How To Make A Long Term Care Law Work In Spain

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1 September 2014 Analysis of the Care Home for the Elderly Market in Spain, France, Germany, UK and Sweden: Outlook for the Spanish Market Report 1

2 Index 01 Objectives Methodology Spanish care home market Regulatory Framework Regulations Funding Prices and Agreements Accreditation and Quality Demand Supply Private operators Findings

3 Index 04 French care home market Regulatory Framework Regulations Funding Accreditation and Quality Demand Supply Private operators Findings German care home market Regulatory Framework Regulations Funding

4 Index Accreditation and Quality Demand Supply Private operators Finding UK care home market Regulatory Framework Regulations Funding Accreditation and Quality Demand Supply Private operators

5 Index 6.5 Findings Swedish care home market Regulatory Framework Regulations Funding Accreditation and Quality Demand Supply Private operators Findings

6 01 Objectives 6

7 01 Objectives The aim of this report is to identify the main trends in the Spanish care home market, updating the 2006 study and comparing them with the situation in other European countries. This report was commissioned by the Association of Long-Term Care Service Companies (AESTE). It updates and extends a similar report published jointly by AESTE and in General objective: Identify the main trends in the Spanish care home market from a study of the current situation of the sector in Spain and in the consolidated European markets of France, Germany, UK and Sweden. Specific objectives: Draw conclusions regarding the development of the markets. Provide an individual presentation of the market in each of the countries studied in order to understand how each of them operates and how it has developed in recent years. Present a comparison of the five markets, highlighting their similarities and differences. 7

8 02 Methodology 8

9 02 Methodology The presentation of each of the care home markets is structured in four sections which describe the key issues which affect them Objective: Learn about the changes in the organisation, legislation, financing, licensing and accreditation of the care home service for older people. 1 2 Legal Framework Demand Objective: Identify the current and projected demands of the 65 and over and 80 and over population (on ageing). Objective: Identify the main private operators and their most relevant market characteristics. 4 3 Private operators Supply Objective: Identify the key figures in the care home supply for each market. 9

10 02 Methodology The material presented in this report is based on: 1. The review of official information sources for each of the countries analysed. 2. The review of available published studies, selecting the most rigorous sources. 3. Contact with experts from the sector in several of the countries analysed. 10

11 03 Spanish care home market 11

12 03 Spanish care home market Acronyms GSA: Administración General del Estado. (General State Administration) AC: Comunidades Autónomas. (Autonomous Communities) PRI: Indicador Público de Renta de Efectos Múltiples. (Public Revenue Index) PADCL: Ley de Autonomía Personal y Atención a la Dependencia. (Personal Autonomy and Dependent Care Law) GDP: Gross Domestic Product. SACD: Sistema para la Autonomía y Atención a la Dependencia. (System for Autonomy and Care for Dependency) HCS: Home Care Service. NMW: Salario Mínimo Interprofesional. (National Minimum Wage) NHS: National Health System. OECD: Organisation for Economic Co-operation and Development. WHO: World Health Organisation. 12

13 03 Spanish care home market Glossary of terms used in the Spanish care home market Users/ residents: Customers of care homes, i.e. the individuals who occupy care home beds. Operator/ developer: Companies and organisations which own care homes. Ownership of care homes and care home beds: In general, the ownership of care homes and care home beds is understood as public or private. In the case of some countries covered in this document, private ownership is divided into private (commercial) companies and non-profit bodies. Funding of care home beds: Who funds/pays for the bed. Based on the ownership of the bed and the funding, three types can be distinguished: Private beds: Beds in privately-owned homes which are privately funded (paid for by the resident). Public beds: Beds in publicly-owned homes which are funded by the public sector. Public contracted beds: Beds in privately-owned homes which are funded/paid for by the public sector through an agreement signed with the private supplier. The supplier therefore reserves the beds for the public authority and charges a fee for their use. Flat-rate contract: An agreement in which the price of a product, a service or pack of products/services is set in advance and fixed. 13

14 03 Spanish care home market 3.1 Regulatory framework Regulations 14

15 03 Spanish care home market 3.1 Regulatory Framework - Context The main change from the situation in 2006 in the Spanish regulatory framework is the development of the System for Autonomy and Care for Dependency (SACD) The care of the elderly in Spain is governed by: A universal, free healthcare system, the National Health Service, which limits copayment to pharmaceutical provision. Since 2007, a long-term care system (regulated by the 2006 Personal Autonomy and Dependent Care Law, PADCL) which for the first time recognises individual rights for care in situations of dependency. The implementation initially anticipated for the period up to 2015 has been substantially altered by the restrictions on public spending made over the last few years. The main changes that have taken place since 2006 are as a result of the serious crisis in funding that has been suffered since 2008: Cost control and introduction of new copayment in the healthcare system. Delay in the PADCL implementation plan and restriction of the funding. Additionally, the co-payment systems in social services are in the process of review and change, with regional approaches that tend to include assets in the assessment of economic status. In terms of the general policies of the Spanish state, of particular note are the publication of the White Paper on Health and Social Care Coordination in Spain (2011) and the adoption of the NHS Strategy for Addressing Chronicity (2012). It is still difficult to gauge the real impact of these two documents. 15

16 03 Spanish care home market 3.1 Regulatory Framework Regulations Law 39/2006 on Personal Autonomy and Dependent Care (PADCL) has meant a significant change in the regulatory landscape of social protection in Spain The prerequisites in order to benefit from the PADCL are: To have Spanish nationality. To have lived in Spain for at least five years prior to the application for assistance. To be declared dependent by one of the Autonomous Community bodies. The PADCL sets out three levels of dependency, according to the individual s degree of autonomy: Level I Moderate Dependency: when the individual needs help to perform several basic day-to-day activities at least once a day, or needs intermittent support. Level II High Dependency: when the individual needs help to perform several basic day-to-day activities, but does not require the continuous support of a caregiver. Level III Maximum Dependency: when the individual, owing to their total loss of physical, mental, intellectual or sensory autonomy, requires the indispensable and continuous support of another person. The services included in the PADCL are: Services for the prevention of dependency. Telecare Service Home Care Service. Daycare and Nightcare Centre Service. Care Home Service. 16

17 03 Spanish care home market 3.1 Regulatory Framework Regulations Following its implementation in 2007, the application of the PADCL has been limited for various reasons (1/2) Budget cuts, discrepancy between the State and the Autonomous Communities about who should take on the larger share of the cost of provision, the difficulties in organising a system that requires skilled professionals efficient and well-equipped structures as well as a private sector willing to work with the public organisation but which is increasingly subjected to partnership agreements at lower prices and a single price with no differentiation for higher quality service, have resulted in a slowdown in the Longterm Care Law. The above is reflected in a delay in the initial schedule planned for progressive application of the Longterm Care Law. Chart of effectiveness initially established in the Long-term Care Law Phase 1 During the first year of application of the PADCL (2007) Maximum dependency, levels 1 and 2 Phase 2 During the second year of application of the PADCL (2008) High dependency, level 2 Phase 3 Phase 4 Phase 5 Includes the third and fourth years of the application of the PADCL (2009 and 2010) Includes the fifth and sixth years of the application of the PADCL (2011 and 2012) Includes the seventh and eighth years of the application of the PADCL (2013 and 2014) High dependency, level 1 Moderate dependency, level 2 Moderate dependency, level 1 17

18 03 Spanish care home market 3.1 Regulatory Framework Regulations Following its implementation in 2007, the application of the PADCL has been limited for various reasons (2/2) This Schedule has been altered by the following reforms: Reform Details Impact on Long-term Care Law Law 2/2012, of 29 June, on Finance for 2012 The reforms of Royal Decree-Law 20/2012, of 13 July on Measures to guarantee budgetary stability and boost competition Law on Finance for Adopting measures aimed at budgetary stability and clearly focused on cost savings. For the duration of 2012, the State and the Autonomous Communities are not permitted to reach agreements to establish the degree of financing with regard to the intermediate-level provision of the System for Autonomy and Care for Dependency (SAAD). As a result, the State only contributes the amount relating to the guaranteed minimum level. Impacts on the adoption of measures to address the structural and implementation problems of PADCL, as well as the financial sustainability of the system, introducing regulatory and financial measures. The most prominent are: the Social Security treatment of family caregivers of dependent persons, the classification in degrees (the levels per grade disappearing), the establishment of a minimum intensity of provision to avoid differences between the Autonomous Communities and also common rules on compatibility of benefits; reducing the maximum levels of the financial assistance for care of a relative and the amount of the minimum level funded entirely by the State. 18

19 03 Spanish care home market 3.1 Regulatory Framework Regulations In addition, various changes to the VAT applicable to long-term care service providers have had an impact at three different levels Following the enforcement of RD 20/2012, on VAT for care homes for older people, daycare centres for older people, telecare and home care, the VAT is applied on three levels: VAT-exempt: When the service is provided by a public-law body or private establishments of a social nature (never a private company). 4%: When there is no exemption and the place is authority-contracted or is filled by the recipient of a service-linked benefit, provided that the assistance received from the authorities represents over 75% of the price. 10%: In all the other cases. In addition, the companies providing long-term care pay tax according to the type of customer: Public customer: they have service agreements at a set fee which includes 4% VAT. Private customer: 10% tax rate. The regulation of VAT in long-term care home services is a complex scenario that determines the amount to be paid based on the type of payer and not the service provided. It also differentiates between public and private funding. The reforms of Royal Decree-Law 20/2012, of 13 July on Measures to guarantee budgetary stability and boost competition 19

20 03 Spanish care home market 3.1 Regulatory framework Funding 20

21 03 Spanish care home market 3.1 Regulatory Framework Funding The funding of the Personal Autonomy and Dependent Care Law is carried out by three agents through four contribution mechanisms, the proportions of which are set out in the Law Funding General State Administration (GSA) Autonomous Communities (AC) Users Funding mechanism Minimum protection level The GSA funds the defined protection baseline, which is effective for every recipient recognised as a dependent person entitled to provision according to their level of dependency. Agreed protection level Funded through a State-AC partnership system to increase the minimum protection level set by the State. Additional protection level The AC define additional levels of protection to the minimum GSA baseline and the agreed State-AC level from their own budgets. Co-payment The beneficiaries of the long-term care benefits contribute to the funding, depending on the type and cost of the service and their personal financial situation. Contribution The percentage funding provided by the GSA is significantly below 50% of the cost of the care, especially for service provision. The AC contributions of the agreed level of protection must at least match those of the State. Finance Law 2/2012 suspended the contribution of the GSA to the agreed protection level. The same decision was adopted for Each AC freely decides to what the agreed protection level resources should be allocated. The user co-payment is established by each AC. 21

22 03 Spanish care home market 3.1 Regulatory Framework Funding However, although the individuals cared for by care home services have important healthcare needs, the health authorities do not contribute to the funding of the services Most common user diagnoses Description The most common main diagnosis in users of care homes (over 30% of cases) is dementia. The majority of cases are also diagnosed with other related illnesses. The healthcare costs in the care of these individuals are very high, and substantially increase the cost of the care. Alzheimer s 11.4% Senile dementia (simple or not complex) 10.5% Arteriosclerotic dementia 5.1% Essential hypertension 2.5% Fracture treatment convalescence 2.2% Parkinson's disease 2.1% For care homes, the total cost per resident and per day is significantly increased by these costs. If these individuals were not resident in a care home, these costs would be assumed by the healthcare system. Breakdown of costs in private care homes Management cost Operating cost Staff cost Staff cost Direct care cost Services cost Direct care cost Healthcare cost Social and dependency care cost Rehabilitation cost Description 100% 28% 72% 100% 73% 27% 100% 33% 65% 2% Source: 4th Cibad Conference. Spanish Long-Term Care Observatory. December 2013 Analysis of healthcare costs in care homes for the elderly. Fundación Edad y Vida. 22

23 03 Spanish care home market 3.1 Regulatory Framework Funding In 2013, the total cost of the System for Autonomy and Care for Dependency (SACD) was 6,363 million, declining for the first time since the implementation of the PADCL, by 3% from 2012 Changes to distribution of contributions to the cost of SACD, total and by payer ( ). Figures in millions of Euros GSA AC Co-payment TOTAL According to the source cited, the cost distribution by type of funding is: 60% AC 21% GSA 19% users The initial trend of increases stabilised in 2011 and in 2013 the cost decreased. A continual decline of the GSA contribution can be seen since 2010, with a marked increase in regional contributions until , when these started to decline. This decline contrasts with the steady increase in user contributions. Source: Report on the development and regional evaluation of PADCL. 12th Report from the Long-Term Care Observatory. January

24 03 Spanish care home market 3.1 Regulatory Framework Funding In addition to the budgetary limitations, as the total number of beneficiaries continues to increase, average public expenditure per user for long-term care has markedly declined since 2011 Average public expenditure per user/year ( ). Figures in Pubicexpenditureper user, , , , , , Average expenditure/user Other factors that can explain the reductions are: A 15% decline in the amount of the financial assistance for care in the family setting. Change in the mix of services provided: increase in home care vs. residential care. Source: Report on the development and regional evaluation of PADCL. 12th Report from the Long-Term Care Observatory. January 2014 Statistics from the SACD information system. Spanish Long-Term Care Observatory. July

25 03 Spanish care home market 3.1 Regulatory Framework Funding There are differences between the Autonomous Communities in public expenditure per dependent person, due to their different proactivity in policies to recognise of the rights and funding for protected individuals Differences between the AC in public expenditure per dependent person and the coverage of beneficiaries with provision (2012) Coverage (No. of beneficiaries of SACD provision/ /1000 inhabitants Castilla y León Cantabria La Rioja Andalusia Castilla La Mancha Murcia Catalonia Basque Country Extremadura Aragón Galicia Navarra Asturias Madrid Ceuta and Melilla Balearic Islands C. Valenciana Canary Islands Public expenditure per dependent person cared for, thousands of The coverage rates do not appear to relate to the differences determined by the ageing of the population. For instance, Galicia, one of the most ageing autonomous communities, has a lower coverage, and Andalusia, which has a younger population, has a high rate. This information appears to show how the different communities are being affected by the established policies and priorities. The redistribution function that the system should carry out does not appear to be working very well. Source: Report on the development and regional evaluation of PADCL. Annex to the 11 th Report from the Long-Term Care Observatory. January Information from the SACD at Spanish Long-Term Care Observatory. Julio

26 26 03 Spanish care home market 3.1 Regulatory Framework Funding In line with the above, public expenditure per inhabitant in the long-term care system also varies between autonomous communities, and more so if variables such as disability-free life expectancy at 65 are considered Average annual public expenditure per inhabitant vs. Disability-free life expectancy ,6 162,1 153,4 25,0 Average annual public expenditure per inhabitant, 160 5,3 140,6 148,6 135, ,1 5,5 4,6 4,6 20,0 113,7 5,4 6,5 5, ,7 4,1 4,6 4,7 4,9 100,5 5,9 101,9 5,9 108,4 5,9 5,0 97,9 93,9 5, ,2 89,5 88,6 15, ,1 59,7 10, ,9 40 5, ,5 16,5 15,4 15,4 12,7 15,5 14,2 14,0 13,5 15,4 14,3 15,4 15,9 14,4 15,5 14,9 15,2 13,0 0 0,0 Spain La Rioja Basque Country Navarra (Comunidad Foral de) Murcia (Región de) Madrid (Comunidad de) Galicia Extremadura Comunidad Valenciana Catalonia Castilla La Mancha Castilla y León Cantabria Canary Islands Balearic Islands Asturias (Principado de) Aragón Andalusia Life expectancy with and without disability at 65 Disability-free life expectancy at 65 Life expectancy with disability at 65 Average annual public expenditure per inhabitant Source: Report on the development and regional evaluation of PADCL. 12th Report from the Long-Term Care Observatory. January 2014 Envejecimiento en red, Are we changing mortality for disability? August 2013.

27 03 Spanish care home market 3.1 Regulatory Framework Funding Lastly, co-payments by users (the third funder of the services) have rapidly increased over the last few years Average annual user co-payment ( ). Figures in Co-paymentper user, 2.000, , ,00 500,00 0,00 835, , , , , Average co-payment/user The user contribution or co-payment is determined by each autonomous community. Therefore, it varies greatly due to: Different criteria for calculating the beneficiary s financial capability: income, assets, earnings, etc. Different methods for calculating exclusion on the basis of low income: national minimum wage, Public Revenue Index and others. Different methods for calculating the maximum co-payment limit. Source: Report on the development and regional evaluation of PADCL. 12th Report from the Long-Term Care Observatory. January 2014 Statistics from the SACD information system. 27

28 03 Spanish care home market 3.1 Regulatory Framework Funding The cost of the System for Autonomy and Care for Dependency was forecast at 1% of GDP at the time of creation. However this may underestimate the projected needs. In 2011 Spain allocated 0.7% of GDP to long-term care. This is less than half the OECD average public expenditure on long-term care (the OECD average is 1.6% of GDP). According to an OECD report, public expenditure on long-term care in Spain, as a percentage of GDP, will triple and could even grow to six times the current expenditure by Monthlyincome of beneficiary Comparison of the expenditure on long-term care in the OECD and Spain, differentiating the health and social components. Long-term care expenditure as a % of GDP (health component) Long-term care expenditure as a % of GDP (social component) OECD (average for countries) 1,0 0,7 SPAIN 0,6 0,1 Source: Long-term care public expenditure (health and social components), as share of GDP. OECD, October

29 03 Spanish care home market 3.1 Regulatory framework Prices and Agreements 29

30 03 Spanish care home market 3.1 Regulatory Framework Prices and Agreements The public authorities have three main formulas for contracting services from private operators Formula Description Duration Renewal Agreements for beds Agreement signed between the AC and the authorised provider, establishing as a general framework the availability of a number of beds (a % of the total) for the chosen users and a public fee for those beds. The public fee is updated on an annual basis. Varies according to the AC, generally from 4-5 years to years. These agreements are generally renewed. An agreement can be questioned if there are serious quality or administrative problems. Service agreements (service voucher, residential care) Some AC contract services without a set number of beds, and finance those residents who choose that home. In some cases this system includes a public contribution towards the construction of the care home. It is known as a care home voucher or cheque ( bonoresidencia or cheque residencia ). Variable, when it includes construction the agreements tend to be for long periods (20-30 years). If there is demand, the agreements are generally renewed. Management concessions Private management of public institutions engaged in care services years or shorter periods. The renewal is open to all suppliers. However, the number of care institutions in this system is very limited. 30

31 03 Spanish care home market 3.1 Regulatory Framework Prices and Agreements As the fees for contracting care home beds are set by each AC, the fees vary significantly between the regions Average authority contract price per nursing bed/day, Average fees paid by the Autonomous Communities to the care homes under agreements, per nursing bed and per day. Excluding VAT figures. ( ) 77,3 Basque Country 63,9 60,4 57,3 57,0 55,0 Balearic Islands Navarra La Rioja Catalonia Madrid 49,6 49,6 48,9 48,8 48,8 47,5 45,2 43,4 42,7 Galicia Based on 2014 figures, large differences can be seen in the amounts paid by the various AC to the service providers. There is a difference of 34.6/ day between the communities that pay the most and the least. These differences can be even greater, depending on the three VAT rates that are applied, according to whether the payment is made by a public authority (4%), a non-profit social body (exempt) or a private individual (10%) -see page 19- Andalusia Extremadura Aragón Cantabria Murcia Valencia Asturias Castilla La Mancha Source: Information provided by AESTE. 31

32 03 Spanish care home market 3.1 Regulatory framework Accreditation and Quality 32

33 03 Spanish care home market 3.1 Regulatory Framework Accreditation and Quality The development of the SACD implies the formulation of stable conditions in the accreditation of the services that form part of the system Following the approval by the Territorial Council, in November 2008, of the Resolution on common criteria for accreditation to guarantee the quality of the homes and services of the SACD, the Autonomous Communities are responsible for accrediting the homes, services and bodies. It is the AC who have the obligation to ensure the quality requirements and standards are fulfilled. They also establish the legal regime and the operating conditions of the public-contracted private homes. In addition, they accredit the non-public contracted private care homes and services which provide longterm care services to older people. Currently, the regulations published by the AC very often mix accreditation with other processes such as the inspection or authorisation of homes. It should be stressed that accreditation is a process with a particular aim that is different from the inspection or authorisation processes. Authorisation: Public Authorities act in which it is determined whether a care home satisfies the necessary conditions to ensure adequate care for users. In most AC it includes requirements such as the authorisation by the Social Services Authorities, municipal permit, registration in the Social Services Authorities and a prior inspection visa. Accreditation: Act in which the Public Authorities guarantee that the social services and homes to whom the accreditation is granted meet the requirements of the regulations and also meet the quality parameters required by the Public Authorities to establish agreements with organisations who provide these services. Source: Model of accreditation for care services for older people in a situation of dependency. Fundación Edad & Vida, March

34 03 Spanish care home market 3.1 Regulatory Framework Accreditation and Quality The Autonomous Communities are developing regulations in this sector that will require the movement to certain quality standards (1/2) 1. Note that not all the AC have specific regulation for the accreditation of care home and daycare centres for older people. According to the study published by the Fundación Edad y Vida in 2012: Asturias and Cantabria have approved new regulation subsequent to the Territorial Council Resolution of Andalusia, Catalonia and Castilla-La Mancha have specific legislation on the accreditation of social service centres (Andalusia also has specific legislation for care homes). In the case of Castilla la Mancha, this pre-dates the implementation of the PADCL. Aragón and Extremadura, although they have not regulated the accreditation of centres, have functional, material, structural and staffing ratio prerequisites in order to enter into agreements with the Authorities for public-funded places. Castilla León, Galicia and la Rioja deal with accreditation within the regulation for authorisation, inspection and/or disciplining of care homes. The ACs of Valencia, Balearic Islands, Canary Islands, Madrid, Murcia and Navarra do not have any form of regulation for the accreditation of centres. Source: Model of accreditation for care services for older people in a situation of dependency. Fundación Edad & Vida, March

35 03 Spanish care home market 3.1 Regulatory Framework Accreditation and Quality The Autonomous Communities are developing regulations in this sector that will require the movement to certain quality standards (2/2) In the Basque Country, the Provincial Councils are responsible for social services. Guipúzcoa Provincial Council has regulated the conditions required for authority contracts for care home services for older people. 2. There are differences between in the AC in terms of levels of legislation. These include orders, decrees and resolutions. 3. There are important differences in the years of development of the regulation. Some AC have subsequently developed and approved a new social services law that establishes the need to promote the accreditation of homes and services. At the present time, only six AC have published specific regulations for accreditation of care home services, and in more than one it is very out-of-date. 4. The results of the care home evaluations are never published as is the case in Germany or the UK, for instance. 5. Currently in Spain, in the majority of AC, there is no differentiation in the access of suppliers to the provision of a high dependency service. Nor is a greater funding or a higher fee granted to providers who offer a higher-quality service and can meet the health and social accreditation standards that are indispensable for high dependency care. Source: Model of accreditation for care services for older people in a situation of dependency. Fundación Edad & Vida, March

36 03 Spanish care home market 3.2 Demand 36

37 03 Spanish care home market 3.2 Demand In 2013, the 65 and over population in Spain amounted to 17.7% of the total population, an increase of 13.2% over 2006 The over 65 elderly population ( ) % of populationover65 19,0 18,7 18,3 18,4 18,1 17,8 17,9 17,6 17,7 17,4 17,1 16,8 16,6 16,5 16,6 16, In 2013 Spain had a total population of 46.7 million, of which: 8.26 million were over 65, which was 17.7% of the total population, just below the European average (16 countries) of 19%. In 2013, life expectancy at birth according to the National Institute of Statistics was 79.3 years old for men and 85.2 years for women. Spain Euro area (16 countries) Source: Eurostat. National Institute of Statistics. Projections for life expectancy at birth:

38 03 Spanish care home market 3.2 Demand The 80 and over population was 5.5% of the total population and 31% of the over 65s, an increase of almost 26% over 2006 The over 80 elderly population ( ) In 2013, 2.57 million inhabitants were over 80. % of populationover80 6,0 5,0 4,0 3,0 2,0 1,0 4,4 4,6 4,7 4,3 4,4 4,5 4,9 5,0 4,7 4,9 5,2 5,3 5,1 5,3 5,5 5,5 31% of the over 65 population were over 80. In 2013, the percentage of older people over 80 is in line with the average for the Euro area of 16 countries. Taking into account the proportion of the older people of the total population, Spain is one of the countries with the most adults over 80 in Europe. 0, Spain Euro area (16 countries) Source: Eurostat. European Comission. People by age group

39 03 Spanish care home market 3.2 Demand The years of life in good health at 65 in Spain are 9.2 for men and 9 for women Years of life in good health at 65, European countries, ,0 Men Women Source: European Health and Life Expectancy Information System (EHLEIS); Eurostat Statistics Database ,5 3,1 5,9 5,1 7,8 7,2 10,9 11,9 10,7 11,1 10,6 10,5 10, ,1 9,5 10,4 9,2 8,9 9,5 8,6 8,4 8,5 8,4 9 8,3 8,9 7,7 8,2 7,4 7,8 7,3 6,9 6,7 6,9 6,4 6,4 5,6 6,1 5,4 5,5 7, ,6 14,2 12,9 15,4 15,9 15,4 15,0 10,0 5,0 Descripción 0,0 Norway Sweden Switzerland Ireland Belgium Denmark UK Netherlands France Spain Austria Greece Europe Finland Czech Republic Italy Croatia Poland Slovenia Germany Hungary Romania Lithuania Estonia Slovakia

40 03 Spanish care home market 3.2 Demand Spain is facing a constant increase in the number of older people. In 2013 there were 8.26 million, and the number is expected to increase to 9.72 million in 2023 Projection of the 65 and over elderly population ( ) Population 65 and over, millions of inhabitants ,26 8,43 8,56 8,68 8,79 8,93 9,07 9,21 9,36 9,52 9, According to the projections, the average annual increase in the elderly population in the period will be 1.64%. In addition, the life expectancy at 65 will increase to 20.2 for men and 24.1 for women in Source: Population: National Institute of Statistics. Population Figures and Demographic Censuses. Short-term population projections. Last data published: series (21 November 2013). National Institute of Statistics Base. Short-term Projection of Population in Spain Press releases. 22 November

41 03 Spanish care home market 3.3 Supply 41

42 03 Spanish care home market 3.3 Supply By 2013 the supply of care home beds had increased by 29.13% over However, between 2012 and 2013 it fell by 0.6% Numberof carehome beds Number of care home beds( ) Plazas Private Privadas beds Plazas Publicpúblicas beds Sin No datos data Total plazas beds Between 2006 and 2012 there was an annual increase in the number of beds of almost 4.5%. In 2013 the figures showed a drop of 0.6% (figures still provisional). In 2013, the supply of private beds represented 72.5% of the total care home bed supply, whereas the public supply was 26.8% (no information is available regarding the ownership of the remaining 0.7% of beds). Source: Envejecimiento en red. Online reports: Statistics on care homes

43 03 Spanish care home market 3.3 Supply Catalonia, Madrid, Castilla y León and Andalusia have the greatest number of beds, 53.5% of the total number of beds for 51% of the over 65 elderly population Breakdown of care home beds by AC vs Elderly population over 65 (2013) Nº No. de of plazas care home residenciales beds Población Population de and y over más años Population 65 years old and over Numberof carehome beds 0 0 Ceuta Melilla Rioja (La) Cantabria Murcia (Región de) Balears (Illes) Navarra (C. Foral de) Canarias Asturias Extremadura Aragón País Vasco Galicia Castilla-La Mancha Comunidad Valenciana Andalucía Castilla y León Madrid (Comunidad de) Cataluña AC with under 10,000 beds AC with 10,000-20,000 beds AC with 20,000-40,000 beds AC with over 40,000 beds Percentage of the total no. of beds 42.55% 26.16% 22.10% 9.20% Source: Envejecimiento en red. Online reports: Statistics on care homes

44 03 Spanish care home market 3.3 Supply The care home bed coverage varies significantly between the various Autonomous Communities Care home bed coverage rate by AC (2013) Carehome bedratio per 100 elderly 65 and over 8% 7% 6% 5% 4% 3% 2% 1% 0% 7,20% 7,08% 6,56% 5,62% 5,40% Castilla y León Castilla-La Mancha Aragón Extremadura Navarra (C. Foral de) 5,07% 4,73% 4,53% 4,50% 4,22% 4,20% 4,12% 3,91% Rioja (La) Madrid (Comunidad de) Asturias Cataluña España Cantabria País Vasco Melilla 3,30% 2,96% 2,92% 2,87% 2,42% 2,27% 2,08% Balears (Illes) Comunidad Valenciana Andalucía Galicia Canarias Murcia (Región de) Ceuta The coverage rate has increased since 2006: 4.22 care home beds/ 100 elderly over 65. However, this indicator is still under the target of 5 care home beds/ 100 elderly over 65, which is regarded as the ideal coverage. There continue to be differences between Autonomous Communities: Castilla y León, Castilla la Mancha and Aragón are at the top with rates above 6 beds/ 100 elderly over 65. The Canary Islands, Murcia and Ceuta have coverage rates below 2.5 beds per 100 elderly over 65. Source: Envejecimiento en red. Online reports: Statistics on care homes

45 03 Spanish care home market 3.3 Supply The average coverage rate for private beds is 3.06 beds per 100 elderly over 65, showing large differences between Autonomous Communities Private care home bed coverage rate by AC (2013) Privatecarehome bedratio per 100 elderly65 and over 6% 5% 4% 3% 2% 1% 0% 5,30% Castilla y León 4,55% 4,11% 3,69% 3,60% 3,58% 3,55% Castilla-La Mancha Aragón Navarra (C. Foral de) Madrid (Comunidad de) Cataluña Cantabria 3,31% 3,19% 3,06% 2,69% 2,64% 2,36% 2,23% 2,22% Rioja (La) Asturias España País Vasco Extremadura Comunidad Valenciana Galicia Andalucía 1,85% 1,78% 1,47% 1,36% 1,31% Murcia (Región de) Balears (Illes) Ceuta Melilla Canarias In comparison with 2006 figures (2.63 private beds/ 100 elderly over 65), in 2013 the private care home bed coverage rate had increased by 0.43 private beds/100 elderly over 65. Only three Autonomous Communities, Castilla y León, Castilla La Mancha and Aragón, have coverage rates above four private beds per 100 elderly over 65. Murcia, the Balearic Islands, Ceuta, Melilla and the Canary Islands have coverage rates below 2 private beds/100 elderly over 65. Source: Envejecimiento en red. Online reports: Statistics on care homes

46 03 Spanish care home market 3.3 Supply The average coverage rate for public beds is 1.13 beds per 100 elderly over 65. There is a difference of 2.57 beds between the AC with the highest and lowest rates Public care home bed ratio per 100 elderly 65 and over 4% 3% 3% 2% 2% 1% 1% 0% 2,99% Extremadura Public care home bed coverage rate by AC (2013) 2,54% 2,53% 2,20% 1,89% 1,76% 1,71% 1,44% 1,40% 1,34% 1,13% 1,09% 0,96% 0,91% 0,69% 0,64% 0,61% 0,60% 0,56% 0,42% Melilla Castilla-La Mancha Aragón Castilla y León Rioja (La) Navarra (C. Foral de) Balears (Illes) País Vasco In comparison with 2006 figures (1.01 public beds/ 100 elderly over 65), in 2013 the public care home bed coverage rate had increased by 0.12 public beds for every 100 elderly over 65. Only four Autonomous Communities, Extremadura, Melilla, Castilla La Mancha and Aragón, have coverage rates above 2 public beds for every 100 elderly over 65., whereas there are eight AC that have coverage rates of under 1 public bed/100 elderly over 65. Source: Envejecimiento en red. Online reports: Statistics on care homes Asturias España Madrid (Comunidad de) Canarias Cataluña Andalucía Galicia Ceuta Comunidad Valenciana Cantabria Murcia (Región de) 46

47 03 Spanish care home market 3.3 Supply The number of private care homes has grown by 7.4% since In the last couple of years, the sector s growth has slowed down Ownership of care homes ( ) Numberof carehomesbytype of ownership No data Public Private Total Between 2007 and 2010 the number of private care homes experienced an annual increase of 2.2%, whereas between 2010 and 2012 this increase was only close to 1%. These figure should be considered bearing in mind the time it takes to open a home from the time when the decision is taken to invest until it is operative, which is never less than two years. Source: Envejecimiento en red. Online reports: Statistics on care homes Alimarket, Openings 2012: The trend to a decrease continues. February

48 03 Spanish care home market 3.3 Supply The Spanish care home market continues to be fragmented: over 50% of care homes have less than 50 beds although they represent only 20.51% of the total care home bed supply Percentage distribution of homes according to their size 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Size of care homes ( ) 16,44% 17,92% 18,92% 20,21% 20,02% 20,81% 21,24% 21,67% 23,09% 23,80% 24,55% 24,58% 24,27% 24,91% 26,02% 27,00% 28,07% 28,31% 27,31% 27,24% 27,34% 27,47% 27,21% 27,23% 32,40% 29,96% 29,21% 27,96% 28,36% 26,81% 25,53% 24,11% Breakdown of care homes and beds by size of care home, 2013 Breakdown of care homes and beds accordingto thesizeof thecarehome 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 21,67% 27,00% 27,23% 24,11% Distribution of care homes by size 50,90% 28,59% 14,68% 5,83% % of beds by size of home < 25 beds >100 The distribution of care homes by size has changed only slightly, however in the last two years there has been an increase in the proportion of care homes with over 50 beds. Half of Spain s care home bed provision is concentrated in 21.67% of care homes, which are also homes that have over 100 beds. Only 20.51% of beds are in care homes with less than 50 beds. Source: Envejecimiento en red. Online reports: Statistics on care homes < 25 beds >100 48

49 03 Spanish care home market 3.3 Supply In spite of the low coverage, according to some sources, the occupancy of beds in the existing care homes is not high and there are large differences between Autonomous Communities Level of occupancy of the care homes, % 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 10,3 89,7 Catalonia 17,3 82,7 Navarra 20,1 79,9 Madrid 20,3 79,7 Galicia Level of occupancy of care homes for the elderly by AC, ,8 79,2 Rioja (La) 21,4 78,6 Asturias 21,5 78,5 SPAIN 22,6 77,4 Andalusia 22,8 77,2 Basque Country Ocupadas Occupied According to a study published in 2013 by the website Envejecimiento [en-red], One of every five care home beds is empty, and the average occupancy of care homes is under 80%. Additionally, the report points to significant differences in occupancy: 60% in the Balearics and, at the other end of the spectrum, 90% in Catalonia. This appears to link to the differences in funding we saw earlier, as the AC with lower coverage rates and expenditure per inhabitant have the lower occupancy. Source: Abellán A. One of every five care home beds is vacant. In: Envejecimiento en red. In:: 23,0 77,0 Cantabria Vacantes 24,1 75,9 Castilla-La Mancha 24,3 75,7 Extremadura 24,6 75,4 Castilla y León 25,0 75,0 C. Valenciana 25,4 74,6 Murcia 26,9 73,1 Aragón 33,9 66,1 Canary Islands 40,9 59,1 Balearic Islands 49

50 03 Spanish care home market 3.4 Private operators 50

51 03 Spanish care home market 3.4 Private operators The big operating groups continue to seek alternatives to expand their business activity and their turnover Development of the aged care sector (*), ( ). Net turnover(m ) , , , , Facturación Net turnover neta (M ) (M ) Workforce, no. of staff Plantilla Workforce (*) Includes the evaluation of the top 217 groups and companies in the aged care sector. The search for new options to increase business activity, whether through acquisitions of care homes, developing new ranges of services or reducing margins in public tenders, has enabled the 217 operators evaluated by SANImarket to achieve a combined growth of 7.2% in their turnover, reaching 3,268 M, and also facilitated the growth of their workforce. Source: SANImarket magazine. No. 35 November-December

52 03 Spanish care home market 3.4 Private operators The turnover of the top ten operators has grown by 15.23% to reach a total of 1, M, 40% of the turnover of the 217 groups included in the SANImarket study Principal carehome groupsbyturnoverin 2012 Source: SANImarket magazine. No. 35 November-December Revenue(M ) Group Headquarters No. staff 1 CLECE, S.A. - DIVISIÓN SOCIAL MAYORES San Sebastián de los Reyes (M) 300 (2) 248, SARquavitae Barcelona 280,00 205, EULEN SERVICIOS SOCIOSANITARIOS, S.A. Madrid 170,31 169, INTERCENTROS BALLESOL, S.A. (GRUPO BALLESOL) Madrid 114,45 113, SANITAS RESIDENCIAL, S.L. Barcelona 106,80 104, AMMA GEROGESTIÓN, S.L. - GRUPO Madrid 89,00 86, GERIATROS, S.A. - GRUPO Vigo (PO) 66,70 56, GRUPO SANYRES Córdoba 54,83 53, SUARA COOPERATIVA Barcelona 51,27 47, ORPEA IBÉRICA, S.A. - GRUPO Madrid 50,40 30, CASER RESIDENCIAL, S.A. Madrid 58,00 46, GRUP MUTUAM Barcelona 45,85 48, CLAROS S.C.A. DE INTERÉS SOCIAL Sevilla 45,00 44, CENTROS RESIDENCIALES SAVIA, S.L. Valencia 40,53 40, VITALIA PLUS, S.A. - GRUPO VITALIA HOME Zaragoza 39,70 37, (2) Only includes revenue from services for older people 52

53 03 Spanish care home market 3.4 Private operators The top five developers and operators had almost 12% of the total supply of private care home beds in 2013 Main care home groups by number of operative beds (*) Does not include religious institutions or congregations. (1) Includes sheltered accommodation (2) Includes beds in sheltered accommodation Position Company No. of No. of % beds/ total Planned care Beds /care Turnover Planned beds private new care homes home 2012(M ) new beds (2) commercial beds homes (1) 1 SARquavitae ,20% INTERCENTROS BALLESOL, S.A. (GRUPO 2 BALLESOL ,70% ASOC. EDAD DORADA-MENSAJEROS DE LA PAZ ,12% SANITAS RESIDENCIAL, S.L ,98% , AMMA GEROGESTIÓN, S.L. - GRUPO ,73% Subtotal ,73% GERIATROS, S.A. - GRUPO ,61% , CLECE, S.A. - DIVISIÓN SOCIAL MAYORES ,57% GRUPO SANYRES ,38% ,83 9 VITALIA PLUS, S.A. - GRUPO VITALIA HOME ,21% , FUNDACIÓN SAN ROSENDO ,18% CASER RESIDENCIAL, S.A ,03% CENTROS RESIDENCIALES SAVIA, S.L ,02% ,53 13 ORPEA IBÉRICA, S.A. - GRUPO ,00% ,40 14 CÁRITAS ESPAÑOLA ,85% GRUPO LOS NOGALES ,81% Subtotal ,66% Total private supply Source: SANImarket magazine. No. 35 November-December

54 03 Spanish care home market 3.4 Private operators The financial situation and cuts in spending in the social sector have resulted in an ever increasing reduction in the numbers of openings of new care homes for older people In 2012, according to a SANImarket study, a total of 57 care homes, including two complexes with housing and services, represented 87.7% of the total openings of the year, and 4,535 new beds (80.8% of the new beds). The difficulties of access to credit and cuts in the public authorities budgets have significantly limited the authority agreements to contract beds in private and municipal care homes, which has been the main cause of the lack of growth in the sector. More than a few private and public projects, which in 2012 were completed and awaiting opening, did not go ahead in light of the uncertainty as to whether they would receive public residents. The most recent limitations on support for long-term care approved in the General State Budget for 2013 have not helped to improve the situation. The main groups are opting more for the management of already open public or private care homes than for new projects whose viability is uncertain. Source: SANImarket magazine. No. 35 November-December Alimarket, Openings 2012: The Downward Trend Continues. February

55 03 Spanish care home market 3.4 Private operators Some recent developments in the major care groups for the elderly in 2013 Operator Recent developments Clece Inclusion of new care homes in the network, such as its entry into Aragón through the award of the care homes in Villanueva de Gállego (Zaragoza) and Tardienta (Huesca). The group has also been awarded municipal projects that are still under construction in Villaornate y Castro (León), Almáchar (Málaga) and Dueñas (Palencia). Inclusion of new home care contracts with the Madrid and Seville City Councils. Inclusion of telecare in their range of services as of April 2013, starting two service contracts with the Valladolid and Ourense Councils. EULEN Searching for new contracts, both to include more homes in the network (for example in October 2013, it took over the Care Centre for Individuals with Alzheimer s and other Dementias in Salamanca) and extending its presence in the areas of telecare and home care (for the latter, the group has been awarded one of the Madrid City Council s home care contract packages). Commitment to increasing investment in the international expansion process in Latin America, driven by the economic and social growth of these countries, and the growing demand for the type of services offered by the Group. SARquavitae New care home additions have positioned the group as the leader by number of beds: 8,155 located in 51 care homes and 5 housing complexes. In addition to these, the new homes in Cádiz (120 beds and 30 daycare places) and Jaén (87 beds and 30 beds) have now been opened, taking the care home total to 53. The projects announced in Sabadell and others that have nearly been completed in Fuengirola, Sevilla and Palma de Mallorca will be added to this. Award of the management contract for the Mirasierra care home in Madrid, as well as the Alicia Koplowitz Multiple Schleroris care home and daycare centre also in Madrid. Diversification of services: Implementation of a plan to open night-time care services in some homes, and the development of telemedicine. The group continued its telecare network and continued its strong investment in the home care division. Source: SANImarket magazine. No. 35 November-December