Nursing Homes for the Elderly

Silvia Díez Sastre (coord), Jorge Castillo Abella, Juan Antonio Chinchilla Peinado, Mónica Domínguez Martín, Alfonso Egea de Haro, Moneyba González Medina and Lucía López de Castro García-Morato, Instituto de Derecho Local, Universidad Autónoma de Madrid

Relevance of the Practice

Municipalities in Spain play an important role in the provision of residential services for the elderly. They are one of the many services that municipalities provide to the aging population and which can be defined as one of the most intrusive in the elderly’s existence, as they deprive them of the autonomy to organize their everyday life. It is also undeniable how living in a nursing home affects considerably some fundamental rights of the resident, such as freedom of movement or the right to privacy.

In general, municipalities have the power to create and operate nursing homes by themselves and to do so according to plans or decisions rendered at the regional level, always with their consent. De iure, all municipalities have these powers, regardless of their size. Although there are some budgetary or financial provisions that may prevent municipalities, especially smaller ones, from creating these nursing homes, it can be said that all municipalities have, in principle, the power to do so.

Notwithstanding, the map of residential services for the elderly is not evenly drawn throughout Spain. The first factor that must be considered is the distribution of the elderly population. It can be said that the smaller (or more rural) the municipality, the older the population (on average). In rural municipalities, 28.5 per cent of the population is over 65 years old, whereas this percentage is 20 per cent in middle-sized municipalities and in urban municipalities, it sinks to 18.5 per cent.[1] Interestingly, however, this does not seem to be strongly related to the relative poverty risk ratios present in each municipality or region or the percentage of elderly people who own their own homes. On the contrary, this clearly shows the relevance of the rural-urban cleavage as regards nursing home policies and allows for a rich analysis of public services provided by municipalities and the influence the urban-rural divide exerts.

Description of the Practice

Nursing homes provide residential service to persons, especially elderly and/or dependent persons, who find themselves in need of such a residence. As such, they are part of the social services catalog that each autonomous region passes and executes since social assistance is under their jurisdiction according to the Spanish Constitution. Although this leads to relevant differences in the regulation and provision of social services in each region, including residential services, it is nonetheless possible to study them as an aggregate.

From an organizational perspective, there are two basic types of nursing homes: public and private. Public nursing homes are those created and operated directly by a public body, without the intervention of private agents. Private homes, on the other hand, are created and held by private persons or entities, including those which comprise the Third Sector (associations, foundations, etc.). It is also possible that the administration, be it regional or local, implicates private nursing homes in order to provide residential services for which that same administration is responsible. Therefore, there are three main kinds of nursing homes: public, private, and private but publicly funded. This connects with the forms of public service management and delivery discussed above. What should be now underlined is that all autonomous regions have roughly the same regulations regarding the organization of nursing homes.

Hence, it is interesting to note that not all regions invest equally in nursing homes. Even when only the regions with an older population are considered, there are noteworthy differences between them. This may be due precisely to the fact that the aging population in some of these regions lives in rural areas. The dispersion of elderly persons in rural settings may well hinder the provision of ‘aging in place’ services (directly at home) and, in turn, encourage the creation of nursing homes and day-care facilities. That is the case of regions such as Extremadura, Castile and León, Aragon and Galicia, and contrasts with the highly urban region of the Basque Country. This also connects with the fact that elderly persons in rural areas need more intense attention due to the lack of proximity services, which is not the case for urban zones. This very housing dispersion may be a cause of the preference for nursing homes over ‘aging in place’ services, given the difficulty of providing with proximity services to such disperse populations. 

The role of local governments as regards nursing homes is partially influenced by regional policy on that matter. Municipalities can choose to collaborate with the respective regional government in the execution of the regional residential policy or to develop their own, always within the confines of the applicable regulations. They may also opt for a combination of the two. Among the many elements that factor into the municipal decision regarding its nursing home policy, the financial element stands out (section 3 on local finances). In general, it can be said that municipalities have more financial incentives to collaborate with the regional government than to undertake their own policy execution. This is because the collaboration model will, as a rule, include provisions regarding the economic means to finance the residential service, which will be provided totally or partially by the regional government.

The existence of two decision levels regarding residential policy hinders, to some extent, the diagnosis of the causes of the uneven distribution of nursing homes. It is as yet unclear whether the abovementioned data regarding the distribution of nursing homes in rural and urban areas is a consequence of a regional policy choice, whether it is caused by local policy, or if it is the result of both.

Assessment of the Practice

The relevant differences in the provision of residential services not only between autonomous regions but also between regions with similarly aging population but the different urban-rural structure, suggest that this cleavage plays a decisive role in the nursing home policies of rural and urban municipalities. Therefore, this topic is ideally suited to provide another field in which to analyze the urban-rural axis and how it influences local policy-making and execution. Nursing homes also represent a fertile area in which to explore how local governments deliver public services, especially regarding the different forms in which this can take place according to the applicable regulations. The data, so far, clearly show us that the rural or urban nature of municipalities correlates strongly with the choice in relation to which public services are provided to the elderly and how this is carried out. These are, however, provisional results which would require a more thorough analysis to confirm this tentative assessment. The question that remains is to what extent local governments contribute to the provision of these services and their peculiar distribution between rural and urban areas when compared to the effects of regional policy on that same matter. This precise area is where the urban-rural cleavage between municipalities may play a decisive role.

References to Scientific and Non-Scientific Publications

Abellán García A, Aceituno Nieto P, Pérez Díaz J and Ramiro Fariñas D, ‘Un perfil de las personas mayores en España, 2020. Indicadores estadísticos básicos’ (2020) 25 Informes. Envejecimiento en Red

Alemán Bracho C, ‘Políticas sociales para personas mayores’ (2013) 9 Gestión y Análisis de Políticas Públicas 1

Arroyo Jiménez L and Domínguez Martín M, ‘Municipios y Comunidades Autónomas en la gestión del sistema de autonomía y atención a la dependencia’ in José María Rodríguez de Santiago and Silvia Díez Sastre (eds), La Administración de la Ley de Dependencia (Marcial Pons 2012)

Díez Sastre S, ‘Los servicios municipales para mayores en el entorno rural y urbano’ (2020) 2 Istituzioni del Federalismo 441

Egea A and Navarro C, Mayores: Análisis comparado de políticas de mayores en municipios de la Comunidad de Madrid (Instituto de Derecho Local, UAM 2019)

Eurostat, ‘Ageing Europe — Looking at the Lives of Older People in the EU’ (Eurostat 2019) <>

García-González J and Rodríguez-Rodríguez P, ‘”Rompiendo Distancias”: un programa integral para prevenir y atender la dependencia de las personas mayores en el medio rural’ (2005) 40 Revista Española de Geriatría y Gerontología 22

Lebrusán Murillon I, ‘Envejecer en casa. ¿Mejor en el pueblo o en la ciudad?’ (Observatorio Social La Caixa, May 2018) <>

[1] Rural municipalities are those with a population up to 2,000 inhabitants, middle-sized municipalities have a population between 2,001 and 10,000, whereas the population of urban municipalities is greater than 10,000 inhabitants.