The consensus on social care is that it is in need of reform. While there are differing opinions on the specifics, the majority of people agree the solution must have a long-term view.
In a report published on 22nd October, the Commons Health and Social Care Select Committee called on ministers to put forward a long-term reform package before the end of this financial year and to publish a 10-year plan for social care, to match the one for the NHS. The wisdom being, of course, that the difficulties involved are too complicated to be resolved by short-term actions.
One of the biggest issues facing social care is a relatively new one; an issue that several developed countries around the world are also trying to understand and counteract: we’re getting old. As the age of the nation rises, so does the cost of social care. Given that this issue is a relatively new one, there aren’t a lot of examples on which to base our response. But they do exist. Notably in the form of the Japanese care insurance system, ‘Kaigo Hoken’.
In the early 1990s, Japan was in a very similar situation to the one facing England today. The number of people aged over 65 kept rising, while the number of people aged under 16 fell. A victory for family planning and healthcare, but a dangerous concoction when preparing to fund elderly care. Japan was one of the first countries to recognise this growing issue in its society and, in response, it started to ‘aggressively attack’ the problem. This dedicated approach led them to produce their current long-term care insurance (LTCI) model. The basis for this model is that the responsibility for funding elderly care is borne by society as a whole, rather than by the individuals or families receiving it. However, it is designed to allow for a competitive private market to exist within this payment structure.
The model in short
In a nutshell, everyone aged 40 and over is insured under LTCI and pays insurance premiums. Premiums cover 45% of LTCI’s bill. Taxes cover another 45% and the remaining 10% is funded by co-payments from clients (although co-payments may be removed for poorer applicants). People aged 65 and over are eligible for care services whatever the cause of their disability or needs, regardless of income or whether family help is available. Your budget for services is determined by your assessment, which allows for seven ‘levels of need’.
Admission to the programme and classification into levels of need in the programme are completed by computer analysis of a standard questionnaire filled out by the applicant, which is then reviewed by an independent expert committee. Similar to the Scandanavian model, only formal services are provided. This means there is no option to reward informal carers with cash, or purchase non-professional care with your allowance, as people can in Germany. However, there is still a focus on driving consumer choice and market competition amongst care providers. By promoting national uniformity in the types of eligible service while allowing providers to compete for the opportunity to provide said service, the model preserves one of the most sacred aspects of British social care: freedom of choice.
However, the freedom to choose your own care and the ability to choose the right care are two separate things. You need experience, knowledge and empathy to do the latter. You need a care manager.
The role of the care manager
The Japanese system is designed to allow clients to choose which provider they go to and what services they want to receive from them. In practice, the care manager plays a key role in determining what services a client receives. They write a weekly ‘care plan’, which is a schedule of service provision for the client.
To become a care manager within the Japanese system, you must pass an exam and attend a brief training programme. Typically, care managers have experience in the field and, in many cases, they are employees of the provider who supplies most, if not all, of the care services to the client. To safeguard this system from abuse, final confirmation on a care plan always resides with the client and/or their family. They have to approve the care plan before it is actioned, and they can change their care manager at any time.
Moving the care manager into a more central role in the care process allows for a more direct application of knowledge to needs. Few would doubt the insight or empathy possessed by senior carers and co-ordinators here in the UK. Giving them more ‘official’ influence on the care their clients receive helps maximise the return on the expertise we, as a community, receive from them.
A care manager is effectively a regulatory body in the Japanese system. By making both the care manager qualification and service availability universal, the Japanese system creates a common denominator for care providers across the country. On the other side of the service, it makes the potentially daunting task of choosing care for yourself or a loved one a more straightforward process.
Keeping it fluid
There is no simple solution to the issues faced by social care. The Japanese have been amongst the most proactive Governments in the world to try and address their ageing population and they still face issues routinely. Recruitment remains one of the major concerns for LTCI in Japan. Major reasons for this are noted as: the wages are not very high, working conditions are tough, and there is little chance for promotion. These will sound distressingly familiar for many who currently work in the British social care system.
The rising cost of the system is also a concern. Premiums have risen since its implementation. The Government underestimated the amount of applications they would receive and, as the years went by, the cost of care continued to rise. This brings us to our final point of comparison: the LTCI review process.
The law establishing Japan’s LTCI specifies a fiscal review every three years. This review has become an opportunity to review the effectiveness of the system and implement changes as necessary.
One example is the introduction of ‘care prevention’ for people in the lower needs groups. Efforts to reduce cost have involved developing community involvement in long-term care and focusing on ways to help people stay independent. This review process was also used in 2010 to increase pay for care workers to help improve recruitment and retention in the sector.
It would be naive to think these reviews solved every issue the LTCI faced. However, as a practical approach, establishing a routine for review helps establish a framework for improvement. In the UK, we have had The Care Act 2014 – which was the first major overhaul of social care legislation in 60 years – as well as official reports such as the Dilnott Commission in 2011, a report whose suggestions went largely unimplemented, something that Sir Andrew Dilnott admitted was due to cost and, ‘A lack of strong support from the Treasury and strong support from the Prime Minister.’
Here, too, the UK can take a leaf out of Japan’s book. The Japanese LTCI system is far from perfect, but it has become a cultural tentpole in Japanese society. The country faced a national demographic crisis and, through focused response and ongoing review, has been able to build something that provides care to vulnerable members of society and a sense of security and pride to younger generations who
pay into it. Despite all its issues, the results have been a source of great national pride.
The Nuffield Trust produced a Green Paper on this same topic two years ago. One of the major obstacles to UK implementation it identifies is a lack of public ‘buy-in’ or cross-party support to get reform of this scale onto the legislative agenda. A lot has changed in the past two years.
The social care sector in the UK is in the spotlight in a way that it has never been before. We are at the forefront of the national consciousness by virtue of being on the front lines of a national crisis. There is no perfect solution, but there’s an awful lot of people calling for a new process, and we must act quickly to utilise this consensus to our advantage.