The Government aims to move towards zero restraints, that is, that the elderly and dependent people who live in residences or attend day centers are not immobilized or sedated to reduce their agitation. This is stated in the latest working draft on the new requirements that will be demanded of dependency services, where the Ministry of Social Rights states that within a maximum period of three years after the entry into force of this text, which is still being negotiated , the centers have implemented a restraint-free care plan, which will contemplate their “total and safe elimination”.
They can only be used exceptionally, when there is no other alternative to a danger that must be imminent. Changes are also added to the document with respect to the previous draft, such as an increase in staff ratios in nursing homes, the limitation to a maximum of 50 places in those for disabled people (compared to 90 in those for the elderly) and it is proposed a period for the centers and services currently in operation to adapt to the new model: they will have seven years, with the exception of privately managed public resources, in which case they will wait until the end of the contract to implement the modifications.
A complex negotiation
The negotiation is complex and three bands. On the one hand, the text has been discussed with the social dialogue table, which has met this Friday and where employers and unions sit. On the other, with the civil dialogue, which brings together associations, family members of users and experts in the sector. And, lastly, with the autonomous communities, to which this latest draft will be delivered to start addressing it with them and that, being the competent ones in management, have the key for this agreement to go ahead. It is therefore likely that the text will undergo further modifications. The objective is that the final pact can be reached throughout this first quarter in the territorial council that brings together the regional governments and Social Rights.
The need for a new care model has been on the table for some time, and has been accentuated as a result of the pandemic, when the weaknesses of the system became evident. In fact, many autonomies have carried out regulatory changes in this line. The task of the Government is coordination, and this document will establish a common minimum in all dependency services provided in the country. The previous pact, from 2008, is much more concise. The document sets requirements for residences, day centers, home help and telecare.
Several sources consulted, familiar with the negotiation, have expressed their concern about the way in which these changes will be financed. The Association of Directors and Managers of Social Services, a member of the civil dialogue table, considers it essential that there be an analysis of costs and an economic report that guarantees that they can be implemented. It is the same idea that Cinta Pascual, president of the Ceaps dependency employers association, insists on. “We are in favor of a transformation, but we are very concerned about the financing,” she says.
There is no specific item planned for this framework agreement, but the state financing of the dependency has received an injection of 1,800 million euros between 2021 and 2022, the largest since the law was approved (there are also more than 3,000 million planned for care of long-term European funds, between 2021 and 2023). Part of this financing is linked to compliance with a shock plan that, among its measures, includes precisely the approval of this agreement on the minimum requirements that the services of the dependency system must meet.
The drafts that have transpired so far have always emphasized that those cared for in the dependency system have the right to receive “care free of restraints, whether physical, mechanical, chemical or pharmacological.” The exact number of people who are immobilized in these centers is unknown, but according to estimates by the confederation of associations for the elderly, CEOMA, it may be around 55,000. In recent weeks, the death of two elderly people when they were immobilized in residences has been known.
This last text establishes that the plans to eliminate the restraints of day centers and residences will have to be approved by the inspection services of the autonomous communities. They will only be admissible in “exceptional and urgently needed” situations in which there is an “imminent danger” for users or other people and after verifying the failure of other alternative measures, which must be documented. It is emphasized that informed consent will be necessary (it is already a requirement), which cannot be generic or deferred over time. It will be mandatory to inform the Prosecutor’s Office, which this January issued an instruction in which prosecutors are urged to increase control over these practices.
That the centers adapt to the person
The document proposes a paradigm shift: that it be the centers and services that adapt to people, and not the other way around. What is known as person-centered care, a concept with which some services already work, although the panorama is very disparate. According to the text, all users of the dependency system will have a personalized care plan, in which their preferences and needs are taken into account.
In residences for the elderly, the maximum size for the centers that are built after the agreement comes into force is set at 90 places, with 65% of individual rooms, and those already existing must be adapted within a period of seven years, dividing into units independent of each other and up to 35% of individual rooms. In disability residences the maximum limit will be 50 places. This was established in a first draft for all residences, but dependency employers complained that it would be unsustainable. There will be coexistence units for a maximum of 15 people that will have a home-type operation, where there will be a kitchen, dining room, living room and, preferably, access to an outdoor area, such as a terrace or garden. They must be located on urban land, promoting daily relations with the community.
Regarding the ratios, the ministry proposes, in the first place, that they be calculated by full working days, and not by the number of employees. Secondly, it speaks of first-level direct care personnel —assistants and geriatricians—, of second-level direct care —university graduates from the social and health branches— and of indirect care, which includes the rest of the staff.
At the beginning of February, the State Platform of Organizations of Relatives and Users of Residences showed its disappointment with the previous draft at the civil dialogue table, especially in terms of the ratios. They considered them insufficient and warned that, when calculating on the number of occupied places (although it can never be lowered from 80%) instead of the total number of places, it could happen that there were centers that in 2023, with the proposal that did for auxiliaries, they were required to have less staff than that established in the 2008 agreement. This latest draft raises that proposal.
The text proposes that the ratios escalate in 2023, 2025 and 2027: from 0.35 to 0.43 for geriatric workers and assistants in nursing homes (that is, 35 or 43 full days of first-level direct care staff for each 100 residents), a figure that for people with disabilities stands at 0.42 in 2023 —in the previous text, 0.50 was already foreseen in 2025—, and 0.50 in 2027.
That 0.43 would imply, for a unit in which 15 elderly people live together, that there would be five workers: two on the morning shift, two on the afternoon shift and one on the night shift. In global direct care, that is, also including university graduates such as social workers or nurses, it is planned to reach 0.51 in 2027 in nursing homes and 0.58 in people with disabilities.
Alejandro Gómez, a consultant who has studied the regional regulations —one of the agency’s employers’ associations, Ceaps, published his conclusions in a recent study— ensures that the draft represents an improvement in the ratios with respect to the state averages, although in his opinion they should differentiate by types of dependency, since in the future there will be users with more and more support needs. Relatives continue to consider the new proposal insufficient and ask to equate them to those of disability.
The document also requires at least one inspector for every 25 residences (regardless of whether they must also supervise day centers or other social services), instead of one for every 30, which was established in the previous text. The relatives had requested 1 for every 15. According to the data compiled last year by EL PAÍS, only three communities (Asturias, Catalonia and Extremadura) exceeded the threshold of 25 residences for each inspection service worker on average at that time. A technical working group will be set up which, within a year, will set common standards to measure the quality of services, the results of which must be made public. Currently there is nothing like it.
In the draft it is also proposed to include family members in the participation councils of residence users, whenever the residents deem it appropriate. Regarding home help, it is indicated that at least 5% of the assistants’ working day must be dedicated to coordination tasks and that the movement of workers will not count as care time, although it will as part of their working day. .
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