How innovative Japan could show the UK the future of healthcare
With attempts to tackle Britain’s demographic crisis proving politically toxic, ministers are looking further afield for answers. Laura Donnelly investigates
When Hideo Ishikawa holds the microphone close, to belt out a classic Japanese love song, he can forget his cares. The 79-yearold, who lost his wife to cancer earlier this year, has limited mobility and is crippled by constant pain. But when the karaoke track begins, he is transported to another time, when he would take to the stage to perform.
“I have a bad back, I can’t stand up, and I have to have injections to manage it,” he says. “But when I’m singing I completely forget the pain.”
Mr Ishikawa is among around 90 elderly visitors to Dream Lake Village that day. At first glance, the facility, based in a Tokyo suburb, looks like a primary school, with bright colours everywhere and evidence of amateur arts and crafts activities at every turn.
But the centre is part of a larger experiment – an attempt by Japan to face up to a growing demographic crisis which means there will soon be fewer than two people of working age to every pensioner.
Six thousand miles away in Britain, Theresa May is examining a similar dilemma.
It is one that successive governments have promised to face, but ultimately ducked, for many decades. Society is ageing, advances in medicine are vastly extending life expectancy, while a tide of “lifestyle” diseases means many of the extra years are spent heavily dependant on healthcare.
And all in an increasingly atomised society which means elderly relatives often live far from those they raised, all too often with little help at hand. State funding is failing to keep pace with the heavy demands on it, with the providers of care facilities increasingly walking away from the industry – claiming they cannot make a profit –and predictions of a £2.5billion funding shortfall within two years.
The current model is unsustainable, most experts agree. But every call for new ways to fund care of the elderly results in toxic political rows, and election setbacks, with models of social insurance that were mooted derided as a “dementia tax”.
Last month Mrs May announced increases in NHS funding, amounting to an extra £20billion a year by 2024. But the still bigger challenge will come later this year, when a Green Paper examines how to fund long-term care of the elderly.
Twenty years ago Japan was facing many of the same issues. Its population is ageing still faster than Britain’s, with life expectancy now at 84, three years more than that in the UK. More than 27 per cent of those living in Japan are aged 65 and over, compared with less than 18 per cent of those here. And neither country has enough working-age adults to support their elderly.
While the UK has 3.1 pensioners for every 10 working-age adults, in Japan, the figure is 4.6, latest research shows. Both trends are forecast to worsen sharply.
At the turn of the millennium, Japan introduced a new strategy: a new funding model for social care, and a concerted attempt to prevent ill-health and foster communities, keeping those approaching later life healthy and supported by their neighbours for as long as possible. Around half the funding comes from general taxation. The rest comes from compulsory insurance payments made by all citizens aged 40 and over – usually less than 2 per cent of income – while those who take up care are means-tested before paying 10 to 30 per cent of their costs.
In return they get a system with what experts describe as an intentionally wide remit, which promises to be universal and comprehensive.
Contrast this with the situation in Britain, where state provision of such care is focused on those with the highest needs and the lowest incomes. Now ministers in Britain are looking closely at the Japanese model – with indications that the forthcoming Green Paper could propose a system of compulsory insurance, as well as ways to use pensioners’ assets to contribute towards care.
Jeremy Hunt, the Health Secretary, has also commissioned a review into the use of genomics, robotics and artificial intelligence in the NHS, led by Dr Eric Topol, a US geneticist who tells The Daily Telegraph he is “really impressed” by the work going on in Japan.
At the offices of Tokyo’s Ministry of Health, Labour and Welfare, Dr Chieko Ikeda, the senior assistant minister, says Japan’s strategy is not just about the way it is funded, nor the breadth of coverage. Two other elements are central to the approach: the attempt to build communities, in order to keep older people connected to others and as independent as possible; and increasing use of automisation and artificial intelligence to help cope with ever-increasing demand.
“We want inclusive community care. The elderly people being ‘raised’ by the community. In this situation, the elderly – we need them to live well as long as possible. That is the most important thing,” she says.
Dream Lake Village is a prime example. Yuzo Okada, the deputy representative manager of Setagaya Ward, one of two locations run by the group, says even the physical environment is designed to foster independence and community. No handrails here, and little in the way of adaptations. Instead, those struggling with their balance can reach for a nearby chest of drawers, or steady themselves on a table.
“We want to create a situation that is similar to their own homes,” he says. “It is training them to make sure they can cope with real life.”
Anyone over the age of 65 and assessed as being in need of long-term care can come here, along with those aged 40 and over with particular disabilities, such as stroke patients. The centre has around 350 registered users in total, 90 visiting each day. “The purpose here is to encourage people to be active,” Mr Okada says. “They are set goals, and this helps them to fulfil their potential.” At the heart of this is a system which means all users of the home are able to earn currency, to spend on their favourite activities.
Washing their own dishes, helping fold laundry, and taking part in daily health checks are all ways to boost the 7,000 “yumi” they begin with. Winnings can be spent on karaoke, sessions in the music room or enjoying massage, art, swimming or baking. Those working at the centre say the autonomy is key to the success of the approach. “They chose their own programmes and make their own plans,” says Mr Okada.
“We encourage them to be as proactive as possible. When we get new staff from other care homes we find they want to do more of the tasks for the elderly. That might seem sweet, but actually it will make them deteriorate. We want people to stay self-reliant for as long as possible, so we try to stand beside them, not to always help them.”
Many of the activities are designed to keep people physically active, but they also provide mental stimulation, emotional engagement and help friendships to develop, he suggests.
“One purpose is to stimulate people’s cognitive abilities but we also want to stimulate emotions,” he says. “When they participate in games we see them become happy, and sometimes we see them become angry; sometimes there are a few fights.”
In the music room, Takeshi Nagano, 88, is playing the drums. The widower took up the instrument after registering with the centre five years ago. “I like the rhythm,” he says, simply, after completing a marathon session that belies his years.
More peace can be found in the art studio, where Hideki Akiyama and Hiroko Ozawa are painting. Mr Akiyama 60, a retired dentist, is painting with his left hand, after the stroke affected his right side. Mrs Ozawa has taken up sculpture and handicrafts in her 60s, after a brain haemorrhage five years ago ended her career as a professional wood carver. Both say the activities have helped to improve their use of their hands.
But it is the final hour of the day that garners most excitement. When the bell signals “Casino Time” just before 4pm, dozens of pensioners amass in groups for fiercely competitive card games, such as Yakuza and Mahjong, while others play boules and tombola. It also provides a last chance to boost the day’s dwindling currency stocks. “If I do well at Mahjong I can increase my yumi,” Mrs Ozawa says, smiling.
A small boy wanders into the fray, and is warmly greeted. Staff are allowed to bring children to work after schools finish, they explain. “We think it is good to bring generations together,” says Mr Okada.
The same theme emerges in another day centre, in another Tokyo suburb. Clock Tower House in the prefecture of Musashino City is one of eight 10 Million Houses – so-called because each receives a subsidy of up to 10 million yen from local authorities.
Meiko Hisamori, its manager, says the idea came from a group of mothers who became friends through the local Parent Teacher Association – and wanted to help their ageing parents, in the way that their parents had helped them bring up their young.
The centre offers classes in cooking, crafts, singing, Tai Chi, jazz and dance. On the day we visit, a group of well-dressed women are enjoying origami in an upstairs room. Downstairs, a smaller group are taking part in a class in Buyo, a traditional Japanese dance.
“My generation was helped by our elders when we were raising our kids,” Mrs Hisamori says. “Now that the generation who helped us is getting old we want to do more in return.” The same centre has groups for mothers and children, allowing the generations to mix over lunch, she says.
“We are trying to recreate the traditional Japanese community,” she continues. The classes build communities, while improving and maintaining motor and cognitive skills, says the manager. They also help older people to keep a sense of self-pride, she suggests.
“We see they start to care about themselves, about what they wear, about their make-up,” she says. “You can see a change in people.”
The centre is open to all those over the age of 65, who are independent enough to make their own way to it. Officials intend to expand the programme further, with one in every neighbourhood of the suburb.
Many might think that Japan already has a sense of community and duty that is fast disappearing in modern Britain. But officials say it is a country that is changing rapidly, with predictions that half the population will be living in single-person households by 2035.
And helping elderly people to help each other can only go so far. Japan’s forecasts show that by 2060 there will be just 1.2 people of working age to every pensioner – compared with a ratio of 2.6 to 1 in 1990.
Health officials believe that more radical solutions lie in a high-rise building not far from the centre of Tokyo. At Shintomi, a robot called Pepper is leading a class of around 20 pensioners in a singalong, with actions. The song is a traditional Japanese song, Spring Has Come, that the pensioners learned in their youth.
Here there is severe frailty, but there is plenty of laughter, especially when the robot responds with “It tickles” when an elderly person pats its head.
Mrs Kazuko Yamahada, 85, is beaming, “These songs remind me of my childhood,” she says. Over the last decade robots have been welcomed with affection into Japanese culture, in a way that might not be repeated if the model is exported. In brightly-lit Tokyo streets, hotel check-ins are performed by robots, with robot restaurants and bars widely advertised. Asked whether she would rather the class was led by a human or robot, the widow has no doubts.
“It’s more entertaining to be guided by a robot,” says Ms Yamahada, who visits the centre daily. It feels like a wonder to me that there is a robot talking and behaving like a human.”
Down in the basement, Takeo Takahashi, 88, has been unable to walk since a spinal operation 10 years ago. Twice a week he attends the centre for a 30-minute session on Popo (literally Step Step). The contraption raises him from his wheelchair, and supports his body weight, enabling him to step forward with ease, while building his muscle strength.
In the next room, Fumiko Shiota, 92, who is unable to walk unaided, is using another device called Walking Assist, aimed at those who have restricted mobility or are paralysed from the waist down. “I feel my legs become light when I use this. It makes me very happy, I feel younger,” she says, as she glides across the floor.
About 250 Walking Assists have been installed in hospitals and care facilities in Japan, with interest from other countries, and hopes it could be on the market in Britain within two years, its makers Honda say.
Mrs Shiota has only positive things to say about the role of robots – even going as far as to suggest she prefers them to humans. “I think they are a very good thing. It’s interesting especially when we communicate with the robot,” she says. “Pepper is so cute, with her big blinking eyes.”
Robot designers have made it so, well aware that the baby-faced features are likely to find most favour among old and young.
“Being guided by humans is also OK, but there is this cuteness with robots that humans don’t have.”
Given the choice between humans and robots to care for her, she says she can’t really see “any difference”.
Up on the sixth floor, dementia sufferers Uehara Teruko, 91, and Reiko Shimuzu, 87, gaze fondly at three robot seals – called Paro – as they pet them.
Hideo Aoyagi, a care worker, says: “Without the robots they just sit around and watch television. This kind of interaction helps to ease their stress and anxiety.”
Kitako Shina, 84, and Yasu Urari, 99, are more animated, as they play with Aibo – a dog-like robot, watching it perform tricks for them. Other robots in action include Cyberhal, a device that protects the back when heavy lifting, a bed that can be turned into a wheelchair and a monitoring system, which means the elderly can be checked without being disturbed.
Health officials from Britain are understood to have shown interest in the technology, called Sleepscan, and its potential to be used to monitor patients at home, reducing the numbers facing long periods in hospital. Sensors under the mattress can check vital signs such as heart rates and breathing, and monitor whether a person is awake, trying to get out of bed, or in a position that puts them at risk, with data continuously sent to a nurses’ station.
Last month the British think-tank the Institute of Public Policy Research suggested that within a decade robots and artificial intelligence could do a quarter of the work now done by doctors and almost one third of that done by nurses. At Shintomi,
The key planks of Japan’s health and care system Compulsory insurance to fund social care from the age of 40 A generous entitlement to care from the age of 65 onwards Inclusive community care The creation of services which keep pensioners active and connected Attempts to create intergenerational care Bringing old and young together
managers are more circumspect. Kimiya Ishikawa, the director of Silverwing Social Welfare, the corporation that runs the facility, says the main function of the robots is to reduce the burden on care workers.
“Under the current conditions, I think robots should stay being the assistants. But in the future, in Japan we know that there will be a severe shortage of caregivers. So, I think the robots are expected to evolve to have improved functions,” he says.
It is a development that other countries, including Britain, are watching closely. Last year Michael Gove was among those paying a visit to Shintomi, as part of a trip exploring Japanese expertise in technology.
Jeremy Hunt has shown a sustained interest in Japan’s policies, and speaks the language fluently, having spent two years living there as a teacher.
He has spoken frequently about the need to learn lessons both from Asian culture and technology.
“Earlier this year I visited Japan,” he says. “By 2040 a third of the country’s population will be aged over 65, and Japan has responded by capitalising on its well-known love of electronics to help patients monitor their health at home via smartphones and use robots to support patients in care homes.
“We need more of this kind of innovation in the NHS if we are to change the centre of gravity from cure to prevention – a National Health Service and not just a National Sickness Service.”
At the House of Representatives in Tokyo, Yasuhisa Shiozaki, the minister of health until last year, says he shares with Mr Hunt a belief in the power of technology to tackle rising demographic pressures. Over dinner in Kyoto in April they discussed the lessons Britain could learn from Japan – and vice versa.
“We have thinking in common about the role of digitisation and artificial intelligence in improving productivity,” says Mr Shiozaki, who describes Mr Hunt as a close friend. “We have to have a technological revolution.” The MP says that while Japan has done pioneering work in the field of robotics, the roll-out of such technology has been limited, with the Japanese government keen to encourage far more investment in the field. “In order to overcome the ageing issue we have to improve productivity far faster,” he says.
Chieko Ikeda, the senior assistant minister, agrees. “Robotics are important because the number of care givers is going to decline; for the sustainability of the care system we need greater efficiency,” she says.
And there are other benefits, she suggests, in a country where good manners reign supreme. “They don’t have to be nice to a robot!” she laughs.
In Britain, there is rather more unease. Last month Esther Rantzen, the campaigner against loneliness and isolation, spoke for many when she raised concerns that technology could leave already isolated pensioners with ever less human contact. “Nothing replaces people,” she told
The Telegraph. “All this remote care that you can do where you can track the little old person wandering from the kettle to the fridge so you know that they’re still up and about, I suppose that’s OK as a sort of fail-safe, but nothing replaces company.”
The 77-year-old added: “I can imagine a spaniel as company, I’m not a cat person but I can imagine a Persian cat could be company, but I cannot see myself sitting next to a robot watching television.”
When it comes to lessons from Asia, the Health Secretary has frequently suggested that such countries are better than Britain at engendering a sense of community.
Mr Hunt has previously suggested British families should feel “national shame” about the number of pensioners who have no company at all. The Health Secretary, whose wife is Chinese, said he was struck by the “reverence and respect” for older people in Asian cultures, where families were far more likely to take in their elderly.
“In those countries, when living alone is no longer possible, residential care is a last – rather than a first – option. And the social contract is stronger because as children see how their own grandparents are looked after, they develop higher expectations of how they too will be treated when they get old,” he said in 2013.
Natasha Curry, the senior fellow in health policy from the Nuffield Trust, visited Japan this spring to examine its systems of care for the elderly. She believes Britain has a lot to learn from the country – but should not attempt to import its policies wholesale.
Part of the problem with social care reform in Britain, she says, is that most people are unaware they are likely to have to pay for long-term care if they need it – meaning any proposed new deal is seen as worse than the status quo. Under the system, those in need of social care are means tested, with public funding available only when assets fall below £23,250, and free care only available when assets have shrunk to £14,250. This leaves Britons facing a lottery. Around 10 per cent of people will incur care costs of £100,000 or more over their lifetime, but it is impossible to predict who, and there is no market in social care insurance to protect against it.
“Part of the challenge with the English system at present is its opaqueness, and the sense of injustice that stems from the complexity of means testing and from national variation in access to services,” the think-tank’s report says.
While Japanese politicians recall little opposition when they brought in major reforms in 2000, which mean all workers must pay social insurance from the age of 40, on top of tax, and a contribution to care, Ms Curry warns of a “febrile” political environment in Britain. She says Britain could learn from the way Japan introduced its reforms – offering a positive vision of ageing, and clear, consistent and fairly generous levels of provision of care, targeted at an age group that was likely to respond to the message.
Looking back, some of the politicians involved in the Japanese long-term care reforms system wonder if it was too generous. Keizo Takemi, the former senior vice health minister, says the government took a “Keynesian” approach to social care, investing heavily in the reforms in 2000 in order to stimulate their success. “There was not much protest politically,” says Mr Takemi, now the chairman of the Liberal Democratic Party’s special mission committee on global health strategy.
Despite the fact those receiving social care had to make an upfront contribution to it, take-up far exceeded forecasts. Since then, the state has attempted to claw back part of the costs, with care home residents now expected to pay the hotel costs of meals and accommodation.
And Japanese politicians and officials are now asking their own questions about the sustainability of their system, and considering slimming down the level of provision on offer. To that end, the country’s policies are now focused on prevention, community services and the use of technology to meet the rise in demand. Asked what Britain might learn from Japan’s experiences, Dr Chieko Ikeda, the senior assistant health minister, hesitates. “One of the lessons that can be learned from Japan is that it took us about 30 years to change the system,” she says.
“Maybe if Britain can learn lessons from us it won’t take so long.”
Use of robotics and artificial intelligence to deliver care and monitor health