This blog is based on an article in Social Policy and Society by Margarita León, Marco Arlotti, David Palomera and Costanzo Ranci. Click here to access the article.
As institutions, nursing homes have been particularly vulnerable to covid-19. Although the official and comparative reporting is problematic, it’s estimated that nursing home residents have accounted for a large percentage of all covid-19-related deaths, particularly during the first wave of the pandemic (March-June 2020). Lombardy (Italy) and Madrid (Spain) represent two regions that were amongst the most severely affected by the pandemic during the first wave. Our empirical analysis shows that due to policy legacies, nursing homes in these two regions were trapped in a blind spot, being only marginally considered in the emergency action plans. Indeed, during the first wave of the covid-19 pandemic, the policy response in both regions was late and weak, especially when compared to actions taken within the National Health Systems. In our analysis, we distinguished four policy tools poorly implemented in both regions: lockdown, testing, resourcing, and discharging/hospitalization.
The delays in closure and the weak restrictions for access to nursing homes paved the way for the virus to spread in these institutions. During the first week of the pandemic, emergency protocols were promptly activated in hospitals. In Lombardy, visits to patients in hospitals were discontinued. Anyone with symptoms or that had come into contact with a covid-19 patient was tested and then monitored for 14 days. All confirmed covid-19 cases were hospitalised in isolation rooms. Healthcare staff working in hospitals and in contact with covid-19 patients were required to wear appropriate personal protective equipment (PPE). However, such emergency protocols were not immediately adopted in nursing homes. Restrictive rules about external visitors in nursing homes were only partially implemented at the discretion of managers. When a general lockdown of the country began, nursing homes were still allowed to admit a limited number of visits.
During the first week of the pandemic in Madrid, the regional government delivered a protocol on how to isolate infected users and ordered the closure of recreational centres for retired people if a cluster of covid-19 cases was detected, but not of nursing homes. However over the same week, the regional government changed its approach and restricted family visits to nursing homes. Complete isolation of nursing homes was not mandated until the end of the second week after the pandemic emerged, when the country already had 2,000 confirmed cases and 47 deaths, with around 50 per cent of these cases in the Madrid region.
Key interventions such as buying PPE, expanding bed capacity and distributing quick tests, which affected the reporting of cases, were delayed for weeks in both regions, compared with the same measures implemented in hospitals. Furthermore, nursing homes were not only left to deal with a dramatic crisis alone but were even wrongly considered a resource to reduce the pressure of covid-19 patients in hospitals (in Lombardy). In addition, they were denied support, with residents failing to be hospitalised due to the implementation of highly controversial criteria and triage systems.
How much of what happened can be explained? We argue that the association with policy legacy factors is a crucial explanatory dimension in this regard. We group these policy legacy factors into three main categories.
Firstly, we look at the relevance of nursing homes within the two national LTC systems, as shown by the reforms and policy innovations recently introduced or proposed in the field. Spain made significant policy innovations and financial investments in this field in 2006 through the LTC Act (Ley de Dependencia), which formally universalized access to care provision by recognising it as a right for accredited dependants. Conversely, Italy has been characterised by prolonged institutional inertia, with very limited policy reform over recent decades. In spite of different trajectories in LTC policy, nursing homes have been poorly embedded within both the Italian and Spanish welfare states, including a lack of national funding and a strong regulatory setting. Indeed, strong familialism led to a very residual supply of publicly funded (both home-based and residential) care services for frail elderly people. In the case of Spain, the priority on cash-for-care measures under the LTC Act left residential services in a permanently marginal position.
Secondly, we consider coverage rates and public funding in nursing homes compared to other EU countries. Also in this case, in spite of recent divergent institutional trajectories in LTC policies, Italy and Spain share a weak level of investment in nursing homes, as well as coverage rates at the lowest levels in Europe.
Finally, we consider governance aspects, including both regulatory and coordination capacities. The governance structure is characterised by high institutional fragmentation in both countries and a lack of coordination between social and health care services. This is a critical point for services, such as nursing homes, that need to provide both these services to their residents. Furthermore, the private sector clearly dominates service delivery, with an increasing role of profit-making agencies and extremely weak forms of public control and regulation.
To conclude, these policy legacy factors have cemented a structural residualism of nursing homes in both regions that severely hindered a swift response to a crisis of unprecedented magnitude. Consequently, the article implicitly signals clear directions for improvements in the nursing home sector. These include better financing and resourcing of nursing homes; better integration and coordination between the health and the care sector as well as between the central and regional governments; and a better regulated private sector that allows for an improved stirring and coordinating capacity of regional and central governments. Without such improvements, the nursing home sector will not only still be highly vulnerable to covid-19 and other future epidemic risks, but also continue to deliver both poor service quality and labour standards.
About the authors
Margarita León is Associate Professor at Universitat Autònoma Barcelona.
Marco Arlotti is Researcher at Politecnico di Milano.
David Palomera is a PhD Candidate at Universitat Autònoma Barcelona.
Costanzo Ranci is Professor of Economic Sociology at Politecnico
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