With the world’s most ageing society, Japan faces a serious challenge in meeting the unprecedented demand for health and social care for its older population. Already, a quarter of Japan’s 1.26 million populations is aged 65 or over – compared with 17 per cent in the UK.
Japan has devised radical solutions to meet this challenge. Despite a prolonged recession and ingrained assumptions about the family’s responsibility to care for elderly relatives, in 2000 the government introduced an ambitious social care system for its older citizens, running parallel to its established healthcare system.
The new social care system is distinctive. Its philosophy is universal and collectivist. Its approach is needs-based, not means-tested. Its finance is open-ended, not budget-driven or capped. Above all, this system has managed to achieve financial sustainability and enjoy popularity – in marked contrast with the English social care system. Yet, preserving its sustainability poses major challenges and demands a continuing search for workable responses. Japan’s experience could therefore provide England with timely and valuable lessons as the Care Bill is about to be enacted.
Japanese ‘care’ and drivers for reform
A look at the situation prior to the fundamental reform of 2000 may inform our understanding of the impetus behind the radical measures, with the perspective revealing uncomfortable and unexpected truths within Japanese ‘care’ and justifying the rationale for the reform.
A widespread assumption that children would look after elderly parents remained intact and embedded in a post-war Japanese society influenced by pervading Confucian values. This assumption explains the limited commitment to the provision of care by successive governments. Public social care was means-tested, extremely limited and associated with a strong stigma.
By the 1980s the situation was exacerbated by changes in family structures, a shift in social norms, changing residential patterns and the nature of care itself. Urbanisation and modernisation privileged the nuclear family and contributed to the rise in female employment at a time of economic growth. The implementation of a comprehensive national healthcare system in 1961 together with free healthcare for the over-70s from 1973 ensured a much longer, but not necessarily healthier, life span for the Japanese population.
One consequence of these trends was the growing number of frail or disabled older people and subsequent increasing pressures on family carers, especially women, to provide them with more demanding and longer-term care.
In turn, this created conditions in which the potential and actual incidents of the abuse of older people by their exhausted families increased. Extreme instances of this involved the murder of frail relatives by family ‘carers’, a growing social problem referred to as ‘Care-giving hell’.
Alternatively, burnt-out families abandoned older relatives, who needed social rather than medical care, to hospitals. There, patients often became ‘residents’ sometimes in facilities not commissioned to provide the necessary care.
Growing awareness of these problems discredited the family’s ascribed role, while fuelling propelling public expenditure on ‘social hospitalisation’ of elderly patients.
The need to improve existing care arrangements was increasingly felt. One option was private care but unlike England the private market in Japan was extremely slow to develop, ironically thanks to accessible hospital beds, free for users but hugely costly for government and not a preferred option since most wanted to be supported and live at home.
New care reform
Despite on-going financial difficulties, in 2000 the government launched a mandatory public Long Term Care Insurance system (LTCI) as a universal right for every older person deemed to need it. Many saw this as the end of family care.
LTCI is co-funded drawing equally from tax revenue and insurance contributions paid in by everyone aged over 40. The mixed-funding formula was chosen partly because of its familiarity in the Japanese public healthcare and pensions systems.
People over 40 contribute to the scheme on a progressive scale, underlining the concept of collective risk-sharing. The LTCI guarantees an explicit entitlement for everyone over 65, along with some over-40s with age-related disabilities. A national objective assessment is based only on clinical need, disregarding social and financial circumstances.
LTCI benefits are generous by international standards, intended to cover the full costs, (except the 10% use-fee) of 52 services provided at home, in the community and residential care settings, including a medical component.
Significantly, however, no cash payments to family carers are available. The aim is to encourage the use of public services and so reduce care by the family. This contrasts strikingly with the English approach, which provides family carers with cash allowances and now personal budgets to acknowledge and further promote their informal contribution.
Initial impact and adjustments
Unsurprisingly, initial uptake was dramatic, in particular the uptake of community-based services. Significantly, usage of homecare, respite and day care facilities increased unprecedentedly. Japanese day care provision per capita ranks the top in the world, its users representing 7.5 per cent of over-65s (compared to 0.9 per cent in England).
But success inevitably meant runaway LTCI expenditure leading to reforms in 2005 to bolster the system’s sustainability, particularly the financial integrity. Accordingly, the reforms introduced room-and-board charges for residential care and the trimming of services for low-needs groups. These measures successfully slowed the growth of LTCI expenditure but arguably with consequences both for the service-users affected and their families.
Aspirations and innovations
The reforms are not all about cost-cutting, however. Among these two aspirations stand out. First, they propose to make the scope of LTCI more comprehensive, inclusive and prevention-led, thereby developing health promotion programmes and optimising community resources to serve the entire older population, involving the whole community. This encouraged greater openness to innovations with a radical shift from a reactive approach to prevention, outreach and active ageing. Another vision is to develop a seamless and joint-up care package to enable older people to live independently at home for longer. New, imaginative measures have been launched. Both aspirations resonate with English counterparts.
The Japanese lessons on social care
In summary, the Japanese experience suggests that even a needs-based, universal and pay-as-you-go system can operate within controlled costs and achieve financial sustainability. This contrasts with England’s targeted and budget-driven/stripped approach. More cogently, Japan’s LTCI has achieved an expenditure of 1.2 per cent of GDP, well below the OECD average (1.6%). Yet controlled expenditure is partly attributable to cost-cutting measures enshrined in post-2005 reforms, resulting in continuing burdens on many family carers. Moreover, future sustainability remains a major challenge.
Financial sustainability requires not only budget-balancing but also a broad consensus on the distribution of increasing cost burdens. Japan’s case suggests that this is possible, and to achieve this, notions of equity and universality are indispensable. Japan’s system involves every pensioner as well as workers paying insurance premiums. Inclusive and generous coverage, embracing a large, diverse clientele, has heightened the system’s popularity.
Crucially, Japanese people acknowledge the shameful history and limitations of family care, and accept the need for expanded public provision, albeit with increased cost burdens. Care has come to be seen as a collective, social responsibility, marking a revolution in popular thinking. This contrasts with the tenacity of a means-tested, safety-net system sustained in England. Here, although both the government and public consider the system unfair and unsustainable, neither side seems prepared to share extra financial burdens and take on collective responsibility for the care of all disabled or older people in need.
Something to offer
The Japanese experience also suggests that transparency and clarity concerning service entitlements and content are indispensable, though they may feed a ‘consumerism’ which potentially fosters unrealistic expectations. Accordingly, the Japanese LTCI system increasingly highlights explicit service entitlements and content. This contrasts with the English more localised and whole-person approach to delivering care which emphasises person-centred care and well-being, incorporating flexibility, autonomy and choice through personal budgets, but which also potentially admits certain ambiguities about service availability and the individual’s responsibilities.
Perhaps most importantly, there must be realism and candour about the appropriate role of the family in providing care. Japan’s experience suggests the need for caution here.
Finally, given that retaining popular support underpins financial sustainability, cost-cutting measures, involving restricted eligibility and service reduction, can be counter-productive with only temporary or transient gains. In this respect, Japan’s response has been interesting, adopting a comprehensive and prevention-led vision, extending LTCI’s scope for the entire older population. The results are still difficult to interpret with confidence but this vision may be something to offer policy-makers in England.
This article can also be seen in the Health Service Journal website