2007: Social support systems
Organisation and financing of social support to people with dementia and carers
Background information on the social/healthcare system in Spain
Juan Carlos I became the Head of State in 1975 following the death of the dictator Franco. In 1978, a new constitution was passed which led to the establishment of a Parliamentary Monarchy and a new territorial organisation of the State. 1978 also saw the creation of the National Health Institute and in 1986 health care financing was transformed from an insurance-based system to one that is mainly based on taxation. The National Health Service does not cover social and community care (Rico, et al. 2002).
The organisation of social support for people with dementia and carers
The Ministry of Employment and Social Affairs (M.T.A.S.) is responsible for social support to people with dementia/dependent elderly people. However, the actual organisation of social support is regulated by each autonomous community and its respective town councils. Services are generally provided by local authorities and the private sector (mostly non-profit organisations).
The State finances projects carried out by associations and NGOs. Unfortunately, support for Alzheimer associations is sometimes insufficient and irregular which means that projects sometimes have to be discontinued.
The health care and social welfare systems are independent. They are under the authority of different Ministries and have different sources of funding. There is no interaction between the two.
The overall funding of social support for people with dementia and carers
Home social services are financed jointly by the Ministry of Employment and Social Affairs, the regional ministries of Social Welfare and the town councils. Rico et al. (2002) estimated the percentage of financing for social care as being 20% central State funding (i.e. taxation), 30% regional funding and 20% local funding. In addition to government provided services, voluntary associations and non-profit associations such as the Red Cross also provide social home care services (Carrillo, 2005).
Home-based care services that are publicly provided or arranged are means tested. They are free for people who are on the minimum pension. People who have an income twice as high as the minimum pension must pay for the services whereas those on an intermediary income must pay a certain amount which is calculated on the basis of their income. In Catalonia, the overall family resources are taken into account when calculating how much the service user must contribute. In this community, the service user can sign an acknowledgement of debt in which he/she agrees to make a future payment as part of an inheritance (Comas-Herrera et al. 2003).
The legal framework surrounding the provision of social support
It is stated in the Constitution of 1978 that elderly people are entitled to social support:
Article 50: To citizens in old age, the public authorities shall guarantee economic sufficiency through adequate and periodically updated pensions. Likewise, and independently of the family obligations, they shall promote their welfare through a system of social services which shall take care of their specific problems of health, housing, culture, and leisure.
However, there is no actual law covering the provision of social services at state level. Each of the 17 communities has its own laws. For example, that the law for the Community of Madrid is: Law 11/2003 on Social Services of the Community of Madrid of 27 March. Decrees and regulations are determined by the autonomous communities and town councils. Consequently, citizens do not have a legally established right to social services.
A law reform is currently underway to promote the personal autonomy of dependent people i.e. Law 39/ 2006 of 14 December promoting the Personal Autonomy of Dependent People.
The suitability of social support for people with dementia and carers
Adequacy and accessibility in general
According to the Fundacíon Alzheimer España, social services and benefits are insufficient and do not respond to the specific needs of people with dementia.
People from ethnic minorities
There are no services specifically for people with dementia and their carers from ethnic minorities.
Services and support for people with dementia and their carers
Types of care
Day care centres exist but are insufficient. They are partly funded by the State and partly by service users. The provision of this service is means tested and can, in certain cases, cost about 25% of a person’s pension (Comas-Herrera et al. 2003). Volunteers and NGOs also provide day care services.
Respite care in the home as well as short-term and long-term residential respite care services exist but are insufficient. Services users have to contribute towards the cost. Volunteers and NGOs also provide respite care services.
Palliative care services in the home as well as in centres exist but are insufficient. Palliative care at home is part of the health care system and is completely financed by the State. The cost of palliative care in centres is either shared by the State and service users or completely covered by the State.
Monitoring in the home via alarm systems
Tele-assistance and tele-alarm services are offered in at least 10 of the autonomous communities (Imserso in Larizgoitia Jauregi, 2004). This is insufficient. The autonomous communities that do have such systems are sometimes partly subsidised by the State, but sometimes service users have to pay the full cost of the service.
Personal assistance and home help
The following services exist but are insufficient. They are all either partly or completely financed by service users. In certain cases, the State contributes towards the cost.
- Assistance with personal hygiene
- Supervision taking medication
- Assistance with mobility e.g. lifting, moving and walking
- Assistance with skin care e.g. hydration, preventing and dealing with bed sores
- Companionship and social activities
- Occupational therapy/ergotherapy
- Assistive devices
- Assistance dealing with incontinence
- Assistance with eating and drinking (not with the preparation of food)
- Home adaptation/transformation
The first two services are also provided by volunteers and NGOs. Those numbered 3 to 7 are also provided by NGOs. Home adaptation/transformation is extremely insufficient. However, in Andalusia, Castilla-Leon and Valencia, a service exists which consists of helping to adapt the home to the needs of a dependent person (Imserso in Larizgoitia Jauregi, 2004).
As with personal assistance, home help services exist but are insufficient. They are also either partly or completely financed by service users, with the State contributing towards costs in certain cases. The available services include the following:
- Assistance with housework
- Help with the preparation of meals (including meals-on-wheels)
- Assistance with shopping
The first three services are also provided by NGOs. A meals-on-wheels service is only available in the cities of Malaga and Cordoba (Andalusia) and in the city of Lerida (in Catalonia)( Imserso in Larizgoitia Jauregi, 2004).
Psychosocial support and training for people with dementia and carers
Psychosocial support and training for people with dementia A general information service covering access to services is available and is funded completely by the State. NGOs also provide general information services. Counselling, support groups and holiday services for people with dementia and carers exist. Such services for people with dementia are either partly or totally funded by the State, whereas those for carers are only partly funded by the State. NGOs also provide these services. Some NGOs provide training for carers which is either partly or totally funded by the State.
Work/tax related support for people with dementia
People with dementia in paid employment are entitled to an incapacity pension if they have to give up their job due to dementia. They are also entitled to tax refunds/benefits based on their incapacity. However, they are not entitled to tax refunds/incentives for employing a person to provide home care services, tax refunds/incentives for home adaptations or direct payments to purchase services. People with dementia benefit from reduced fares on public transport.
Work/tax related support for carers and carer allowances
Carers are entitled to paid and unpaid time off work for caring. Flexible working hours are not sufficiently used as a solution to help carers organise their caregiving tasks. They do not benefit from free or subsidised pension contributions from the State.
Carers are entitled to tax relief for caring for a person with dementia provided that they first obtain a certificate of disability (certificado de minusvalía) for the latter. According to Comas-Herrera (2003), this tax relief is quite small in absolute terms and is for heads of families who pay user charges for privately purchased care for an older person with dependency.
Unless otherwise stated, the information in this report was provided by Ms Ines Quiroga on behalf of the Fundación Alzheimer España in March 2007.
- Carrillo, E. (2005), WHHO International Compendium of Home Health Care: http://www.nahc.org/WHHO/WHHOcomptext.html
- Comas-Herrera, A. and Raphael Wittenberg, R. (Eds.) (2003), European Study of Long-Term Care Expenditure: Investigating the sensitivity of projections of future long-term care expenditure in Germany, Spain, Italy and the United Kingdom to changes in assumptions about demography, dependency, informal care, formal care and unit costs. Report to the European Commission, Employment and Social Affairs DG. PSSRU Discussion Paper 1840:
- Larizgoitia Jauregi, A. (2004), National Background Report for Spain, EUROFAMCARE: http://www.uke.uni-hamburg.de/extern/eurofamcare/documents/nabare_spain_rc1_a4.pdf
- Rico, A. et al. (2002), Health Care Systems in Transition, HIT summary for Spain, European Observatory on Health Care Systems, http://www.observatory.dk
- Spanish Constitution of 1978 (with amendments up to 27 August 1992): http://expired.oefre.unibe.ch/law/icl/sp00000_.html
Last Updated: Wednesday 15 July 2009