With the NHS under increasing pressure due to an ageing nation, Charlie MacEwan explains why the UK should be looking eastward for tips on how to run a healthcare system.
To paraphrase Lewis Carroll's Alice: "'You are old, Father William', the young man said. 'And just how are we going to pay for your healthcare?'"
It is a question that is concentrating minds across the western world, where an increasingly elderly society is being supported by a reducing working population. In the UK, rising medical and pension costs are combining with an ageing demographic to place NHS geriatric care under huge pressure within a system already under stress. UK taxes, though levied at a rate higher than most other countries, are unable to keep pace with the growing needs for medical, palliative or the community care of longer-living parents and grandparents.
There is one country, however, that is tackling this situation head on - Japan.
Japan has the fastest-ageing and one of the longest-living societies in the world. According to the World Health Organisation, it has the healthiest women in the world (though an increasingly western diet is leading to growing problems of obesity and related medical conditions in the young); and it has over 25,000 centenarians, four times as many as the UK. Some 20% of its 127 million population is now over 65. By 2025 it will be 28%, and by 2055 it will be 40%. At the same time, the birth rate is falling through the familiar social pressures of later marriages, more working women and smaller families. At the moment, it takes three workers to support one person over 65. By 2055, those three workers will need to support nearly four pensioners.
Acting decisively
On top of a long recession, and in spite of the traditional Japanese veneration of the elderly, the country is facing an elderly care crisis. The Government has responded decisively, and on a number of fronts. Although results are mixed, it is developing a policy in a number of ways that could well demonstrate an effective route to dealing with the same problems in the UK.
Japan does not have a state-run health system like the NHS. Rather, it has a more universal health coverage run closer to the American system, with 80% of its hospitals and 94% of its clinics being privately operated. The most prestigious hospitals, however, tend to be in the public sector or owned by universities or other non-profit organisations such as the Red Cross. Many hospitals have long-term care units. Virtually all residents in Japan are covered by a health plan either provided by their employer or by the municipality in which they live if they are self-employed or retired, and they are free to visit any doctor or hospital they choose. All the schemes are based on the principal of co-payment - where the policyholder shares some of the cost of any medical expenses - which were originally set at 10% of the cost of treatment, had to be raised to 20% in 1997, and to 30% in 2003, with a cap of around £300 a month.
In 2000, a long-term care insurance scheme was launched to which everyone over the age of 40 was required to contribute £20 a month, to pay directly for the care of the elderly whose needs are ranked on a scale. However, demand has outstripped supply to such an extent that the premium has already had to be raised 40% in five years, and elderly applicants have been reclassified to reduce their benefits.
The Government is additionally mounting a concerted programme of health education and offering incentives to reduce diabetes caused by obesity by 25% by 2015. Medical facilities will be required to offer health checks to anyone over 40 - and some organisations have already gone down this route. Mitsubishi Motors claims its staff has reduced 'risk factors' by 30% after health checks identified lifestyle problems.
working together
One of the consequences of the system is that the population has a very good grasp of the real costs of healthcare. They have discovered that if the user de-linked from the payer - in any system - that system becomes open to abuse and inflation. Re-establishing the link produces a demand for quality as well as value for money - and a scenario where the users and the providers are working together, to a degree, towards producing what is needed for those who need it, within the financial capabilities of all parties. The level of contribution, or co-payment, acts to encourage an informed customer base to lobby hard for the control of medical inflation and the introduction or maintenance of decent standards of care and treatment.
There is a real pointer here for the UK. Governments cannot go on raising taxes; there is an economic limit, and, therefore, a limit to the extent that a state health system can be funded through taxation. Many would argue that the limit has already been reached in the UK, and that co-payment must be the way forward if the country is to rediscover the basics of a healthcare system fit for the purposes and requirements of the 21st century.
And that should not be such a political risk, when all is said and done. Depending on which survey one reads, at least 70% of people in the UK are already prepared to top-up their NHS care. Brave leadership would surely recall the principles of the original NHS, outlined by its founding father Sir William Beveridge: "No one is to fall below a certain standard, leaving everyone free to spend his income above that standard as he will. It preserves the maximum of individual freedom and responsibility that is consistent with the abolition of want." n
Charlie MacEwan is communications director at WPA
