The funding of long-term care for older people in England and Wales is currently in a state of crisis and recent government proposals are seeking a way to resolve a situation whereby older people are required to pay for their care until almost destitute. The situation is compounded by continuing reports of substandard care, both in residential institutions and in people’s own homes. Abuse and ill treatment of frail and vulnerable older residents in care homes and hospitals make recurrent news headlines. Residential care for older people has suffered from disproportionate under-funding since the 1948 National Assistance Act and remains a low priority in welfare provision. The local authority budget for adult services has come under increasing strain due to the re-branding of long-term care by the NHS as social, means-tested care, with the gradual withdrawal from hospitals, since the 1990s, of the provision of long-term care for patients suffering from chronic disease. Japan is also undergoing difficulty in funding care for older people. However, most of the problem stems from its status as the fastest ageing society in the world and its population having the highest longevity.
Thus, Hayashi’s book, comparing residential care in England and Japan, could not have been timelier. It succeeds in its aims of addressing the gaps in knowledge of residential care in both countries and of bringing a historical perspective to the subject. The format consists of separate chapters for each country covering national issues, followed by regional and local perspectives. Similarities and differences between the two countries are drawn in the conclusion and there are more of the former than one might have thought.
The coverage of the English Poor Law system is only intended to provide a brief overview, but it gives the impression of a uniform national system and fails to identify the complexity and diversity of provision for older people under the system. This is the least satisfactory section of the book. By comparison the chapter on the national context in Japan is more nuanced, bringing out the influence of cultural and religious societal attitudes in the provision of care. Hayashi is not the first to conclude that residential care in England is currently under the influence of the poor law philosophy of limiting provision to force families to shoulder the burden of care, usually without assistance from the state. However, it is more surprising to learn that this is also true of Japan, although the poor law was not enacted until 1932. Stronger family ties meant that children frequently looked after dependent parents at home, but lack of help from community services meant that abuse and neglect were not uncommon.
Although there was a period in both countries when older people had free access (financially) to long-term care, in England in 1948 after the start of the NHS and in Japan in 1973 after the commencement of an insurance-based health scheme, long waiting lists for admission to residential homes were not uncommon. In time, due to escalating costs, authorities in both countries resorted to restricting older people’s access to institutions as a means of saving money. Many examples of inadequate provision of institutional care are contained in the regional and local studies, which focus on the period from the 1920s into the twenty-first century: plans to provide a ‘paradise for the elderly which never materialised; authorities describing large buildings as ‘a homely environment’; delays in replacing dilapidated buildings due to funding restrictions; laudable sentiments but no action. The major strength of Hayashi’s study lies in the local perspectives developed from oral testimony of residents and staff, which demonstrate how poor practice can still occur in the best residential settings. It makes clear that the failure to provide good quality residential care lies in the low priority given to funding of older people’s services in both countries.
Hayashi has been able to include provision for severely dependent and bedridden older people in Japan, in both nursing homes and hospitals, because the 1963 Elderly Welfare Act regulated both health and social care services. In contrast, the health and social care divide that existed in England after 1948 has made it difficult to examine the shifting boundaries between long-term care in hospitals and care homes. As a result, it has not been possible to explore dependency levels of residents in social care homes from the 1990s onward and to include older people in hospital long-term care prior to that time. Services for ‘frail older people’ are covered at varying time periods, but we are left uncertain as to their degree of dependence. Some discussion of the concept of frailty would have been useful. By comparison, the dependency level of older people in homes in Japan comes across more clearly.
Concentrating mainly on residential social care, the book may be of limited interest to medical historians. However, despite the few minor reservations described above, it is essential reading for welfare historians, social gerontologists and those who wish to understand the historical perspective behind today’s arrangements for residential care. Policy-makers with the responsibility for the provision of care for older people should read this account in particular.
