Transparent and fair: what England can learn from Japan’s social care reform England could look to Japan’s universal care system as it awaits publication of the social care green paper

The long-awaited green paper on social care in England will finally be published this summer. But despite a royal commission, multiple independent reviews, and social care green and white papers over the last two decades, pledges to address problems in the system have become politically toxic and the issue has been repeatedly kicked into the long grass.

What is the social care green paper?

The much-anticipated green paper on social care for older people is set to be published by summer 2018 – although, having been promised before last year’s general election, there were hopes the paper would appear much sooner.

It was also hoped the paper would address needs across the entire adult social care sector. Instead, the paper will be limited to the government’s plans for improving care and support for older people and tackling the challenges presented by an ageing population.

There will be a ‘parallel work stream on working age disabled adults’, but some are concerned this report will focus on getting more disabled people into work.

The government has invited a number of people to advise on the paper, including Paul Burstow, chair of the Social Care Institute for Excellence; and Caroline Abrahams, charity director of Age UK. However, no user or care worker representatives have been invited.

During a cabinet reshuffle in early January, Jeremy Hunt became secretary of state for health and social care. Despite already having social care in his mandate, the change gave Hunt lead responsibility for the green paper.

The proposals set out in the paper will build on the additional £2bn the government has provided to meet social care needs, reduce pressures on NHS services and stabilise the social care provider market over the next three years. Once published, the paper will be subject to a full public consultation.


At the Nuffield Trust, we have been looking into Japan’s long-term care system to discover how the country managed to transition from a setup of highly variable and largely unaffordable care in the 1990s to a universal care system supporting nearly 6 million people. Although the context is different, Japan can teach us valuable lessons about implementing change with widespread public support.

Social care green paper: it would be wrong to bail out business as usual
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1. Shift social care up the public agenda
In Japan, the need for long-term care became a priority in the 1990s. A confluence of economic difficulties and social change – with increasing numbers of older people living alone – created pressures that affected a large proportion of the population. The lack of affordable care led to people sending their elderly parents to hospitals – with little medical justification – because they provided relatively low-cost care and accommodation. As a result, the average hospital stay reached more than 50 days and costs soared. There was collective recognition that something had to change.

While the public’s attention may be distracted by Brexit, the British government might face more of a struggle to gain such acceptance, but it will be critical that it does so.

2. Engage the public
When a new system of care was proposed in Japan, there was a good understanding that it would be an improvement. This was critical to gaining public and political support.

Research has revealed that the public in England has limited understanding of the current system, with many people unaware that care is not fully funded as an extension of the NHS. Manifesto pledges to introduce caps on costs or to change means-testing have been met with widespread public discontent and media outrage – the assumption being that the proposals signify a worse offer than the existing one. For there to be genuine public debate about social care, there must be a good understanding of how the current system works.

Human stories will convince the public that social care is worth investing in
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3. Make the benefits visible
Japan carefully considered who should contribute to the system and when, ensuring that – at launch – large numbers of people would be able to access a relatively generous package of services and support.This helped to convince the public of the value of the system. Access was later reduced to curb expenditure – those eligible for the lowest two levels of care were referred to preventative services – a tactic that may be less palatable here. In Japan, everyone starts to contribute financially to the system – through general taxation and social insurance premiums – from the age of 40 because it is assumed that, at that point, most people will have older relatives or friends in need of care. Generational inequality is such a live issue in England that any new funding proposals will need to be sensitive to who contributes and who benefits.

4. Transparency and fairness 
Transparency and fairness underpin the Japanese system. People understand what they are paying in. A national eligibility assessment process is consistently applied and means that a person’s entitlement is the same regardless of where they live, and assigned monthly care budgets offer complete clarity about what services are available. Such clarity is painfully lacking in our social care system, where access to care varies hugely from area to area and costs are potentially unlimited.

5. Time
Japan didn’t transform its system overnight. It built on what had gone before, taking time to consult the public and interest groups and preparing the market. Discussions about reform began in the early 1990s, legislation was passed in 1997 and the system was implemented in 2000. Given the state of England’s social care sector, time is a luxury we don’t have, but the government should ensure it has support for change, otherwise this will be another wasted opportunity.

Looking forward
Japan’s system may not be perfect and its experience has certainly not been without challenges – including facing serious shortfalls in the care workforce. But like other countries that have made this journey, Japan gives hope that radical change is possible. Ensuring public understanding and support for change, coupled with the careful design of a system underpinned by the principles of transparency and fairness, appear to be the necessary ingredients for effective transformation.

@Natasha Curry from, the guardian

Natasha Curry is a senior fellow in health policy at the Nuffield Trust

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