Long-term Care System Implementation in Spain

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The development of the National Long-Term Care System is one of the political reforms of major relevance to the health and social care field, and one of the star policies of the current Socialist government. Guaranteeing the right to long-term care services via a tax funded approach and the inclusion of all authorities attends to the following three basic problems: rapid ageing; shortage of services and the infrastructure to provide these services; decentralised framework of this competence.

Neue Entwicklungen

On November 30, 2006, the Spanish Parliament approved the law for the promotion of independent living and help for dependent individuals (Ley de Promoción de la Autonomía Personal  y Atención a las Personas en Situación de Dependencia). This law has facilitated the implementation of the System of Attention to Dependence during this year. Few changes have taken place in this phase with regard to the previous approach of this policy. The most prominent aspect is the enshrinement of criteria on which the degree of dependence is evaluated, which has provoked certain polemics and conflict among the Autonomous Communities (ACs) and the political parties.

The model is formed as a network of public utilisation that integrates and coordinates the centres together with both public and private services. The participation of the private sector is within a number of services provided by either the public administration or from accreditation granted by the corresponding ACs.

Coordination among administrations is structured at three different levels:

• Basic level of protection defined and guaranteed financially by the Central Government, according to the degree and the level of dependence.
• Protection level agreed between central government and ACs, and is to be financed jointly up to 50% by each administration
• Additional level of protection established by each ACs.

 Upon completion, three types of services will be offered:

• Assistance in kind (tele-assistance, home helps, day centres and residential care).
• Economic assistance linked to services (when impossible to utilise the public service or compounded by the high degree of patient dependence)
• Cash payments to assist family carers. In exceptional circumstances, the formalisation of non-professional carers is required.

The provision of these services, though as yet uncertain, depends on the degree of dependency (three degrees: mild, moderate and severe level of dependency) and an assessment of care needs, and also on the economic capacity of the beneficiary, for which is defined a structure of co-payments according to income and financial assets.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral
current    previous

The implementation of the new LTC scheme is one of the most important initiatives in social and health policy of the last few years; indeed it has been labelled the "fourth pillar" of the welfare state. This is mainly due to three reasons: first, its configuration as a pre-funded tax-based system that guarantees a basic coverage for the dependent population; second, the indirect effects that can stem from its introduction, for example the conciliation between family life and labour. Finally, its contribution to the reduction in the number of unnecessary hospital stays.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Initiators of idea/main actors

• Regierung: It is the star policy of the current Socialist government in the social field

• Patienten, Verbraucher: They are to be the main beneficiaries of the NDS

• Bürgergesellschaft

Stakeholder positions

In general, the initiative has had wide parliamentary support in its approval. However, in the phase of regulation development, which takes place in the Territorial Council for the National Long-Term Care Regulation, and which supposes the design of concrete aspects of the system, some differences have become evident. In particular, motivated by the political confrontation between the Central Government and the regional governments either controlled by the PP (the right-wing opposition party in the Spanish parliament) or with major self-government capacity think that the State acts outside its jurisdiction.

Other relevant actors in the configuration of this policy are the associations of dependent persons who have shown themselves to be very much in favour of the development of the Law and who are exercising an influential role in the specification of significant aspects of the system, in particular the design of the mechanism used to evaluate the degree of dependency.

Actors and positions

Regierung
Central Government	sehr unterstützend		stark dagegen
Regionals Governments	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Elders	sehr unterstützend		stark dagegen
Handicapped people	sehr unterstützend		stark dagegen
Bürgergesellschaft
Families	sehr unterstützend		stark dagegen
Civil societies	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

The law was modified with regard to the original bill put forward by the Ministry of Work and Social Affairs because it supposed a decentralization of several competences that are under the responsibility of the autonomous regions. The most prominent changes during the legislative process have been the adjustment to this decentralized framework with the creation of the Territorial Council of the Dependence, where the basic aspects of the system were made concrete as the definition of the scale that is used to determine the degree of autonomy of the beneficiaries, being this the most troubled point up to the moment in which the various actors have exercised a major influence.

Legislative outcome

Enactment

Actors and influence

Regierung
Central Government	sehr groß		kein
Regionals Governments	sehr groß		kein
Patienten, Verbraucher
Elders	sehr groß		kein
Handicapped people	sehr groß		kein
Bürgergesellschaft
Families	sehr groß		kein
Civil societies	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

The implementation process for the new dependency assistance scheme is gradual. It will be put in place in three stages beginning with its introduction on January 1, 2007, until total deployment planned for 2015. The reason for this progressive development is to adapt the development assistance to the creation of the necessary infrastructure.

Initially, the system began with coverage to those qualifying individuals deemed to have the most severe level of dependency (3rd degree). In the following three years the coverage is to be extended to beneficiaries qualifying as moderately dependent (2nd degree). Finally, in the subsequent years up to 2015, coverage will be extended to all remaining beneficiaries.

The funding system is another unresolved matter by the Territorial Council, since this entity must specify the contributions of the different implied administrations and the scheme of co-payments that users face according to their personal circumstances.

Monitoring and evaluation

As yet, indicators have not been proposed to measure the results nor impact of the above policy.

Expected outcome

The importance of this policy is reflected not only in the degree of coverage that is offered to dependent persons but also to the extent of forecasts evaluating its likely economic effects.

Earlier estimates realised by the Central Government foresee that the system is going to give coverage to over 1.125 million people in its initial stages and, once completely put in place, 1.5 million beneficiaries. The public expenditure is estimated to approximate 0.33% of the national GDP for 2007, which will rise to 1% in 2015, but concurrently generating an increase of 0.28% per year in GDP. It is also expected that the implementation of the system will have important effects on the occupation and 300,000 new jobs will be generated over the next ten years.

Other anticipated effects, that are as yet unvalued, include efficiency gains for society and the health and social care system. Individuals without medical care needs could be discharged from the hospital to an appropriate social care service, and families that were previously supporting the informal care, would have the opportunity to continue in the labour market, avoiding a reduction in productive capacity.

Yet a further important effect is the improvement in the equity of the system. Assistance is constituted as a universal right, embodied in the tax funded approach, in which the economic situation cannot be a barrier to access the package of care services. This is obtained via the co-payment system, which considers the economic situation of the beneficiary following an assessment of income and financial assets.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch
current    previous

The impact of this policy depends on how the as yet unresolved issues (access criteria, funding, co-payments) are dealt with. According to the initial design, the system will have a very important impact due to the need to develop a sufficient supply of resources to provide the service. It will liberate health resources, previously taken up by the non-existence of this social service, which in turn will improve cost-efficiency by replacing the current system with one of greater efficiency and lower cost.

However, concerns still exist about the real impact, because some relevant aspects of the system configuration are undefined. Some doubts raised are focused on the effectiveness of the co-ordination mechanisms between health and social care services and among ACs. Another as-yet unsolved and relevant problem concerns the financial and decision-making capacity of the ACs (complementary services that they could develop). Finally, it remains to be specified the co-payments scheme through which the patients assume a part of the service cost, and what mechanisms will check the economic situation of the beneficiary.

References

Sources of Information

• Casado Marín, D: El nuevo Sistema Nacional de Dependencia: algunas reflexiones sobre sus aspectos económicos. Spain: Análisis Local; 70 (1):3-13, 2007.
• Costa-Font, J and García-González, A: Long-term Care Reform in Spain. Eurohealth; 13(1): 20-22, 2007.
• Valcarce García, A: El fortalecimiento del Sistema de Atención a la Dependencia: La Ley de Autonomía Personal y Dependencia. Spain: Presupuesto y Gasto Público; 46: 175-178, 2007.
• Ministry of Work and Social Affairs. Available at: www.mtas.es
• Various specialized newspaper articles. Available at: www.elmedicointeractivo.com

Reform formerly reported in

Integrated care for the elderly Process Stages: Gesetzgebung

Author/s and/or contributors to this survey

Gabriel Ferragut Ensenyat

Empfohlene Zitierweise für diesen Online-Artikel:

Gabriel Ferragut Ensenyat. "Long-term Care System Implementation in Spain". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/es/b10/3