Reforming social care – the Japanese experience

How is the oldest population in the world – Japan – coping with the long-term health and social care needs of its population?

That is the question that a new report published by the Nuffield Trust attempts to answer:Caring for an ageing population: points to consider from reform in Japan.

I was one of a group who visited Japan as part of this project. In the report we describe how Japan introduced compulsory social care insurance to pay for care in older age.

Briefly, everyone over the age of 40 pays a monthly amount. This then funds social care for older people whose needs are assessed as meeting nationally standardised criteria. The scheme is also funded by a 50 per cent contribution from general taxation, with co-payments from care recipients on a means tested basis.

The interesting point we tried to probe was how Japan reached a political consensus in 2000 to introduce the scheme and how they achieved a consensus in the population that they were agreeable to pay.

The general population still think that social care is free or at least should be, so there is no public will to pay in more, in advance of care needed, in the form of social insurance

It was a time of political stability, with a general consensus amongst the public that the burden on families to care for older relatives was too great. Something had to be done, particularly to release women, the traditional carers into the labour market.

Although there was a backlash from conservative politicians, who felt that women’s place was in the home, that view did not prevail. Japan already has a compulsory health insurance system and so the introduction of co-payments for social care was acceptable to the public.

Initially, the eligibility criteria were fixed low so that a lot of people would benefit from some services, including domestic help. The monthly payment has been kept low to keep the popular consensus.

However, as the population ages and more people have more needs, the eligibility criteria have had to be raised, with an increasing level of need to be demonstrated before receiving these services. The financial viability of the scheme is under increasing strain and is being kept under constant review.

In the future individuals will either have to pay a larger co-payment, the monthly insurance premium will have to be raised, eligibility criteria will have to rise to a higher threshold, more money will need to be put onto the scene from general taxation, or a combination of those options may be required.

As we try and tackle the issue of social care funding for older people in England, it is apparent the social and political landscape is very different to Japan. We would like to have joined-up services but have separate health and social care budgets.

Health care is free at the point of delivery, with virtually no co-payments, (some exceptions are dental care, prescription charges and eye tests) whereas social care is currently means tested, resulting in the majority of people contributing towards the cost of their care.

The general population still think that social care is free or at least should be, so there is no public will to pay in more, in advance of care needed, in the form of social insurance. Whether the new arrangements if enacted in the English care bill will have widespread public support remains to be seen.

It is always fascinating to look at solutions to universal challenges in different countries and to see what we can learn. Caring for an ageing population is one of the biggest challenges facing our health and social care system and looking at Japan may help us reach some new solutions.

Dr Linda Patterson is a Consultant Physician. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.