Jorge Hernández-Moreno and Manuel Pereira-Puga On the Corona Frontline The Experiences of Care Workers in Spain

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE Europe needs social democracy! Why do we really want Europe? Can we demonstrate to European citizens the opportunities offered by social politics and a strong social democracy in Europe? This is the aim of the new Friedrich-Ebert-Stiftung project»Politics for Europe«. It shows that European integration can be done in a democratic, economic and socially balanced way and with a reliable foreign policy. The following issues will be particularly important: – Democratic Europe – Social and ecological transformation – Economic and social policy in Europe – Foreign and security policy in Europe We focus on these issues in our events and publications. We provide impetus and offer advice to decision-makers from politics and trade unions. Our aim is to drive the debate on the future of Europe forward and to develop specific proposals to shape central policy areas. With this publication series we want to engage you in the debate on the»Politics for ­Europe«! About this publication In Spain, already tough working conditions in the underfunded elder care sector, with low salary levels in all professional categories, as well as the high proportions of temporary and part-time contracts became worse during the pandemic. Lack of training, testing, and personal protective equipment, strenuous days and the refusal of time off led to physical and mental exhaustion. During the period of analysis, trade unions worked to improve conditions but found it difficult to get their demands accepted by the different institutions(both central and regional). About the Author Jorge Hernández-Moreno is currently a doctoral researcher at the Institute of Public Goods and Policies(IPP-CSIC). He is participating in two competitively funded research projects on territorial governance of social policy, and has published several papers and book chapters on this topic. jorgejose.hernandez-moreno@cchs.csic.es Manuel Pereira-Puga holds a PhD in Sociology from the University of A Coruña(Spain). He works at the Institute of Public Goods and Policies(IPP-CSIC) and teaches Sociology at Carlos III University in Madrid. His research interests cover a range of topics related to research and development and higher education systems and policies, as well as to health and social policy. manuel.pereira@csic.es Acknowledgements The authors would like to thank the interviewees for their willingness to help, which was essential in preparing this report, and the Friedrich Ebert Foundation and Fundación Alternativas for providing interviewee contacts. They would also like to thank Eloísa del Pino for her comments, criticism and suggestions regarding an earlier version of this work and Francisco Javier Moreno Fuentes for his advice. Any errors are the sole responsibility of the authors. Partner organizations Arena Idé is a Stockholm-based independent progressive think tank, funded by the Swedish trade union movement. www.arenaide.se Kommunal is Sweden’s largest public sector union with more than 500,000 members. www.kommunal.se Responsible for this publication within the FES Dr Philipp Fink, Director, FES Nordic Countries Josefin Fürst, Policy Officer, FES Nordic Countries

 1 Jorge Hernández-Moreno and Manuel Pereira-Puga On the Corona Frontline The Experiences of Care Workers in Spain 1 INTRODUCTION 2 2 ELDERCARE IN SPAIN 2 2.1 Governance of the long-term care system 2 2.2 Homecare and care homes 3 2.3 Working conditions 4 3 THE IMPACT OF CORONAVIRUS ON OLDER ADULTS IN SPAIN 4 4 ELDERCARE WORKERS DURING THE FIRST WAVE OF COVID-19 5 4.1 Multi-level governmental responses 6 4.2 Eldercare personnel 6 4.3 Training and qualifications 7 5 TRADE UNION PERSPECTIVE 8 5.1 Increasing personnel in care homes and homecare 9 5.2 Improving working conditions and increasing salaries 9 5.3 Guaranteeing quality training for workers 9 5.4 Occupational health and safety 9 5.5 Improve SAAD funding 10 5.6 COVID-19 and the trade union struggle 10 6 CONCLUSIONS AND RECOMMENDATIONS 10 References 12 Acronyms 14

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 2 1 INTRODUCTION Within the framework of the project entitled On the Corona Frontline – Elder care workers in nine European countries and regions, this report analyses how the eldercare sector was affected by the coronavirus crisis and identifies the main problems and difficulties for people working in care home and homecare services from the start of the pandemic to 1 September 2020. At the same time, this report relates working conditions to service quality in this sector and compiles work-related demands made by the main Spanish trade union organisations. For this purpose, eleven semi-structured interviews were conducted with experts, trade union representatives, former political decision-makers and the president of an employers’ organization from the residential care sector. 1 In addition, legal documents, guidelines, protocols, national and international reports, and other documents were analysed. difficult to get their demands accepted by the different institutions(both central and regional). 2 ELDERCARE IN SPAIN 2.1 overnance of the long-term care system The 1978 Spanish Constitution and the Statutes of Autonomy for the 17 autonomous communities(instituted 1979 to 1983) acknowledged and enabled an extensive decentralisation process(Colino 2020). In this respect, the welfare state has evolved in a federalizing direction like the territorial model, where sub-national governments(regional and local) have considerable legislative, executive and management powers in essential policies such as health, education and social services(Gallego/Subirats 2012). Within the context of the first wave of the pandemic, all the institutional stakeholders(central and regional public administrations) and the private sector promoted a range of initiatives to address the lack of personnel in the different eldercare services. However, these efforts were insufficient due to a pre-existing shortage of workers in the sector and the major impact of the virus, particularly in care homes. As in other countries, this meant that exceptional measures had to be taken, such as using military personnel or other emergency services to guarantee service provision. In Spain, problems relating to training and skills among care home and homecare personnel worsened during the first wave of the pandemic. This was partly due to implementation of the new“exceptional and provisional regime” that allowed personnel to be contracted without holding a training certificate or experience in the care system. In addition, non-medical workers in the sector found it hard to manage an infectious disease, as they lack sufficient healthcare training. The deficient job quality in this sector, with low salary levels in all professional categories, as well as the high proportions of temporary and part-time contracts, became worse in the context of the pandemic. Care personnel have had to work double shifts, string together jobs in different eldercare social services or give up days off and holidays. In addition to the shortage of diagnostic tests, workers in the sector were generally short of resources, essential medical supplies and sufficient appropriate protective equipment, risking their own health and that of the users of these social services. During the period of analysis, the trade union demands focussed on the need to: 1) increase the number of workers in all eldercare social services; 2) increase pay and improve working conditions; 3) guarantee appropriate training; 4) ensure health and safety; and 5) improve the funding system. However, trade unions state that they have found it 1 An extended version of this document in Spanish has been published by the Fundación Alternativas, available at: http://bit.ly/DOC_Cuidados. The milestone in Spain for policy on care for dependent persons, which includes care for dependent older adults, came with the Law for the Promotion of Personal Autonomy and Care for People in a Situation of Dependence(LAPAD) that established assistance for dependency as a subjective right. This law came into force on 1 January 2007 and implemented the System for Autonomy and Care for Dependence(SAAD). The LAPAD also established the SAAD Territorial Council as a multilateral cooperation body bringing together central government, the regions and, in some cases, local government. This body is responsible for decisions regarding the criteria for distributing funds, and decisions on various aspects related to implementation of the LAPAD.  MANAGEMENT AND FUNDING In Spain, the regions are responsible for implementing and managing the system. The potential beneficiary or their family can apply to access the SAAD, while social services in the regions assess each individual’s dependence level using a scale, with the assessment then entitling the beneficiary to particular services and/or cash transfers. The regional administrations, working with the beneficiary or their family, decide what type and intensity of service should be provided. The role of local authorities varies significantly between regions, depending on the regional sectoral laws. In general, they provide services using their own resources, such as specific services like homecare. SAAD funding is structured into three levels(Sánchez Maldonado et al. 2010; Moreno Fuentes 2015: 65–66). The central state covers the cost of the guaranteed minimum provision, while the region is in charge of its management. Beyond this, the level of protection is agreed between the central state and the regions, with funding from the region matching or exceeding the funds provided by central government. Furthermore, there is an additional level of funding established by each region which is financed out of its

Introduction 3 own budget(Del Pino/Ramos 2017: 139), and this causes severe territorial imbalances in the quantity and quality of services(Marbán 2020). The LAPAD establishes a series of services and cash transfers for dependent persons. 2 The services include: 1) prevention services for dependency situations and for promoting personal autonomy, 2) remote care service, 3) homecare service, 4) day and night centre service, and 5) residential care service. In turn, there are three types of cash transfers: 1) for care provided by a family member, 2) for contracting an assistant or 3) for acquiring a service. According to the law, services should be prioritised over cash transfers. The underlying idea is that the best way to guarantee the well-being of dependent people is by setting up a high quality public social service system and professionalisation of care, which in Spain has been traditionally tied to the family; particularly women and, in more recent times, to foreign domestic employees(Moreno Fuentes 2015: 67). However, this goal has not been entirely met to date as cash transfers still account for too high a proportion of the total. As of 31 August 2020, out of 1,410,049 cash transfers and services to dependent persons(of all ages), 3 services only accounted for 57.1%, compared to 42.9% for cash transfers(IMSERSO 2020a). While it is true that services have been gaining ground over recent years(increasing by 3% over the last five years[IMSERSO 2015]), the increase is seen mainly among the cheapest services, particularly remote care(which expanded its coverage from 12.4% in 2015 to 17.7% in 2020). According to most participants in the study, the relatively deficient implementation of a SAAD based on public services is due to the contrast between the great ambition of the LAPAD and deficient funding of the SAAD, which made it difficult to implement. Due to this deficient implementation of the SAAD, many dependent people and their families attempt to access long-term care through the market, both to receive care when they are not beneficiaries of the SAAD system and to complement the aforementioned services. As one of the experts interviewed said: “The combination of strategies used by the families[…] (consists of) using the public system, to the extent that it offers you something; complementing it with social assistance, with care services for dependent persons in the private market, let’s say the regulated market; and then complementing that with a wonderful safety net we have in Spain, which is domestic service employees caring for people in a situation of dependency.”(IN: 4). 2.2 Homecare and care homes Within the context of this research, we examined two social services for older adults: homecare and care homes. Homecare service is provided by a care assistant who helps the dependent person with household tasks and personal care, such as hygiene or medication control(Del Pino/ Catalá Pérez 2016: 180). Homecare for dependent older adults is managed by the corresponding local entity(Franco Rebollar/Ruiz 2018: 49). According to data from the Institute for Older Adults and Social Services(IMSERSO 2019), 451,507 older adults receive home help services, which represents a coverage rate of 5%, 4 with vast differences between regions, ranging from 1.3% in Extremadura to 9.2% in the Madrid Region. Demographically, 68.9% of beneficiaries are aged 80 years or over, and 72.3% are women. In turn, more than 300,000 citizens in Spain live in care homes. 5 Estimates based on data from 2019 quantify the care home population between 322,180(Abellán García et al. 2020a) and 333,920(Abellán García et al. 2020b). Although there is no official record of the number of care homes, the“Envejecimiento en Red”(Ageing Network) website run by the Spanish National Research Council (CSIC) offers unofficial statistics. 6 According to these, there were 5,417 care homes in 2019, providing 372,985 places. This means that there are 4.1 places for every 100 persons aged 65 and over. 1,573 care homes are publicly owned (29%) and 3,844 are privately owned(71%). 72.8% (271,696) of the total places are in private care homes, compared to 27.2%(101,289) in the public system. 7 Care homes differ considerably in terms of size. 51.4% of places are in care homes with 100 beds or more; 29.1% in care homes with between 50 and 99; 14.4% in homes with between 25 and 49 places and the remaining 5% in homes with fewer than 25 places. There are significant differences between regions and even between provinces within regions in all these aspects(Abellán García et al. 2019).  AND PRIVATE – OWNERSHIP AND SERVICE MANAGEMENT Here, it is necessary to distinguish between ownership of the care home and service management. Publicly-owned care homes can be managed publicly or privately. In turn, privately-owned care homes might offer government-assisted places. In 2018, only 9% of places were in publicly-owned 2 The LAPAD defines dependency as:“The permanent status of persons that, for reasons due to their age, illness or disability, and lack or loss of physical, mental, intellectual or sensory autonomy, require care from other people or significant help to carry out basic daily activities or, in the case of people with an intellectual disability or a mental illness, other support for their personal autonomy.”(art. 2). 3 Bear in mind that the sum of cash transfers plus services is greater than the number of beneficiaries. On 31 August 2020, the total number of beneficiaries rose to 1,111,792. Therefore, the provision/service ratio per beneficiary was 1.27. This data refers to all dependent persons, not just older adults. 4 The percentage of users out of the total population aged 65 and over. 5 Note that only a proportion of the people living in care homes are actually dependent. 6 The CSIC care home statistics define a care home as collective accommodation for the older adults in one of the following: residences, including mini residences; sheltered housing; geropsychiatric centre(or sections within these centres); public health centres(older adults section, if differentiated); residential blocks(flats, etc. with common services, publicly owned); other collective centres”(Abellán García et al. 2019: 6). 7 However, there are significant differences between ACs and even between provinces(Abellán García et al. 2019).

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 4 care homes that were publicly managed. 16% were in public care homes managed by private entities. 26% were government-assisted places in privately-owned care homes and 49% were purely private(PWC 2020: 25). As can be seen, the private sector, through different operators, accounts for the bulk of residential eldercare provision. Large companies are significant. In 2019, the top five companies in the sector held a market share of 24.8%(DBK INFORMA Observatorio sectorial 2020). In general, this trend is in line with other European countries, which have also turned to the private sector over the last few decades, fundamentally by subcontracting care services funded with public money (e.g. Armstrong/Armstrong 2020). 2.3 Working conditions The deficient quality of employment in long-term care has been identified as a fundamental problem for attracting and retaining professional staff in a sector where demand for workers is expected to grow over the coming years (OECD 2020: 10). PAY Firstly, pay for workers in the care home sector, the vast majority of whom are women, is significantly lower at all levels than equivalent posts in the Spanish National Health System(SNS)(Martín Serrano, 2014). This was mentioned by several interviewees:“If I earn 2,000 euro in the SNS and I have better working conditions, I’m not going to work in a care home for not much more than 1,000 euro” (IN:5). Pay is especially low in the posts associated with a lower level of formal education(such as geriatric assistant and homecare assistant); here it is often under 1,000 euro per month for a full-time contract. 8 PART-TIME WORK In the care sector, there is also a high incidence of temporary and part-time work(Jiménez-Martín/Viola 2017; CCOO 2018). According to social security data for the third quarter of 2020, less than half of contracts in the sector of residencial social services were permanent and full-time (47.8%), 22.6% were temporary and full-time; 15.6% were permanent and part-time; 11.6% temporary and part-time; 0.2% were permanent seasonal contracts; and 2.2% were for an indeterminate duration(IMSERSO 2020b: 17). 9 Parttime work, often not out of choice, leads workers to take on several jobs that even together do not guarantee fulltime hours. Temporary, part-time work and multiple jobs are associated with lower social protection(such as in terms of unemployment benefit and pensions). 8 Pay for private nursing home personnel and home carers is regulated in the VII Collective Labour Agreement(BOE, No. 229, 21 September 2018). 9 This data includes not only care homes but also other collective accommodations such as homes for disabled people. PHYSICALLY AND MENTALLY TOUGH WORK In addition, tough working conditions in the long-term care sector can affect physical and mental health(Aragón et al. 2008). Some of the basic tasks, such as getting dependent people up, and dressing and moving them, require great physical effort that can lead to potential injuries and musculoskeletal disorders. Stress, pressure and working conditions could have a potential impact on the mental well-being of many workers:“It is a very stressful job; it burns you out”(IN: 8). In the homecare field, there are additional occupational and psycho-social risks. Furthermore, the fact that the carer is alone in the house can lead to problematic situations, such as harassment from the dependent person’s family, as mentioned by participants in the study. HARD WORK MADE EVEN HARDER DURING THE PANDEMIC: This working situation, in its different dimensions, has been worsened by the pandemic. The heavy workload associated with staffing shortages and recruitment difficulties(described above) has left staff facing gruelling workdays, giving up time off and holidays, and even working more overtime:“Shifts lasting 12 or 14 hours. It was too much. They gave the workers a token to get breakfast from the vending machines”(IN: 5). Multiple jobs and temporary work created COVID-19 transmission risks. As one expert explained: “When you have a system based on permanent rotation of workers and on very short contracts[...], with shift work, weekend work... you are facing a pandemic where the major premise to avoid the spread is reducing the number of contacts and it turns out that you have floating personnel; they are possibly working on two or three different contracts in two or three care homes; or in a day centre in the morning and a care home in the afternoon. These are not the most appropriate conditions to face this type of crisis, don’t you think?”(IN: 4). Finally, it should be noted that not only the residents’ but also the workers’ health was put at risk due to the lack of testing among personnel and care home residents during the first weeks of the crisis, and due to the lack of sufficient, appropriate Personal Protective Equipment[PPE](Amnesty International 2020). In some cases, workers’ demands for protective equipment led to dismissal(Sindicato Asambleario de Sanidad 2020). The shortage of PPE, although uneven among centres and regions, was also identified as a major problem in homecare. 3 THE IMPACT OF CORONAVIRUS ON OLDER ADULTS IN SPAIN The Health Alert and Emergency Coordination Centre (CCAES) reported a total of 470,973 confirmed cases (CCAES 2020) by 1 September 2020. These were the high-

Eldercare workers during the first wave of COVID-19 5 est figures in Europe at this point, above the United Kingdom(335,873), France(281,025) and Italy(269,214). Up to that date, 29,152 deaths due to coronavirus had been recorded in Spain, 10 which meant that the case mortality was 6.2% at that time. However, according to various studies and indicators, this total significantly underestimates the number of deaths related to coronavirus in the country, as it is based on cases confirmed by a PCR test or an antibody test. As we know, the effects of COVID-19 are more severe in older groups. According to the National Epidemiological Surveillance Network(RENAVE) report on 3 September 2020, the percentage of people infected by coronavirus who require admission to hospital and who die increases with age, and these indicators reach 22.8% and 5.7% respectively in people aged over 79 years old, compared to 4.8% and 0.4% among the general population in the period of analysis(RENAVE 2020). The Institute for the Older Adults and Social Services[IMSERSO] analysed excess mortality among persons linked to the SAAD between March and July. Its calculation estimates excess death during this period of 29,687 among the collective of people with SAAD cash transfers and services, which would represent 2.65% of the total individual care receivers(IMSERSO 2020c: 4), of which the majority were older adults. A large proportion of those who died from COVID-19 in Spain during the first wave were care home residents. 11 During the state of alarm, an order from the Ministry of Health 12 instructed the regions to submit a series of indicators by 8 April – and from then on every Tuesday and Friday, before 9 pm – regarding the development of the pandemic in residential social services centres(older adults, people with mental and/or physical disabilities, etc.). These indicators include the total number of persons who died in residential centres, deaths due to COVID-19 and deaths with compatible symptomatology. A report from the Ministry of Social Rights and 2030 Agenda(2020a) puts the number of people who died in residential social services centres(of all types), up to 23 June 2020, at 20,268. The 10 The CCAES warns that the definition of death by COVID-19 differs between countries, so data related to fatalities and lethality are not directly comparable. Consequently, this section does not compare Spain with other countries regarding these two indicators. 11 It is not possible to give a totally reliable figure for deaths related to COVID-19 in care homes, or the specific proportion they represent in relation to total deaths related to the virus in Spain. Firstly, the shortage of tests, particularly during the first weeks of the pandemic, made it very difficult to estimate the total deaths in the country. In turn, and specifically in the field of residential care centres, the data from the first wave suffers deficiencies and comparability issues. According to Zalakaín et al.(2020: 2–3), some regions distinguished between deaths in confirmed cases and cases with comparable symptoms, while others offered a single figure without specifying whether these were confirmed cases or confirmed plus suspected cases. Furthermore, some regions notified total deaths in residential centres without separating the information by type of centre(older adults, disability). 12 Order SND/322/2020, of 3 April, modifying Order SND/275/2020, of 23 March and Order SND/295/2020, of 26 March, and new measures were determined to cover the urgent social or healthcare needs in the field of the healthcare crisis caused by COVID-19(BOE 4 April 2020). Available at: https://www.boe.es/eli/es/o/2020/04/03/snd322. report estimates that the deaths in these centres represent between 47% and 50% of the total deaths related to COVID-19 in Spain up to that date. This would place Spain at an intermediate level compared to other countries for which data is available. In addition, the study estimates that the total number of older adults who died from coronavirus or compatible symptomatology in care homes during the first wave is equivalent to about 6% of the Spanish care home population before the pandemic was declared (Ministerio de Derechos Sociales y Agenda 2030 2020a: 13). THE IMPACT OF THE CORONAVIRUS ON CARE HOME PERSONNEL Along with the impact of COVID-19 among care home residents, the fate of the personnel providing services in them should also be considered. In Spain, there was no systematic data collection regarding infections and deaths among long-term care service personnel(Zalakaín et al. 2020: 2). Recent serological studies provide information on the high impact of COVID-19 in care homes. A study carried out in sixty-nine care homes in the Barcelona area found that 15.2% of tests on workers were positive, and 55.8% of infected workers had been asymptomatic. The percentage of positive residents was 23.9%(69.7% asymptomatic) (Borrás-Bermejo et al. 2020). For its part, the Madrid Region, one of the regions most affected by COVID-19 in the first wave, ran a serological study among residents and workers in residential centres(for older adults and disabled people). The preliminary results of the study, carried out between July and September, show that 37% of the 27,437 workers who took the test had long-term antibodies(IgG). Among residents, this percentage reaches 53% (Valdés 2020). Infections and deaths are not the only problems associated with COVID-19 in care homes. The crisis has impacted other aspects related to quality of life and health(physical and psychological condition) of older adults in institutions(GDT 2020: 1). Specifically, restrictions regarding social contact and isolation of older adults in institutions can be related to the appearance of emotional disorders, worsening of some previous pathologies, emergence of other new pathologies(such as sarcopenia, associated with sedentary lifestyles) and negative effects in emotional and motivational terms(SEGG 2020: 1). 4 ELDERCARE WORKERS DURING THE FIRST WAVE OF COVID-19 Long-term care systems(including those for older adults) have a great capacity to create jobs and fuel the demand for labour(Rodríguez/Jiménez 2010; CCOO 2017, 2018). However, in Spain difficulties finding qualified staff have been clear for some time(Jiménez-Martín/Viola 2017; AEDGSS 2020). The incomplete implementation of the LAPAD shortly before the start of the financial crisis, its institutional design deficiencies, the cuts and funding shortages

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 6 that affected both care for dependency and the social services sector between 2011 and 2015, and the social-demographic pressures of an ageing population, have only worsened prior structural issues(Aguilar-Hendrickson 2020). The pandemic has highlighted pre-existing issues such as staffing levels, working conditions, and training and qualification. 4.1 Multi-level governmental responses All levels of government have attempted to influence the management and organisation of workers in the sector. The main measures regarding personnel have been agreed between the central government and the regions within the SAAD Territorial Council. Although this forum has registered relatively low levels of activity(in terms of number of meetings), it has been successful in reaching agreements (Ministerio de Política Territorial y Función Pública 2020). The first example is the Agreement of 20 March 2020, 13 which established a“provisional and exceptional regime” to temporarily make the management and recruitment of workers in the sector more flexible as an emergency response for an initial period of three months. Furthermore, this regulatory framework has made it possible to hire people with less qualifications. This new settlement has also obliged people that were on leave due to their trade union activity to take up their posts temporarily. 14 The central government also promoted a range of initiatives. The Ministry of Health, as the competent authority since the declaration of the state of alarm on 14 March 2020, drafted legislation and regulations related to services intended for older adults. Specifically, Ministerial Decree SND/295/2020 of 26 March focuses on workers from the sector. This measure, which must be applied to all care centres irrespective of their ownership(public or private), allows the central government and the regions to force workers into positions that might differ from their original job and specialisations. It also allows the(re)location of workers and modifications to working and rest hours. The Ministry of Social Rights and 2030 Agenda, through the IMSERSO, also instituted out a range of fundamentally technical measures. As in other multi-level systems(for the case of Canada, see for example Béland and Marier 2020), the regional governments implemented all these initiatives. The official documents centralised by IMSERSO tell us that the regions took measures relating to the management and organisation of personnel in the different eldercare services, although with varying scope and intensity(Ministerio de Derechos Sociales y Agenda 2030 2020b). 4.2 Elder Care Personnel In general, the long-term care sector(all types, not just for older adults) presents structural problems related to the professional resources that the systems require(ILO 2019; Eurostat 2020). One of the main obstacles to properly understanding the needs of the sector in Spain is that there is no official register of persons employed in the eldercare sector. This is due to the territorial dispersion of information sources and lack of action from competent central institutions, 15 among other factors. One interviewee pointed out that“we are a million miles from all the statistics required by the law[on dependence]; we require a proactive and collaborative attitude from the different administrations”(IN: 2). In the case of care homes, another problem was that the regional legislation diverges in terms of staff ratios(Ordoki 2019). In general, regional legislation is very old, some even pre-dating the LAPAD, which makes it impossible to cover the sector’s present needs. Furthermore, as this report is being written, the care ratios set by the central government and the regions in 2009 16 are not always met. According to several of the interviewees, both from trade unions and business organisations, this is due to factors such as insufficient funding of the sector, the shortage of available workers given the current working conditions and, according to various interviewees, shortcomings of the regional inspection systems and sanctions(IN: 2, 5–6). SHORTAGE OF PERSONNEL As a result of the situation outlined above, the main problem in eldercare in the first wave of COVID-19 was precisely the shortage of staff. This problem was particularly severe in care homes, as a consequence of the pandemic’s impact on personnel. The main reasons behind the staffing shortages during the first wave were: 1) the high infection rate, 2) the obligation to isolate after contact with an infected person(quarantine), 3) having a prior condition or risk factor, 4) psychological issues in the light of the difficulty of the situation, and 5) questions related to the social or family environment(Del Pino et al. 2020: 67). The shortage did not affect all professions equally. As in the period prior to the crisis, the shortage of personnel was more pronounced in the higher-qualified healthcare professions, such as doctors, nurses or physiotherapists. 13 Decision of 23 March 2020, by the Secretary of State for Social Rights. 14 The trade union leaders interviewed reported that a large number of trade unionists who are doctors, nurses or have other medical related professions were asked to take jobs in a wide range of eldercare services in regions such as Valencia, Castilla y León, Andalusia, Madrid and Catalonia. Meanwhile, the same professionals had to continue with their trade union activity. 15 The SAAD Information System(SISAAD), implemented in 2014 to centralise the collection, processing and availability of information related to human resources, has not generated statistics in this regard so far. 16 Decision of 4 November 2009, from the General Secretary of Social Policy and Consumption, publishing the Agreement from the Territorial Council for the System for Autonomy and Care for Dependence, on common certification criteria in terms of training and information on non-professional carers.

Eldercare workers during the first wave of COVID-19 7 “Entire teams deserted, such as the nursing team. There were no nurses in many care homes. In Spain, no care home has a 24-hour doctor. None. Furthermore, in homes with less than 50 places, the legislation does not require them to have a nurse, so they don’t have one. There were only some nursing assistants(geriatric assistants) who barely had any medical training”(IN: 1). – Managers and directors of private residential care services also used their own work placement programmes, work placement schemes from companies or even developed new tools during the crisis. They also used informal channels, such as internet small ads pages or religious congregations(such as parishes) to find workers(IN: 6). In this respect, there seems to be a structural factor related to the preferences and(self) perceptions of these workers. According to the people interviewed, health professionals (doctors, nurses and psychologists, among others) prefer to work in hospitals and health centres, where the workload might be lighter, social prestige and pay are higher, and the work is perceived as more attractive(IN: 1–3, 5–6, 10–11). This situation aggravated the staffing shortage during the first wave of the pandemic. The staffing shortages and retention problems varied geographically and between types of residences. So, care homes in urban areas had better chances of recruiting and(re)locating personnel. Care homes in rural areas had much greater difficulties. This is how one of the interviewees expressed it: “We couldn’t find anyone to work and even less so here[...]. In some towns, the mayors themselves came to wash the linen at the care home”(IN: 1). EFFORTS TO RECRUIT PERSONNEL During the first wave of COVID-19 in Spain, several mechanisms were used by public administrations and private companies to tackle the lack of personnel: –(Re)allocation of civil servants from other regional ministries to social services, as happened in Andalusia and Asturias. For example, the Asturias Health Service (SESPA), provided care homes(both public and private) with nurses and cleaning and laundry staff. – In the search and recruitment of professionals, many regions tried new ways to recruit former health care workers. In Cantabria, the social services department created a platform to identify former healthcare workers or care professionals and re-employ them in residential care services(Government of Cantabria 2020). – In other regions, the regional social services ministries centralised management of job placement programmes to make it easier for care home directors to hire personnel, or they made direct contact with entities and associations that have their own list of job-seekers(third sector entities, universities, training centres, professional colleges, etc.), as happened in Castilla-La Mancha(El Digital de CLM 2020). However, all these institutional and organisational efforts, both public and private, were not enough to tackle the critical situation in residential care services. Two interviewees mentioned that when they contacted these job placement programmes,“no workers were available”;“when you wanted to recruit someone through your job placement programmes, you couldn’t find anyone”(IN: 1, 6). This human resources issue led to extreme measures, such as using the Emergency Military Unit(UME)(Ministerio de Defensa 2020) or other emergency services, such as SUMMA 112(Region of Madrid 2020) in the Madrid region, to perform basic functions and tasks in these centres. 4.3 Training and qualifications Internationally, there is a skills and training problem for many people working in the care sector, including eldercare(Spasova et al. 2018). Care personnel must often perform complex tasks that go beyond activities of daily living, such as monitoring the state of health of older adults (OECD 2020: 24). Consequently, and given the vulnerability of many older adults, a guarantee of appropriate training for carers would be desirable. Some countries such as Canada, Denmark, Germany, Austria and Belgium have developed institutionalised training programmes, who are required to hold a licence or a certificate of basic skills to be able to work in social care services for older adults(OECD 2020: 66–91). However, in most countries, the entry-level training requirements are lax. This is the case in Spain, which is characterised by low formal qualifications and insufficient training and professional certification for these professional categories(geriatric assistants, carers and homecare assistants, among others) that make up the vast majority of the workforce in residential care and homecare services(CCOO 2018; Marbán 2019). In this respect, the main political response was the agreement on common criteria for training accreditation and information on nonprofessional carers from 2009 17 between the central government and the regions, which aimed to certify the professionalism of workers in the sector who were not in possession of a vocational training qualification. A new agreement remains to be completed and therefore the 2009 agreement had to be extended on many occasions(most recently, on 1 January 2018). – Some regional governments implemented plans to hire additional personnel(expanding staff and creating new posts) or developed legislation to prevent dismissals in this sector, such as in Aragón(El Justicia de Aragón 2020) or Castilla-La Mancha(INJUVE 2020). 17 Decision of 4 November 2009, by the General Secretary of Social Policy and Consumption, publishing the Agreement from the Territorial Council for the System for Autonomy and Care for Dependence, on common certification criteria in terms of training and information on non-professional carers.

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 8 “Despite being approved, the same level of development and commitment did not exist in all the regions. There was no investment effort from[the ministries for] employment, education and social services.[...] Nor has the government of Spain done enough to force the regions. Nor has it proposed resources from central ministries”(IN: 8). Although there is no official data, the interviewees reported that over the last few years, a lot of progress had been made in certifying care personnel in care homes, although not as much for homecare services. However, in response to the COVID-19 crisis and the shortage of personnel, the regime developed by the central government and the regions(mentioned above and extended for another three months through a new Agreement in the Territorial Council of Social Services and SAAD on 2 October 18 ) has allowed workers to be hired without a training certificate or experience, making it difficult to meet the improvement objectives. In addition to these problems, there is the added need to train non-medical personnel in matters regarding infectious diseases and their management(use of PPE, protocols to avoid virus transmission, etc.). With no specific plans or training courses, different international organisations such as the World Health Organization[WHO] and the European Union[EU], through the European Centre for Disease Prevention and Control[ECDC], have drafted many reports with guidance and recommendations in this respect, that reach beyond the environments of health infrastructures (ECDC 2020). The different administrations, through the central health and social services ministries and the sectoral regional departments, have drafted technical documentation(basically in the form of protocols and contingency plans) for medical and non-medical workers. Despite the lack of coordination between care homes and the health system(Del Pino et al. 2020: 85–88), some of the latter’s services, such as primary care, also attempted to alleviate the lack of basic medical training for a large number of workers over the first weeks of the pandemic. PASSING ON KNOWLEDGE – IN THE WORKPLACE AND DIGITALLY The actual care homes played an important role in training workers, constantly implementing measures and training actions, in line with the material provided by the different authorities and the multidisciplinary work groups that were constituted under these special circumstances within care centres. This training focussed on organisation of spaces (signs and subdivision of zones), handling protective equipment, food distribution, personal hygiene, and waste management. “We did all the training ourselves during the pandemic. The doctors trained the nurses, the physiotherapists (trained) the geriatric assistants...[...]. We trained each other as we went along. How to put on a mask, how to put on the gown, where you have to keep it, if it can be reused, hand washing.... We were training people as we found out more. We all learned as we went along”(IN: 6). Within the context of the pandemic, technology has played a key role in training; specifically, in transmission, dissemination and continual updating of the knowledge generated by the different institutional actors and by care workers themselves. Audiovisual materials(infographics, informative videos, digital presentations, etc.), video calls and instant messaging have been widely used. The intensity and regularity of this training work was mentioned by many managers, directors and medical directors of care home services(Del Pino et al. 2020: 69). In the case of other services for older adults, such as homecare, there were few measures and guidelines related to training workers by the competent administrations(regional and local governments). The Ministry of Social Rights and 2030 Agenda drafted a technical document(Ministerio de Derechos Sociales y Agenda 2030 2020c) containing general recommendations for the administrators of these services, but not for the technical personnel or the personnel involved directly in homecare(such as homecare assistants). 5 TRADE UNION PERSPECTIVE As described in the previous sections, the pandemic exacerbated a range of structural problems in the care systems’ professional resources, many of which had been identified by trade unions years before and formed part of several complaints to the Ombudsman(e.g. CCOO 2017; Defensor del Pueblo 2019). 19 During the first wave, the response from the trade unions fundamentally focused on providing organisational support for workers in the sector and demanding labour-related improvements; the trade unions took these matters to the different institutions(national and regional) and, later, to the negotiation table with the main business organisations in the sector. This section mainly compiles demands from the largest two Spanish trade unions: Comisiones Obreras[CCOO] and Unión General de Trabajadores[UGT]. 20 18 Decision of 27 October 2020, by the Secretary of State for Social Rights, leading to the publication of the Agreement from the Territorial Council for Social Services and the System for Autonomy and Care for Dependence, that partially modifies the Agreement of 27 November 2008 on common certification criteria to guarantee the quality of the centres and services of the System for Autonomy and Care for Dependence. 19 This is a national parliamentary institution charged with defending citizens’ fundamental rights and public freedoms by means of supervising the activity of the Spanish public administrations. 20 Other trade union organisations such as the Confederación Intersindical Galega(CIG), the Confederación General del Trabajo(CGT) and the Central Sindical Independiente y de Funcionarios(CSIF) also organised and defended the rights of these workers in the pandemic.

Trade union perspective 9 5.1 Increasing personnel in care homes and homecare One of the main demands revolved around the need to increase human resources in the light of lack of personnel in the sector that had been worsened in the pandemic. Specifically, they demand that staffing ratios should be set by professional category, not overall. This aims to cover the needs of each professional category and adapt them to dependence levels and the residents’ morbidities. Additionally, they complain about systematic noncompliance with ratios in many care homes, particularly during the pandemic. In this respect, the trade union proposal suggests enforcing minimum ratios and compliance with the 2009 agreement(mentioned in section 4.3) by all administrations, through regulation at the state level. In direct relation to this demand, the trade unions have also demanded an intensification of inspections by the authorities(mainly regional) in care homes(both public and private), and regular audits(UGT 2020a). In this respect, another demand would be to exclude from public contracts any companies that are repeatedly sanctioned by workplace inspections. ries under the slogan“Continuous professional and personal development”. Both the UGT and the CCOO have repeatedly reported that geriatric assistants are engaged in tasks for which they do not possess the necessary training. The trade unions complain that in some care homes, part of the ancillary personnel is obliged to undertake tasks that should be performed by medical personnel, which could lead to legal consequences for the workers. The imbalance between training for these workers and the complexity of the tasks involved in caring for vulnerable people has deteriorated as a consequence of the regime approved by the central government and the regions. The main trade unions came out against this recruitment framework(which was in force for the public health sector until June), as there was no evidence that the work placement programmes were exhausted at this time and because of the loss of professionalisation they meant for the sector: “this is not the way out of this, quite the contrary”(IN: 9). In the context of COVID-19, the trade unions demanded that the different administrations and the private sector should give specific training to workers, particularly any who are in close contact with older adults in homecare services(UGT 2020b). 5.2 Improving working conditions and increasing salaries 5.4 Occupational health and safety The largest trade unions also call for penalties for companies that violate the sector-based state agreement. 21 The trade unions demand improvements in pay, restrictions on part-time contracts and reduction of temporary contracts. They also highlight that the poor quality of jobs prevents many workers from living a decent life and in some cases, despite their jobs, such workers live in poverty. In this respect, the widespread existence of company agreements that allow business owners to apply the minimum wage creates a situation that is hard to reverse:“this is almost ingrained for a lifetime, because retrieving them and inserting them in state agreements is very complicated.”(IN: 9). CCOO insists on regulation of part-time contracts, requiring that they should be no less than 60% of a full working week. Trade union organisations regard the working week as 37.5 hours, with an annual maximum of 1,696 hours. In terms of pay, trade union demands revolve around setting a minimum wage of 14,000 euros per year for the lowest categories. They also identify and demand improvements to working conditions directly related to the pandemic(IN: 10–11). 5.3 Guaranteeing quality training for workers One of the main trade union campaigns in the context of the pandemic related to improving training for all catego21 The labour reform carried out by the conservative Partido Popular(PP) central government in 2012 reduces the relevance of sectoral state agreements. In the COVID-19 crisis, the unions have unsuccessfully advocated common regulation at state level of the guidelines established for the performance of work in care homes, so as to prevent noncompliance related to PPE distribution(and ensure sufficient stock) and diagnostic tests for all personnel, irrespective of their position. In addition, the trade unions have demanded improved care staff training on matters such as use of PPE and guidelines to avoid infection. Within the context of the pandemic, one of the main demands from the major trade unions, put before the Ministry of Inclusion, Social Security and Migration many times, was to recognise COVID-19 as an occupational illness, as in other countries(such as Germany or Italy) working from Directive 2020/739 from the European Commission. 22 The Royal Decree-Law 19/2020, 23 approved on 26 May 2020 by the central government, complies(although only partially) with this demand. It recognises a“work-related accident” for people working in healthcare and public health centres who were infected with the disease. Although this legislation represents progress, for the trade unions it is insufficient in relation to possible future physical and psychological consequences of COVID-19 on the health of affected personnel. Consideration as an occupational illness is associated with 22 Directive(EU) 2020/739 of 3 June 2020, modifying annex III of Directive 2000/54/CE from the European Parliament and Council regarding the inclusion of SARS-CoV-2 in the list of biological agents that are known human pathogens, and Directive(EU) 2019/1833 of the Commission. Available on: https://www.boe.es/doue/2020/175/L00011-00014.pdf. 23 Royal Decree-Law 19/2020, of 26 May, which adopts complementary measures in agricultural, scientific, economic, employment and social security and tax matters to alleviate the effects of COVID-19.

FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 10 better provision from the National Social Security Institute, both financially and in terms of health care(CCOO 2020a). 5.5 Improve SAAD funding Improving all these matters requires better funding, according to everyone interviewed for this report. As the trade union officials warn, improvements to the quality of services and employment in the care sector requires a significant increase in SAAD funding. Specifically, CCOO proposes a three-year agreement to increase the budget by 3.1 billion euro, bringing state funding of the SAAD to 40%(currently 16%) plus 60% funding from the regions. An increase is demanded in the agreed price, unfreezing the prices that the administration pays for care services, setting a cost per place price and a cost per hour price for minimum services across the whole country, and a guarantee that the funding improvement will be reflected in pay and conditions. Within the context of the pandemic, trade unions have made proposals on the use of the EU’s reconstruction fund. One of these is for part of the resources to be used to strengthen the health and care system and improve the quality of employment in it and other sectors, emphasising the fight against excessive temporary work. Finally, the trade unions are asking the central and regional governments to encourage compliance with the VII State Framework Agreement for the sector. At the time of writing, all the stakeholders(business associations and trade unions) have come back to the negotiating table. However, both trade union confederations are pessimistic about the future of this matter:“The negotiating commission is at an impasse. We have asked the business associations for joint action and requested greater funding[in the general budget] to improve working conditions and salaries for workers[...]. The answer was no”(IN: 9). In light of this impasse, the trade unions have called on central government to push forward negotiations with the business associations in the sector. 5.6 COVID-19 and the trade union struggle Few of the trade unions’ demands have been met to date. All the matters mentioned above have been presented in formal and informal bilateral meetings with the central government(and the ministries of health and social services), several parliamentary groups in the Spanish parliament and regional sectoral institutions and departments(IN: 5, 9). However, despite the will to cooperate, they encountered difficulties, repeatedly requesting their inclusion in the main national political and multilateral forums, such as the Commission for Economic and Social Reconstruction. 24 24 Established on 21 May 2020, the purpose of the Commission for Economic and Social Reconstruction is to receive proposals, hold debates and draw conclusions on the measures to be adopted for social and economic recovery from the COVID-19 crisis. The main trade unions(UGT and CCOO) complain that the central government and most of the parliamentary groups in the national parliament have not given as much consideration to the workers in the care system, as, in their opinion, was given to the business associations(CCOO 2020b). At the end of August 2020, they suggested that the Ministry of Social Rights and 2030 Agenda call a plenary session of the SAAD Advisory Committee(in which business associations and trade unions take part), to continue developing the commitments made in the technical committee “Care homes and COVID-19” on best practices in staff management. Within the framework of the Social Dialogue Roundtable on Dependency(Ministerio de Derechos Sociales y Agenda 2030 2020d), the stakeholders(trade unions and business associations) have prepared a series of documents for joint action involving the SAAD, in some cases addressing aspects related to workers. Through this forum, they propose the elaboration of a“map” of social and health resources, containing staffing ratios broken down by professional categories in care homes, as well as the number of workers on staff and the labour capacity used(percentage of working hours) in the case of homecare services. They also request setting up a fund that should improve the fixed-price directly linked to meeting care and employment quality standards set in the Certification Agreement(mentioned in the previous section) and in the sectoral collective labour agreement. As this report was being finalised, these proposals were still being discussed by central government and stakeholders. 6 CONCLUSIONS AND RECOMMENDATIONS On the basis of the findings of this report, we can draw a series of conclusions and make some recommendations. As demonstrated throughout this report, the care sector has difficulty attracting and retaining workers. The poor quality of employment and limited perspectives for professional development mean that many workers with qualifications in the health sector(particularly doctors and nurses) perceive work in care homes merely as a stepping stone to securing a stable job in a hospital or health centre. In turn, care professionals, mainly women(assistants and geriatric assistants, among other profiles), end up leaving the sector due to the poor working conditions. This situation needs to be reversed by promoting better pay and permanent, full-time contracts. Within companies, the organisation of shifts, holidays and days off should take into account the physical and mental difficulty of care work. Training is another important issue. People working in care homes and homecare must tackle complex tasks, due to the vulnerability of the older adults in their charge. This requires qualifications to be designed to give future professionals appropriate skills. In addition, these qualifications should be attractive and future students should perceive geriatric care as a sector with a bright future. Designing and implementing training programmes requires signifi-

Trade union perspective 11 cant coordination between the departments of education, work, health and social services, and between the central state and regional governments. In Spain, it is also necessary to finalize the process of developing certification for all health care workers(both in care homes and homecare services) and guarantee that anyone caring for older adults has the appropriate training. Back in the first wave of COVID-19, workers had to work long strenuous days and double shifts and were denied days off and holidays, leading to physical and mental exhaustion. This was the consequence of covering sick leave for their colleagues and making up for the care homes’ difficulties in recruiting staff. They did a remarkable job, often lacking the appropriate PPE, with no access to diagnostic tests and with insufficient and confusing information often due to the lack of guidelines and contingency plans at the start of the pandemic, as well as the lack of coordination between the public sector and government authorities. Some staff(such as assistants and geriatric assistants) did not have enough appropriate training on how to protect others and themselves from a contagious disease such as COVID-19(how to put on and take off gloves, masks and disposable gowns, how to avoid contaminating their clothes and personal belongings, etc.). Until the pandemic is over, it will be essential to guarantee appropriate equipment and external support(particularly from the health system) for people looking after older adults, both residents in institutions and those receiving care in their own homes. It is also important to acknowledge the link between working conditions in the long-term care sector and the effectiveness of the fight against SARS-CoV-2. In this respect, the effectiveness of some of the measures intended to stop transmission of coronavirus in care homes might be limited by the labour relations model. Very short contracts, parttime and multiple jobs increase rotation and mean that the same worker is likely to move between different workplaces. This working situation does not seem compatible with best practices such as creating bubbles or limiting the number of social contacts. Finally, it is necessary to think about the low social prestige of the professions that ensure the well-being of vulnerable people in the final years of their life. All participants in this study agree that society does not value the work performed by long term care sector workers as much as it should. In the context of the crisis, care home and homecare workers have been fighting on the front line with precarious means and little external support to safeguard the lives of our older adults while they receive scant recognition from society.

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Marbán, Vincente(2020): Los(Des)cuidados de larga duración en España: ¿Reforma o Perfeccionamiento del SAAD?, in: Moreno Fuentes, Francisco Javier; Del Pino, Eloísa(eds.): Las Transformaciones Territoriales y Sociales del Estado en la Edad Digital, Madrid, pp. 331–354. Martín Serrano, Enrique(2014): ¿Es todavía posible un sistema de dependencia como motor económico y de empleo?, Revista Actas de la dependencia, 11, pp. 1–29. https://www.fundacioncaser.org/sites/ default/files/emartin_empleoysaad.pdf(02.01.2021). Ministerio de Defensa(2020): Intervención de la UME en las residencias de mayores, mucho más que una desinfección, https://www. defensa.gob.es/ume/noticias/2020/04/Noticias/covid19_06_abril.html (15.01.2021). Ministerio de Derechos Sociales y Agenda 2030(2020a): Informe del Grupo de Trabajo COVID 19 y Residencias, Madrid, https://www.mscbs. gob.es/ssi/imserso/docs/GTCOVID_19_RESIDENCIAS.pdf(15.01.2021). 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Rodríguez, Ángel; Jiménez, Antonio(2010): Potencial de creación de empleo y otros efectos económicos de la Ley de Promoción de la Autonomía Personal y Atención a las Personas en Situación de Dependencia, Fundación Alternativas, Documentos de Trabajo, 159. Sánchez Maldonado, José; Molina Garrido, Carmen; Rivas Sánchez, Carlos(2010): La Ley de Dependencia: especial consideración de los aspectos financieros, Fundación Democracia y Gobierno Local, Barcelona, http://repositorio.gobiernolocal.es/xmlui/bitstream/han�dle/10873/688/Sanchez_Maldonado_p_53_90.pdf?sequence=1 (02.01.2021). Sindicato Asambleario de Sanidad(2020): Trabajadores de residencias de ancianos denuncian despidos por exigir los equipos de protección adecuados, https://sasmadrid.org/index.php/noticias/ sanidad/1855-trabajadores-de-residencias-de-ancianos-denuncian-despidos-por-exigir-los-equipos-de-proteccion-adecuados-30-04-2020(02.01.2021). 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FRIEDRICH-EBERT-STIFTUNG – POLITICS FOR EUROPE 14 ACRONYMS AEDGSS BOE CCAES CCOO CGT CIG CSIC ECDC EU IASS IgG ILO IMSERSO INJUVE LAPAD OECD PCR PP PPE PWC RENAVE SAAD SEGG SESPA SISAAD SNS SUMMA UGT UME WHO Asociación Estatal de Directoras y Gerentes en Servicios Sociales(State Association of Directors and Managers in Social Services) Boletín Oficial del Estado(Official State Gazette) Centro de Coordinación de Alertas y Emergencias Sanitarias(Coordination Centre for Health Alerts and Emergencies) Comisiones Obreras(trade union) Confederación General del Trabajo(trade union) Confederación Intersindical Galega(trade union) Consejo Superior de Investigaciones Científicas(Spanish National Research Council) European Centre for Disease Prevention and Control European Union Instituto Aragonés de Servicios Sociales(Aragonese Institute of Social Services) Immunoglobulin G International Labour Organisation Instituto de Mayores y Servicios Sociales(Institute for Older Adults and Social Services) Instituto de la Juventud Ley de Promoción de la Autonomía Personal y Atención a las personas en situación de dependencia(Law for the Promotion of Personal Autonomy and Care for People in a Situation of Dependence) Organisation for Economic Cooperation and Development. Polymerase Chain Reaction Partido Popular(conservative political party) Personal Protective Equipment PriceWaterhouseCoopers Red Nacional de Vigilancia Epidemiológica(National Epidemiological Surveillance Network) Sistema para la Autonomía y Atención a la Dependencia(System for Autonomy and Care for Dependence) Sociedad Española de Geriatría y Gerontología(Spanish Society of Geriatrics and Gerontology) Servicio de Salud del Principado de Asturias(Asturias Health Service) Sistema de Información del Sistema para la Autonomía y Atención a la Dependencia(System for Autonomy and Care for Dependence Information System) Sistema Nacional de Salud(National Health System) Servicio de Urgencias Médicas de MAdrid(Madrid Emergency Medical Services) Unión General de Trabajadores(trade union) Unidad Militar de Emergencias(Military Emergencies Unit) World Health Organisation

Friedrich-Ebert-Stiftung The Friedrich-Ebert-Stiftung(FES) is the oldest political foundation in Germany with a rich tradition dating back to its foundation in 1925. Today, it remains loyal to the legacy of its namesake and campaigns for the core ideas and values of social democracy: freedom, justice and solidarity. It has a close connection to social democracy and free trade unions. FES promotes the advancement of social democracy, in particular by: – political educational work to strengthen civil society; – think tanks; – international cooperation with our international network of offices in more than 100 countries; – support for talented young people; – maintaining the collective memory of social democracy with archives, – libraries and more. IMPRINT © FES Nordic Countries 2021 Dr. Philipp Fink The views expressed in this publication are not necessarily those of the Friedrich-Ebert-Stiftung and the partner organisations for this publication. Commercial use of all media published by the Friedrich-EbertStiftung(FES) is not permitted without the written consent of the FES. Cover photo: Fredrik Sandin Carlson Design / Typesetting: pertext, Berlin| www.pertext.de

Covid-19 has uncovered many societal fault lines. The virus hit the elder care sector in many countries especially hard, leading to many deaths and pushing care workers fighting on the corona frontline to the end of their limits. The pandemic has underscored deficiencies in elder care that have been warned about and protested by trade unions for years. Precarious working conditions, understaffing and underfunding devastatingly undermined the ability to protect the most vulnerable during the corona pandemic: our elderly. It is high time we listen now. The Friedrich-Ebert-Stiftung has, on the initiative of the Swedish municipal workers’ union, Kommunal, and the Swedish progressive thinktank Arena Idé, commissioned reports from several European countries. By focusing on the plight of those in need of care and their caregivers, the reports shed light on the pandemic’s impact on elder care and highlights the justified demands of the care workers’ trade unions as well as the long overdue need for reform of the sector as a whole. Further information on the project can be found here: www.fes.de/en/on-the-corona-frontline