Introduction

The arrival of COVID-19 was a major shock to health systems globally, and had immediate and major effects on the Irish health system (Government of Ireland, 2020; WHO, 2020). COVID-19 highlighted pre-existing deficiencies and inequalities in the health care system and broader society and resulted in many agile health system responses (Burke et al, 2020; Department of Health, 2020a; Murray, 2020). The pandemic hit during the second year of implementation of a major Irish health reform programme, known as Sláintecare – a 10-year plan to deliver universal access to timely, integrated care (Houses of the Oireachtas Committee on the Future of Healthcare, 2017; Department of Health, 2018b; Department of Health, 2019).

As part of Ireland's whole-of-Government coordinated approach, the National Public Health Emergency Team (NPHET), and HSE National Crisis Management Teams for COVID-19 were convened and commenced their work at the end of January 2020 within days of confirmation of Europe's first cases (Department of Health, 2020b). NPHET was chaired by the Chief Medical Officer and advised by a Coronavirus Expert Advisory Group (CEAG) (Department of Health, 2020c). Its remit was to oversee and provide national direction, guidance, support, and expert advice on the development and implementation of a strategy to contain COVID-19 in Ireland (Department of Health, 2020c).

On 12 March 2020, the government announced immediate closure of schools, colleges and childcare facilities, cancelling of indoor mass gatherings of 100 people or more and outdoor mass gatherings of more than 500 people and a strong encouragement for people to work remotely (Department of the Taoiseach, 2020a; (Pierce, 2020; Nolan et al, 2021).

Introduction

Long-term care (LTC) for older people has been a traditionally underdeveloped social policy area in Spain, with national measures addressing situations of dependency and care needs in a somewhat fragmented way until the early 2000s. The creation of the System of Autonomy and Dependency Care (SAAD, by its Spanish acronym) in 2006 attempted to provide a coherent answer to increasing demands for dependency care. However, its practical implementation has been hindered by several structural problems: vertical and horizontal fragmentation across actors in the health and social service domains, weak coordination, precarious employment conditions, and shortages of professional caregivers. As highlighted in the following pages, the outbreak of the COVID-19 pandemic, which hit Spain early and severely, exacerbated these structural problems, (re-)opening a public and political debate on the weaknesses of the LTC system for older people in the country.

The chapter is structured as follows. The first section presents an overview of the country's evolution and key features of the LTC system. In contrast, the second section provides the key facts and figures concerning the evolution of the COVID-19 pandemic and its impact on the Spanish health and care sectors. The next section delves into the institutional and organisational measures adopted to prevent and minimise the impact of the health crisis on care homes for older people across the country.

Introduction

In French residential care homes,1 the epidemic evolved in the same way as it did in the general population, with a first wave from March to July 2020 and a second one starting in October/November 2020. In total, 224,500 care home residents were infected, with 29,300 deaths in 2020. The two waves in 2020 led to just under 15,000 deaths (Miron de l’Espinay & Richroch, 2021).

As for the general population, the studies available about the French case point to wide local disparities, with high impacts in some regions (the north, the Paris region, and the east) and lower impacts in others (the west). The pandemic was the cause of 2.5 per cent of deaths in residential care homes, but non-representative surveys, such as one carried out on 52 residential care homes all over the country, identified variations ranging from 2.3 per cent to almost half of the residents dying following contamination (Plateforme de Recherche sur la Fin de Vie, 2021).

On a national scale, during the second wave of the COVID-19 pandemic in the autumn of 2020, the incidence rate of the epidemic in residential care homes was about 1,600 residents per week for every 100,000 residents, compared to 500 people per 100,000 for the over-70s, and 450 for the general population (Miron de L’Espinay & Pinel, 2021). However, this gap began to shrink considerably in the spring of 2022 thanks to the vaccination campaign, which brought down the incidence rate to 200 for every 100,000 people in residential care homes, making it almost identical to the level for the over-70s, compared to 140 per 100,000 for the general population.

Introduction

In the spring of 2020, the COVID-19 pandemic shocked Swedish society and put unprecedented pressure on the Swedish health and long-term care (LTC) system for older people. The pandemic functioned as a stress test of how prepared, robust, resilient, and well-organised the Swedish welfare system was to confront a crisis of this magnitude. The handling of the pandemic seriously challenged the Swedish self-image as an efficient and well-organised welfare state.

During the very first phase of the pandemic, Sweden had similar ambitions and strategy as most other countries: slowing down the spread of the virus (flattening the curve) and protecting older people. However, it soon became clear that the Swedish COVID-19 strategy stood out among European countries and most of the world. Unlike most EU countries, Sweden did not respond with a general lockdown or harsh restrictions. Instead, the Swedish strategy was based on voluntary measures, emphasising individual responsibility to follow government recommendations. As a result, Sweden was considered an international outlier at this time, where the efforts to stop or slow the spread of infection were few, weak, and late.

The first months of the pandemic were in fact chaotic. The healthcare system was ill-prepared and had not yet reorganised and adapted to the situation, or developed routines and effective treatments for COVID-19. There was a severe shortage of personal protective equipment (PPE), hospital beds, and care personnel. The situation in the LTC and care homes was even worse: lack of PPE and insufficient knowledge of basic hygiene routines among care personnel.

Introduction

Luxembourg established in 1999 its system of long-term care (LTC) insurance when the law of 1998 came into effect (Grand-Duché de Luxembourg, 1998a), which recognised dependency as a new social security risk, similar to a disease, work accidents, and old age disability. Even though the care system implies home and residential care, the general preference is for home care.

Luxembourg is a small country with a population just a bit higher than 600,000 and 52 residences for the elderly; their system does not count multiple structures. Moreover, there are no regional authorities; apart from the national ones, there only exist ones at the municipal level. That is why evaluating COVID-19's impact, and political response is much easier than it would be in the case of a larger country.

The Luxembourg government started to evaluate the situation in China on 22 January 2020, and an inter-ministerial working group was installed 7 days later. The first two people showing symptoms were only tested 1 month later, on 24 February 2020, and 5 days later the first infected person tested positive.1 The first two deaths were noticed on 17 March 2020.

The impact until 31 May 2020 was 4,019 COVID-positive out of 78,265 people tested; 110 died, of which 59 were residing in residential care homes. The death toll reached the maximum of 110 on 26 May 2020, of which 62 were men and 48 were women. On 31 May 2020, 29 hospitalisations were counted, out of which three were in intensive care. On 4 April 2020, the hospitalisations peaked at 190, while the intensive care patients arrived at the maximum twice on 3 April 2020 and 15 April 2020 (35 in total).

Introduction

The coronavirus pandemic COVID-19 appeared and spread in Greece from 26 February 2020 onwards. Most cases in the early days were related to people who had travelled to Italy for business, and to a group of pilgrims who had visited Israel and Egypt and, subsequently, to their contacts.

Table 8.1 refers to the general population data as presented in the NHPO's official report of 31 May 2020. The highest level of mortality occurred in the over-65s and especially in men, who made up 51.4 per cent of COVID-19 deaths. In contrast, women over 65 appeared to be less diseased in the general population and over-65s, with the mortality rate almost half that of men, at 24.6 per cent.

From 27 February 2020, to 31 May 2020, confirmed cases and deaths due to COVID-19 were very low. Greece was among the countries with the lowest mortality rate due to COVID-19, with only 175 deaths despite the 2,915 confirmed cases (6 per cent of confirmed cases). Following the opening of the borders at the end of June, the daily number of confirmed cases reported included those detected following checks at the country's entry gates. In addition, a total of 3,562 recoveries had been announced by 26 July (Prouskas, 2020a).

In Greece, the overall COVID-19 death rate in the elderly care units was minimal, almost zero per cent for the semester of 2020 (February to July 2020). The Greek long-term care (LTC) sector exceeded expectations during the outbreak of the COVID-19 pandemic. The Greek elderly care units managed to work together and overcome obstacles and bureaucratic impediments.

Introduction

The first confirmed COVID-19 case in the Netherlands was reported on 27 February 2020. Two weeks later, the number of new cases had risen to around 200. It was decided not to conduct contact tracing anymore for all identified cases because the regional public health services could not handle the caseload. Over March, the number of new cases continued to rise, and so did the number of hospital admissions and deaths, a problem for the Netherlands, a country with a relatively small number of hospitals and, especially, intensive care beds. On 13 March, only 2 weeks after the first confirmed case, ‘code red’ was promulgated for hospitals in the (catholic) province of Noord-Brabant – where Carnival turned out to have been a super spreading event. All non-emergency surgeries were postponed, and the leaves of care workers were revoked. Many hospitals in other parts of the county took the same measures, preparing for a large influx of COVID-19 patients. In addition, many GPs contacted their older patients – either on their initiative or asked to do so by hospitals – to talk with them about whether they wanted to be treated in an ICU in case they contracted COVID-19.

Consequently, the public and political debate in the Netherlands and government policies throughout this first wave revolved around hospital capacity and, in particular, the capacity of ICUs. As a result, lockdowns were promulgated to avoid collapsing the healthcare system and the hospital sector.

By 15 June, the cumulative number of confirmed cases was nearly 50,000 (281 per 100,000 population); the cumulative number of hospital admissions was nearly 12,000 (68 per 100,000); and the cumulative number of deaths of confirmed COVID-19 patients was 6,000 (35 per 100,000).

Introduction

Despite the news and experiences from Italy and Austria, the COVID-19 pandemic surprised Germany. Especially during the first wave, which according to the Robert Koch Institute (RKI), lasted from January to mid-June 2020, the healthcare system faced immense challenges. The first confirmed infection with COVID-19 occurred on 28 January 2020, the first significant outbreak about 1 month after a carnival celebration. By mid-March the virus had spread to all 16 of Germany's federal states (Länder). By the end of the first wave of the pandemic in mid-June 2020, 190,816 cases of COVID-19 had been reported, of which 25,697 (13.5 per cent) occurred in institutions, as defined in section 33 of the Infection Protection Act (Infektionsschutzgesetz – IfSG). These include residential homes, shelters for the homeless, shared accommodation for asylum seekers, and youth detention centres.

As a result of many cases, there were shortages of protective masks and other personal protective equipment (PPE), as well as problems in adequately separating infected or ill persons and maintaining the ongoing provision of healthcare services. Policymakers responded with a wide variety of short-term measures to alleviate immediate pressures on the healthcare system, gain control of the epidemic and ensure adequate treatment. Actions taken at the federal level to relieve the stress on the outpatient sector, which was the first point of contact for suspected COVID-19 infections (KBV, 2020a), included the possibility of taking sick leave without seeing a GP in person and the funding of unlimited video consultation hours.

Introduction

Throughout the 20th century, dependency and the need for care traditionally constituted a neglected social risk by most European welfare states. In the Fordist society, the social division of care conceived the family as the leading actor in charge of caring for dependent family members. At the same time, state intervention was relegated to assistance measures for specific, limited circumstances, such as lack of family ties, poverty, or a very high degree of disability (Ranci & Pavolini, 2013). Entitlement to receive care ‘was framed implicitly as an entitlement to be cared for by a female family member. It certainly did not result in a social right’ (Saraceno, 2008: p 2).

During the last three decades, however, demographic and social transformations and economic considerations created a ‘problem pressure’ (Ferrera, 2005) no longer negligible for European welfare states. On the one hand, the share of older people steadily increased over the last decades (Eurostat, 2022). In 2021, people aged 65+ represented more than one-fifth (20.8 per cent) of the population in the EU, against 17.6 per cent in 2011. The old-age dependency ratio, which measures the relation between the population aged 65+ and the working-age population (15– 64 years), was 33.5 per cent in January 2021, compared to 26.4 per cent in 2011. According to the latest population projections, those aged 65+ will account for 31.3 per cent of the EU's population by 2100, and the old-age dependency ratio is projected to almost double, reaching 57.1 per cent in 2100.