Taiwan, Hong Kong, UK & Japan Two Years before the Nursing-care Insurance SystemMarch 1998

As the ratio of the elderly has increased rapidly, prompt measures are demanded. The number of the elderly people who need care because of being bedridden, dementia and/or frail is 2,800,000 in total in 2000 and will be 5,300,000 in 2025 (the Ministry of Welfare). Since the public long-term care insurance law will be enforced two years later, the municipal governments are hurryingly preparing manpower and facilities nationwide in accordance with the New Gold Plan. Three years ago, when a plan for the long-tern care insurance law was announced, Ogaki City started the twenty-four-hour visiting care services immediately. We can see Japanese welfare of tomorrow in Ogaki City, Gifu Prefecture.

“He wet his bed three times and his sheet sopped. His wife can’t change his sheet, because she can only manage to look after herself.” “I’d like to suggest his using diapers. Do you know anyone who can tell him about it without hurting his pride?” Home care aides were talking at a home-visit nursing care station.

The man and wife whom the home care aides were talking about live in a luxurious mansion with a gate and walls that seem very expensive. You can get a ready-built house for the gate and walls alone. “I’m ashamed that my house is very messy,” said the doctor’s wife (63), who was suffering from aphasia after the operation for cerebral hemorrhage, guided me with the help of a stick to the room where her husband (74) was lying on the bed. The left lower half of his body is paralyzed after he had a stroke. In the living room with a mantelpiece, there are two steel beds instead of a table and sofas. “He worked and worked. When we could afford to go on an overseas trip, we went there,” she said, pointing to the pictures on the wall. “But that was our first overseas trip and would be the last.” The wall is covered with the pictures of them standing in front of the Vienna Ferris wheel, which can be seen in the movie “The Third Man,” and the pictures of their grandchildren.

The man was the head of a hospital. Eight years ago when he had a stroke, he stopped admitting patients to his hospital, and he closed it four years ago. He has rented his hospital building to the city as a day-care service center. Now he uses short-time home-visit care service twice a day in the morning and evening and long-time home-visit care service twice a week, and he also goes to and from a day-care service center by bus once a week.

At 7:15 a home care aide came to give short-time home-visit care. Since he is a doctor, it is easy for him to be hospitalized through his connections. But he himself knows better than anyone else that he doesn’t need to stay in hospital for treatment. All he needs is a nutritionally balanced diet, clean and well-regulated living and rehabilitation training. The home care aide asked him first if he wanted to go to the toilet and washed his artificial tooth and glasses, and then she cleaned his face and hands with a hot towel.

“Take it easy,” she said and helped him to his feet. There is a chair a little less than two meters away from the bed. It’s very tough for him to balance himself and take a step to the chair. He is training himself for rehabilitation, by standing up from the chair and sitting down 50 times with the help of a walking frame. When he does this training with his wife, he will not do more than 30 times. But the home care aide, who is unrelated to him, makes him tense moderately. “It takes a lot of time to recover from this kind of disease, but this therapy is effective,” he said, putting a towel around his neck to the outer corner of his eye. “I can take a bath and have a nutritious meal at the day-care center in the afternoon. Welfare work here is wonderful.” He appreciated it.

They have two daughters and one son. One of their daughters married and lives in another city, and the other daughter is a career woman who travels all over the world on business. Their son is a doctor, but he works for a hospital in Tokyo and cannot come home even on the New Year holidays because of his duty. It can safely say that their children can devote themselves to their own works because their father can use nursing care service provided by Ogaki City. The city started to carry out the New Gold Plan earlier than the other cities. After cleaning up around the bed, the home care aide asked him, “Is there anything else you want me to do?” Then she checked the locks. After that she got into her car and drove off for another elderly person’s house.

Ogaki City, where a haiku poet Basho Matsuo concluded his famous travel writing Okuno-hosomichi, has a population of 150,000 in the area of 80 square kilometers. Among of them, people aged 65 and over are about 23,000. The percentage of the elderly in the population of Ogaki is 15%, same as the national average. The percentage of the social work expenses in the general account is 20%, which is also the average. Not only day care and short-stay services but also an around-the-clock home-visit care service are started early in Ogaki City. What made these services available so early were Mayor Mitsuru Ogura’s top-down policy of ‘an approach run for implementation in 2000’ and citizen’s feedback on the welfare of elderly people to the assembly.

Ogaki City entrusted the work of providing care services for the elderly in need of care to the Ogaki Council of Social Welfare, a social welfare corporation, and Shinsei Medical Inc. on July 12, 1995 and the care services started in six junior high school districts. And the services have been also provided for handicapped persons under the age of 65 since November 1996. As of March 1998 there are 30 full-time home care aides, and besides, 245 people have registered as home care aide. Some home care aides work on the day shift, and the others work on the early shift, the late shift or the late-night shift in rotation. There are two types of home-visit care services. One is short-time home-visit care service: a home care aide assists an elderly person to urinate/defecate, and with meals and dressing within thirty minutes. The other is long-time home-visit care service: a home care aide stays for about three hours, caring for an elderly person and doing household work as well. The home care aides are housewives aged between 34 and retirement age 60. The pay for home-visit care work including physical care is 1,390 yen per hour, and the allowance for late-night work is 5,000 yen. Their pay seems to be comparatively high, but their work is not easy at all. It’s very tough physically and mentally. And some home care aides say that their income is not steady because their work conditions often change due to family reasons, hospitalization or death of the elderly.

Home care aides are recruited among the people who have completed a training course in home care aid level two or three. The course is sponsored by Ogaki City, and every time the course reaches the full quota on the day following the start of accepting applications. A person who has finished the course can register herself as home care aide. However, the number of the people who actually work as home care aide is 84, a third of all the registrants. A certified social worker, Takashi Yamada (36) in personnel of the Council of Social Welfare, who takes charge of home care aides, explained this, “A registered person will quit soon unless she is serious, because demand for the home care service comes all together in the morning and evening when housewives are very busy with their own household chores. The New Gold Plan is supposed to be started nationwide with 170,000 home care aides. Toshiko Kondo (50), a chief home care aide, has a first-grade home care aide qualification and a care-and-welfare help qualification. She became a home care aide in 1991 when the name of the job was unfamiliar to the public. She said, “Every applicant is kind and thoughtful, but that is not enough to be a home care aide.” She explained how difficult their job was. “The mutual trust between an elderly person requiring care and us is essential, but we can’t and shouldn’t meet every request from the elderly person. Thanking us for our help, his/her requests endlessly increase. To meet such increasing requests not only makes our business bogged down but also prevents the elderly person from being self-reliant. Since the dispositions and family situations of the elderly in need of care differ from one person to another, making a home care aide’s manual is so difficult. Therefore, home care aides are required to be a person of observation and sound judgment.” The question of what the home care service ought to be seems to be an everlasting open question even in Ogaki City, where a daily report and a verbal report must be made without fail when a home care aide hands over her duties to her successor.

Yoshiko Kobayashi (47) became a home care aide five years ago, influenced by a welfare commissioner who had taken care of her father bedridden for seven years. She told me an episode when she felt her job was really worthwhile. “Once I took care of an old woman who had been bedridden because of cerebral infarction. The woman could not speak a word, and even her doctor thought she was helpless, but she had an amazing revival. She became to be able to talk clearly and write letters.”

A handicapped woman (54) is sick in bed in a house on the main street. She has suffered from joint rheumatism. She has lived alone since her mother moved to a nursing home because of dementia. But her illness got serious and became to need thorough care. Now she uses a long-time home-visit care service every day and short-time home-visit care service six times a week. She said, “I’m happy to live in my house, not in facilities. Nature calls frequently because of medicine for kidney trouble, but I don’t have to worry about it even at night.” She has the same telephone installation in her house as the elderly do, so that she can call a home care aide or an ambulance by pushing a button.

Three fourths of all the people in need of care are on welfare or exempt from taxation so that they don’t have to bear the expenses. The rest of them share the expenses ranging from 2,000 yen up to 40,000 yen a month according to their income. Most of the total cost of 150 million yen is covered by a subsidy for home care welfare. After the year of 2000 the long-term care insurance premium and taxes will go to this welfare work, but the service will not be intended for the people under the age of 65 and handicapped people whom the city is now providing with the home care service according to their needs. An acting chief of the welfare section for the elderly of the city Tsutomu Kitajima (42) said, “When the long-term care insurance system is enforced, some people will have to shoulder more burden and some will not be able to use the care service any longer. But we cannot stop providing it for humanitarian reasons. The city should continue it even by supplying the deficit.” His words are reassuring. He added, “The government should administer organizations entrusted with the care service work so that they will neither be mean with their services nor think only of profit. I’ll watch it carefully.”

The city is planning to establish a system in which there is a welfare cooperator in every 50 households. The welfare cooperator will visit an old person living alone once a week and notifies the city if the old person needs care service. The welfare cooperators are supposed to be volunteers living in Ogaki City, and about 450 cooperators have already been in activity. The city is also building up a closer connection with medical institutions including family doctors of the elderly and home-care centers, by making full use of the ‘Telephone Care System’ that enables elderly persons in need of care to talk on a TV phone. In the New Gold Plan there should be a home-care support center in each junior high school district. In Ogaki City home-care support centers have already opened in seven junior high school districts out of nine. There are people who moved into this welfare-advanced city, where the citizens can take care of their aged family member easily at home and even an aged person can live alone without anxiety.

‘I was struck down by a illness on my journey, and I had a dream of my running around a desolate field.’ This is a passage of the travel diary written by Basho, aged 51. In those days 51 years of age was long enough to live. Since then 300 years have passed. The average life span of Japanese men is 76.70 years, and that of Japanese women is 83.22 years. Both of them rank first in the world.

“I’m pleased that the long-term care insurance was not discussed ideologically. It was an urgent matter,” said Professor Yuzo Okamoto (54). He analyzed that what delayed the development of Japanese welfare system and made medical expenses skyrocket were 1) old Japanese way of thinking that accepting charity from the government was a shame, 2) politicians’ and public opinions that welfare was encumbrance, and 3) old reformists’ nonsensical idea of comparing welfare and defense.

There are old people who cannot leave hospital even after treatment has finished, because they have no one who cares for them at home. When Professor Okamoto was active in the forefront of medicine, he was distressed in a dilemma of whether to discharge such old patients from the hospital or not. If he let them stay in hospital, the hospital would not function well. If he discharged them, the patients’ families would be in great difficulty. “There was an old person caring for her parent, and she was also on the verge of breaking down. When I saw them, I realized that things would come to a serious pass.” Having studied about the care of the elderly in England, America and Northern Europe, he was convinced that those problems would be solved only under a new social system. “In a real rich country, welfare is improving and economy is growing at the same time,” said in his latest work Welfare will revitalize towns (published by Nihon Hyoron Co.).

According to NHK survey, 90 % of the local governments in Japan replied that they would not be able to carry out the New Gold Plan prerequisite for the long-term care insurance before the year 2000 because of their financial difficulties. The unemployment rate recorded the highest since the war because of the protracted business depression.

But he said public investment in welfare would be more effective on economic recovery and creation of employment opportunities than investment in conventional construction work, referring to the trial calculation by Osaka Autonomy Research Center. If a public investment of 100 billion yen is made in construction work in Kitakyushu City, 15,889 people will be employed, but in welfare work, 29,266 people will be employed. Construction work is now highly mechanized and rationalized, while welfare work is a labor-intensive industry and still untouched. In passing, the calculations for Osaka Prefecture, Shimane Prefecture and Shizuoka Prefecture showed the same results. “Demand pulls supply in welfare work same as in medical care service, welfare work for the elderly is already popularized,” Professor Okamoto said. He also said definitely that investment in welfare work in demand is the trump card for recovery of economy and revitalization of societies. He has appealed to the local governments to promote infrastructure of welfare work that is effective to create employment opportunities and revitalize the communities and by no means inferior to other public works.

Professor Okamoto, a specialist in geriatrics, is the brains behind the Welfare Ministry’s project for making ‘the guidance to judge the requirements for long-term care service’ to make the long-term care insurance function fairly. Professor Okamoto, a welfare economist as well, believes that his theory will be proved and everyone will live in affluence in a true sense in the 21 century.

The Public Long-term Care Insurance System is a social insurance system in which the government offers home-care service such as sending a home care aide to a person in need of care, or care service at facilities including a special nursing home for the elderly. An elderly person who wants to use the service should make an application to a municipal government, and the municipal government decides whether the applicant is eligible for the benefits. Then a qualified person can choose the welfare services he/she needs. A user of welfare service should pay 10% of the expenses and the rest of them will be covered by taxes and insurance premiums collected from people aged 40 and older. In principle, the beneficiaries of this insurance will be people aged 65 and over. The government estimated that it would take 4.2 trillion yen to provide the twenty-four-hour care service. At the beginning an insurance premium shall be 2,400-odd yen per month. In the case of medical care insurance for employees one half of the long-term care insurance premium will be borne by the employer, and in the case of the National Health Insurance the same will be borne by the national government.