FES MADRID LABOUR AND SOCIAL JUSTICE CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA Continuity and reform in working conditions and quality of employment Jorge Hernández-Moreno June 2023 • This report reviews the main reforms carried out in Spain’s care sector during the COVID-19 pandemic and their impact on working conditions and employment quality. • The Dependency Action Plan and the new agreement on accreditation of care homes and services make significant strides in terms of the number of professionals, staff qualification and training, and hiring. • The success of these initiatives, however, will depend on structural factors such as funding; the system of multi­ level governance in Spain; coordination among health and social services systems, and ­social dialogue.

CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA Continuity and reform in working conditions and quality of employment • Despite considerable job growth in the care sector, Spain has lingering structural problems related to labour shortages. Trade unions and institutions such as the Ombudsman decried care homes’ staffing deficiencies both before and during the pandemic. The figures also reveal a high concentration of low-level jobs(administrative assistants, semiskilled and unskilled workers). There is general agreement on the need to improve training and working conditions. • The COVID-19 pandemic proved to be a catalyst, opening a rare window of opportunity to implement significant reforms in long-term care(LTC). In 2021, Spain approved the Dependency Action Plan, an initiative very well received by all actors in the system(central and regional governments, unions and employers). Broadly speaking, the Action Plan lays the foundations for the recovery of the Spanish LTC system. The main measures focus on the funding, management and accreditation of care homes; jobs; improving services, or greater local government participation in the decision-making process. • Also in 2021, a road map was approved to revise the agreement on the accreditation of centres and services in the LTC system dating from 2008. As well as establishing minimum quality criteria throughout the service structure, the reform includes measures to regulate the number and allocation of professionals, the qualification and training of personnel, and matters relating to hiring. The effective implementation of all these measures, however, is highly contingent on factors such as the central state’s budget availability; multilevel dynamics and politicking in sectoral cooperation bodies(which jeopardise territorial cohesion); the design of models to coordinate or integrate health and social services systems on all territorial levels, or the results of social dialogue. For further information on this topic: https://madrid.fes.de/

LABOUR AND SOCIAL JUSTICE CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA Continuity and reform in working conditions and quality of employment

CONTENT Content 1 INTRODUCTION 2 2 BACKGROUND 3  governance, public policies and funding mechanisms of the LTC system............................................................................ 3 2.2  Residential care services for older adults.......................................... 3 2.3  Labour sector and human resources............................................... 4 3 MAIN MEASURES AND REFORMS IN THE LTC SYSTEM DURING THE PANDEMIC 5 3.1  Dependency action plan.................................................................. 5  agreement on accreditation of care homes and residential services................................................................... 6 4 CONCLUSIONS AND REMAINING ­CHALLENGES 10 Acknowledgments................................................................................. 11 Bibliography.......................................................................................... 12 Methods................................................................................................ 14 Annex................................................................................................... 14 1

FRIEDRICH-EBERT-STIFTUNG – CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA 1 INTRODUCTION On 11 March 2020, the World Health Organisation(WHO) declared COVID-19 to be a global pandemic and called on all countries to take»urgent and aggressive action« to prevent infections, save lives and minimise the socioeconomic consequences of the crisis 1 . On 14 March, Spain’s central government declared a»state of alarm« throughout the country and took measures in response to the pandemic in areas such as freedom of movement, defence, the economy, the labour market, education, and leisure. However,(almost) no provision had been made to protect care homes, one of the main pandemic hotspots(Wagner, 2020; Gardner et al., 2020). In the report On the Corona Frontline – The Experiences of Care Workers in Spain(Hernández-Moreno and Pereira-Puga, 2021), we highlighted how the pandemic had put a strain on every structural component of the labour sector in the care field. Nearly two years on, with the vaccination campaign extended to the population at large – 85.8% fully vaccinated and over 87% with at least one dose 2 – and most of the response measures to the crisis having expired, in the post-COVID-19 era it is not entirely clear what has happened to the long-standing structural problems besetting care workers. What reforms have been introduced in the care sector? How far-reaching and deep have they been? What action has focused on care workers? What role have the different stakeholders played in the reform processes? Which battles have been lost, or not won yet? To answer these questions, this research takes a qualitative exploratory approach based on various secondary sources, an extensive review of scientific literature and documentary analysis that includes legal texts, regulations, reports, evaluations, government and trade union news releases, and articles from digital media outlets, as well as European Union (EU) documents. In addition, eight semi-structured interviews were conducted with key players 3 , including trade union representatives(five), the leader of an employers’ organisation from the sector and central government policymakers(two). The report is organised as follows: after this brief introduction, Section 2 describes the institutional structure of the Spanish long-term care system, paying particular attention to residential care services, the characteristics of the labour sector and human resources. Next, Section 3 assesses the impact of the main measures and reforms of the care model on the workers in the sector, while providing some comparative observations. Finally, Section 4 sets out the study’s main conclusions and reflects on the remaining challenges. 1 WHO Director General’s opening remarks at the media briefing on COVID-19 on 11 March 2020. 11 Mar 2020. Available at: https://www.who.int/director-general/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-on-covid-19---11march-2020 2 Ministry of Health(2022). Integral Management of COVID-19 Vaccination. Report on Activity. Available at: https://www.sanidad.gob.es/ profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/ Informe_GIV_comunicacion_20221111.pdf 3 The key interviewees were selected on the basis of their professional profiles, as well as their high level of expertise in the subject matter. The interviews lasted between an hour and an hour and a half and were conducted via videoconference or face-to-face between October and December 2022. In the text we refer to each one of the ­interviews with a specific code. Appendix A provides more details about the profiles and institutional affiliation of the interviewees. 2

BACKGROUND 2 BACKGROUND 2.1  MULTI-LEVEL GOVERNANCE, PUBLIC POLICIES AND FUNDING MECHANISMS OF THE LTC SYSTEM In contrast to Scandinavian countries, long-term care(LTC) in Southern Europe is a poorly developed public policy area (Flauquer, 2004; Saraceno and Keck, 2010). In Spain, provision of care has traditionally been associated with families and, more recently, caregivers of immigrant origin(Jiménez-Martín and Villaplana-Prieto, 2012; Ibáñez and León, 2014; Spijker and Zueras, 2020). The formalisation of the current Spanish LTC system came in 2006 4 , with the passing of the Law for the Promotion of Personal Autonomy and Care for People in a Situation of Dependence(commonly known as the Dependency Act) and the introduction of the System for Autonomy and Care for Dependence(SAAD). This reform was part of the process of adaptation and modernisation of the Spanish welfare state undertaken by the Socialist Party (PSOE) governments of Prime Minister Rodríguez Zapatero (2004-11)(Del Pino, 2013). Most European care models are characterised by their institutional fragmentation and organisational complexity(see Ranci and Pavolini, 2013; Social Protection Committee--European Commission, 2014, 2021). In Spain’s case, the current governance of the LTC system is based on a multi-level structure of powers shared between central government and the Spanish regions(or autonomous communities). The regions 5 comprise the operating structure, responsible for the dayto-day running of the system. Regarding staff, among other matters the regions regulate professional qualifications and the accreditation of professional skills acquired through work experience. The Territorial Council for Social Services and SAAD(CTSSD) has a central role in the system’s governance. Policymakers and officials from every level of government sit on this multilateral sectoral council. Agreements in the CTSSD – on implementing measures or the distribution of funds – are reached by consensus or by the vote in favour 4 Until 2006, state intervention in care had been based on plans and programmes of the regional and local social services, and on supplementing state pensions(Aguilar-Hendrickson, 2020: 1302-1303). 5 It is important to recall that under Article 149.1 of the Spanish Constitution social services fall within the exclusive competence of the regions and municipal authorities. of the central government and a majority of the regions and autonomous cities 6 . The Dependency Act lays down a mixed model of public-private funding. The system is funded by the central government and the regions with resources obtained through general taxes and a system of co-payment 7 on the part of beneficiaries. In the early 2000s, Spain’s levels of spending on the care sector were well below those of other European countries around it(OECD, 2020a, 2021). After the initial rollout of the system, characterised by a gradual – though contained – increase in funding between 2007 and mid2011, came a second phase of severe financial and budget constraints. Between 2012 and 2017, the central government of the conservative Partido Popular(PP) greatly reduced its contribution(called the»guaranteed minimum level«) and suspended the supplementary funds it transferred to the regions(the»agreed level«). From 2018 to the arrival of the pandemic, there was a gradual increase in state funding, though it fell some way short of the initial projections laid out in the Dependency Act. 2.2  RESIDENTIAL CARE SERVICES FOR OLDER ADULTS The Dependency Act sets out a service structure 8 and a series of financial benefits 9 for dependent persons(including older people). However, the Dependency Act makes no stipulation about professional teams, staffing levels or staff/user ratios. Regarding care services or residential care, the chief object of this analysis, as there is no social services act for the whole of Spain(OECD, 2022) each region has developed its own legislation, and it varies considerably from one to another 6 Rules of operation of the CTSSD: Available at: https://imserso.es/ autonomia-personal-dependencia/sistema-autonomia-atenciondependencia-saad/el-saad/organos-sistema/organos-cooperacion/ consejo-territorial-servicios-sociales-sistema-autonomia-atenciondependencia. 7 This system is based on the type and cost of the service and on users’ levels of income and wealth. 8 The services include: 1) services to prevent situations of dependency and promote personal autonomy, 2) remote care service, 3) homecare service, 4) day and night centre service and 5) residential care service. 9 There are three types of financial benefits: 1) for care by a family member, 2) for hiring a caregiver or 3) for acquiring a service. 3

FRIEDRICH-EBERT-STIFTUNG – CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA (Arriba and Moreno, 2009; Montero, 2014; Jiménez-Lara, 2015; Jiménez-Martín and Viola, 2017; Marbán Gallego, 2019). Operationally, there are two types of residential facility: »housing for older people«(also»sheltered housing« in the UK and Irish care systems) provides shared or individual accommodation and residents have complete independence within the home, while»care homes« provide accommodation and specialised assistance to elderly people who because of their family, economic or social circumstances cannot be looked after in their own homes. In 2020, these centres accounted for 97.7% of care services or residential care(Ministry of Social Rights and 2030 Agenda, 2020). In 2021, there were some 5,567 care homes for the elderly in Spain, providing a total of 384,251 places(Abellán García et al., 2021). The coverage rate(number of places/population aged 65 or over) is 4.29%. However, there is a considerable difference from one region to another. In Castilla y León, for instance, the coverage rate is 7.86%, while in the region of Murcia it is 2.33%(Ministry of Social Rights and 2030 Agenda, 2021). The private sector has led the growth in residential care services for older people over the last few years, through big capital and investment funds(Montserrat Codorniu, 2020: 47; Montserrat Codorniu, 2021: 150). Out of all the care homes, 1,642 are publicly owned(29.5%) 10 and 3,925 are in private hands(70.5%)(Abellán García et al., 2021). 73.2% of the total places are in private care homes, compared to 26.8% in publicly owned facilities(Abellán García et al., 2021). In public and private care homes alike a very high proportion of places(around 50%) are in facilities with 100 or more beds(Abellán et al., 2021). 2.3  LABOUR SECTOR AND HUMAN RESOURCES According to the OECD(2020b), care workers are people who provide care at home or in institutions(other than hospitals), including nurses and personal care workers who offer assistance with the activities of daily living or other personal support. Using data from the National Accounts of Spain, it is estimated that the number of people working in the LTC system has increased steadily over the last decade, from 273,150 in 2008 to 452,026 in 2021, of whom 283,694 are engaged in direct jobs(Rodríguez Cabrero et al., 2022: 114). If we look exclusively at the residential services sector, the number of actual jobs 11 increased by 26,554 between 2012 and 2018(Montserrat Codorniu, 2020: 49). A large proportion of the workforce in care homes is female(Comas-d’Argemir y Bofill-Poch, 2022). In 2020, nearly 90% of the actual work was performed by women(Montserrat Codorniu, 2021: 148). Despite the considerable job growth in the sector, structural problems related to the shortage of workers persist. Before and after the pandemic, trade unions and institutions such as Spain’s Ombudsman’s Office decried the care homes’ shortfalls in terms of staff(see CCOO, 2017; Ombudsman, 2019; UGT, 2021). Regarding training and qualification, some 60% of workers from the residential care services sector have received primary education(including some degree of professional training), 20.4% have secondary studies and 22.6% have studied in higher education(Montserrat Codorniu, 2020: 50; Marbán Gallego et al., 2021: 163). These figures reflect a high concentration of the lowest professional categories (administrative assistants, semiskilled and unskilled workers). On this point there is a general consensus on the need to boost training – with particular emphasis on regulated and certified training – and professional accreditation 12 for certain job profiles, such as geriatric assistants or carers (Marbán, 2019; CES, 2021). However, training and support for informal carers remains a challenge for most EU countries (Rodríguez Cabrero, 2020; OECD, 2020). Lastly, on the subject of working conditions, there are several key aspects to touch upon. First, regarding pay, measuring it is a complex task, as there is insufficient statistical coverage. According to the Annual Wage Structure Survey by Spain’s statistics office the INE(available to 2020), the gross yearly salary in the care sector went from 17,082 euros in 2009 to 18,876 euros in 2020. In the care home sector, the average yearly salary is 17,813 euros, 24% less than the gross yearly salary in the service sector in general(Montserrat Codorniu, 2020: 53). In the case of direct carers, their base salary is below 1,000 euros a month(Comas-d´Argemir y Roca-Escoda, 2022: 140). Regarding the gender pay gap, men earn 38.98% more than women. While salaries are within the margins prescribed by law, the European Commission(2014 and 2018) voiced its concern about them being too low. The average salary in the Spanish care home sector stands at 1,617 euros a month, compared to 2,086 euros in the eurozone as a whole(Montserrat Codorniu, 2021: 82). Second, the residential care sector has a high incidence of, largely involuntary, temporary and part-time employment – few days or few hours of work(Jiménez-Martín y Viola, 2017; CCOO, 2018). This dynamic has only intensified over the years. The rate of temporary employment in Spain’s care home sector is five times higher than the EU average(Eurostat, 2022). 10 The public administration uses public-private collaboration instruments to»delegate« the running of centres to private sector bodies. To do so, it uses formulas such as»agreements«,»leases« or»public service licences«. 11»Actual employment« measures the»personnel equivalent to fulltime«, according to the annual hours laid down in the VII State ­Collective Agreement on care services for dependent persons. This indicator takes into account both the number of days with a contract and the number of hours contracted. 12 In Spain, the Dependency Act mandates the professionalisation of workers in care homes for older people, via accreditation that certifies their training(in each region’s legislation on recruitment of staff). 4

MAIN MEASURES AND REFORMS IN THE LTC SYSTEM DURING THE PANDEMIC 3 MAIN MEASURES AND REFORMS IN THE LTC SYSTEM DURING THE PANDEMIC Care workers have been on the front line of the pandemic, subjected to unprecedented situations, work overload, high levels of infection and significant psychological damage(see Del Pino et al., 2020; Montserrat Codorniu, 2021; Marbán Gallego et al., 2021; Rodríguez Rodríguez y Gonzalo Giménez, 2022; Comas-d’Argemir y Roca-Escoda, 2022, among others). This section looks at the main measures and reforms implemented in the care model between 2021 and 2022, as well as their impact on the quality of employment and working conditions in general. It also covers action on the part of some of the stakeholders in the system that helps to assess the scope and intensity of the changes in the sector. 3.1  DEPENDENCY ACTION PLAN In autumn 2020, talks began among the central government, regional governments, trade unions and employers’ organisations(in the case of the latter two, via the national Social Dialogue Roundtable) to devise a Dependency Action Plan 13 . Following a long process of communication and negotiation, the Dependency Action Plan was approved on 15 January 2021 14 . Table 1 gathers the plan’s main measures, as well as the timetable for their implementation. These measures focus on the funding, management and accreditation of care homes, employment, the improvement of services or greater local government participation in the decision-making process. All the stakeholders in the system had a very positive opinion of the initiative. In the central government’s view, »it is an agreement that had the great merit of squaring the circle of very diverse interests: those of the employers and trade unions, for one, and those of the regions and the state too«(Interview 7). According to the employers’ organisa13 This measure is included in Spain’s Recovery, Transformation and Resilience Plan, approved by the European Commission in June 2021 to manage and distribute the Next Generation funds[Available at: https://planderecuperacion.gob.es/]. To be precise, this measure is included in Lever Policy VIII»New Care Economy and Employment Policy« and Section 22,»Action Plan for the Care Economy and Reinforcement of Equality and Inclusion Policies«. Likewise, the plan is directly in line with Principle 18 of the European Pillar of Social Rights (approved in 2017) and the European Commission’s Action Plan 2021, as well as with the European Care Strategy 2022(European Commission(2022b). 14 Agreement for the launch of the Dependency Action Plan 2021: https://www.balancesociosanitario.com/wp-content/uploads /2021/01/Plan-de-Choque-en-Dependencia.pdf tions,»the Action Plan is a major step. It is highly ambitious and most necessary«(Interview 4). The trade unions, for their part, also saw the measure as a major opportunity:»The plan is ground-breaking and cross-cutting. It is the first time all sides have acknowledged the need for the improvement in working conditions to go hand in hand with an improvement in the care for users«(Interview 5). Table 1 Dependency Action Plan measures and implementation dates. Measures Evaluation of LTC system Recovery and improvement of state funding Reduction of waiting lists Reform of care home sector(agreement on accreditation of centres) Improvement in working and professional conditions of LTC system workers(e.g., qualification programmes) Regulation of Personal Carer Review of co-payments Improvements in the structure of LTC system services and benefits Improve local government participation in the management and funding of the LTC system Implementation Dates First quarter of 2022 First quarter of 2021 February 2021 First half of 2021 From first quarter of 2021 to end of 2023 Over the course of 2021 First half of 2021 Over the course of 2022 and 2023 Over the course of 2021 Source: Author’s own creation. Broadly speaking, the Action Plan has laid the foundations for the recovery of the Spanish LTC system. In terms of funding, the plan provides for an injection of 3.6 billion euros between 2021 and 2023. In 2021, the central government injected 623 million euros via the budget and 735 million via European funds, restoring for the first time since 2012 the additional funds allocated to the regions(also known as »agreed funds«). In 2022, the central government injected a further sum of nearly 600 million euros into the LTC system. Overall, the plan has enabled the budget for the system to increase by 75.03% in relation to 2020(Rodríguez Cabrero et al., 2022: 106-107). However, at the close of this analysis(winter 2022) some of the goals set out in the Action Plan had not been achieved, such as a considerable reduction in the lengthy waiting lists, one of the sector’s chief problems for years(AEDGSS, 2015, 2017, 2018; Jiménez-Martín y Viola, 2017; CES, 2021; 5

FRIEDRICH-EBERT-STIFTUNG – CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA Huete-García et al., 2021; Ramírez-Navarro et al., 2021). According to the reduction plan 15 agreed by the central government and the regions, the waiting list had to shrink by 60,000 people by the end of 2021. Yet, according to the latest published data, to summer 2022, the waiting list had shortened by 38,807 people – and that included all kinds of dependent persons(Ramírez-Navarro et al., 2022). The central government cites the increase in the number of beneficiaries and the system’s administrative complexities as the factors to explain the delay in achieving this goal. »Large numbers of new users are entering the system. It is hard to better this entry rate. On the other hand, we have seen that it takes a very long time for the bureaucratic machinery of the state and each region to crank up[...] the administrative apparatus was rusty« (Interview 7). »The system has grown by 180,000 people. If the system had remained as it was, without growing, at the time the Action Plan was approved, today we would have zero people on the waiting list. There is a pull effect: when more funding is injected and benefits improve, people apply to access the system«(Interview 8). The establishment of remote care services as a subjective right and the regulation of the figure of personal carer are to be included in a»surgical« reform of the Dependency Act. In its present form, the Dependency Act hinders operational change in the care model(Marbán Gallego, 2020). The new text is in the process of being drafted and several stakeholders in the system(i.e. organisations of people with disabilities) are being consulted, as well as other departments of the central government. »We are working with the regions on a possible reform through the SAAD Delegated Committee. It is not a major transformation of the Act, rather a readjustment and an adaptation to bring it more in line with the United Nations Convention on the Rights of Persons with Disabilities«(Interview 7). Several measures in the plan have a direct or indirect impact on workers. In broad terms, the plan provided for the creation of 35,000 jobs. However, by spring 2022, 27,453 new jobs had been created 16 (AEDGSS, 2022). The Action Plan did improve the intensity of the Home Help Service. In 2022, the average intensity of the service stood at 39.6 hours a month, compared with 33.4 hours a month in 2020 15 Agreement of 30 April 2021 by the Territorial Council for Social ­Services and SAAD on the waiting list reduction plan for the SAAD. Available at: https://sede.imserso.gob.es/web/imserso/autonomiapersonal-dependencia/sistema-autonomia-atencion-dependenciasaad/el-saad/organos-sistema/organos-cooperacion/acuerdosadoptados-consejo-territorial-sociales-saad#ancla1. The Civil Dialogue Roundtable, comprising sectoral consultative bodies, scientific societies and professionals, also took part in the agreement. 16 These were direct jobs. They do not include the jobs to have arisen in the public administration to assess, monitor or support the administrative and accounts management of the system’s users. (Ramírez-Navarro et al., 2022). Meanwhile, the plan also provided for boosting the quality of services and employment through the reform of the care home sector. We shall devote the following pages of the report to this reform. 3.2  STATE AGREEMENT ON ACCREDITATION OF CARE HOMES AND RESIDENTIAL SERVICES a) Stakeholders and ideas present in the process of negotiation and adoption of the reform The»window of opportunity« to reform the care model appeared against the backdrop of controlling the pandemic. In the summer of 2021, the main stakeholders in the system agreed on a road map to modify the agreement on accreditation of facilities and services in the LTC system, which had been approved by the CTSSD in 2008 17 . The reform has triggered a broad political debate beyond the basic consensus on the need to transform the system. The main differences have arisen over the size of homes(number of places) and the ratios of the professional teams. The proposal of the central government, led by the Ministry of Social Rights and 2030 Agenda, suggested limiting the size of homes(with fewer co-living units and more individual rooms) and raising the staffing ratios above those of most regional regulations. The paradigm steering the reform is Integrated Person-Centred Care(IPCC). This model, pioneered in the Nordic countries and the Netherlands, focuses on achieving improvements in the wellbeing of the person, based on respect for their rights, interests and preferences(Rodríguez Rodríguez, 2010). »We aimed to be the conduits of a historic moment, after a listening process conducted with experts in the field of care homes and gerontology, disability organisations, [and] civil society organisations. People knowledgeable about other experiences such as that of the Nordic countries wanted to bring this model to Spain«(Interview 7). The negotiating process was highly complex, with diverging and sometimes conflicting interests. A significant proportion of the regional governments(from the PP and PSOE alike) expressed their discontent with the lack of clarity surrounding the sources of funding of the new model. Meanwhile, from the outset of the negotiations the employers considered the new model to be unworkable, as it would involve a rise in prices for the system’s users and unsustainable investment for private operators. The trade unions also expressed their opposition to the initial drafts of the text, as they failed to include any of the pertinent measures put forward at the Social Dialogue Roundtable. 17 Resolution of 2 December 2008 by the Office of the Secretary of State for Social Policy, Families and Dependency and Disability Attention, publishing the agreement by the Territorial Council of the System for Autonomy and Care for Dependence on common accreditation criteria to ensure the quality of the facilities and services of the System for Autonomy and Care for Dependence. Available at: https://www.boe.es/buscar/doc.php?id=BOE-A-2008-20451 6

MAIN MEASURES AND REFORMS IN THE LTC SYSTEM DURING THE PANDEMIC Finally, on 28 June 2022(six months after the established deadline), the CTSSD approved the new care model 18 . Every stakeholder achieved at least some of their goals. And yet the final text did not secure a broad consensus. The agreement was carried in the CTSSD thanks to the votes in favour of nine regions(Extremadura, the Canary Islands, Navarre, Valencia Region, Asturias, La Rioja, the Balearic Islands, Cantabria, and Aragon) and one autonomous city(Melilla). The eight regions that voted against the agreement(Galicia, Madrid Region, Andalusia, Murcia, Catalonia, the Basque Country, Castilla y León, and Castilla-La Mancha), plus the autonomous city of Ceuta, cited serious misgivings about the system of funding and the»invasion of powers« on the part of the central government(Sosa Troya, 2022). Similarly, the unions and employers rejected the final agreement at the Social Dialogue Roundtable, though for different reasons. In contrast, some civil society organisations, consultative sectoral bodies, and certain scientific societies publicly backed the document(SEGG, 2022). includes measures that regulate the number and staffing levels of professionals, the qualification and training of workers, and matters related to recruitment, as we shall see below. 3.2.1  Staffing levels Regarding the number of professionals, the reform revises the ratios of staff providing first-level direct assistance(carers, auxiliary personnel, and geriatric assistants) in care homes for older people, which is to be 0.31 per user in 2023 and 0.43 in 2029. Currently, the first-level direct assistance ratio stands at between 0.15 and 0.28(SEGG, 2020). Meanwhile, it also revises the ratios for all second-level direct assistance staff. These are the more qualified staff, such as occupational therapists, psychologists, educators, physiotherapists, rehabilitation personnel, or nurses. In this case, the reform stipulates a ratio of 0.51 in the case of care homes for older people and 0.58 for homes for people with disabilities. At present, this ratio stands at between 0.29 and 0.39 workers per user(SEGG, 2020). The regions have until spring 2023 to adapt their legislation to the provisions of the reform. Regarding implementation, the deadline for complying with the requirements of the new care model has been extended until 31 December 2029. At the close of this research, there was considerable legal and technical debate over whether the agreement is binding on all the regions. According to the rules of the sectoral conferences 19 , when the central government acts in a coordination and cooperation capacity, the agreements signed in the CTSSD are compulsory for all public administration bodies, regardless of how they voted. »There is a very tough legal debate over whether it is a coordination and cooperation agreement or not. We (the central government) believe it is indeed compulsory for all the regions, including those that did not vote in favour of it. At the same time, we believe that»forcing« the regions to abide by this agreement is not the best way of getting the change of model to come about. That is why we have chosen the path of financial incentives and not the legislative path of a Royal Decree(the highest-ranking regulation in the Spanish legal system)« (Interview 7). b) Labour sector and human resources dimensions impacted by the reform As for the content of the reform, as well as establishing minimal quality criteria throughout the service structure, it 18 Resolution of 28 July 2022 by the Office of the Secretary of State for Social Policy, publishing the agreement by the Territorial Council of the System for Autonomy and Care for Dependence on common ­accreditation and quality criteria for the facilities and services of the System for Autonomy and Care for Dependence. Available at: https://www.boe.es/boe/dias/2022/08/11/pdfs/BOE-A-2022-13580. pdf. This reform concerns the privately-owned, state assisted facilities and services and the non-state assisted facilities and services that provide care for people in a situation of dependence. 19 Law 40/2015 of 1 October on the Public Sector Legal Regime. Available at: https://www.boe.es/buscar/act.php?id=BOE-A-2015-10566 Despite these improvements, the timetable for implementing the changes in the ratios creates limitations on staff numbers in the short and medium term that could lead to chronic staffing problems in the sector(particularly in care homes for older people). Firstly, the reform fails to require a minimum number of staff from care homes for the elderly until 31 December 2023. At the same time, the reform makes the increase in staff to 2029 conditional on an additional rise in public funding. Secondly, in comparative terms the new staffing ratios continue to be lower than those of other countries around Spain. In France, care homes have a ratio of 0.62 workers per user. In Germany, a federal country with a relatively similar territorial model to that of Spain, the various regulations of the Länder stipulate a ratio of between 0.36 and 0.42 workers per user. In the case of the Scandinavian countries, with a long tradition of intervention in this area of public policy, the overall ratio is 0.95 workers per user of the system(SiiS, 2020: 82). In short, it appears that the battle over staffing levels has ultimately been won by a»coalition« of various public and private stakeholders with converging interests(primarily economic), which came into play during the process of negotiating the reform. »The negotiations with the regions have been the key to the ratios. Many regions are not meeting the ratios from the agreement of 2008. So there was a very considerable budget impact for these regions and they had no wish to face it«(Interview 7). »The burden of the cost of staff in a care home is high in relative terms. So the regions believe the increase in ratios is going to have a direct impact on their budgets« (Interview 8). 7

FRIEDRICH-EBERT-STIFTUNG – CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA »The increase in the ratios means having more workers in every area and every professional profile. The CEOE and CEPYME[employers’ organisations] had no appetite for it. Certain regions also pushed for no major changes in this regard. Any rise or increase in ratios was going to mean an increase in costs for the regions. You could see this in the votes on the agreement«(Interview 3). 3.2.2  Qualification and training of professionals Quality in employment is determined, among other things, by the professional qualification and training of the workers. The reform of the care model lays down some minimum requirements and standards regarding skills, via qualifications and professional certificates. It also establishes two complementary procedures for professional accreditation (exceptional qualification and provisional qualification), as well as special arrangements for rural areas and Spain’s islands that allow hiring unqualified staff. However, objectively speaking, the reform does not provide for reinforcement measures that facilitate and help the regions to comply with the agreement on common accreditation criteria regarding training and informing non-professional carers from 2009 20 , the primary political response for combating the low level of formal qualification in the sector. This agreement has still to be implemented, having had to be deferred on repeated occasions(the last time, to 31 December 2022). As one of the trade union chiefs interviewed said: »In theory, the accreditation and validation of the qualifications of all the people working in the sector should have been completed by now. However, the agreement has not been fulfilled yet. What’s more, new criteria were added during the pandemic(because of the lack of workers), allowing the hiring of professionals without a training certificate or experience. All this has increased the job opportunities of this nature.[...] We haven’t achieved much in terms of professionalisation with this reform«(Interview 3). The reform contains measures relating to ongoing training in gender perspectives, mental illness, or professional ethics. It also establishes the development of specific training programmes for workers in rural areas. The reform provides for the development of a General Training Plan between 2021 and 2023(also mentioned in the Dependency Action Plan). This plan seeks to improve the qualification of staff and adapt workers’ skills and capabilities to the new care model. However, at the time of concluding this report there was no official record of the central government and regions working on that. Nor has it been on the agenda of the meetings held in the Territorial Council of Social Services and SAAD (Ministry of Territorial Policy, 2022). 20 Resolution of 4 November 2009 by the Office of the Secretary of State for Social Policy and Consumption, publishing the agreement by the Territorial Council of the System for Autonomy and Care for Dependence on common accreditation criteria regarding training and informing non-professional carers. Available at: https://www.boe.es/buscar/doc.php?id=BOE-A-2009-18959 3.2.3  Basic working conditions ■ Recruitment criteria The reform lays down common recruitment criteria for all the facilities and services in the system. The agreement sets permanent contracts at 80% of the total workers at a facility(except in cases of staff supply shortage). In the case of carers, auxiliary personnel and geriatric assistants(the largest group in care homes), the percentage of full-time contracts must be at least 66%(for home help services it is 50%). The formalisation of these minimum guarantees regarding recruitment was one of the trade unions’ chief demands during the process of negotiation(UGT, 2022). Whereas the employers’ organisations say these new recruitment criteria are incompatible with the very nature of care services and overstep the reform’s regulatory framework. »The first to make a stand(at the national Social Dialogue Roundtable) were the employers’ organisations. For the employers, it was almost a matter of principle[...] they didn’t believe that an agreement on accreditation, with the status it had and where it was being approved (the CTSSD), could interfere in matters of collective bargaining«(Interview 7). From an extra-sectoral perspective, the labour market reform 21 approved in Spain in late 2021 was the legal framework for making these changes regarding recruitment. This law, the main goal of which is job stability, abolishes work or service contracts(which allowed a temporary contract to last up to three years) and raises the fines for fraud in temporary recruitment, among other matters. Several of the key players consulted highlighted the importance of the new labour market legislation for the LTC system: »The biggest impact of the labour market reform is the transformation of temporary contracts into permanent ones. Companies are adapting slowly to the labour market reform, but we can give a positive assessment because of the indisputable benefit the increase in permanent contracts in the care sector entails«(Interview 2). »The labour market reform has curtailed temporary work at facilities, as many contracts have become permanent. According to our figures, we calculate permanent contracts have increased by around 10%«(Interview 6). ■ Wages Wages fall outside the reform’s scope of action. However, we must draw attention to certain points in this field. The validity of the VII State Agreement on Dependency, which establishes the salaries for workers in the sector, has been extended beyond its original expiry date and its revision has been the subject of considerable dispute. Article 8 of the agreement states that workers’ salary increases shall be in line with the rise in Spain’s Consumer Price Index(CPI). 21 Royal Decree-Law 32/2021 of 28 December on urgent measures for labour reform, guarantee of stability in employment and the transformation of the labour market. Available at: https://www.boe.es/buscar/act.php?id=BOE-A-2021-21788 8

MAIN MEASURES AND REFORMS IN THE LTC SYSTEM DURING THE PANDEMIC This indexation is conditional on yearly GDP growth of the Spanish economy above 2%. In 2022, in view of the breach of the agreement on the part of the employers, the majority unions(led by the General Union of Workers[UGT]) took the matter to court. Eventually, on 2 November 2022, the courts ruled in favour of the trade unions. Owing to this ruling and the Resolution by the Labour and Social Economy Ministry 22 companies are required to deliver a retroactive wage increase of 6.5% across all professions in the sector. In parallel with this litigation, the negotiation of the VIII State Agreement on Dependency remains deadlocked. At the close of this analysis, the positions of the trade unions and employers in the sector in the negotiating committee remained poles apart. In the words of the key players consulted: »It is going to be very hard to get them to sign the VIII State Agreement on Dependency. Even if there are more resources for the system«(Interview 3). »We are not very optimistic about the final outcome of the negotiations. According to the Bank of Spain, inflation for 2022 will be 8.5 percent. We(the employers’ organisations) have told the unions we can’t implement that salary increase. The numbers don’t add up. A company has to make money to survive. It is not about the business community’s ambition. It is not sustainable, and it will go to the courts again«(Interview 4). 3.2.4  Health and safety at all workplaces COVID-19 revealed the importance of having a general framework of assessment of risk to workers’ health, as well as preventive measures, in both the public and private sectors (European Commission, 2021). The reform of the care model gives a central role to the inspection services when it comes to ensuring the safety of all workplaces. However, the final wording of the agreement drops the reinforcement of the body of inspectors, something that was indeed included in the working drafts 23 . According to several of the key players consulted for this research, the jurisdictional issue was a determining factor, since the regions are responsible for laying down the basic inspection mechanisms and criteria, via Inspection Plans(which are drawn up periodically):»for the regions it was a matter of jurisdictional principle[...] you can’t impose a ratio of inspectors on them«(Interview 7). On another note, the reform of the care model also mentions occupational health, but only as one more criterion for assessing the system’s facilities and services. »The care sector continues to have major shortcomings as far as occupational health is concerned.[...] between 30% and 40% of workers have to take medication regularly to relieve the pain and inflammation resulting from their daily work.[...] what’s more, psychosocial and musculoskeletal disorders are not recognised either« (Interview 2). Given this situation, the central government classified COVID-19 as an occupational disease for healthcare workers and workers caring for people in a situation of dependence, via Royal Decree-law 3/2021 of 2 February. This recognition allows workers who have contracted the disease caused by COVID-19 in the workplace to acquire specific rights, such as the right to compensation. Most EU member states recognise COVID-19 as an occupational disease. France, for example, has allowed the automatic recognition of healthcare and care workers and professionals since September 2020. In Denmark, in all professions COVID-19 is recognised both as an occupational disease and in terms of an accident at work. In the case of Spain, however, recognition is exceptional and temporary. This has been the target of fierce criticism from the unions: »COVID-19 is a disease that is not going to disappear from our daily lives. This measure is inadequate, and we demand COVID-19 be included on the Spanish list of occupational diseases caused by pathogens«(Interview 2). »The recognition of COVID-19 as an occupational disease has not been achieved yet in our country, but there are several individual decisions concerning affected workers where the courts have ruled in their favour«(Interview 5). This demand to extend the cover is in line with the EU Strategic Framework on Health and Safety at Work 2021-2027, as well as with Commission Recommendation Concerning Occupational Diseases to include COVID-19, agreed by the Advisory Committee on Safety and Health at Work(ACSH) in spring 2022(European Commission, 2022b). 22 Resolution of 2 November 2022 by the General Directorate of ­Labour, recording and publishing the National High Court edict on the ruling referring to the salary tables for 2022 of the VII State Framework Collective Agreement on Care Services for Dependent Persons and the Development and Promotion of Personal Autonomy. Available at: https://www.boe.es/diario_boe/txt.php?id= BOE-A-2022-18678 23 In the working drafts of the reform, it was proposed that there would be a minimum of one inspector for every 25-30 care homes, irrespective of whether the inspection units also covered day or night centres, or other social services. Available at: https://dependencia. info/imagenes/borrador-requisitos-acreditacion-diciembre-2021.pdf 9

FRIEDRICH-EBERT-STIFTUNG – CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA 4 CONCLUSIONS AND REMAINING ­CHALLENGES The Spanish welfare state faces a steady process of demographic ageing and increasing rates of dependency to 2050, as well as a change in labour, family, and gender structures. In view of this scenario, and for the first time since the drafting of the Dependency Act in 2006, there is a basic consensus among government, social partners, social stakeholders, and professionals on the need to transform the care model and develop a system of quality in the labour field. Between 2021 and 2022, various measures and reforms were debated and adopted that, directly or indirectly, took care workers into consideration. Section 22 of the Recovery, Transformation and Resilience Plan(Action Plan for the Care Economy) is a milestone in this respect, as it sets out the goal of»the improvement of the quality of professional services and working conditions«. The Dependency Action Plan and the new agreement on accreditation of facilities and services contain significant quantitative and qualitative advances; in the number of professionals required in centres, in the qualification and training of workers, and basic working conditions, as well as on matters of recruitment. These initiatives are recognition of the existence of longstanding structural problems. Moreover, in both cases, an attempt has been made to address significant gaps in the Spanish social protection system. However, the scope of these measures and how they carry over to the real workplace will be determined by the development of various elements of a structural nature: – Funding. The level of adherence to the new care model will be determined by budget availability. The fact that the funding depends on the outcome of multilateral negotiations raises further uncertainty about the reform’s long-term implementation. The increase in funding from the state(»guaranteed minimum level«) and the maintenance of the»agreed level«(supplementary funds, restored in 2021) via the national budget are essential if the regions are to keep to the established timetable. It is important that the public funding is delivered according to strict, previously established criteria tied to the goals of the Action Plan and the new accreditation agreement. To this effect, progress must be made on the system of incentives devised for the»agreed level« of funding – implemented as of 2022 –, which ties part of the amount to the regions’ achievement of goals in the labour field. – Multi-level governance and institutional design. International evidence shows the more collaborative and cooperative the structures of intergovernmental relations are, the more successful the multi-level systems in their response to crises(see Colino, 2021; Del Pino et al., 2020; Greer et al., 2022; Hernández-Moreno, 2021; Mattei& Del Pino, 2021; Pereira-Puga et al., 2023; Schnabel& Hegele, 2021; Schnabel et al., 2022). In the case at hand, the ambiguity of the institutional design and the partisan exploitation that surrounds the action of the CTSSD – with several regional governments transformed into political»battering rams« of the central government – are causing major legal uncertainty, which raises questions about the final implementation of the reform and jeopardises territorial cohesion. Recent research proposes an operational reform of the CTSSD to bring it line with the European Union’s Open Method of Coordination(OMC) (see Rodríguez Cabrero et al., 2022). This would mean breaking with the tendency towards overregulating cooperation through a kind of»governance in networks«. This adjustment would involve a dynamic management of regional diversities through common indicators and objectives, comparative assessments of performance among peers(benchmarking) and the formulation of joint plans of action. – Socio-sanitary coordination. The pandemic has exposed the weaknesses of the Spanish healthcare and social services systems. The complex distribution of responsibilities on an organisational level – with several ministries and departments operating under different rationales and approaches – hampers coordination and gives rise to inefficient management. Care for dependent persons must be a priority goal at every political-administrative level. On this point, the reform of the care model tries to move forward on the regulatory front, establishing a reference framework and laying the foundations of the strategies to follow for the regions. However, in order to consolidate an integrated care model throughout the country care workers themselves must receive attention. To this end, consideration must be given to the staffing levels models in both systems, in contexts of crisis and in moments of normality alike. State-region mechanisms of cooperation, such as a hypothetical intersectoral conference on health and social services, should be used to jointly devise models of coordination and/or integration 10

CONCLUSIONS AND REMAINING ­CHALLENGES at all territorial levels to remove the administrative obstacles to, for instance, identifying and transferring staff between systems. – Social dialogue. According to the International Labour Organisation(2022), collective bargaining contributes to the fight against inequality and is crucial for laying the foundations of an inclusive, sustainable, and resilient recovery. At the time of the close of this analysis, the negotiation of the VIII State Agreement on Dependency was deadlocked. All the social partners must sit back down at the National Social Dialogue Roundtable. The trade union organisations must continue to play an active role in proposing measures, as has happened throughout the crisis 24 . The state has no authority over collective bargaining, an autonomous and independent area. However, the public authorities must use every tool available to them, both formal(such as regulation, funding, and investment) and informal, to try to improve working conditions in the sector. If social dialogue is not addressed in an appropriate manner, the current shortfalls in staff numbers will remain, the persistent gender inequalities in the system will increase, and the goal of eliminating(or reversing) precarious work will become even more distant. ACKNOWLEDGMENTS The author would like to thank the interviewees for their willingness and cooperation, which were indispensable in producing this report, as well as the Madrid office of the Friedrich-Ebert-Stiftung for providing contacts with several participants. He would also like to express his gratitude to the colleagues who took part in the workshop»On the Corona Frontline«, organised by the Swedish Municipal Workers’ Union(Kommunal), Arena Idé and the FES Nordic Countries in Stockholm in the summer of 2022. Lastly, the author cannot omit to extend thanks to Manuel Pereira-Puga for his detailed reading and comprehensive appraisals of a previous version of this report. Any errors or omissions are the responsibility of the author. 24 In countries such as Sweden, Portugal, France or Italy, the unions have also played a decisive role in the decision-making process ­during the pandemic. However, the extent of their participation has been conditioned primarily by the political will of the stakeholders (see Eurofound, 2021; Spasova et al., 2022). 11

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FRIEDRICH-EBERT-STIFTUNG – CARE WORKERS IN SPAIN IN THE POST-COVID-19 ERA METHODS The key informants were selected using the purposeful sampling technique on the strength of their professional profiles and their high level of expertise in the research topic (»information-rich« participants, in the words of Patton, 2002: 230). They were found through the author’s existing contacts and networks and those of his colleagues. Internet searches and the analysis of previous works and documents from various official sources were also utilised to determine the informants. The eight experts we interviewed represent around 70% of the potential participants contacted initially. The remaining 30% could not or did not see fit to take part in the research in the time frame established for collecting primary data. The selected interviewees were first contacted by email. We then made follow-up calls to determine their interest in taking part and responding to a series of questions. To win the participants’ trust, we explained the full purpose of the research during the telephone call. We then contacted a member of staff of those willing to take part and a date for the interview was set. The interviews lasted between an hour and an hour and a half and were conducted via videoconference or face-to-face between October and December 2022. In order to comply with privacy regulations, all participants were guaranteed confidentiality and anonymity. They all gave their individual consent, agreeing to take part in the research and to the interviews being audio recorded (with one exception). In the text, we refer to each one of the interviews with a specific code(the appendix provides more details on the interviewees’ profiles and institutional affiliation). ANNEX Codes and professional profile of study participants Codes used for in-text citations Interview 1 Interview 2 Interview 3 Interview 4 Interview 5 Interview 6 Interview 7 Interview 8 Participants’ professional profile Trade union representative Trade union representative Trade union representative Leader from an employers' association in the nursing homes sector Trade union representative Trade union representative Policymaker at central level of government Policymaker at central level of government The analysis of the data required a stringent process of methodological and systematic review of all primary and secondary sources of information to determine patterns of ideas and concepts, as well as emerging topics. We then established the topic prevalence in the interviews. The detailed account of the results, including illustrative quotes from the various participants, allows the reader to review the findings in a clear and precise manner. It also increases the study’s credibility. 14

Imprint ABOUT THE AUTHOR IMPRINT Jorge Hernández-Moreno is currently a researcher at Spain’s Institute of Public Goods and Policies(IPP-CSIC). He is a graduate in international relations from the Universidad Complutense de Madrid(UCM) and holds a master’s degree in government, administration and public policies from the Instituto Universitario de Investigación Ortega y Gasset and the Universidad Internacional Menéndez Pelayo. He was the recipient of a Spanish government grant for predoctoral research and university lecturer training, the holder of a scholarship to train at the Centre for Sociological Research (CIS) and a visiting researcher in the Department of Social Science and Politics at the Università degli Studi di Milano. He forms part of the Constitution, Integration, Power and Territory Research Group at the Universidad Nacional de Educación a Distancia(UNED) and is a member of the international network Intergovernmental Coordination from Local to European Governance(COST Action CA20123). Since 2021, he has been academic secretary for the journal Gestión y Análisis de Políticas Públicas(GAPP). His research focuses on territorial governance of welfare state systems, comparative federalism and the reform of the Spanish state of autonomies, having published several scientific papers, book chapters and reports on these topics. Published by: Fundación Friedrich Ebert Calle Manuel Silvela ,7, bajo dcha. 28010 Madrid – España https://madrid.fes.de/ Responsible: Luise Rürup Orders/Contact:: info.madrid@fes.de Typesetting: Ludger Stallmeister, Wuppertal The views expressed in this publication are not necessarily those of the Friedrich-Ebert-Stiftung. Commercial use of all media published by the FES is not permitted without the written consent of the FES. Publications by the FES may not be used for electioneering purposes. © 2023 Friedrich-Ebert-Stiftung(FES) was founded in 1925 and is the political foundation with the richest historical tradition in Germany. It has remained committed to the legacy of the President it is named after down to the present day today and works to promote the fundamental values of Social Democracy: freedom, justice and solidarity. In terms of its philosophical values, it is linked to Social Democracy and the free trade unions. www.fes.de/bibliothek/fes-publikationen