Japan currently has the world's highest proportion of older people and the largest number of centenarians. According to the stereotype, Japan's tradition of strong family care for older people means that dedicated and responsible children look after dependent older parents within extended family living arrangements, with very few institutionalised elderly. In reality extensive family 'care' sometimes featured disturbing neglect and abuse of vulnerable older people, with many 'abandoned' older patients effectively left resident in hospitals with little or no need of medical care. Japan's post-2000 social care reform widened the spectrum of service delivery beyond traditional family practice, but has resolved neither 'care-giving hell' nor 'social hospitalisation'.
How and why have these problems arisen? This paper examines three long-term care arrangements: public residential provision, family care and hospitalisation, allowing for cultural norms, particularly traditional values of filial piety and the stigma surrounding institutionalisation of older people (often associated with Obasuteyama or 'granny-dump mountain'). It then considers current issues, briefly exploring the new social care reform, and challenges vague assumptions concerning Japan's care of older people, thereby adding to current policy discourse on feasible aid for ageing populations.
Traditionally the Japanese family was the principal source of support for older people, with children looking after their frail parents as a matter of course under the Confucian ethic of filial piety. This was reinforced legally under the Meiji Civil Code of 1898, which stipulated the patriarchal family Ie system. Under the system the eldest son was responsible for his elderly parents - though actually cared for by his wife - and for other members within extended family living arrangements, in return inheriting the family's entire assets.
Correspondingly, institutionalisation of older people suggested family neglect, failure of filial piety, abandonment and shame. Public residential homes were commonly associated with Obasuteyama, a legendary mountain upon which eldest sons left aged, dependent parents who had outlived their usefulness to die of starvation and exposure. Japanese literature and folklore sustain this image in the public imagination.
Long after the 1868 Meiji Restoration, Japan's post-feudal government remained extraordinarily centralised, authoritarian and paternalistic, emphasising familistic nationalism based upon worship of the Emperor as a living deity, with little concern for needy individuals. From 1874 poor relief legislation offered minimal help - usually food - to the over-70s lacking any family support, alongside orphans and the severely impaired. This represented at best discretionary, charitable assistance; ostensibly mutual support driven by compassion but deterring requests for relief and associating these with shame and stigma. Accordingly, the numbers of recipients were minimal - a mere 1,200 in 1877 and 3,800 in 1909.
Belatedly, the 1929 Public Relief Act, effective from 1932, lowered the age limit to 65 years and introduced 'indoor' assistance. A few public almshouses were built in big cities where demand was high, while state subsidies supported some existing almshouses elsewhere. Yet people who were considered able-bodied, non-solitary, 'lazy' or morally inadequate were still excluded, recipients had no rights to poor relief and were disfranchised. They were stigmatised as pitiable failures - neither self-reliant nor with supporting families, a trouble to the Emperor and the state. This hardly represented systematised relief: in 1935 recipients constituted only 0.05 per cent of the general population and just 2,000 older people were aided in some one hundred almshouses from an over-65s exceeding 3.2 million.
Japan's post-war Constitution ostensibly assumed state responsibility for all citizens and its 1950 National Assistance Act required local authorities to provide old people's institutions for those unable to live independently. Admission to these 'assessed institutions' was determined by local authorities through means- and needs-assessments of applicants and their families. Such legislative provision remained essentially supplementary: family support preceded public assistance in care and only 'marginal' older people - poor, less frail and completely alone - were helped. The pre-war position - that only totally destitute individuals might, as a last resort, receive public relief - remained intact. Accordingly, institutional expansion was limited and stigmatised, while legal, customary and moral obligations and social pressures surrounding family care for older people remained strong.
Meanwhile, the poor but frail or chronic sick requiring continuing care were effectively excluded from old people's institutions, as were others needing medical attention. They were left to self-help or any available family care due to the absence of affordable home or residential forms of continuing care. Of course, these shortcomings must be placed in the context of Japan's post-war problems: in a country with huge numbers of people of all ages in poverty, the government and the public still regarded care of older people as a family responsibility, and economic recovery was the national priority rather than public welfare services for the 'unproductive'. Nor was there mass demand for long-term care for older people: with average life expectancy in 1950 just 58 for men and 61 for women, only 4.9 per cent of the total population were aged 65 or over and 1.3 per cent aged 75 or over. Lack of residential care provision, its quality or related services, was yet not a major political concern.
Belatedly, the 1963 Elderly Welfare Act introduced nursing homes for this more infirm elderly clientele. Admission was needs-based, but there was a sliding scale of fees for residents and their families according to their means. As nursing homes were also regulated as 'assessed institutions', application processes required information about family background, income and assets to be disclosed to local authorities. The stigma of being left uncared for by family members and dependence on public welfare remained strong, and many people were reluctant users: they still associated new nursing homes with Obasuteyama. Moreover, the slow expansion of nursing homes in the face of demographic ageing and economic slowdown after the 1973 oil crises meant that the shortage of facilities intensified, resulting in more cases of family neglect and abandonment of vulnerable older people.
Historically Japanese family care did not involve long-term constant or intensive nursing for very sick or disabled older people because of insufficient medical care and correspondingly low survival rates after acute or critical illnesses, or among survivors with severe disabilities or poor health. Only 30 per cent of Japanese people reached the age of 65 and average life expectancy was 63 years for men and 67 years for women in the mid-1950s. A universal health care insurance system was introduced in Japan in 1961, but this covered only half of older people's total medical costs, leaving many without access to medicine and medical treatment.
Fully 80 per cent of Japan's older people still lived with their offspring in extended families, but many became victims of neglect or abuse from family carers too poor or too busy making ends meet. For example, in rural Japan the main cause of death was cerebral vascular disorder; its survivors were usually left with severe disabilities or medical conditions. With their families fully occupied with housework, agriculture or sericulture, such people were often left with just rice balls and water at home during the daytime, as were the chronic sick, frail or senile elderly. Malnutrition and poor sanitary amenities often caused severe bedsores and those frail elderly who became wholly bedridden or fell into an acute condition, and families, simply gave up and accepted their fate. With severe poverty, lack of time and resources for care, and the absence of public institutional alternatives, Obasuteyama seemed to have arrived in the family home.
Japan's economic recovery failed to alleviate matters. In 1968 the first comprehensive investigation revealed that about 200,000 of the over-70s living at home were bedridden, one-half lacking medical treatment and just 8,000 receiving extra-family support. Experts were shocked that four per cent of Japan's older people were bedridden, about twice the European rate, and the exposure of domestic Obasuteyama challenged conventional depictions of family care and the stigmatisation of public residential care. Although the government subsequently encouraged expansion in nursing homes, this failed to keep pace with demand, with 360,000 bedridden older people at home, compared with the 40,000 available nursing home places in 1975. Meanwhile, public forms of care at home remained limited to the most needy elderly and subject still to association with stigma.
Equally disturbing were the high suicide rates among Japanese older people, averaging sixteen deaths daily. Loneliness, family conflicts, illness or financial matters featured, but most common was self-sacrifice to eliminate stresses upon others, placing family above all, a practice seemingly morally and socially endorsed. Interestingly, at Pokkuri-dera (literally 'sudden-death without suffering') temple near Kyoto, over 40,000 elderly visitors annually placed underclothing before the Buddha, praying 'please let me die peacefully before I am no longer able to change my underclothing and have to face shame and burden my family'.
Alarmingly a 1994 national survey claimed that one in two family carers had subjected frail older relatives to some form of abuse, with one in three acknowledging feelings of 'hatred'. This state of affairs was partly attributable to shrinking numbers of care-givers and the heavier burdens placed upon them, reflecting further changes in demographic and residence patterns, gender roles and employment practices. According to a 1999 official survey, nearly one-quarter of family carers daily spent over eight hours on caring tasks and half were aged 60 or over. Many concealed their abusive conduct, suffered strong guilt and shameful feelings, or blamed themselves rather than inadequate public care provision. Here was the context for the social problem of 'care-giving hell', extreme cases involving the killing of whole families and forty reported homicides annually.
Fortunately more families found a new institutional alternative: the hospital. Until 1973 Japan had no geriatric or psycho-geriatric hospitals as such, although some general hospitals dealt with older patients. Their subsequent growth followed provision of free health care for most over-70s in 1973 and a surge in elderly admissions: by 1980 there were 432,000 hospital inpatients aged 65 or more, four per cent of all over-65s. With an average hospital stay of 103 days, many such patients were seemingly 'living' in hospitals, requiring social care but little or no medical treatment, a situation dubbed 'social hospitalisation'. Most were sent by their families who felt crushed under care burdens and could no longer cope.
Why did this happen? First, public nursing homes, then the only alternative to 24-hour family care for bedridden or frail older people, offered only 80,000 places in 1980, compared to the 432,000 hospital beds noted above. Second, hospital provision was now free for most over-70s, although per capita costs were two or three times those in nursing homes. Third, unlike nursing home provision, hospital admission involved no means-testing and little needs-assessment and thus entailed no welfare stigma or lengthy and often degrading assessment procedures. Hence elderly users and their families availed themselves of such support and avoided the stresses of family care: the latter was still legally and socially endorsed, but hospitals offered medical and social assistance and camouflaged the shifting of social care arrangements. Families could disguise as 'a necessary hospitalisation', the admission of their aged parents, thereby avoiding their domestic or nursing home care.
Thus another Obasuteyama was arguably created at hospitals, less appropriate or comfortable than nursing homes for the non-sick frail elderly but a cost-free, non-means-tested option which freed up family carers. And, if social hospitalisation was a problem, families usually could not or would not take older relatives back home, since there was hardly any public or affordable community support for them.
Official responses to media disclosures concerning levels of abuse and neglect of older patients and excessive profitability and poor management of hospitals were limited. Central government reacted to social hospitalisation, not from concerns over patient welfare but because of the rocketing increase in elderly health care costs. It did so by focussing upon allegedly irresponsible and uncaring families who abandoned older relatives to hospitals, similarly condemning such hospitals for helping 'bad' families and profiting excessively through social hospitalisation, but without providing appropriate alternatives.
In 1982 the Elderly Health Care Act targeted social hospitalisation. Free medical care for most over-70s was abolished and small user fees introduced as disincentives. Flat-rate monthly fees for non-acute older inpatients replaced pay-as-you-go charges, to stop hospitals profiting from unnecessary and excessive medical treatment and prescription. More disturbing were efforts to make hospitals target those older patients deemed to be socially hospitalised and discharge them to their families or to local authorities. Meanwhile, the government retained supplementary and means-tested measures in flagship nursing home provision, still stigmatised and in scarce supply. Thus official emphasis remained firmly upon family care, with older hospital patients seen as financial burdens rather than victims. Nonetheless without stigma-free alternatives beyond family care, some 275,000 older patients were still socially hospitalised, costing two billion yen, in 1999.
Internationally, Japan's reputation for strong family care and a lack of institutionalised elderly was sustained for a long time. There were insufficient cross-national statistics on the longer-term institutionalised elderly who were not to be found in care homes. Japanese data typically excluded socially hospitalised older patients, who were effectively residents. When they were taken into account, the ratio of institutionalised elderly in Japan was not particularly low by the early 1990s - and these elderly patients experienced the world's longest hospital stays. In 1993, some six per cent of Japan's over-65s were institutionalised, higher than some European countries and only slightly lower than the USA (6.5 per cent) and UK (under 7 per cent).
Japan's comprehensive Long-Term Care Insurance (LTCI) scheme in 2000 was funded equally by taxation and insurance premiums paid by everyone aged 40 or over. These arrangements finally removed supplementary and means-tested measures and, instead, featured mandatory contributions, uniform entitlements and elements of consumer choice. LTCI represented a decisive shift from family care towards a spectrum of service delivery within the mixed economy of care, in effect the socialisation of care as part of a social contract. Existing nursing homes and two other long-term medical institutions have been duly integrated within LTCI, although the post-1950 old people's homes remain outside as 'assessed institutions'.
LTCI was popular and expanded much faster than official predictions: by 2005, LTCI expenditure totalled 6.4 billion yen, compared with the predicted 5.5 billion yen. This was largely due to significant increases in community care services for older people with light care needs - 1 million people in 2000 and 2 million by 2003. In contrast, services for those with heavy care needs, particularly residential care, increased only moderately, from 0.5 million residents in 2000 to 0.7 million in 2003. This suggests unequal service distribution among qualified older people: the burden of family carers looking after severely disabled older relatives barely changed after LTCI, according to a 2002 official survey.
Government responses focused upon cost cutting through stricter rationing, tightened service eligibility criteria and top-up fees, all integrated into LTCI revisions in 2005. Home-help services are now restricted to older people living alone and with severe disabilities. For those in residential care, additional 'hotel costs' were introduced on top of ten per cent copayment of the care component. As a result, although almost 5 million older people (17 per cent of all over-65s) were qualified for LTCI services in 2009, nearly 1 million used no services whatsoever and 3 million choosing home care took up less than half of their maximum entitlement, partly reflecting their financial difficulties.
Meanwhile, social hospitalisation continues, with 250,000 hospital beds - one sixth of the total - still occupied by older patients with chronic conditions, as does the acute shortage of nursing home places due to restrictions on public capital investment subsidies. Some 420,000 older people are currently on waiting lists, almost equivalent to the total of existing places. Nevertheless, the government recently announced the closure of all these 250,000 hospital beds and some 130,000 more LTCI beds used for long-stay places, producing a public outcry and fears that thousands of 'refugees' will be thrown out into the community without 24-hour care alternatives.
This brief survey suggests that LTCI is no panacea, although it has greatly alleviated the burden upon many family carers. It confirms the importance of limited resources and the familiar question - 'who is entitled to what?' - when it comes to care of older people as the state reduces its responsibilities. It also suggests that initial ambitions to replace family care with LTCI statutory provision soon proved unfeasible and seemed unsustainable in the context of Japan's rapidly ageing population and continuing economic uncertainty. By 2025 LTCI expenditure needs to double just to keep pace with the doubling of the over-75s, with further increases in insurance premiums or taxation or both. With neither option easy, older people who are already losing out from the recent policy changes will inevitably be affected badly.
The prospects for long-term care for growing ageing populations are daunting, but this does not mean that efforts on future planning are pointless. However, innovative thinking about alternative resources to supplement LTCI provision and family care will be required. For example, Japan has developed mutual-help networks of local people based upon a time-banking system, under which volunteers earn 'time credits' for caring for older people in their community. They can use credits to buy similar services for themselves later in life or currently for their frail elderly parents living elsewhere or for others in need. Over the past 25 years, several schemes have developed wider networks, enabling credits to be transferred between branches nationwide.
Such schemes may represent cost-free and humane alternative resources, noted by the British government in the context of the Big Society agenda. Windsor and Maidenhead Council is ready to implement a pilot time credit-based scheme, 'CareBank' from September 2011, which may be delivered on a national scale. Yet Japan's schemes remain small-scale by comparison with LTCI statutory community care, and their further expansion requires sustained public funding to deal with growing demand in regular and continuing personalised assistance for older people with different needs. Neither the Japanese nor British governments seem to be allocating appropriate levels of funding towards voluntary organisations and families who are willing to take on care responsibilities, despite the shared 'Big Society' agenda.
This survey of care for older people in Japan has revealed some of its complexities, deeply rooted in the legacy of paternalistic and familistic nationalism, traditional values of filial piety, and the persistent stigma associated with institutionalisation and public welfare.
Family responsibility with minimalist supplementary and means-tested state involvement characterised Japan's legislative approaches towards social care for older people throughout the twentieth century, influencing the 1929 Public Relief, 1950 National Assistance and 1963 Elderly Welfare Acts. Residential provision was stigmatised, with compulsory means- and needs-assessments of elderly applicants and their families, even as eligibility criteria were widened. Post-1963 nursing home provision represented a move towards needs-based, specialised care, but compulsory assessments still featured, with limited places confined to the most needy elderly who lacked financial means and family support, thereby sustaining the stigma associated with Obasuteyama and public assistance.
Moreover, by 1970 Japan was becoming an ageing society, requiring far more long-term care, particularly for frail older people - although the capacity of families to provide this continued to decline. Accordingly, Obasuteyama featured in two further ways. In stigma-free, non-means-tested hospitals, large numbers of older patients were effectively abandoned as residents, producing the phenomenon of 'social hospitalisation', on par with some European countries by the early 1990s, when Japan's older patients had the longest hospital stays in the world. Meanwhile, some forms of domestic family 'care' featured disturbing levels of neglect and abuse of older people, producing 'care-giving hell' and even homicide.
Hospital, public residential and family 'care' were not positive alternatives to family care but last resort measures - another form of Obasuteyama. They arose at least in part because successive Japanese governments throughout the twentieth century continued to limit state support for care to supplementary means-tested measures and maintained separate health and social care systems.
Only in 2000 did this approach change with the comprehensive LTCI reform, offering a wide spectrum of care service delivery beyond traditional family practice. Nursing homes and two other long-term medical institutions are now integrated within LTCI, but the post-1950 old people's institutions still remain outside with the more dubious official status of 'assessed institutions'. Moreover post-2005 economies and revisions to LTCI are rolling back care responsibilities from the state to the family, echoing restrictive approaches to residential care provision under the 1929, 1950 and 1963 Acts.
More positive indicators of government commitment to elderly care are required than economy measures and the downsizing of public sector provision, above all, in avoiding the problems of care-giving hell and social hospitalisation. The growth of Japan's mutual-help networks under a time-banking system could be one way to supplement statutory provision in reducing the burden on family carers. Their co-ordinated expansion requires regular public funding, albeit at lower levels than LTCI provision: Japan's experience has already revealed that neither LTCI nor voluntary time-banking schemes should be regarded as catch-all solutions, but should both be seen as valuable and necessary. A best-case scenario could involve a tiered system with sufficient and good statutory specialised care, supported by various voluntary services that can meet the volume and variety of less-specialised care requirements. But pursuing this objective, as populations age and economies continue to struggle, remains a challenge for Japan and Britain alike.
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