As we recently argued, cuts to public health budgets are short-sighted and simply store up problems for the future. Despite the evidence about the value of upstream preventative care, our health and social care system is still largely run with a short-termist mindset. Whenever the finances get tricky, the first things to go are the services and interventions that don’t deliver immediately. But, with our increasingly ageing population, can we afford to be so short-termist?
I was in Japan earlier this month with my colleague Sophie Castle-Clarke, looking at their social care system (known as long-term care – or LTC).
We will be writing in greater depth about that system soon as there are valuable lessons for us in our thinking about the future of social care. What really struck me, however, was the emphasis that Japan places on prevention and upstream care. We had three intense days of meetings and visits and almost every single person we met talked about the importance of preventing deterioration. In fact, prevention is one of the central approaches being taken to ensuring the system remains affordable.
The demographic challenge
If you think our future demographics are challenging, Japan’s are terrifying. Their population is not only ageing, but shrinking too. By 2060, those over 65 years old will represent 40 per cent of the population, meaning that each working-age person will be supporting 0.96 dependants. With a dwindling birth rate and no tradition of immigration, that’s a daunting prospect.
Japan’s response to these challenges is not dissimilar to our own. Are they restricting access to care services and increasing eligibility levels to reduce expenditure? Yes. Are they asking the population to contribute more to their care? Yes. But the big difference between the rhetoric in Japan and the UK is the emphasis on prevention.
There is acute awareness that, as eligibility for services has risen, it’s leaving people with mild needs vulnerable and less able to access LTC support. But, instead of just waiting for those people to deteriorate to the point where they need care, the Japanese Government is encouraging municipal governments to invest in community facilities, volunteering and social support networks.
This has taken the form of small pots of money being used to develop facilities for volunteers to run. In some places, municipalities have taken over vacant buildings and transformed them into community facilities, creating an easily accessible support hub.
By harnessing the power of the community and volunteers, they are trying to embed and strengthen an informal social support network. With changes to the family structure and the rapid rise of older people living alone, this has become a top priority.
Focusing on prevention: maintaining independence
We visited a “Ten Million House” (so called because 10 million Yen is allocated to such projects, usually to redevelop a vacant building) run by volunteers. The ‘House’ offers an informal meeting space along with various activities such as a lunch club, tai chi classes and craft workshops. The service users we saw there were mostly in their early-to-mid-70s, seemingly fit and mobile. To use the centre, the only criteria are that you are over 65 and able to get there yourself.
They didn’t look like they needed much support at all. So we asked why resources have been redirected to projects like this. The answer was that this group of people generally live alone, far from family and are at risk of becoming isolated. By looping them into the community network before they deteriorate, they are able to create an informal network on which they can rely when their care needs increase.
As well as plugging the care gap with informal support, the centre is well placed to identify issues early, and ensure that people are enabled to access the formal care system while they can still be supported to live at home. The pressure on space in Tokyo, and concerns about affordability, mean that few new nursing homes can be built, so there is a growing need to deliver as much care as possible in people’s homes.
A day centre’s role
The other example we saw of prevention being hard-wired into thinking was in our visit to the ‘Dream Lake Village’ day centre.
There are many small centres like this across Japan, providing low-level care to older people who live at home but who need some help with daily activities. The centre we visited was carefully designed around the goal of increasing users’ independence and preventing decline. Every tiny detail was designed deliberately to get people moving or thinking.
It was a far cry from the passive environment of many care homes with older people sat around watching TV. In this centre, users arrive for the day transported by a fleet of minibuses. On arrival, they have to find their name on a board and then pick activities that are displayed on magnetic cards – they use these to design their timetable for the day.
Each person designs their own plan. The only thing they all do at the same time is eat lunch. There were staff present but they were very hands off. The philosophy is that the staff don’t do things for people that they can do for themselves.
Once activities are chosen, users have to walk to the opposite side of the sizeable building to put their belongings in lockers. Along the way are games – word games, number games, picture games – and taking part in them earns the users ‘currency’ that they stow in a purse that they hang from their neck. They need this currency to ‘pay’ for activities. As the manager and owner of the day service said: nothing here is free! They also earn currency by setting goals for themselves – perhaps walking upstairs instead of taking a lift – and they earn even more if they achieve those goals.
Some also run their own activities, such as painted nails or leading an origami class. Or they can help out with chores – matching up pairs of chopsticks and putting them together with the same colour bowl, for example. Such activities are carefully designed to improve the short-term memory of those with dementia. Currency is then spent on activities like baking, pottery, craft and even woodwork. Or they can spend it on a session in the in-house gym, or watching a film on the large projector screen.
The centre is a big investment – the facilities are incredible and every detail is thought through. But the manager thinks it is paying off. He says they have found that people’s care needs reduce after a few months of attending, reversing (or at least slowing) what is often assumed to be inevitable deterioration.
There is no strong tradition of service evaluation in Japan so it is difficult to quantify this impact, but the manager is convinced. And it’s not in his interests for this to happen – the funding received by the centre increases as an individual’s needs increase. He is in talks with the Government about how to adjust the fee schedule to avoid this perverse incentive.
What also makes the centre an efficient use of funds is that it is multi-purpose. As well as the day-centre facilities, it also has small units where low-income older people live, and six short-stay beds for people whose carers need a break.
And, by night, the day centre is transformed into an after-school club and a community meeting space. The gym is used for classes and the rooms can be booked (for free) by anyone in the community. As such, it acts as a hub for the whole community, embedding a culture of mutual support and sense of community among younger people too. Again, thinking long term.
Taking a long-term view
The centre is exceptional – operated by one provider chain in a handful of places – so it is not representative of all such care in Japan. But it is a good example of how the idea of investment in the long term has become a central priority in a country that really can’t afford to be short-termist.
Japan believes that prevention is the main solution to its growing demographic challenge. It may pay off or it may prove to be wildly optimistic. Either way, before dismantling what remains of our preventative infrastructure, perhaps we should pause and reflect on the value of thinking longer term. Our circumstances are much less challenging than Japan’s, but the ageing population is an issue that is not going to go away.
*Natasha Curry and Sophie Castle-Clarke visited a Ten Million House in Musashino Ward and the ‘Dream Lake Village’ day centre in Setagaya Ward, Tokyo. Their visit was part funded by the Great Britain Sasakawa Foundation, a charitable foundation established to develop good relations between the United Kingdom and Japan by advancing the education of the people of both nations in each other's culture, society and achievements.
Curry N (2017) "Looking to the long term: the Japanese approach", Nuffield Trust long read. https://www.nuffieldtrust.org.uk/news-item/looking-to-the-long-term-the-japanese-approach