Modernising Social Services in Spain

8. Measures to improve the quality of social services in Spain

Abstract

The chapter discusses different aspects of possible improvements in the quality of social services. The first part deals with measures to strengthen staffing lighten their workload and improve their continuing education. The second part proposes ideas for integrating the provision of primary and specialised care and social services with services in other sectors. The third part contains proposals on strengthening the accountability requirements of private providers.

The creation of a national law and the co‑operation of the autonomous communities in defining a new minimum catalogue can help improve the supply of social services in Spain. However, substantial improvements in the quality of services mostly depend on the efforts of the relevant authorities, particularly the autonomous authorities. The existence of strategic plans for social services and the periodic reformulation of regional legislation make it clear that the autonomous communities are committed to improving services. This chapter discusses promising initiatives in Spain and in other countries to improve the quality of services through human resources, the integration of services, and the accountability of social providers. These aspects have been identified as potential areas for improvement that affect all or a large majority of autonomous communities.

8.1. Rethinking staffing

Staffing remains a challenge for social services that should be addressed by a combination of measures. On the one hand, an increase in the number of social workers and other professionals working in social services could lighten workloads and improve the ratio of staff to service users. On the other hand, measures to improve the working conditions of social service professionals could also help facilitate their work. These measures would include simplifying administrative procedures and facilitating staff training.

8.1.1. Ensuring adequate ratios of staff to users

Social services staffing is not the same in the different autonomous communities. In approximately half of the regions, regulations define statutory ratios of primary care staff to inhabitants, which in some cases are differentiated according to the size of the local entity. Regulatory ratios vary from around 1 600 to 4 000 inhabitants per professional. Although staffing improved from 2012 to 2018, the actual ratios still sometimes remain below the minimum ratios established by the regional regulations, where these exist. There are still disparities between and within autonomous communities. Differences in needs linked to the age, socio‑economic and regional structure of the population partially explain these disparities, but most likely do not explain all of them, since the difference between the autonomous communities with the lowest and the highest ratios can reach a factor of ten.

Although the statistics are not complete or fully comparable, other countries in the European Union appear to employ relatively more staff than Spain. In Spain, there are approximately 90 inhabitants for each person who reports that they work in the social services sector. This ratio is higher in Greece (301) and several eastern and southern European countries; however, it is lower in Norway (17) and other mostly Nordic and western countries.

Social service professionals tend to have a significant workload in Spain as well as in other countries. In Spain, various studies and autonomous community representatives note excessive workload that can reduce well-being and, in the worst-case scenario, lead to staff burnout. Inevitably, this is also reflected in deteriorating service quality. A significant proportion of social service workers in other countries also suffer from stress and work overload, even in Nordic countries that have a more favourable ratio of inhabitants to social service workers.

Central governments of OECD countries use different strategies to maintain acceptable staffing levels across the entire country. In some countries, national legislation establishes minimum ratios of staff to inhabitants or users. For example, in Finland, the Act on Supporting the Older Population has introduced ratios that will increase progressively until 2023 and that vary according to needs. In Germany, the Ministry of Health and the Ministry of Family Affairs, Senior Citizens, Women and Youth have initiated a process to develop a uniform tool for the entire territory to establish the number and mix of professional profiles suitable for care facilities (Rothgang, Fünfstück and Kalwitzki, 2020[1]). In other countries, the central government does not have the power to establish minimum standards, but tries to encourage the relevant authorities to improve these standards. One example is the 2018 act on improving quality and participation in child day care centres in Germany. Based on this act, the federal government concludes contracts with the states to improve various aspects of quality, including the ratio of staff to children cared for.

Establishing and achieving adapted ratios. The regulatory process cannot establish staffing standards that apply rigidly to all social services. Rather, these should reflect the demographic structure of each autonomous community as well as users’ needs. For example, for primary care services, minimum ratios of staff per population could vary depending on the percentage of older people in the community. With regard to specialised social services, in addition to staff-to-population ratios, workload standards that take into account the severity of users’ needs could also be established. A monitoring mechanism is required to ensure that ratios are, in fact, respected.

The experience of other OECD countries can point towards good practices in this area. With regards to adapting staffing ratios to the severity of user needs, in the state of North Rhine‑Westphalia in Germany, one professional is required for every four Grade I residents (with slightly limited autonomy and 1 for every 1.8 Grade III residents (with severely limited autonomy) (Harrington et al., 2012[2]). Concerning the monitoring, the state of Maryland in the United States mandated that child protective services had to meet the standards for the ratio of staff to caseload and their workload proposed by the Child Welfare League of America, and that the relevant authorities must hire independent experts to ensure that standards are met. A first analysis revealed that the state was short of over 100 professionals. However, in some departments, there were more workers than the strict minimum required, while workers were lacking in others (DePanfilis et al., 2008[3]).

Considering elements of flexibility. Demand for services, and even more so the workforce, can vary in a way that is not always predictable. For example, several professionals working in a social services centre may be on sick leave for a few weeks. Most responsible entities are most likely unable to hire staff in excess of current regulations just to deal with surges in demand or temporarily reduced staff. One option may be to introduce elements of flexibility into the system. For example, in its 2017 Social Services Centre Improvement Plan, the City Council of Madrid planned to create mobile work teams to assist in certain circumstances (Dirección General de Personas Mayores y Servicios Sociales del Ayuntamiento de Madrid, 2017[4]).

8.1.2. Simplifying administrative procedures for both staff and users

There are multiple studies on how administrative procedures can increase the workload of professionals in the social services system. If there are no opportunities for the population to learn about the range of available services and benefits, and to directly apply for services that do not require a prior assessment, professionals have to spend time informing and enrolling people even though the same procedure could have been done independently online. Social workers having to enter identical information about a case in two or more computer applications or having to manually request information from other IT systems rather than receiving it automatically, takes away time they could have been using to address users’ problems. Likewise, if a service supervision authority receives information from NGOs in the form of an annual report rather than through information systems, this also increases its administrative burden. The central government and the autonomous communities are undertaking efforts to reduce the administrative burden, for example, through regulatory impact reports (Red Interadministrativa de Calidad en los Servicios Públicos, 2021[5]).

Creating interoperable operational and statistical applications, digitising procedures, consolidating responsibilities, and promoting the use of vouchers could reduce administrative burden and streamline procedures.

Ensuring that applications and records are interoperable. Social services information systems and other information systems in several autonomous communities are currently not very interoperable. Many autonomous communities therefore have projects to improve interoperability, including by creating a single social history. The OECD performed an assessment of the current situation across regions to understand social services information systems and included some suggestions for improvement, including discussions on possible indicators to be collected, a common taxonomy and a new architecture for the repository of indicators (Fernadez, Kups and Llena-Nozal, 2022[6]).

Making best use of digital procedures and services. Allowing social service users to initiate online support requests and, when appropriate, to receive digital services could lighten professionals’ workloads. The central administration (see, for example, Act 39/2015 of 1 October on the Common Administrative Procedural Regime Applicable to the Public Sector and the Plan for the Digitalisation of Spain’s Public Administration 2021‑25) and the autonomous administrations (Fernadez, Kups and Llena-Nozal, 2022[6]) already have multiple activities to increase opportunities for requesting services digitally. However, the digitisation of procedures and services goes beyond technical capabilities:

• Facilitating the online processing and, where possible, evaluation of applications: In various autonomous communities and in other countries, both appointment requests and applications for benefits such as the minimum living income are frequently handled online; and sometimes,the same is true for the initial application for long-term care services. For example, Catalonia is considering creating a self-service platform for citizens. Of course, for the evaluation and assessment stage, there are dozens of situations in which only a personal assessment is appropriate. However, in some specific situations, a telephone or video consultation may suffice. The experience of the municipality of Trelleborg in Sweden shows how online and in-person assessments can be combined: people wishing to receive financial assistance must first contact a social worker. Afterwards, they can apply for continued assistance online; and in most cases, an algorithm takes the decision (Ranerup and Henriksen, 2019[7]; Lind and Wallentin, 2021[8]).

• Assisting professionals through tools: University students in Barcelona have developed an application that can help social workers assess the degree of applicants’ (in)dependence (Ortiz et al., 2021[9]).

• Strengthening remote consultations, especially in rural areas: For example, in Finland, the Virtu.fr platform offers video consultations, for example, for people with disabilities and families (in the field of legal and psychosocial assistance).

Consolidating responsibilities. In some cases, social service professionals’ workload increases because rules require co‑ordination despite it not being necessary for ensuring continued care for users. Identifying and eliminating these cases of redundant co‑ordination can alleviate workload. For example, in a 2021 decree, Andalusia acknowledged that the administrative procedure to recognise the applicant’s entitlement of a situation of dependency – which required back-and-forth between the local and autonomous administrations – increased workload and slowed down decision-making. To alleviate this burden, the decree consolidated assessment within the regional or provincial delegation of the regional ministry. However, the existence of multiple service areas can confuse people with multiple support needs, leading to them not using services that could help them, or initially turning to entities that are not able to help them. Several autonomous communities have recognised this problem, and have established or strengthened the role of the “reference social professional” in their recent (draft) laws. This professional can direct users to the appropriate services.

Enabling social professionals to use vouchers. It may be appropriate to use vouchers when there is a range of service providers, allowing the user to choose their preferred provider. For example, in Bologna (Italy), instead of allocating subsidies to providers, older people and their families received social vouchers to access the appropriate services. This change improved services and reduced costs (OECD, 2021[10]). In Chicago (United States), the CommunityRx system created an index of potentially helpful resources for recurring social and health problems, and referred users to it. Participating organisations and users had a positive perception of the programme, and one‑fifth of users followed recommendations (Lindau et al., 2016[11]).

8.1.3. Facilitating staff training and development

Social service professionals have varied professional profiles and qualifications, and as in other professions may benefit from continuous training. According to a 2017 survey in Andalusia, social workers identified the main areas of their training needs to be family intervention, promotion of social inclusion, social care needs assessment and social report preparation (Secretaría General de Servicios Sociales, 2018[12]). Some university studies also suggest that high-quality initial and continuous training can prevent burnout among social workers (Caravaca-Sanchez et al., 2019[13]).

According to Fustier i Garcia (2018[14]), postgraduate training for social services professionals is very poorly developed in Spain, and continuous training depends on individual employers rather than being required and regulated by a government entity. An exception (of voluntary participation) is the permanent social services training classroom recently established in Cantabria, which holds monthly workshops to encourage attendees to reflect on possible reforms in the sector (Servicios Sociales Cantabria, 2021[15]). Some recent strategic plans also recognise the importance of training. For example, in Catalonia, the 2010‑13 Strategic Plan for Social Services included the objective to increase the number of organisations in the public social services network that have professional development tools and specific training plans by a quarter. Recently, the 2021‑24 Strategic Plan highlighted that the Committee of Social Action Training Experts was consolidated as an advisory body in the definition of training programmes for the professional community, and noted that from 2010 to 2018, over 4 000 professionals were trained annually in the specialised training programme (Generalitat de Catalunya, 2020[16]). The Department of Social Rights recognises continuous education and postgraduate courses as training of interest in social services (DIXIT, 2021[17]).

Several European countries have launched initiatives to ensure the quality and continuity of continuous education for professionals in the sector. These initiatives suggest strategies that could also be adapted to the Spanish context:

Leveraging European funds to implement training strategies: The 2007‑13 Human Capital Investment Operational Programme in Poland, co-funded by the European Social Fund, trained more than 50 000 people in the social services and employment sectors, from both public and private entities. The programme aimed to improve staff’s competencies and interpersonal skills (Baltruks, Hussein and Lara Montero, 2017[18]).

Establishing training priorities among the various stakeholders: In France, the government launched the Estates-General of Social Services in 2013, a consultation process between politicians and associations to reform social work that involved over 50 000 people, in addition to 14 000 responses to an online survey. The consultations resulted in a proposal that the state, local entities and social actors should agree on national priorities in the area of continuous education, and that the state and regions should establish quality criteria for training. It also proposed that continuous education should be compulsory for public service employees (Perrin, 2015[19]). However, the first evaluation of the action plan found that in 2017, negotiation between the state and the regions had not yet started (Soulage and Reymond, 2017[20]).

Establishing minimum compulsory continuous training for professionals and employers: In Scotland, continuous education and training is compulsory for social workers, with varying requirements depending on whether or not they are newly qualified. Social workers have to document their time spent learning and training; but in addition to formal training, they can fulfil the requirement through reading relevant works (SSSC, n.d.[21]). While this flexibility may be desirable, employers are under no obligation to assist professionals in fulfilling their training obligations, and almost half of newly qualified social workers were not offered training or education by their employers (Grant, Sheridan and Webb, 2016[22]). In contrast, in the Czech Republic, social service employers must provide training options for the mandatory 24 hours of continuous education social workers must complete (Borská and Švejdarová, 2016[23]). A possible lesson for Spain is that training requirements could be formulated flexibly, but that this should not release employers from offering formal training options and compensating employees.

Establishing advanced and administrative training. The skills required to manage the provision of social services differ from the skills required to work directly with users, and this is not always sufficiently reflected in training. In Catalonia, the strategic plan includes a proposal to offer postgraduate studies in social services management, as well as to build a network of managers for sharing best practices.

8.2. Designing integrated services within a broader strategy

Integrating different social services, and social services with other services such as health and education, can contribute to positive results. These may include reduced duplication of administrative steps and thus reduced costs; better strategic planning; a reduced need for emergency assistance; reduced barriers to accessing services; more comprehensive and tailored support; and improved results for users. However, there is little empirical evidence to confirm these benefits, in particular reduction of costs (OECD, 2015[24]). In fact, the second of Leutz’s (1999[25]) five “laws of integration” was that integration initially generates higher expenses before reducing costs. Nevertheless, user outcomes may improve significantly due to the integration of services.

There can be different forms of integration. A distinction is made between vertical integration (between services administered by various levels of government, such as primary services generally under local responsibility, and specialised services generally under regional responsibility) and horizontal integration (for example, between specialised services from various fields, such as personal autonomy and family services; or between social services and employment services). A distinction is also made between the various levels of integration, including the co-location of various services in a shared space; the collaboration between various providers with an increased exchange of information on individual users; and co‑operation between different professionals within the same team. Finally, a distinction is made between integration at the macro level, i.e. functional and organisational integration, and at the micro level, i.e. integration of professionals’ work and service provision. Although organisational and funding bodies affect the success of integration projects, this section focuses on integration at the micro level only.

8.2.1. Integrating social service provision

The way in which social services are organised and the lack of information exchange can lead to fragmented care for users with multiple needs, which is why autonomous communities are already taking steps to avoid this situation. The compartmentalised structure between primary and specialised social services, although necessary from an organisational point of view, can make it difficult to offer integrated and personalised solutions (Fresno, 2018[26]). The lack of a single social history and of interconnectivity between primary and specialised information systems hinders holistic intervention. This issue is particularly significant for the management of complex cases requiring attention from several professionals at once (e.g. from the health, education and employment systems). Currently, many information technology tools have limited capacity to exchange data automatically, meaning the same piece of information has to be collected multiple times. The current central information technology tool for social services (SIUSS) does not have application programming interfaces (APIs), thereby limiting the possibility to strengthen interoperability between the information systems used for primary and specialised services. Finally, none of the autonomous communities has an integrated management system for all social services (Fernadez, Kups and Llena-Nozal, 2022[6]).

To address these difficulties, autonomous communities are investing in technical and non-technical solutions:

• Since the first legislative introduction of the reference social professional through the 2003 Social Services Act of the Community of Madrid, the vast majority of communities have this role (Barrales and Trujillo, 2020[27]). In many cases, this person must be a social worker. Depending on their assigned role and workload, this person can “guide and support people throughout the whole process of social intervention” (Social Services Act 11/2003 of the Community of Madrid of 27 March), and help ensure “coherence, comprehensiveness and continuity of the intervention process” (Social Services Act 9/2016 of Andalusia of 27 December). However, the reference professional often only exists in primary care and lacks the role of a manager co‑ordinating the integrated intervention of primary and specialised services.

• Several strategic plans aim to improve co‑ordination and are working towards inclusion trajectories. The new strategic plan of Navarre foresees improvements to legal instruments to facilitate social services integration through inter-agency agreements. One option is to create a public sector foundation able to foster new forms of co‑ordination between the levels of administration in the public social services system, and between those levels and the third sector of social action. The plan also highlights the possibility of having response models defined in terms of “care packages” with sectoral itineraries. Likewise, Catalonia’s new strategic plan proposes shared assessment instruments and protocols.

• Several autonomous communities are working on a closer integration of the information systems for primary and specialised social services. Examples include the Protecnica systems in La Rioja, ASIST/MEDAS in Castile‑La Mancha and the SAUSS system/social action centres in Castile‑León.

A strategy that simultaneously improved these technical and non-technical routes would likely be more successful in delivering services that are more integrated to users:

• Strengthening the role of the reference professional. Strengthening the role of the reference professional to that of a true case manager who can connect users to specialised services can prevent users from having difficulty navigating the system. At the same time, Barrales and Trujillo (2020[27]) (referring to the 2010 special report on the state of basic social services in the autonomous community of the Basque Country) observe that the role of the reference professional is not just to advise the user about the network’s services.

  Identifying people with complex needs. Individuals whose needs that go beyond what individual professionals can provide may benefit more from integrated care, but are also less likely to approach the social services providers in the first place. The integration of databases from different sectors has the potential to help identify people in need who do not reach out to services on their own account (OECD, 2015[24]). As a first step, this would require information systems to be more closely integrated than they currently are in any autonomous community, and would raise questions about data privacy and the autonomy and freedom of choice of the population identified in this way. The efforts on the technical side should be accompanied by the development of strategies to remove or lower barriers to access, to identify the size of the population with complex needs and to reach out to them. The good practice of offering a “cascade” of services combining universal services with problem assessment and services that are more intensive is fully compatible with the two‑ or three‑level model of care in autonomous communities.

8.2.2. Increasing the interoperability of social services with other sectors

The problems associated with service integration, including the challenges of collaboration and information exchange, are even more evident when co‑ordinating with the activities of other sectors. People suffering from a loss of autonomy, for example, could benefit from collaboration between the primary health care system and the home‑based care system. Individuals who have been inactive for a prolonged period due to a combination of social and employment problems may require simultaneous and co‑ordinated support from social and employment services.

In other countries, the most intensive areas of co‑operation tend to be with employment services (generally to promote the social and labour market integration of users) and with health services (generally to ensure that living circumstances do not have a negative health impacts, as may be the case when a person requires help with daily activities). In some cases, it is simply a matter of ensuring a smoother information exchange, or that the case managers of the two or three respective systems exchange information on the monitoring of users with complex needs. In other cases, it ranges from creating common structures to formalise co‑operation, up to the creation of “one‑stop shops” to treat people holistically. For example, in Finland, multisector services centres were established in 2015. These centres provide employment, social, health, rehabilitation and social security services to vulnerable people referred by public employment offices or social centres. In Catalonia, a draft bill is currently being drawn up for the Integrated Social and Health care Agency of Catalonia, which aims to ensure more integrated care for older people, people with disabilities, and those experiencing social problems due to mental health.

Ensuring that responsibilities and competencies are understood. An analysis of the collaboration between professionals from the education, health and social sectors in Stockholm, Sweden, revealed some key prerequisites for fruitful co‑operation (Widmark et al., 2011[28]): having a mutual understanding of the responsibilities and competencies of the professionals from other sectors appears to be important to create the trust required for good working relationships. Without this understanding, practitioners in one sector may have expectations that are either too high or too low in terms of the results that services in other sectors can provide to typical users (Lara Montero, 2016[29]). This lesson most likely equally applies to collaboration between different social service areas. Joint training for the professionals involved can deepen the understanding of the role and skills of professionals from other sectors.

Defining care packages. As mentioned in Chapter 7, Section 7.3.1 (on prevention services), people with complex needs may require co‑ordinated services from different sectors. A resource summary table defining integrated service packages that respond to different need profiles can facilitate the work of professionals in the health, social or another sector (Pinzón-Pulido et al., 2016[30]).

Creating co‑operation councils on an equal footing. Attempts to integrate health and social services in England have suffered in several instances from an overly dominant position of National Health Service (NHS) representatives; while the NHS and local services (including social services) have a comparable number of staff, the NHS has a much higher budget. It is important for the representatives of the service with the most weight (in terms, for example, of its budgetary or political significance) to be aware of this imbalance and be willing to remedy it to avoid this kind of situation.

Sharing the financial responsibility. A common difficulty when treating people with complex needs is that each provider has an incentive to move users to other providers. For example, to save costs, hospitals may prematurely discharge “expensive” patients back to nursing homes in order; or nursing homes may not invest enough in preventive care services that could have avoided the need for a hospital stay in the first place. During the process of developing integrated services, it is worth reflecting on the possibility of creating cost-sharing and cost-saving mechanisms. Pooled funds under common supervision can be useful in achieving a more efficient and equitable distribution of expenditure on services in different areas serving the same population (OECD, 2015[24]). However, this would require a thorough understanding of how investments in social services can decrease health care costs.

8.3. Strengthening accountability requirements for private and third-sector providers

The lack of data transmission from non-public social service providers can be a barrier to more integrated service delivery and evidence‑based policy making. The regional social services legislations allow for-profit and non-profit providers to participate in the social services system to different degrees and under different conditions, especially in providing specialised services. Contracting occurs through different legal instruments through tenders, subsidies or agreements. Providers are typically required to report basic information about their expenditure and users to the co-funding administration. In particular, documentation of expenditure is generally required, as well as an overview of the served users. In some communities (Castile‑La Mancha and Castile‑León), the information is communicated through their information systems, while in other communities, the information is communicated in the form of reports or briefings and is not linked to databases or information systems.

Defining accountability requirements within new regional legislation. Some regions, such as the Community of Madrid, are currently exploring the possibility of developing new regulations that would define mechanisms necessary to facilitate collaboration with the private sector in more detail and to anticipate all possible forms (such as subsidy, agreement and tendering) and the suitability of each of them as a function of the service in question. In several autonomous communities, the social accordance (concierto) has been regulated since it is considered to potentially be an ideal method for providing quality social services as it allows for a stable model of collaboration.

Regardless of method, if several entities take care of a person, there must be administrative and technological means to record their trajectory and to guarantee service continuity. Within this context, accountability requirements could be strengthened. In addition to annual reports that summarise expenditure and characteristics of services and users, providers could also be required to transmit microdata at predefined intervals. Of course, this requires a transition period so that providers can either adapt their case management IT programmes or establish the technical conditions for data to be transmitted. This also requires a common method of identifying users.

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