Colourful sheets of paper were deftly transformed into flowers, boxes and spinning tops as the elderly women focused intently on their origami task.
The room was a hive of activity – elsewhere a fierce game of bowls was under way, a woman warbled along to a jaunty karaoke tune, and a man received a massage from a physiotherapist.
The Express was visiting Michiai nursing home in Kawaguchi City, just north of Tokyo, where a few dozen locals attended a day centre.
The activities were carefully chosen to keep their brains and bodies active; origami and bowls encouraged fine motor skills and movement, while karaoke exercised the lungs.
Japan is home to the oldest population in the world, with around 29% of people – 36.3 million – aged 65 and over. Two decades ago, the country was facing a social care crisis much like that now gripping the UK.
The Express received a warm welcome at care homes in Kawaguchi City (Image: Jonathan Buckmaster)
But while successive governments here have tried and failed to reform elderly care, Japan grasped the nettle in 2000 and radically overhauled its system of funding and provision.
The Express travelled 6,000 miles to find out what Britain could learn from Japan’s revolutionary Long-Term Care Insurance (LTCI) system.
Considered to be a world-leading model, it is funded by a combination of social insurance contributions, general taxation and user contributions.
Every worker pays insurance premiums from the age of 40, set by their local authority and dependent on their income. When they need support, those over the age of 65, or aged 40-64 with age-related conditions, undergo an assessment and receive a care budget.
They are then asked to contribute a small amount depending on their income, with the rest covered by state funding and the social insurance system. The vast majority of Japan’s elderly residents pay only 10% towards their care at the point of use.
Yuichi Sakamoto, Kawaguchi City’s director of social welfare, told us a typical pensioner contributes around £250 per month. He said the reform created a much fairer system because “society as a whole has started to take care of the elderly, whereas before it was the family.
A game of bowls was being played at Michiai nursing home (Image: Jonathan Buckmaster)
“Previously, there was a strong sense in Japan that women should take care of their families. As a result, many women had no choice but to quit their jobs. This means that, with the active working population declining, the workforce cannot cover the needs of a shrinking population.
“The establishment of the LTCI system has made it possible for women to continue caring for their families while also continuing to work, and I think this has helped in terms of balancing work and care.”
The funding overhaul created an incentive for more providers to join the market, offering a range of services including residential and at-home support.
Day centres like the one at Michiai aim to help people remain independent for as long as possible. They offer therapy and activities to maintain mental and physical functions, as well as encouraging social connection to prevent loneliness.
The home also has 29 inpatient beds for those needing round-the-clock care. Manager Yoshihiro Ushijima, 65, said self-determination was at the heart of services.
Residents make decisions about their care wherever possible and staff carry out detailed assessments for those who do not have the capacity.
Mr Ushijima added: “This is not just a sheet of A4 paper, but the person’s story – place of birth, schools attended, employment, marriage, friendships.
“Hobbies, of course, but also the music they listened to, the newspapers and books they read, which can give us an idea of the person’s ideological background. Even if we cannot communicate with the person, we can imagine the kind of life they would like to lead at the end.”
A day centre attendee was receiving a massage from a physiotherapist (Image: Jonathan Buckmaster)
Kawaguchi City has a population of around 600,000, 23% of whom are aged 65 and over. At another nursing home, Dai-ni Shunko-en, we heard that most residents with typical care needs paid around £800 per month towards their care.
The facility had spacious bedrooms, shared living spaces designed to feel like a home, and regular activities. One wall displayed photos from day trips to locations including a strawberry farm, an aquarium and even Disneyland.
Sachiko Ishii, a 94-year-old former teacher, showed us her worksheets of exercises that keep her brain active. Putting her arm around a staff member, the beaming resident said: “Thanks to this good person, I am 94 and have lived longer than my parents and siblings.
“I enjoy the food every day, and I don’t leave any. The people here have taught me a lot, I eat well and live a happy and secure life.
“I really enjoy it and thanks to them I am living long. I’ve had a good time so if they come to take me tonight, I’ll be happy to go.”
The 2021 Census in England and Wales found that more than 11.1 million people were aged 65 and over, accounting for 18.6% of the population. This was up from 9.2 million, or 16.4%, in 2011.
When Japan’s long-term care insurance system was introduced in 2000, over 65s accounted for 17.4% of its population.
Perhaps unsurprisingly, the services we saw during our time with officials in Kawaguchi City were excellent. But our hosts were also honest about the fact that this funding system is under threat.
Former teacher Sachiko Ishii, 94, was very happy with the care she received (Image: Jonathan Buckmaster)
In the future, it may need to start taking into account people’s financial assets, as the number needing care continues to soar.
Mr Sakamoto said: “Around 30% of Japan’s population is aged 65 and over, with the peak coming in about 15 years. While the number of elderly people is rapidly increasing, the working population is rapidly decreasing, partly due to the declining birth rate.
“This situation makes it increasingly difficult to financially support the system without asking those with assets to bear more of the burden.”
Japan’s LTCI system faced strong opposition from some people who preferred the traditional method of families being responsible for care, and it took three years for the reforms to be passed.
Mr Sakamoto added: “There was also deep-rooted criticism that it would not work because it was creating something that had not existed in the world before.
Japan has a low birth rate and rapidly ageing population (Image: Jonathan Buckmaster)
“But if the UK is going to create a system, I think it will be easier to persuade those who oppose it, because they can see the results from the Japanese precedent.”
Natasha Curry, deputy director of policy at the Nuffield Trust think tank, visited Japan in 2018.
She said the LTCI system was not perfect but had created “a positive vision for the future of care, appealing to the entire population and establishing social care as an essential element of its social and economic fabric”.
She added: “Our society and economy need good collective social care to thrive. Building a system based on fairness, clarity, consistency and sustainability is a good place to start.”
Japan’s system is not perfect but set a positive vision for the future of care, says NATASHA CURRY
Japan has the most rapidly ageing population on the planet. Its working-age population is shrinking, and for every person aged over 65 there are now fewer than two people of working age.
This startling demographic is partly what pushed the country in the 1990s to seriously address how it best supports people who need some form of non-medical support.
The country quickly recognised that such social care was not just an issue for individuals to cope with, but of vital importance to society and the economy.
By the year 2000, Japan had brought about a comprehensive and radical reform of care for the over 65s, based around a positive vision where people are supported to live as independently as possible.
Everyone in work over the age of 40 pays into a national fund which is topped up by national taxes. If someone needs care – which is established via an easily accessible assessment – they are entitled to a notional monthly budget to spend on care of their choice.
That budget is set nationally and increases according to the severity of need.
Importantly, it does not depend on postcode or financial means or personal circumstances.
Care is not completely free but personal contributions are capped at a monthly maximum to protect people from very high costs.
Providers of care are paid adequately and compete solely on quality and reputation.
Alongside this formal care, local authorities have invested heavily in prevention and community networks to combat loneliness and promote independence.
It’s not a perfect system, but Japan has in place the solid foundations of a functional support system.
It did it by setting a positive vision for the future of care, appealing to the entire population and establishing social care as an essential element of its social and economic fabric.
The UK, where social care reform too quickly gets mired in a negative debate focused on individual costs, inheritance and who pays, has much to learn.
Our society and economy need good collective social care to thrive.
Building a system based on fairness, clarity, consistency and sustainability is a good place to start.
– Natasha Curry is Deputy Director of Policy at the Nuffield Trust