9 - Does a strong long-term care system benefit societal wellbeing?

Summary

The aim of this chapter is to illustrate how a robust long-term care system can positively influence the overall wellbeing of society, extending beyond the individual receiving care. Since the primary recipients of long-term care are often older or disabled individuals, it is sometimes viewed as a costly burden on society rather than an investment in the public interest or the common good. This chapter seeks to challenge such perceptions by emphasizing the positive and proactive social impact of a strong long-term care system on society as a whole. By highlighting these arguments, the chapter aims to provide further justification for countries to invest in their long-term care systems.

9.1 Introduction

The purpose of this chapter is to demonstrate how a strong long-term care system can positively impact the wellbeing of society as a whole, beyond the individual older or person with disability receiving care. There has been some criticism of the current public funding of long-term care. It has been argued that the long-term care system is a selective system that benefits a limited segment of the population, even as the number of older people increases. Furthermore, because the primary recipients of long-term care are older people and people with disability, it is often perceived as a costly welfare system that burdens the current generation and society as a whole, rather than being invested in the public interest or the common good of society (Brunk, 1998; Nicholson, 2014). This chapter attempts to challenge this understanding and highlights the positive and proactive social impact that a strong long-term care system has on society as a whole and its members. The arguments in this chapter could provide another important justification for individual countries to actively invest in their long-term care systems.

Before explaining how a strong long-term care systems positively impacts social wellbeing, the characteristics of such a system as focused on in this chapter have to be described. These characteristics can be seen as prerequisites for a long-term care system to have a socially beneficial impact.

• First, it is a sustainable system that is publicly funded, universally accessible and affordable to all. In this regard, it is important that the long-term care system is integrated with the existing universal health care system in order to be sustainable.

• Second, it is an equitable system that responds to and meets the needs and demands of its users, while paying attention to supporting the needs of caregivers. In this regard, in order for a long-term care system to be equitable, it is important for it to focus on person-centred care for individuals who benefit from the care rather than focusing on the service structure itself, and to promote the working environment of caregivers and give them due recognition.

• Third, although the state is ultimately responsible for building and implementing a long-term care system, a democratic system should be introduced, operated, evaluated and fed back on from the municipal to the national level by various stakeholders involved in the system, including care recipients, caregivers, institutions, communities, the market, civil society and the state. In order for a long-term care system to be democratic, it is crucial to have a cooperative community-based system that collaboratively involves various stakeholders – including both care recipients and providers – in the decision-making process and operation of the system.

This chapter examines the positive impact of a strong long-term care system on social wellbeing from three perspectives: social justice, social solidarity and social innovation. A strong long-term care system can contribute to mitigating persistent and entrenched care inequalities (social justice), foster social relationships and solidarity among citizens beyond direct care giving and receiving relationships (social solidarity), and enhance society’s capacity to create new solutions to pressing social problems (social innovation).

9.2 Contribution of long-term care to social justice

A strong long-term care system can contribute to the promotion of social justice. Social justice consists of a set of norms and values that vary from culture to culture and context to context. A strict definition of social justice is not provided here. Instead, the concept of social justice will be approached by utilising Joan Tronto’s (2013) discussion to help us understand social justice in the context of care-related issues.

According to Tronto one of the major injustices in society is the vicious cycle of care inequalities. This is a persistent cycle of inequalities, where care inequalities are linked to other inequalities in society – a vicious cycle where inequality begets inequality. In other words, economically disadvantaged people are generally less likely to have equal access to care, and when they lack equal access to care, they are more likely to be in a disadvantaged economic position. For example, children from socioeconomically disadvantaged families are less likely to receive adequate care, and children from these families are more likely to have a lower socioeconomic status when they grow up than children who receive adequate care (Blossfeld et al., 2017).

Long-term care for older adults is no exception to this vicious cycle. As people age, become frail and lose the core functions and capabilities needed to maintain their daily lives, they will need some form of long-term care. If these needs are not met by informal care from family and friends, older people will need to purchase professional care services which can be quite expensive. Of course, the cost of long-term care will vary depending on the level of dependency and care needs of the individual. However, in the absence of public support, the cost can take up a significant portion of an older person’s income. This creates a barrier to accessing care for those with fewer financial resources, and the expenses involved can result in their being unable to meet other needs, deepening inequalities in the process.

For example, recent data for twenty-six countries and subnational areas in the OECD and European Union show that the total cost of reported long-term care is, on average, between one-half and five times the median disposable income of individuals over retirement age (OECD, 2020; Hashiguchi & Llena-Nozal, 2020). For a low care need of 6.5 hours of care per week, the cost of long-term care would be equivalent to 60 per cent of the wages of a low-wage older person. For moderate care needs, requiring 22.5 hours of care per week, the cost of long-term care is more than twice the disposable income of someone in the lowest quintile (20 per cent) of the senior income distribution. In this case, only the wealthiest older people would be able to rely on income alone to cover their total care costs. Those with particularly high care needs require an average of 41.25 hours of care per week, and while it varies by country, long-term care costs are reported to be up to six times the median disposable income of retired individuals. In general, long-term care costs are a significant financial burden for older people who do not have sufficient savings.

More importantly, the vicious cycle of care inequalities that Tronto notes is not only linked to and reinforced by economic inequality, but also by inequality in other areas of society. Furthermore, this vicious cycle of inequalities extends beyond care recipients to the status of caregivers and their families. For instance, an economically vulnerable person is not only less likely to have access to care, but also less likely to receive quality care. According to WHO, LMICs not only lack a universal health care system, but the quality of health care their citizens receive is often poor, which is one of leading causes of death in these countries. Each year, 15 per cent of all deaths in LMICs are attributable to poor quality of care (WHO, 2020).

Due to the high cost of long-term care, family members may provide informal care. This tends to reduce the family’s quality of life and undermine the family economy. As many studies have shown, family caregivers experience a variety of mental, emotional, physical and economic burdens. Family caregivers speak of a range of depression and mental stresses, including worry about the health of the care recipient, psychological strain from the caregiving situation, as well as social isolation and feelings of inadequate recognition of their work by others (Coe & Houtven, 2009). They are also more likely to experience physical strain from caregiving, which can lead to the development of various chronic diseases such as back and neck injuries, high blood pressure and muscle pain (Zacharopoulou et al., 2015). This of course has knock-on effects in terms of need for health care and associated costs both to individuals and families and to health systems.

In addition, in many cases caregivers are more likely to quit their jobs or reduce their hours of paid work to provide care, leading to losses in the family economy (Nguyen & Connelly, 2014). For example, Choi and Ahn (2019) find that in the Republic of Korea, informal family care reduces family caregivers’ probability of working by an average of 16 per cent and their annual hours worked by about 14 per cent. Even if they do not leave the labour market entirely, family caregivers may have to reduce their hours or take time off work more often due to care responsibilities and are more likely to endure disadvantages such as lower wages and slower promotions (Yamada & Shimizutani, 2015; Bauer & Sousa-Posa, 2015). In addition, family caregivers often have little time for socialising with friends, coworkers, family and relatives, which limits their social interactions and reduces the quality of those interactions (Amirkakanyan & Wolf, 2003). Existing research suggests that as many as two-thirds of family caregivers give up time for social interaction, personal development and leisure to fulfil their caregiving responsibilities (Cranswick & Dosman, 2008).

When family caregivers are adolescents or young adults, the financial challenges they and their families face and the burdens they place on their futures are even greater. As the majority of young caregivers are young people with limited earning capacity, they struggle to meet the costs of living, household labour and health care while providing care (Brimblecombe et al., 2020). With the majority of their time and effort devoted to caregiving and their livelihoods, young caregivers lack the time and financial resources to prepare for and invest in their future. In Canada, the school absenteeism rate for young caregivers is as high as 10.8% (Stamatopoulos, 2018). Research from the United Kingdom also shows that 56 per cent of young caregivers at university say that family caregiving interferes with their academic performance and that they are unlikely to complete their studies (Sempik & Becker, 2014). This creates a vicious cycle in which young caregivers lack time to invest in their future and develop themselves during adolescence, which increases the likelihood that they will remain in poverty in the future.

A strong long-term care system, on the other hand, would provide universal and decent care for all older people with care needs. All older people, regardless of poverty, would have equal access to a certain level of quality care provided by the system. The effectiveness of the system could result in socioeconomically disadvantaged older people receiving more social protection. For example, data for OECD countries show that in countries with higher total public long-term care expenditure, older people tend to be at lower risk of poverty, as their long-term care needs are officially recognised and they receive public support (Hashiguchi & Llena-Nozal, 2020). The data above should be taken with caution, as not all public long-term care spending is used to provide care. But it seems relatively clear that public social protection systems in countries that spend a larger share of GDP on long-term care tend to reduce the expected risk of poverty associated with long-term care needs more than those with lower public expenditure (Hashiguchi & Llena-Nozal, 2020).

Many other studies also report how a strong publicly funded long-term care system has positive impacts that extend beyond the care recipient to caregivers and family members. Following the introduction of universal long-term care insurance in the Republic of Korea in 2008, a survey of older people, primary family caregivers and family members who used the system found that a high proportion reported that their functioning and psychological and emotional state had improved after using the system: for in-home services, 30.6% of primary caregivers reported that the older person’s physical condition had improved, and 41.6% reported that the older person’s psychological and emotional state had improved. Many primary caregivers reported that their caregiving burden had decreased in terms of the physical burden (80.3% of respondents), psychological burden (81.2%), social burden (47.3%) and economic burden (39.1%). Many also reported that family relationships had improved after using the programme due to increased trust between the older person, the primary family caregiver and other family members: 32.2% of respondents reported improved relationships with other family members when their spouse was the primary caregiver, and 52.4% when their adult child was the primary caregiver in in-home services (Choi et al., 2011) .

In sum, inequalities in care are linked to and reinforce not only socioeconomic inequalities for care recipients, but also socioeconomic and psychological, emotional, physical and temporal inequalities for caregivers and their families. A strong long-term care system, however, can have the effect of weakening this vicious circle of care inequalities. Beyond meeting the care needs of older people and people with disabilities, it can make an important contribution to social justice by arresting the vicious cycle of inequalities perpetuated in society.

9.3 Contribution of long-term care to social solidarity

Social solidarity is a difficult concept to define: some see it as collective action in pursuit of a common purpose and value, while others see it as a historical concept that was fundamental to the creation of the welfare state in Europe (Douwes et al., 2018; Weale, 1990). In practice, social solidarity manifests differently in different countries and societies. Despite this diversity of concepts and manifestations, at its core social solidarity is about relationships – about fostering relationships among citizens. These relationships are based on empathy and responsibility for other vulnerable citizens in need, and trust between interdependently connected citizens. A strong long-term care system can make an important contribution to fostering broader social solidarity based on empathy, responsibility and trust among citizens, beyond direct caregiving relationships.

First and foremost, care is a relationship (Ruddick, 1995). It is a relationship between a vulnerable care recipient and a caregiver who cares for that recipient. The health and wellbeing of the care recipient is directly dependent on the caregiver’s role in providing biological and psychological care to them. In this sense, the relationship between care recipient and caregiver is one of power asymmetry. However, in a good caregiving relationship this power asymmetry does not become hierarchical or dominant (Kittay, 1999). For example, in a typical caregiving relationship such as a parent-child relationship, the parent (caregiver) has an asymmetry of physical, mental and material power over the child (care recipient), but the parent does not dominate the child and enables the child to survive, grow and learn. In this respect, good care from the perspective of the care recipient can be seen as a state of empathy and responsiveness to one’s situation and needs, as well as responsibility and trust for each other, rather than the perfect performance of any care function per se.

Therefore, a good care relationship is one in which there is empathy, responsibility and trust for each other. The caregiver must empathise with the vulnerability of the care recipient and take responsibility for meeting their needs. Conversely, the person receiving care must trust that the person providing care will fulfil their responsibilities in caring for them and will not abuse that power and responsibility. This empathy, responsibility and trust in a care relationship is primarily formed and maintained through interpersonal relationships in the personal sphere, such as parent-child relationships or relationships between friends. Importantly, however, the experiences of empathy, responsibility and trust that are nurtured in care relationships can be a significant resource for the strengthening and extension of social ties (Held, 2007).

For example, Kathleen Lynch proposes a category of care networks as ‘circles of care’ (Lynch, 2009). The circle of care shows that, just as primary and secondary care relationships are other-centred relationships of love and care, tertiary care relationships with others can also be other-centred relationships of solidarity. Primary care relationships are personal and intimate, such as parent-child relationships; secondary caregiving relationships are those involving the outside world, such as relatives, friends and coworkers; and tertiary caregiving relationships are those with others at the national and international levels that do not require a personal or intimate relationship. According to Lynch, while relationships in these three circles of care may have varying degrees of empathy, responsibility and trust, she argues that other-centred solidarity based on these three characteristics is possible even in tertiary care relationships. An example of this solidarity is when citizens participate in campaigns to improve welfare services for homeless people or migrants who do not seem to have a direct relationship with them.

Expanding the network of care relationships can be accomplished through the operation of the ‘care imaginary’ (Groves, 2014). This is the moral and emotional capacity to extend and transfer the feelings and experiences of giving and receiving care to others in similar situations. It is imaginary but derived from the universal experience of care that each person has had in their own particular life. Thus the care imaginary involves the moral capacity and attitude to feel a sense of bonding and solidarity with other members of society who are excluded, threatened and oppressed, based on relational experiences with vulnerable human beings (identified as my child, my parent and my neighbour), who have been the objects of my affection and attachment in my own life. Thus feelings of compassion for one’s child, parent and neighbour (not traditionally considered as private) can be the driving force behind civic attitudes that can be communicated and extended socially. For example, the care imaginary, derived from the experience of giving and receiving care, leads one to understand oneself in relation to others not as an indifferent individual but as a being connected in the circles of care, which in turn leads to a sense of solidarity based on empathy, responsibility and trust for vulnerable others. In this case, a citizen with a sense of solidarity can advocate for welfare services that support an older stranger living alone, or demand changes to the welfare system to support a child with disability in the neighbourhood.

Social solidarity among citizens can be a trigger and guiding principle for public welfare systems, as is the case in Europe. At the same time however public welfare systems, including a long-term care system, can also contribute to strengthening social solidarity. If caregiving is institutionalised, that is, if caregiving goes beyond informal types of care relationships such as caring for one’s family members and friends to state-wide institutionalisation such as a long-term care system, then empathy, responsibility and trust in care relationships can be further extended socially. Certainly, empathy, responsibility and trust are primarily formed and maintained through private relationships but, as ter Meulen (2017) significantly points out, when interpersonal solidarity can flourish when supported by social care based institutions, it can expand and flourish into social solidarity with the institutional support of a long-term care system.

Ultimately, social solidarity means that citizens care for, trust, support and depend on each other through an institutionalised network of care relationships. However, it can be very difficult to specifically characterise the type of social solidarity based on a long-term care system as opposed to that caused by a long-term care system, or to compare and measure the degree of social solidarity (Rusu, 2012; Lomazzi, 2021). The characteristics of solidarity developed via long-term care can also be very diverse. The easiest and most representative form of social solidarity based on care relationships is where citizens become good neighbours, providing each other with various types of mutual resource. For example, running errands for a sick neighbour, climbing a ladder to change a neighbour’s light bulb, picking up a neighbour’s parcel, clearing snow, holding onto spare keys, watering a neighbour’s flowers or taking care of a neighbour’s pet are all various examples of being a good neighbour (The Care Collective, 2020).

Numerous examples of the network of care relationships being extended to good neighbour relationships can be observed, creating various forms of citizen networking. A care-based community leads to various collaborative associations and cooperatives involving residents, such as gardening communities, workshops and cooking classes (The Care Collective, 2020). In Japan, long-term care insurance was institutionalised in 2000 and the general community support system was established in 2005. The latter is a community-based care service system that provides medical care, nursing care, disease prevention, housing and livelihood support to older people so that they can live out their lives in their own communities. As part of the system, more than 4,600 government-run general community support centres have been established across the country. The purpose of the centres is to provide comprehensive and continuous support for older people, such as care services, living support and medical care. Thus local older people with long-term care needs and their families can easily connect with and receive help from nurses, social workers and care managers who provide professional welfare services, medical care and personal care. In this respect, the general community support centres play an active role in establishing and supporting a systematic care network for older people and residents to connected with each other (Ministry of Health, Labour and Welfare, 2019).

Another specific example of care networks spreading and promoting social solidarity is the Yeomindongrak (‘Sharing enjoyment with ordinary people’) community in the Republic of Korea (Kim & Shim, 2015; Jeon, 2020). This community appeared in 2008 in a small village in South Jeolla Province. At that time the village was ageing and underdeveloped, with the population aged 65 and over accounting for nearly 40 per cent of the total. The Yeomindongrak community started with the establishment of a Yeomindongrak welfare centre for older people by three couples returning to the area with the purpose of offering revitalised community-based activities to support the daily life of older people living in the area and to improve their quality of life. The Yeomindongrak welfare centre offers various care activities for older people based on the long-term care insurance system that has been in operation in the Republic of Korea since 2008. For example, a typical day care service provides for older people with reduced mobility, while a rice cake factory and a bakery have been opened for the older people to run as an activity to meet the demand for work and to earn an income.

In addition to caring activities for older people, various community activities have been introduced. A typical example is the local quarantine and disinfection project. Due to Covid-19 the village needed to regularly disinfect not only public areas but also individual living spaces. With the support of the local government, the Yeomindongrak welfare centre carried out disinfection work down to the smallest detail in the area, including the yards and barns of the members’ homes. These quarantine activities created an important opportunity to communicate with local members, understand the needs of the village and establish a communication link. Village welfare events are held for members, such as a kimchi sharing event, and residents take part in weekend safety activities in connection with local high schools. At the same time, community efforts to revive a local elementary school which was in danger of closing was an important activity that emphasised the importance of the local community for the residents.

All of these community activities and projects have been guided by the opinions of the residents and the needs of the community. The various projects carried out by the Yeomindongrak community have been made possible by the active participation of older people and local residents. In fact, local older people act as social service providers rather than solely as beneficiaries of social services. In addition, the Yeomindongrak community has strengthened social relationships by offering relationship-making activities for local residents who do not otherwise participate in community activities and by forming relationships with other local community welfare and community organisations. According to a representative of the Yeomindongrak community, care activities require expertise, but ordinary residents and communities lack this, so relational competencies between citizens must be improved. The representative noted that creating a structure where members can help each other and engage in regular interactive activities with local specialised institutions can improve expertise. Since 2020 major community projects such as the welfare centre for older people (which offers a day care service), bakery and rice cake factory have been converted into social cooperatives in which all villagers participate as members.

To sum up, the relationships among citizens, which are at the heart of social solidarity, can be promoted and strengthened in a variety of ways. A long-term care system, as well as other social care systems, can contribute to creating and enhancing connections among citizens. In a society with well-organised care systems and institutions, there is more empathy, responsibility and trust for each other, which leads to the creation of various networks of relationships and associations that broaden and strengthen the network of mutual benefit. This in turn helps to strengthen the institutionalised care systems.

9.4 Contribution of long-term care to social innovation

Given the conceptual definition of social innovation as the creation of new solutions to social needs that are not being addressed in existing ways, a strong long-term care system has the potential to create new and better alternatives and practical solutions to the social needs at hand (The Young Foundation, 2012). Because long-term care is primarily targeted at older people and people with disabilities, and because of the high public costs of supporting a long-term care system, long-term care is often misunderstood as a system with narrow benefits and as a costly system that erodes the capacity of society. On the contrary, a strong long-term care system can promote overall social capacity by addressing previously unmet social needs in new and effective ways and is therefore rich in potential for positive social change. The potential of long-term care as a driver of social innovation to solve social problems and induce social change is discussed in this section.

When discussing the potential for social innovation in and through long-term care, several studies highlight the conditions that a strong long-term care system should fulfil (Schulmann et al., 2019; Leichsenring, 2013). First, the long-term care system should be participatory, inclusive and collaborative. This means that the long-term care system should be operated and managed in such a way that decision making is based on collaboration and cooperation involving the various stakeholders and based on a democratic structure that is inclusive of stakeholders (Ayob et al., 2016). Long-term care service providers can be central governments, local governments, NGOs or cooperatives. However, in the operation, management and evaluation of the system, the positions and relationships of the various stakeholders (including care recipients, family members, informal caregivers, local communities, service providers, government agencies and related public officials) should not be excluded from the decision-making process. In a long-term care system, the state should not unilaterally provide care services to people; care recipients and caregivers must be able to contribute to service design and delivery by actively expressing their needs and participating in the system. Second, it is very important to have a community-based long-term care system. Social needs should be defined and met through discussion and consensus among various stakeholders in local situations depending on the demographic and socioeconomic characteristics of the region. Only then can the decision outcomes contribute to the community and society as a whole, rather than merely to specific individuals or groups, and contribute to positive social change (Phills et al., 2008).

The social innovation potential of inclusive and collaborative community-based long-term care is, among other things, the ability to be proactive and responsive to diverse and complex long-term care needs and to find new solutions. In other words, it attempts to generate a variety of new options and new possible combinations of kinds of service, forms of delivery, forms of governance, forms of resourcing and ways of evaluating for the needs faced. The long-term care needs of older people can be diverse, including not only medical treatment and restoration of health, but also self-reliance and independence, employment, relationship connections, social participation and psychological stability. In this regard, community-based long-term care with democratic participation and collaborative systems can be more responsive to the needs of older people.

Various research-based and practical projects that focus on the social innovation potential of long-term care have been launched worldwide (Davies & Boelman, 2016; Ghiga et al., 2018). An example is the InCARE project, the purpose of which is to design and develop innovative long-term care policies and services through community-based participatory and integrated decision making (InCARE, 2023). The InCARE project is currently under the leadership of the European Centre for Social Welfare Policy, conducting research and implementing pilot policies that target the long-term care systems in Spain, Austria and North Macedonia. The focus of the InCARE project is the innovative potential of long-term care and it explores this potential through inclusive participation and collaborative decision making involving care users, their families, caregivers, communities and other stakeholders.

There are examples of socially innovative long-term care systems, such as the Tubbe model in Denmark. Many older people prefer to remain in their own homes and receive care there rather than in remote nursing homes or hospitals, but in some cases it is important to have intensive, specialised care in a hospital-like setting. The Tubbe model is an innovative model of assisted living that emerged as a result of reflection on how older people could receive extra care in a home-like setting. What is remarkable about this model is that residents move from a passive role of receiving care to actively demanding and fulfilling their care needs, directly participating in the nursing home’s operational system, from choosing food to hiring the staff. The Tubbe model is recognised as providing opportunities for meaningful interaction for everyone involved in the care process, and both residents and staff report high levels of satisfaction (Healthcare Denmark, 2019).

Another similar example is The Hogeweyk, a dementia village in the Netherlands, which is often cited as an innovative model for older persons’ care environments. The Hogeweyk is a 1950s-style ‘village’ designed to help older people with severe dementia, who have intact long-term memory, to live comfortably and familiarly with their childhood memories. The model is a paradigm shift away from established models of institutional care, improving the overall quality of life for older people with dementia and approaching long-term care from a prevention and inclusion perspective. Overall, the model has proven to be highly effective in assisted living and dementia care, with long-term care residents reporting improved health outcomes and reduced reliance on medication (Godwin, 2015).

While the Tubbe model in Denmark and the dementia village in the Netherlands are examples of innovative mechanisms within long-term care itself, there are other examples where long-term care has been used to solve social problems and drive broader social change. One example is the time bank experiment in health care services. A time bank is a multilateral time exchange system that saves the amount of time spent helping others and uses that amount of time when receiving help from others. The model is spreading around the world, including the United Kingdom, the United States, the Republic of Korea and Japan, as an innovative way to provide public services (TimebanksKorea, 2023). An older person who knits a neighbour’s newborn baby’s hat gets credit for the time, which can be redeemed for a companion service for their weekend grocery shopping. All members of the programme, not just older people, interact with each other based on the principle of reciprocity. The Rushey Green Time Bank in the United Kingdom, a prime example of a time bank integrated into a health care service, has individual and nine institutional members. The case of the Rushey Green Time Bank has implications for social innovation because the programme has been evaluated as not only overcoming social prejudices against older people who were viewed as a social burden and unproductive, but also solving the problem of social isolation of older people through ongoing relationships with neighbours and encouraging their active participation in society. In addition, the programme has been judged to be effective in raising self-esteem and preventing disease among older people, and it is also estimated that it has had a positive effect on cost savings for the National Health Service in the United Kingdom (Česnuitytė et al., 2022; Rushey Green Time Bank, 2023).

Another innovative long-term care organisation that has found new ways to address pressing social problems is the Older Person’s Cooperative Union (Koreikyo Union) in Japan. Since 2000 Japan has experienced the most significant population ageing in the world due to low fertility rates and high life expectancy. This has led to the emergence of a number of older persons’ needs, including long-term care, jobs, life stability, self-development and opportunities for training. The Koreikyo Union is a nationwide cooperative organisation established in November 2001 by combining cooperatives in seventeen regions. All services are provided by the members, and they are managed via a member agreement system. Healthy people between the ages of 55 and 75 care for care dependent people over the age of 75. The Koreikyo Union helps older people to remain active, independent and well-engaged during their old age. It not only provides the services necessary to maintain a healthy social life, but also provides a platform for people to continue working even into old age. In addition to caring for older people, which accounts for three-quarters of all services, the Koreikyo Union offers various commercial services such as parking management and building management, and hobbies and cultural activities needed in the community, centring on middle-aged and older people (Matthew, 2017; Koreikyo Union, 2023).

One last case to mention is the Seoul Supporting Centre for Workers in the Care of Older People. The centre is a leading example of social innovation that has led to a wide range of social changes, including improved treatment of care workers, improved social awareness of care and changes in care policies, triggered by the introduction of the long-term care system. Since the Republic of Korea introduced universal long-term care insurance in 2008, a large formal caregiving workforce has been created, called Yoyangbohosa. Today there are about 1.8 million licensed Yoyangbohosa, with about 440,000 currently working in the field. The implementation of long-term care insurance led to social demands for improved treatment and working conditions for Yoyangbohosa, which eventually led to the creation of a centre to officially support care workers in the local government. In 2013 there was one location in the city of Seoul; now there are eight in the Seoul area and thirteen nationwide. In addition to conducting research on the treatment of care workers and supporting their health and labour rights, the centre engages in challenging existing social prejudices against care work, leading campaigns to promote a culture of mutual respect and good care, and actively participating in the process of recommending, implementing and evaluating local government care policies. In addition, through public-private governance, the centre serves as a hub of care networks among care workers, older people, care organisations and family caregivers, and it also show potential as civic education centre in that it provides education and psychological support to those who are not direct stakeholders in long-term care insurance, such as informal family caregivers (Seoul Supporting Centre for Workers in the Care of Older People, 2023).

In brief, social innovation through long-term care can take many different forms. It can range from addressing the problem at hand by introducing new changes to the long-term care system itself, to addressing broader societal changes and issues triggered by or through the long-term care system. Whatever the form, what is clear is that long-term care can enhance social capacity and as a result act as an engine and catalyst for positive social change.

9.5 Conclusion

This chapter aims to show that the benefits of a strong long-term care system extend beyond the care recipients to positively impact the wellbeing of society as a whole. It has shown that a strong long-term care system can contribute to mitigating the vicious cycle of care inequalities in society, foster networking and social solidarity among citizens, and enhance society’s capacity to address pressing social issues and promote broader social change.

While this chapter has looked at selected cases and examples, the social wellbeing gains from a long-term care system can vary widely across societies and national contexts. This is an area that will require further discussion and research. What is clear, however, is that investing in the long-term care system benefits more than just the individual older or person with a disability receiving care; it benefits the development and capacity of society as a whole, and so countries will need to continue to invest actively in long-term care systems to ensure that they are actually implemented and fully operational.