Why he matters: A global expert on the “super-ageing” society and the cross-cutting responses needed to deal with the challenges it creates. He spoke at last week’s NHS Confederation conference.
“Japan is facing becoming the world’s most aged society,” says Mr Noritake, “and with that, we see the increase of dementia and chronic conditions. The health system we established for the 20th century focuses on provision of medicine, not of care. So, to meet our population’s needs, we have to have a paradigm shift”.
What does that shift look like?
“It’s actually very challenging. Firstly, our existing system has certain stakeholders, and as a democratic system we can’t change at centrally mandated scale like China or North Korea. So, change is always slow, and it’s a question of have we enough time to handle the tsunami of ageing? Japan’s population ratio in 2025 will be the world’s most aged.” The baby boomers, he adds, are now 70-75.
Co-existing with NCDs
The ageing society is widely known to have been an issue in Japan for some time. What have been the major strategies used to meet the demands it poses on health and care systems?
“To address this, we have to change our perception of what healthy means. Medical care alone is not sufficient for an older population, and we need more care to shift to the community. Now medical care is provided in medical institutions, but that has to change, and we have to alter our perception of health.”
For diabetes, Mr Noritake thinks that means thinking and talking not about patients, but people with diabetes, and likewise, people with dementia: “This change brings another new perception of health. And part of this is understanding that people with dementia or cancer can have roles and work and value in society.”
In other words, broader care needs matter as much as medical ones. And Japan is trying to reach a view of older people as ‘healthy’ people who still contribute to society well into their old age.
How many of those strategies does he think are directly transferable to Western health and care systems?
It’s a question of thinking about things differently, he replies: “The basic new Japanese government policy of dementia and care emphasises two basic concepts: prevention and early detection, and also co-existence.”
This means not trying to fix or cure dementia, but to co-exist with it. “The question becomes partly how people can live with these long-term, non-communicable conditions themselves.”
The second policy change Mr Noritake highlights is decentralisation.
“In the 20th century health and care model, the central government controls everything for all the provinces (which we call prefectures – there are 47).
“This new policy will see the government try to decentralise and make each prefecture in charge of health and community care budgets and allocations. Because [meeting] these non-communicable disease (NCD) needs are more community-based, decentralisation should make things more efficient.”
Social solidarity and public-private partnership
At the same time, Mr Noritake flags the issue of social solidarity – “a key principle of your British NHS. In Japan, we have national health insurance. How we keep social solidarity is a very live issue”.
A key part of Mr Noritake’s experience is in working across sectors to deliver healthcare, as in the civil-military and public-private partnerships. What does he observe to be the key characteristics of effective strategies in this area?
“The reason I emphasise the importance of public-private or cross-sector approach is that the health topic becomes more complex, and healthcare itself requires multisector discussions. For infectious disease, discourse and co-operation is relatively limited to the medical stakeholders.
“For dementia, we have to think transportation (and the UK is a global leader in dementia-friendly approaches), but also supermarkets, food industry, urban design. That expansion of stakeholders requires public-private partnerships in health.”
Another of his areas of expertise is prioritisation. What does he think have been the most effective resource prioritisation strategies in health and care systems around the world?
“If I knew that answer, I’d be prime minister! The history of resource prioritisation is quite diverse in each country, but at the global level, we certainly need to shift to more emphasis on non-communicable diseases.
“In the global health policy arena, so much attention goes to infectious diseases, which are very important, but when I talk to stakeholders in developing nations, they’re very keen to know about Japan’s strategies on NCDs. So, we need to see more global policy shift from infectious disease control to NCD control.”
His MSc is in medical anthropology: what does he think are the principal lessons that studying tribal and cultural behaviours has for the field of medicine?
“Healthcare is cultural. Even in Japan, you can see basically the same clinical guideline used as in the US, but the Japanese take so much less painkillers. The US loves aspirin for everything! That’s cultural.
“In an era of chronic conditions such as dementia, cancer and cardiovascular, the point is about self-management. Not always looking to treatment in acute settings, but how your life and behaviour can adapt to your long-term conditions. Considering the cultural aspects is vital, not just to look at what happens in tribal medicine in Africa to cope with an Ebola epidemic, but in UK and Japan, that approach is needed for health policy.”
Does he think greater attention should also be paid to the anthropology of health service users?
“Exactly so. And I think that more emphasis should be put on the people and the users, and this momentum is expanding not only from an anthropological perspective, but from user-led research.
“Health and care users are in a sense consumers. In other spheres such as supermarkets and banking, people usually listen to consumers. When Johnson & Johnson market a new shampoo, they will first ask what kind of shampoo people want. We need to see how consumers can see more merit from the changes to health and care systems. That’ll be the most effective way to make people healthier and health policy more efficient.
Maintaining social solidarity
“Given that almost all developed nations (perhaps except the US) have comprehensive national health systems, how can we maintain these with the rise of ageing populations and chronic diseases, and innovative devices. The UK was the world leader in introducing health technology assessments with NICE, but is it really bringing patients satisfaction?”
In Japan’s proposed devolution to the 47 provinces of resource allocation, how will their system guard against potential bullying or over-ruling of a province’s choice not to fund a nationally mandated technology or treatment? Will they be allowed to stand by their rationing decision?
Mr Noritake admits that “perhaps there is no clear answer to that, but my general thought is about the nation state. Consider either the UK or Japan as a nation state: a Londoner may pay tax and it is spent helping someone in another UK region.
“That is how nation state solidarity works, but the nation state is a relatively recent [concept] invented within the last 400 years. Why not tax Londoners for healthcare for France, or Ghana?
“National health services provide solidarity that reinforces this imaginary boundary [between countries]. Healthcare is now a global industry: it’s not just cars. The super-rich go anywhere in the world for the best treatment. Globalised firms like Pfizer or Amazon insure the health of their staff around the whole world. So, we have national health and care systems, but these private big giants are floating all over the world.
“How will we keep the solidarity of nation state? By devolving decisions to nation states, seems to be how we share solidarity, sympathy and feeling of care in that level of society.”
Coming up: NHS VAT campaigner Karin Smyth MP, Harvard professor of public health David Williams and Sir Norman Lamb MP
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