Following in the footsteps of Japan: making social care reform happen

With nine out of 10 MPs saying our social care system is “not fit for purpose”, reading that a key government priority in this area is “to secure better value for taxpayers’ money by introducing a new funding structure for social care” should not be surprising.

But this quote is not from Jeremy Hunt’s 2018 speech about reforming the sector. It’s from an earlier white paper, ‘Caring for people’. The date? 1989.

How can it be that, nearly 30 years on from that original white paper, we are still aspiring to reform our creaking social care system?

Great hopes are now being pinned on a forthcoming green paper’s ability to kick-start the process that will deliver tangible and positive change for older people.  Unfortunately history suggests that, unless something radically different happens this time, the odds are stacked against us.

Looking back over the various stalled attempts to implement change in England, the lack of cross-party support or genuine public debate seem to have been the underlying reasons for failure. Proposals for reform tend to become quickly politicised, as we saw in last year’s (and the 2010) election campaign. Pledges to address problems in the system have been repeatedly kicked into the long grass.

So we have been looking at the Japanese long-term care system to find out how they managed to go from a state of highly variable and largely unaffordable care provision in the 1990s to a universal care system servicing the needs of nearly 6 million people. Although contextually different, there are some valuable lessons that Japan can teach us about how they managed to implement change with widespread public support.

1. Shift social care up the public agenda

In Japan, the need for long-term care became the number one issue in the 1990s. A confluence of economic difficulties and social change – with increasing numbers of older people living alone – created a set of pressures that affected a large proportion of the population. The lack of affordable care provision saw older people being admitted to hospital with little medical justification, because they provided relatively low-cost care and accommodation. Average lengths of stay reached over 50 days and hospital costs were soaring.

As a result, there was a collective recognition that something had to change. With the public’s attention here distracted by Brexit and the wider economy, our government may face more of a struggle to gain such acceptance, but it will be critical that they do so.

2. Engage the public

When the proposals for a new system of care in Japan were put on the table, there was a good understanding that what was being offered was an improvement on what people currently had access to. This was critical for gaining public and political support.

The new system also built on mechanisms that were already in place for the health service. Research has revealed that the public in England has a limited understanding of the current social care system. People express surprise that their care is not fully funded as an extension of their NHS care. Pledges in manifestos to introduce caps on costs or to change means-testing have been met with widespread public discontent and media outrage – the assumption being that the proposals signify a worse offer than the existing one. In order for there to be a genuine public debate about social care, there needs to be a good understanding of how the system works now.

3. Make benefits visible

Japan gave careful consideration to who should contribute to the system and when. They ensured that, on launch, large numbers of people would be able to access a relatively generous benefits package. This helped to convince the public of the value of the system. The generosity of the system was later reduced to curb expenditure – a tactic that may be less palatable here.

Everyone starts to contribute to the system from the age of 40 because it was assumed that, at that point, most people would have older relatives or friends who would need care. By making the benefits visible, people were more willing to contribute. Generational inequality is such a live issue in England currently that any new funding proposals will need to be sensitive to who contributes and who benefits.

4. Provide transparency and fairness

Transparency and fairness underpin the Japanese system. The part-social insurance system means that people are aware of what they are paying in. A national eligibility assessment process which is consistently applied means that your entitlement will be the same regardless of where you live. Assigned monthly budgets offer complete clarity about what benefits are available. Such clarity over inputs and benefits is something that is painfully lacking in our social care system, where access to care varies according to where you live and costs are currently potentially unlimited.

5. Allow sufficient time

Japan didn’t transform its system overnight. It built on what had gone before, took time to consult with the public and interest groups and prepared the market. Discussions about reform began in the early 1990s. Legislation wasn’t passed until 1997. The system was implemented in 2000.

Laying the foundations for an entirely new system that requires political and public approval takes time. Given the state of our social care sector, time is a luxury we don’t have, but the government should be mindful of the need to ensure it has support for change, otherwise this will be yet another wasted opportunity.

Looking forward

Japan’s system may not be perfect and its experience has certainly not been without its challenges. But as with other countries that have made this journey, it should give us hope that radical change is possible, even when the issues are so complex. Ensuring public understanding and support for change, coupled with the careful design of a system underpinned by the principles of transparency and fairness, appear to be the necessary ingredients for effective change.

We are hopeful that, through careful consultation and engagement, the green paper will achieve what previous attempts have failed to do and mark a significant step on the journey to a social care system that is clear, appropriate, equitable and sustainable.

A version of this blog was first published by the Guardian Social Care Network.