obreras in the 475 residential care homes of Madrid (both private and publicly funded private ones) indicates that, at the beginning of May 2020, only 27% of residential care homes had protected workers with appropriate PPE, and 37% of them continued reusing protection materials with the risk of contagion that this entailed (CCOO Sanidad Madrid, 2020).

In several cases, the directors/managers of residential care homes have pointed out the fundamental role played by associations, local firms and even citizens in the provision of PPE, including home-made protection materials. They also pointed out how they sometimes relied on referrals of protective materials from other residential care homes or health structures that were not suffering from supply problems.

3.2.5. The design of containment, sectorization and isolation measures

The closing of residential homes to external visits represented one of the first measures adopted by these centers, often before the publication of clear instructions from the competent regional authorities.

During the early moments of confusion, some residential care homes had been warned by the authorities that closures could violate residents’ rights, something which could imply a legal responsibility. Similarly, the sectorization and isolation of people according to symptoms (even more so in the absence of appropriate and reliable diagnostic tests) constituted another complex measure to implement in residential care homes, which largely depended on the architectural reality of each center (size, shared rooms, organization of shared spaces) and its level of occupancy. Then, its effectiveness was affected by the availability of both staff and diagnostic tests.

According to Jiménez-Martín and Viola (2020, p. 40), there was a positive correlation between the size of residential care homes and the number of COVID-19 related deaths: those autonomous communities characterized

◂ back to table of contents 34 ℅ MC COVID-19 by residential care centers with an average number of places higher than 70 beds (e.g. Madrid and Castille-La Mancha) experienced a higher number of deaths during the first wave of the pandemic when compared to those autonomous communities with residential care homes with an average number of places lower than 50 beds (such as Extremadura, the Canary Islands and Asturias).

In any case, all of our interviewees identified the lack of diagnostic tests (for both residents and workers) as the leading cause of the low effectiveness of sectorization measures in the early stages of the pandemic.

3.2.6. The good practice of referring positive residents to third-level centers

Due to the difficulties related to the isolation of COVID-19 positive residents within the same center, some autonomous communities set up specific structures to move the positive cases from the residences where outbreaks had occurred. These structures were very effective to alleviate the occupation of the affected residential care homes, and to offer infected residents with a more personalized attention taking into consideration their clinical and epidemiological circumstances. For example, Castille-La Mancha created a regional network of residential care homes, dedicating 600 places 12 12 Autonomous Community of Castille-La to the referral of COVID-19 positive patients. Asturias developed a specif- Mancha, Resolution of 20/03/2020, ic protocol on referrals (Table 6). According to this latest protocol, passed of the Ministry of Health, by which on June 11, 2020, patients were classified according to six levels of care exceptional measures were agreed based on clinical criteria (confirmed positive COVID-19 case and baseline upon in relation to health actions in residential care homes for older- clinical situation), criteria of need for care, and social criteria (possibility of age adults, regardless of their type home isolation).13 According to this classification, a patient was referred to of ownership and management, different circuits, each one with its protocol of action and technical instruc- as a safeguard of public health due to COVID-19. Available at: tions of reference. https://docm.castillalamancha. es/portaldocm/descargarArchivo. As we elaborate in more detail below, the practice of referring infected per- do?ruta=2020/03/21/ sons to third-level centers had very positive effects both in preventing the pdf/2020_2460.pdf&tipo=rutaDocm; Accessed on: 07.09.2020. spread of the disease within the residential care homes, as well as in allowing to restore some normality to the daily activities and functions of the res- 13 idential care homes from which COVID-19 positive patients were referred. Asturias, “Levels of Care and Clinical Criteria for the Classification of Patients. Specific circuit for 3.3. Ensuring quality healthcare in nursing homes social health centers (last update: 10/06/2020). Document linked 3.3.1. Ensuring intersectoral dialogue at the operational level between to the Healthcare Procedure for possible and confirmed cases Health and Social Services SARS-CoV-2 (COVID-19) in older- age adults’ homes and social One of the central aspects for understanding the impact of the pandemic healthcare centers (23.03.2020)”. on nursing homes in Spain is the position of these centers in the insti- Available at: https://www.astursalud. es/documents/31867/973133/ tutional realm in which social services (whose fundamental logic revolves Niveles+de+Atencion+y+Criterios around the care of people) and health (essentially focused on preventing +Clinicos+de+Clasificacion+del+ illness and restoring health) overlap. Many actors agree on the conveni- Pacientes+circuito+especifico+para+ ence and the opportunity that the pandemic has provided to advance in centros+sociosanitarios-V-2++ 31032020.pdf/205a5ce6-8c7e- the coordination of the health and social systems, a development that has 2830-3009-23c31a1b6b65; been demanded for quite some time. However, the challenge of effectively Accessed on: 06.09.2020.

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Table 6. Asturias: levels of care and circuits of referral – Protocol of of June 11, 2020

Level of care Criteria Circuit of referral

Level 1 Confirmed active COVID-19 cases, suspected cases without laboratory Home care confirmation or probable cases with mild symptomatology with the possibility of home isolation

Level 2 Confirmed active COVID-19 cases, suspected cases without laboratory Accommodation in the Student Residence of Mieres (102 confirmation or probable cases with mild symptomatology without the possibility places) of home isolation

Level 3 a) Confirmed active COVID-19 cases, suspected cases without laboratory • Residential home Santa Teresa de Oviedo, for its confirmation or probable cases with mild symptomatology and patients residents; paucisymptomatic: no dyspnoea or pleuritic chest pain; ii. no data on • Mixed Residential home of Gijon for its residents; decompensation of the basic pathology; iii. in good general conditions; • CREDINE: currently receives confirmed cases, suspected b) Confirmed active COVID-19 cases or probable cases which, in case of cases and negative cases from other centers who cannot worsening of clinical condition, would not be referred to the Intensive Care return home. Unit due to poor functional and cognitive status (total functional dependence, defined as Barthel’s index before acute illness ≤15); c) Confirmed active COVID-19 cases or probable cases who comply with criteria for hospitalisation (acute) but who do not need home isolation or who cannot perform it in the residential care home for clinical and/or social reasons.

Level 4 Confirmed active COVID-19 cases or probable cases who comply with criteria Hospitals for acute cases: HUCA, Cabueñes, San Agustín for hospitalisation (respiratory insufficiency; significant decompensation of basic pathology) and: a) older than 80 yr. with mild to severe functional dependency (Barthel<20-85) or mild to moderate cognitive impairment (Pfeiffer 3-7 or MMSE 10-24); b) younger than 80 yr. with mild to severe functional dependency (Barthel 20- 55), or mild to moderate cognitive impairment (Pfeiffer 0-7 o MMSE ≥10-24)

Level 5 Confirmed active COVID-19 cases or probable cases with symptoms, who Hospitals for acute cases: HUCA, Cabueñes, San Agustín comply with criteria for hospitalisation (respiratory insufficiency; significant decompensation of basic pathology) and: a) independent people older than 80 yr. (Barthel ≥90) and normal cognitive condition (Pfeiffer 0-2 or MMSE 25-30); b) younger than 80 yr. with a mild functional dependency to independent (Barthel ≥60) and normal cognitive condition (Pfeiffer 0-2 or MMSE 25-30).

Level 6 Confirmed active COVID-19 cases or probable cases in need of critical care Hospitals for acute cases: HUCA, Cabueñes, San Agustin

Source: Asturias, “Levels of Care and Clinical Criteria for the Classification of Patients. Specific circuit for social health centers” (last update: 10/06/2020).

implementing this coordination has faced almost ancestral blockages, both institutional and organizational, and even psycho-sociological and cultural.

A feeling widely shared by care home managers is the lack of support and guidance from the various health authorities during the worst phase of the pandemic. The metaphor of the “poor brother” appears recurrently among the directors of nursing homes. The sectorization of responsibilities to articulate responses to the pandemic in the hands of the health authorities made this situation of subordination more visible. That was the perception

◂ back to table of contents 36 ℅ MC COVID-19 of the managers of the nursing homes despite that the latter were function- ally dependent on the regional Social Services Departments. The different organizational cultures of the social and healthcare sectors, as well as the differences in professional status between the managers of the residences and the healthcare professionals (namely medical doctors), also constituted a point of friction that was often pointed out by members of the Social Services staff as a behaviour of a certain arrogance deployed by healthcare professionals.

Professionals in the residential sector claim to suffer the consequences of the lack of knowledge by health authorities concerning the peculiarities of a residential social centers. During the pandemic, those authorities were seen as tending to assimilate social centers with those of healthcare. On many occasions, this lack of knowledge might have had a negative impact on the physical and cognitive abilities of the resident older adult, while at the same time had provoked the absence of their social interaction inside and outside the center. The director of a nursing home pointed out how, after the intervention of the center by the Regional Ministry of Health, the health personnel who took over the residence tried to organize it as a hospital, leaving many residents in bed all day, or sitting in an armchair, and undressed. From their perspective (focused on care and with the nursing home as being the place of life for the older adults), this was interpreted as a negligence that could result in a deterioration of the physical and emotional health of the residents. Another residence director pointed out how “[the Department of] Health asked to confine people with behavioural dis- orders in their rooms, without taking into account the specificities of these residents (they can self-harm or even attempt suicide)”.

All these situations reflect the concern of nursing home managers about the need to adapt to users’ profiles, which can be quite varied and diverse. This plurality of profiles also presents a variety of capacities, which makes nursing home managers question the legitimacy of the restriction of move- ment to which the older adults have been subjected. This was much harder than the one suffered by citizens during the lockdown phase. The freedom and decision-making capacity of residents was disregarded as compared to the citizens living in their own homes.

3.3.2. Clarifying and strengthening the links between nursing homes and primary care

The primary care constitutes an essential part of the SNS, and works as a gateway to the system, responsible for ensuring the continuity of health treatment for patients and for the maintenance of the health of all citizens. The primary care is also supposed to operate as the entry point to the SNS for residents in nursing homes.

The perception among those responsible for the nursing homes about their relationship with the primary care centers in their municipality has been, however, generally ambivalent. A good number of them claim to have a relatively fluid relationship with the health professionals in their primary

◂ back to table of contents SPAIN ℅ 37 care center of reference, although in most cases doctors and nurses of the residences carry the weight of monitoring the health of the residents. They are supported by the primary care doctors to articulate the access of older adults to the services they require (e.g. monitoring of chronic conditions, medication, clinical tests, consultations with specialists or referrals to hospitals). More rarely (although in some cases with some regularity) primary care doctors visit the older adults in the nursing homes.

On other occasions, the relations between the nursing homes and the primary healthcare centers are not particularly fluid. Residence directors and managers often express their dissatisfaction with the way in which the primary care system monitors the health of the older adults, which they consider to be clearly insufficient. Some nursing home directors recall that there were discrepancies between the doctors in the nursing homes and in the health centers on issues such as the treatment some residents should receive. They complained that monitoring was often limited to the management of prescriptions. In some cases, the residences assume responsibility for the cures and post-surgery treatment of the residents, but pointed out that in fact they are not always adequately prepared for this.

As the pandemic progressed, primary healthcare became increasingly important as it was assigned a major share of responsibility for containing the disease. This was done by participating in the tasks of tracking, identifying and accompanying those infected. It also played an important role in many regions during the intervention phase of the nursing homes (in some regions, only those nursing homes that had positive cases, but in others including all the nursing homes in the region). The responsibility of representing the health authorities in the residences was generally delegated to nurses from the primary care centers of reference. Sometimes the nurse was acting as a case manager in the nursing home itself, or just providing a direct channel of communication between the nursing homes and the health centers.

In general, the nurses were enthusiastically welcomed by most of the nursing home managers. This meant reducing the sense of abandonment they had experienced since the beginning of the pandemic. The nurses provided advice on how best to deal with the consequences of the pandemic, developing contingency plans, coordinating action for infected or symptomatic patients, and providing access to testing or medical material. It also involved establishing a more fluid communication channel with the SNS. Some regional governments also established follow-up and support units for the nursing homes. These units regularly visited the facilities of these centers providing support to the management team on how to deal with the pandemic and its consequences. The most intensive interventions involved the ‘medicalization’ of the nursing home and thus the sending of new staff to replace or supplement to the nursing home personnel.

The stress caused by the pandemic has clearly shown the need to put in place much more intense and fluid collaboration between primary healthcare centers and nursing homes. The fact that a good number of nursing homes, usually the largest ones, have their own doctors and nurses, should

◂ back to table of contents 38 ℅ MC COVID-19 not exempt the primary care of the SNS from carrying out a much more comprehensive follow-up of the residents in these centers.

3.3.3. Clarifying the criteria for referral to hospitals

One of the most dramatic circumstances of the pandemic, widely reflected in the media, was the one concerning the obstacles to the hospitalization of older residents in nursing homes infected with coronavirus. The suspicion of age discrimination was perceived as morally unacceptable by society.

Before the expansion of the pandemic, the procedure established for the older adults to receive healthcare involved the diagnosis of the patient’s health status by the doctor in the nursing home. This was carried out in coordination with the primary care physician of reference, after which the hospital was contacted, and a referral was made for treatment. This protocol worked particularly well in those territories in which, in recent years, there had been schemes for social and health coordination between nursing homes and hospitals, usually articulated through the geriatrician in the hospital in per- manent connection with the health personnel of the nursing home.

Where no such previous links existed, it was necessary to establish them, as the seriousness of the situation required a better communication between care homes and hospitals. At the height of the pandemic, protecting hospitals by preventing overflow became a top priority for the authorities. This led to the closure of those normal bypass channels from the care homes to hospitals.

The extreme difficulties in referring patients to hospitals from residential care homes during the peak of the pandemic led to the implementation of strategies in order to overcome these obstacles. These strategies were developed both by those responsible for the nursing homes and even by the relatives of the older people themselves, who were very frustrated by the barriers to hospitalization. The fact that the pandemic did not affect certain regions as badly as others meant that this problem did not arise there as a practical matter. In the other regions, the harshness of the referral protocols was reduced as the incidence of the pandemic decreased.

There were problems concerning the ambiguity of the protocols and the lack of clarity about what should be done with patients who had been admitted to hospitals due to other pathologies once they returned to the residence.

In addition to a series of structural weaknesses within the hospital system (shortage of available beds, staffing operational levels or precarious employment, among others), the pandemic has shown the need to reinforce the links between nursing homes and the hospital healthcare.

3.3.4. Ensuring continuity of general care for residents during the crisis

The ability to guarantee public services (whether provided by the administration itself or by private companies) and their continuity has been severely

◂ back to table of contents SPAIN ℅ 39 affected during the COVID-19 crisis. For example, schools and universities, serving the fundamental right to education, have been closed.

The social services have been extraordinarily reduced in their capacity to serve the general public when it was most needed. Health services have been overloaded, aggravating the conditions of those who were not treated.

This situation has also affected nursing homes. Since measures were taken in these residences, the priority was to protect the residents against COV- ID-19. This disrupted the organization and operation of the nursing homes, altering routines and activities that are fundamental to the health, quality of life and the guarantee of residents’ rights.

The alterations in the daily functioning of the nursing homes have taken place in different ways, related to the conversion of common spaces into COVID-19 patient care areas or the application of hospital management criteria to residents, such as: (a) leaving residents in bed all day and not dressing them; (b) the confinement of residential centers; (c) the isolation of residents in their rooms; (d) the reduction of social life inside and outside the rooms; (e) the suspension of certain activities or their reduction; (f) staff shortages that prevented activities from being carried out properly; (g) the closure of day-centers outside the care homes (and the transfer of their staff) where older people received certain services; or (h) excessive delays in the communication of PCR results that forced the closure of floors and the suspension of activities. In general terms, users’ opinions and preferences were no longer sufficiently taken into account.

In some autonomous communities, the referral of patients with COVID-19 to other intermediate centers prevented new infections and allowed the rest of the residents to enjoy a life more similar to their normal life, which was very important for maintaining their physical and mental health.

3.3.5. Ensuring end-of-life and palliative care

One of the most difficult situations caused by the pandemic was the strict isolation of COVID-19 patients. The circumstances of those who could not overcome the illness and died in solitude, unable to communicate with family and friends in the last moments of their lives, were particularly painful. Their families had to face their grief without being able to say goodbye to their loved ones.

In addition, the circumstances of the death and funeral were frustrating and traumatic. As the director of a nursing home pointed out, health priori- ties took over any other consideration and the lack of human and material resources did not allow a different approach to these situations (for example, the availability of PPEs and of conditioned spaces that would allow family members to visit the residents positive to COVID-19).

The protocols defined during the pandemic established that, at the time of the death of a resident, both doctors of the nursing home and the primary

◂ back to table of contents 40 ℅ MC COVID-19 care physician from the SNS were responsible for certifying the death and in consensus were to agree on the official cause of death (COVID-19, or other condition). The doctor of the nursing home was responsible for con- tacting the family and for getting in touch with the funerary company for the transfer of the body to the funeral parlour.

Among the directors of the residences interviewed, there was a widespread feeling that the public had unfairly pointed fingers at them because of the dramatic situations related to the death of residents and with respect to the treatment given to the bodies of the deceased. Reports in the media about dead bodies not being removed from rooms for hours in the presence of roommates, or of the lack of information to families about where the body was, resulted in explicit accusations against the nursing homes. However, as directors made it clear, it was the funeral companies that were responsible for the bodies and for transferring them to the mortuary.

3.3.6. Humanizing care for residents and families

Humanizing the attention and care of people implies giving equal importance to their physical, social, emotional and psychological needs. In practice, this requires providing different professional profiles, resources and measures not only to promote and protect the health and cure the diseases of people, but also to ensure that they live in an environment that favours a healthy life at a physical, emotional and social level.

Nursing homes become a person’s “new home”. It is therefore essential to ensure both family visits and the possibility for older people to maintain a link with society (e.g. by leaving the residence during the day, participating in lifelong learning activities or enjoying the opportunities offered by technology).

The closure of the nursing homes to relatives’ visits, the sectorization of spaces and the isolation of residents were the first measures adopted by the centers as a response mechanism to the COVID-19.

Although understandable, especially in the first weeks of the pandemic, closure and isolation measures have often been adopted indiscriminately, due to the lack of diagnostic tests to detect positive cases (particularly asymptomatic ones).

Despite this, communication with the relatives of the residents has been continuous in the centers, with daily calls to the families of people positive to COVID-19 or with symptoms, and once/twice a week to the relatives of people without symptoms. This has been a great challenge for many nursing homes, especially in the peak months of the crisis and in the face of staff reductions.

In order to address these problems, for example, the Andalusian Ministry of Health and Families launched the “Humanization Program for hospitalized patients and users of nursing homes for the older adults in isolation due

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to COVID-19”, approved on April 15, 202014. This program aimed at: (a) improving psychosocial care for isolated hospital patients and older people in nursing homes and (b) facilitating remote audio-visual communication between isolated persons. In order to achieve this, it was necessary to ensure that the care homes in Andalusia were adequately equipped with elec- tronic devices, since the vast majority of older people did not have them or did not know how to use them. The institutional campaign “Andalucía somos familia” (Andalusia is family) was also promoted, with the aim of enabling citizens to send messages of support (in text or video format) to older people who were isolated in homes through a mailbox on the website “familiasandalucia.es”.

In fact, the use of technological measures in many parts of the country has been essential to ensure communication between residents and their families during the months of confinement and to reduce the anxiety of family members about the evolution of the situation in the nursing homes.

The nursing homes have also found it difficult to explain to residents the situation arising from COVID-19 and to get them to accept the restrictions introduced on outings and visits, particularly in the case of people with cognitive problems.

Following the adoption of the “Plan for the transition to the new normality” on April 28, 2020, the gradual opening of the care homes to visits was one of the first measures taken by the certified “COVID-19 free” centers. The regions adopted various control measures to allow the progressive relaxation of previous restrictions (daily number of visits allowed per resident and by appointment, distribution of hydro-alcoholic gel and taking temperature at the entrance of the care homes)15. Screens were used in patios, gardens or terraces, in areas outside but close to the entrance of the building.

3.4. The recovery of activity and the future of the residential sector

The harsh experience of the pandemic has accelerated reflection on the future of the nursing home sector. However, this is a long debate that continues after two decades in the social and health fields and at both national and regional level.

14 The Resolution of the Reconstruction Commission of the Congress of Dep- See https://www.juntadeandalucia. uties, organized to respond to the pandemic, echoes numerous proposals es/eboja/2020/517/BOJA20-517- which have been on the table in recent years and which have gained prom- 00002-4588-01_00171998.pdf. inence in this context (Congress of Deputies, 2020). 15 See https://docm.castillalamancha. These proposals include: es/portaldocm/descargarArchivo. do?ruta=2020/05/29/pdf/2020_ 3276.pdf&tipo=rutaDocm; https:// • The preference for the permanence of the older adults in their own docm.castillalamancha.es/ home is assumed by the directors of the nursing homes as a reality. portaldocm/descargarArchivo. This preference defines the role of the nursing homes in the whole do?ruta=2020/06/22/pdf/2020_ 3981.pdf&tipo=rutaDocm; system of care for the older adults. As a consequence, the nursing 07.09.2020. homes have been caring for an increasingly older and more depend-

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ent population (they arrive when they can no longer stay at home and their families cannot meet their needs due to their high degree of physical and/or cognitive impairment).

• This profile of extreme vulnerability of the residents accentuates the need to substantially improve social and healthcare procedures. It is essential to establish more fluid coordination procedures and shared information systems on residents among health and social service professionals, something that is echoed by nursing home managers.

• There is unanimity among nursing home directors in rejecting the idea of “medicalization” of nursing homes that has been raised fre- quently during the pandemic. The recurrent argument among these managers is that the nursing homes are the home of the older people who live in them, and that their function is to care for them, not to cure them (a task which should be the responsibility of the SNS). However, in order to avoid medicalization, they consider it essential to improve cooperation between the social and health systems by strengthening “the coordination mechanisms between primary healthcare, hospitals, emergency facilities, public health, primary social services and residential centers to ensure the effective continuity of comprehensive and integrated care in a social and healthcare network” (Congress of Deputies, 2020). The structures for interaction and coordination with the health system set up during the pandemic are considered a clear step in that direction.

• Another debate that has re-emerged during the pandemic is the advisability of moving towards a specialization of nursing homes according to the different user profiles. The Resolution of the Com- mission for Reconstruction states the need to “...develop a network of medium and long-stay hospitals in all the autonomous communities as a support system for primary care services in residential centers” (Congress of Deputies, 2020). Managers of nursing homes show more ambiguous attitudes towards this type of initiative. Some of them support the creation of convalescent and/or rehabilitation units of medium and long stay that occupy an intermediate space between the hospital and the strictly residential one. The introduc- tion of the dimension of the territorial scale (rural/urban) where the nursing home operates often qualifies the opinions against such specialization of residential centers.

• Another of the tasks considered essential is the need to increase the degree of professionalization of the personnel who carry out their functions in this type of center where the needs are increasingly complex.

• It will also be necessary to redefine the basic parameters of the infrastructure and internal organization of the nursing homes based on what was learned during the pandemic. There is a discussion not only about the reorganization of the spaces, but also on the model

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itself with the idea of moving towards ‘units of cohabitation’, smaller groups of residents with similar profiles. Some nursing homes report having taken advantage of the need for sectorization to advance along these lines.

The changes in the model of care for the older and dependent people pose an urgent need after the long period of austerity in budget that the sector has suffered. For those responsible for private care centers who offer their services to the public administration, the transformations called for must be accompanied by an improvement in the financing of the care system, resulting in an increase of the resources transferred per occupied place. In turn, the unions argue that improved funding should also have an impact on workers’ wages and job quality.

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