Caring for the elderly is a difficult and sensitive issue, particularly when the finances are tight. England can learn from Japan’s historic decision to bring it into the political spotlight

In expressing a desire for England to be the best place in the world to grow old, Health Secretary Jeremy Hunt recently suggested that it should be more like Asia in caring for older people: drawing on the resources not just of the state or the individual, but the family. Yet evidence from Japan highlights why an overreliance on families is problematic and why it may be better to invest in services rather than reduce budgets. The only problem – as ever – is how to pay for it.

Until 2000, caring for older people was a family matter in Japan. Publicly funded social care was non-existent. Changes to the structure of society – increasing numbers of older people living alone and female participation in the workforce – meant that this position was increasingly unsustainable. The burden on families became overwhelming and a third of all carers reported feeling ‘hatred’ towards the elderly relatives they cared for.

Also present was a phenomenon known as ‘social hospitalisation’ where people with care needs, but not necessarily health needs, effectively lived in hospitals for months on end. Breaking point was reached when public pressure, coupled with media stories of extreme abuse and neglect, led the Japanese government to instigate radical reforms.

The government introduced a universal long-term care insurance scheme, where all those over the age of 65 receive care on the basis of needs alone. Income and wealth are not part of the assessment process. The system is part-funded by compulsory premiums for all those over the age of 40, and part-funded by national and local taxation. Users are also expected to contribute a 10% co-payment towards the cost of the service.

The result is that older people in Japan can now access a wide range of institutional and community-based services, with few of the barriers to access that exist in England. Where previously the social stigma of sending a relative to be cared for by strangers meant very little formal care was available, the government has succeeded in creating a highly diverse market for providers of services.

The tricky part, of course, is paying for it. As uptake of services in Japan has far outstripped expectations, costs have spiralled. In response, the government has reduced access to preventative services, and is considering increasing co-payments for wealthier older people. We know that some local authorities in England have also increased fees to service users, and many have restricted services to those most in need.

An important point is that the reforms in Japan were spurred on by a national recognition of the problem – a very public airing of this difficult issue that has still never really taken place in England. This led to a consensus that has proved enduring. Thirteen years on, the Japanese public remain enthusiastic about the insurance scheme and the services they receive.

Westminster is currently debating a Care Bill that attempts to define whose social care needs the state will support (still not many) and who will be left to support themselves or rely on family. The implication of the Care Bill is that social care in England will remain complicated to understand and navigate, and that the majority of people will still be without state support.

But the lesson is not that England should simply import Japan’s solution to the challenges facing social care. Introducing a universal system like the one in Japan would mean hefty tax rises or compulsory insurance and it seems doubtful that the public would accept this without first having a deeper understanding of the current situation and a greater trust in the quality of existing services.

Where England can learn from Japan, though, is having the courage to bring social care into the political spotlight – and accepting that with no end in sight to population ageing, no single reform will be final.

Holly Holder is a fellow in health policy at the Nuffield Trust in the UK. She is the co-author of Caring for an ageing population: points to consider from reforms in Japan