The Long-Term Care Model in Spain: Challenges and Public Policy Proposals
The Dependency Law (LAPAD), approved in December 2006, represented the recognition of a subjective right and universal access to long-term care—undoubtedly a major regulatory step forward in the field of social rights.
However, the developed care model is not only insufficient in terms of intensity and funding but also follows deeply market-driven and assistentialist logics. For far too long, people in situations of dependency have been perceived by the collective imagination as objects of care rather than as rights-holders and protagonists of their own life stories. The LAPAD associates dependency with specific population groups (older adults, people with disabilities, and people with illnesses) and places its focus on individuals’ functional limitations—whether physical, mental, intellectual, or sensory. From this discursive framework, dependency is considered a permanent state and associated with an individual anomaly. Consequently, the SAAD responds to a rehabilitative and assistentialist model, in contrast to the social model and the human-rights approach of the UN Convention on the Rights of Persons with Disabilities (Asís & Barranco, 2010).
However, dependency is a highly complex phenomenon, conditioned by individual functional limitations but also, and to a great extent, by social and environmental limitations and restrictions in the settings where people conduct their everyday lives (Asís & Barranco, 2010).
In this context, one of the main challenges facing the model is improving the quality of benefits and services. We highlight three proposals to move forward:
1. The transition toward a new model of care and support
Care must be governed by ethical values that safeguard the dignity of all individuals, regardless of age, disability, health status, level of dependency, or any other circumstance.
Both the person-centered approach and the rights-based approach go beyond merely meeting needs, as the assistentialist model does. In these approaches, outcomes matter, but so does the way these outcomes are achieved. Caring means addressing basic needs, but it also involves accompanying and supporting every person to maintain autonomy and self-governance, to make free decisions about important aspects of life as well as about daily routines—even when such decisions may involve risks; to carry out activities with the right amount of support, without overprotection; to participate in community life and freely enjoy social interactions; ultimately, to be the protagonist of their own care and to develop their own life project.
It is urgent that the SAAD reverse the existing logic of care, shifting the focus beyond the individual and their basic needs toward relationships and connections, toward the social environment in which life unfolds, moving from an assistentialist model to one that is person-centered, community-based, and grounded in a human-rights approach (Artiaga, 2021).
In this new paradigm, personalized care is fundamental, along with the promotion of meaningful activities with value and relevance for each person and their life project. This implies, among other aspects, significant changes in professional roles, since both the relationships between caregivers and care recipients and knowledge of the person’s social and community environment are essential for providing quality support.
2. The necessary diversification of the SAAD benefits portfolio
a) The housing paradigm
One of the main strategic shifts for the SAAD service portfolio is the incorporation of alternatives to traditional residential care, aligned with the housing paradigm (Sancho & Martínez, 2021; IMSERSO, 2022).
On the one hand, services are needed that respond to new logics of social care organization, distancing themselves from purely market-based criteria, which have emerged partly due to the lack of public co-responsibility (Martínez & Díaz, 2025). These initiatives of mutual support and self-managed care contribute to supporting people in situations of dependency through local and community-based, non-profit approaches. An example is collaborative housing or cohousing projects, which foster intimate, emotionally committed, and solidarity-based relationships that go beyond affinity or kinship ties (Artiaga, 2021; Martín, 2016).
On the other hand, there are interesting residential alternatives, widely developed both inside and outside Spain, characterized by separating the provision of care from the provision of housing (Martínez, 2022; SIIS, 2020).
Some examples include British extracare housing, Swedish safety housing, German shared or group homes, French résidences autonomie, or the “homes for life” in Lugaritz, Basque Country.
b) Housing accessibility
Universal accessibility is a sine qua non condition for people in situations of dependency to exercise their rights on equal terms with the rest of the population.
Accessibility—whether cognitive, physical, or sensory—must be embedded across all environments, public and private alike, including transportation, technology, and public-use facilities and services, in both urban and rural settings. Only under these conditions can people act autonomously, independently, and participate in their community.
The SAAD must include specific measures to promote accessibility across all care environments, including private homes.
c) Assistive products
Assistive products play a key role in enhancing the autonomy of people in situations of dependency, enabling them to remain in their homes and improving care conditions by reducing physical strain and facilitating demanding tasks.
From wheelchairs, adjustable beds, and hoists to smart-home technology and sensors, technological solutions are vast—including 3D printing for personalized adaptations such as mouse emulators, adapted keyboards, or conductive splints.
d) Personal budgets
Personal budgets consist essentially of allocating an individual fund for the purpose of acquiring care and support services.
They are an innovative tool that would introduce flexibility into the SAAD, as they provide individuals with greater choice regarding the services they receive, reinforcing self-determination and control over their lives. They also offer agility, enabling rapid adaptation to people’s changing circumstances, and contribute to personalization by reversing the existing logic of access to benefits—placing the starting point in each person’s life project rather than solely in technical assessment or diagnosis.
To include them in the SAAD, it is essential that each person design their own personal care and support plan with professional guidance. The monetary amount assigned must be sufficient and directly linked to that plan, and services should only be contracted with qualified professionals or accredited entities.
Moreover, it is crucial to develop personalized, continuous guidance and support services for users, both in accessing benefits and managing them. It is also essential that each territory maintain a sufficiently diversified service network.
Countries such as the United Kingdom, France, and Finland have implemented personal budgets, with the Scottish model being one of the most advanced and consolidated. In Spain, Plena Inclusión leads a pioneering initiative called “Self-Directed Support.”
3. A new residential model
Institutional culture goes beyond the size or architectural characteristics of a facility. It involves cultural elements such as depersonalization, collective provision of services, rigid routines, standardized and uniform treatment, social distancing and isolation, paternalism, lack of autonomy, and prioritization of organizational interests over the needs and preferences of individuals. Additionally, institutional culture is characterized by asymmetrical relationships and power imbalances between caregivers and care recipients, with negative consequences for the well-being and dignity of people in situations of dependency (Asís, 2023).
In general, the SAAD residential model reflects an institutional culture. Residential facilities tend to offer standardized, protocol-driven care with limited opportunities for people to make decisions about various aspects of their daily lives (rigid schedules, where and with whom to eat, how to spend the day), activities without personal meaning—sometimes even infantilizing—shared spaces where people are monitored, and shared rooms lacking appropriate intimacy and privacy (Díaz-Veiga & Sancho, 2013). In addition, precarious working conditions in the sector and the lack of social recognition lead to constant staff turnover, hindering the formation of meaningful relationships essential for personalized care.
Following the COVID-19 pandemic, calls for change in the residential model have intensified, with the home-like model—organized around small living units within a person-centered care framework—emerging as the most widespread alternative to traditional institutions (Sancho & Martínez, 2021; Martínez, 2022).
We conclude with the main principles of this new approach to care (Gómez & Castro, 2021; Martínez, 2022):
- The individuality of each person is respected, recognizing them as valuable and unique, with the right to control their own life—even when they require complex care and support. The use of restraints or restrictions is not accepted, as they undermine dignity, autonomy, freedom, and self-esteem.
- Care is organized on a small scale, in home-like, family-style environments that combine private areas with others that promote interpersonal relationships and social interaction.
- Daily activities are personalized so that they are meaningful for each individual.
- Complementarity is sought between community assets (volunteering, social services, healthcare, associations, shops, pharmacies, etc.) and specialized resources (professionals).
- The facility and the people living in it participate in the social spaces and activities of their neighborhood or town.
- Residents and their families are involved in the governance of the facility, so that care adapts to people rather than people adapting to the facility.
- Improving wages, working conditions, and staffing ratios is essential.
References:
- Artiaga Leiras, A. (2021). Community care and the common governance of dependency: collaborative housing for older adults. Revista Española de Sociología, 30(2), a29. https://dialnet.unirioja.es/servlet/articulo?codigo=7891662
- Asís, R. (2023). Study on the processes of deinstitutionalization and transition toward personalized and community-based support models. Retrieved from: https://estudiodesinstitucionalizacion.gob.es/
- Asís, R., & Barranco, M. C. (2010). The impact of the International Convention on the Rights of Persons with Disabilities on Law 39/2006, of December 14.
- Díaz-Veiga, P., & Sancho, M. (2013). Residential facilities, crises, and preferences of older adults. Revista Española de Geriatría y Gerontología.
- Gomez, A., & Castro, J. (2021). VIP residences in the care ecosystem for older adults: a model under discussion. Revista Zerbitzuan, no. 75, pp. 107–136.
- IMSERSO. Evaluation report on the system for the promotion of personal autonomy and care for people in situations of dependency (SAAD). Madrid: IMSERSO, 2022. https://imserso.es/informe-de-evaluaci%C3%B3n-del-saad
- Martín Palomo, M. T. (2016). Care, vulnerability, and interdependencies. New political challenges. Madrid: Centro de Estudios Políticos y Constitucionales.
- Martínez, R., & Díaz, M. (2025). Long-term care and community innovation programs: composition, challenges, and territorial deployment. Investigaciones Regionales – Journal of Regional Research, 61, 2025/1. Spanish Regional Science Association, Spain. Available at https://investigacionesregionales.org/numeros-y-articulos/consulta-de-articulos
- Martínez, T. (2022). Home-like Coexistence Units, an alternative to institutional residential care for older people. Acpgerontologia Document Series, no. 8. Available at www.acpgerontologia.com
- Martínez, T. (2017). Person-centered care. Decalogue. Retrieved from: www.acpgerontologia.com
- Sancho, M., & Martínez, T. (2021). “The future of long-term care in the face of the COVID-19 crisis.” In: Blanco, A. et al. Informe España 2021. Madrid: Universidad Pontificia Comillas.
- SIIS Documentation and Studies Center, Eguía-Careaga Foundation. (2020). Some clues for improving the long-term care system in Spain. Zerbitzuan, 72, 77–90. https://doi.org/10.5569/1134-7147.72.06