COVER STORY • Exploring for the Best Models of an Aging Society – Lessons from Japanese Experience • 4

T

he Care Compact City
Concept for an Aging
Society
Author Satoru Yamazaki

By Satoru Yamazaki

The State of Japan’s Population Aging

100 years ago to 100 years from now, in terms of age composition(0-14, 15-49, 50-64 and 65+), while the population has increased
over the last 100 years, the overall age composition ratio is pretty
stable, and for the next 100 years also, while the population looks set
to decrease, the age composition ratio is expected to stabilize. That
is to say, we are approaching a transition period where systems andtown planning which had up until now been focused on increasing
populations will now have to be completely revamped to adapt to anincreasingly elderly and shrinking population (Chart 1). Under suchcircumstances, it will be difficult to surmount the difficulties of anaging society simply by building a hospital or care facility, andsociety will need to devise systems to underpin the overall
community, and to approach town planning from a whole-areaperspective. As the next era beckons, we are now at the stage ofreconfiguring into a sustainable society.

Japan is facing the problem of an aging society and decreasing
population caused by a falling birth rate. There is a nationwide
increase in people aged over 65, with a particularly strong trend in
the Tokyo metropolitan area. Meanwhile, regional cities are grapplingwith decreasing populations. These dwindling populations mean that
local economies are robbed of their vitality, while in mountainous
regions elderly citizens are increasingly scattered across a wide area.
In terms of households, while 28.5% of all households were single
occupancy in 2005, this ratio is predicted to increase to 36.3% in
2030, meaning one in three households will be single occupancy.
This portends that the function of caregiving within the home will
disappear, and that elderly people requiring long-term care will not
be able to receive it within their homes. Couple-only households arealso increasing, and the near future will increasingly see singleperson households becoming the norm (Table). Predictions are thatthe aging rate of the population over 65 years old of 27.7% in 2017
will reach 30.3% and then 36.1% in 2025 and 2040 respectively,
before stabilizing sometime beyond 2050.
Lamenting such a dire situation, however, achieves nothing.
Considering demographic trends seen over a 200-year period from

With aging, any and every person comes to need support withdaily activities including eating, excretion and moving around. Whileparents and children often used to cohabit in three-generation
households, the increase in single-person dwellings caused by the

TABLE

CHART 1

Change of household type for elderly& future projection (over 65 years old)

A Safety Net for Aging

Transition period of generation
structure stabilization

Single and couple-only elderly households are expected to increase in future.
(10,000 households)

2005

2010

2015

2020

2025

2030

4,906

5,184

5,290

5,305

5,244

5,123

Households where
head of household isover 65 years old

1,355

1,620

1,889

2,006

2,015

2,011

Single households(ratio)

387
28.5%

498
30.7%

601
31.8%

668
33.3%

701
34.8%

730
36.3%

Couple-onlyhouseholds (ratio)

465
34.3%

540
33.3%

621
32.9%

651
32.5%

645
32.0%

633
31.5%

General Households

Despite population
increasing, generation
structure was alsostabilizing.

Society
post-2040
Present

Note: Ratio accompanying single households/couple-only households is that occupied by“households where head of household is over 65 years old”.

Society in
19th/20th
Centuries

Despite shrinking
population, generation
structure will stabilize.

Source: Compiled by the author

Source: “Current state of countermeasures for aging population in urban areas”, May 20, 2013,
Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare)

16 Japan SPOTLIGHT • July / August 2019https://www.jef.or.jp/journal/

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CHART 2

Relation between residences & welfare facilities by aging
HealthResidence for elderly

Housing

Medical service

Residence for elderlywith services,silver housing, etc.

Detached house/
Condo/
Apartment

QOL

Level ofindependence

GH

Group
home

Private (paid for)old people’s
home

Geriatric healthservices facilities

Day service

Nursing home

QOD

Homecare service

Nursing care homes

Handicapped

Terminal care

Retain quality of life!

Death

Age

Source: Compiled by the author

nuclear family trend means that a social system for supporting
lifestyles is now necessary. Compared to other developed nations,Japan has reached an aging society in a short amount of time, andhas under pressure cobbled together a backup system to support
daily lives. Chart 2 plots the change in physical condition fromhealthy to disability on the vertical axis, with the horizontal axis
plotting the time of older age. The yellow line through the middle ofthe chart represents how people weaken with aging, and how
housing and welfare/medical facilities that underpin daily lives copewith the various changes in physical condition that aging citizens
face, as well as economic factors and relationships with families.
While many live in condominiums and apartments during their
younger years, the ratio of those in medical facilities increases withaging. Heart attacks and strokes mean many are in and out of
hospital, with some sustaining permanent disabilities. In somecases, this will mean becoming bed-ridden. Such circumstances are
becoming the rule, and represent a deflationary spiral that everybody
will experience. Facing circumstances that change with aging, andcognizant of the need for a structure that can support our population
come what may, we have built up a seamless safety net as our social
system.

The History of Care Facilities
The year 1961 saw the establishment of medical insurance for thewhole nation, covering the entire population, followed by theenactment of the long-term care insurance system in April 2000. The

long-term care insurance system is an insurance system thatguarantees care for the elderly at the societal level. At the time ofenactment, the system was designed by reference to Germany, which
was already implementing such a system. Before long-term careinsurance appeared, welfare measures and policies had been handled
by the government using tax revenues, yet after the effectuation of
long-term care insurance, private companies began to enter thewelfare field. In line with a widening span of service providers, thesocialization of nursing care began. Long-term care insurance is an
insurance system, meaning that contracts are entered into withservicer providers, with the weight shifting onto individual
responsibility. When individuals over the age of 40 are paying
insurance premiums, unless there is a system establishedconcurrently to provide care for them when they do actually requirenursing care, the overall system is not viable.
Thus, care facilities have been rolled out nationwide as mandated
by the Public Nursing Care Insurance Law, to provide for elderly
persons requiring long-term care. The three types of facilitiesprescribed under this law are: nursing care homes, geriatric healthservices facilities, and sanatorium medical facilities for the elderly
requiring long-term care (these sanatorium medical facilities wereabolished and became “integrated facilities for medical and longterm care” in April 2018).
To briefly explain each type of institution, nursing care homes are
facilities designed for those over 65 requiring nursing care which
they cannot receive in their own homes, while geriatric healthservices facilities are mainly designed to provide rehabilitation forJapan SPOTLIGHT • July / August 201917

COVER STORY 4

the transition between hospital and returning home. Sanatorium
medical facilities for the elderly requiring long-term care provide
recuperative care, nursing care and medical caregiving.
According to a survey conducted by the Ministry of Health, Labourand Welfare, the admission capacities for each of these (as of 2016)
was 530,000 (nursing care homes), 370,000 (geriatric healthservices facilities) and 60,000 patients (sanatorium medical facilities
for the elderly requiring long-term care) respectively. On a national
level, demand is largely being accommodated outside of the Tokyo
metropolitan area, with no likely provision for more facilities infuture.

Dignity of the Elderly & Design of Care Facilities
The architectural design of care facilities has changed in line withthe era. Given that the conventional multi-bed rooms of the latter
1990s did not ensure privacy, individual rooms that prioritized the
dignity of the elderly began to emerge. The design of care facilities
centered upon multi-bed rooms was based on the hospital modelthat prioritized cleanliness and the efficient handling of patients.
However, rather than short-term admission hospitals, care facilities
were reconceived as being “homes” where people spend their daily
lives, promoting a shift to individual rooms. Similarly, instead ofgroup care-giving where meals and bathing are administered on agroup basis, individual care aligned to the lifestyles of each individual
became the standard. Groups of private rooms became units where
each have their own eating and living areas, providing a quasi-family
feeling. In terms of the quality of care also, improvements weremade to both “hard” and “soft” elements, such as administeringbathing and mealtimes tailored to the physical and mental state of
the occupant. Meanwhile, the shift to individual rooms has resulted
in an increased burden on the users themselves. An individual room
provides a higher quality of living than a four-bed room, and in turnthis higher livability translates into higher costs for occupants.

From Care Facilities to Home Care
Twenty years have elapsed since the launch of the long-term careinsurance system, and it is safe to say that nationwide the provisionof facilities for elderly people requiring nursing care has been largely
achieved. Looking ahead, the focus is now shifting to whether people
can continue to live in their own homes, and indeed whether they canspend their dying moments there. There are questions as to whether
elderly people can continue to lead their lives at home while receiving
medical and nursing care after being discharged from hospital, andindeed whether such a safety-net function actually exists in each
community. While continuing to live at home relies upon a suitablesupport system, in the background to this is the idea of “aging inplace”.
This involves elderly people being able to continue to live in a
18 Japan SPOTLIGHT • July / August 2019

community that they are used to, in safety and comfort. In various
surveys conducted by the government and private companies, morethan 60% responded that they would like to continue to live in acommunity that they are familiar with, and many wish to spend theremainder of their lives there even if they require nursing care. The
Ministry of Health, Labour and Welfare attempted to expedite this by
proposing a system called “Community-Based Integrated Care”. The
Community-Based Integrated Care System provides integrated
housing/medical/nursing care/preventative care/livelihood support toenable even those requiring intensive long-term care to live out theirlives in a community that they are used to and in a way that isfamiliar to them. The aim is to provide one system for each juniorhigh school district with a population of 20,000 people (Chart 3).
Multi-function hub facilities encompassing home-visit nursing,short-stay service, day service etc. will be built in each junior-highschool district, providing in-home service to the local area. Juniorhigh school districts are human-scale spheres, where all journeys
can be made on foot. As people get older, it is less safe for them toget behind the wheel, meaning that it is ideal to have every facility
that they require within walking distance.

The Care Compact City Concept
The “Care Compact City Concept” is a neologism made bycombining the Community-Based Integrated Care System with the“compact city”. The compact city is the concept of a virtual city
proposed by two mathematicians, George B. Dantzig and Thomas L.
Saaty, in the early 1970s toward realizing a sustainable city, and isseen as a model for urban policy. Japan’s falling population has
prompted the shrinking of regional cities, and failure to render thesemore efficient and compact will only mean wasteful consumption ofenergy. Mountainous regions in particular face decline, with elderly
citizens dwindling and no end to the flight of children to urban areas.
In the near future as populations continue to dwindle, towns will
have to “smart shrink” in order to continue to thrive. While
compactness offers various advantages, alongside more efficientenergy consumption, various functions can be consolidated to allow
for human scale. In rural areas, there are many households where acar is required to go anywhere. The fact that people need a car to go
to their nearest neighbor is something that is hard to understand forcity dwellers. However, driving by elderly people is dangerous, andthere are cases on an almost daily basis of accidents caused by theelderly including driving on the wrong side of the road, confusing theaccelerator and brake pedals, and collisions caused by distraction of
attention. While it is still somewhat acceptable to have elderly people
with heavy onset dementia walking around, the moment they step
into a vehicle it becomes a lethal liability that causes major damage.
Some areas are already tackling this problem, including
implementing new transport systems such as small local buses that
follow a circular route around the community. A shift is urgently

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CHART 3

“Community-Based Integrated Care System” Model
In case of illness:

Health Care

The Community-Based Integrated Care System Model

Hospitals:
Acute phase, recovery phase,
chronic phase• Community General
Support Center• Care manager

When care becomes
necessary…

Nursing Care

Outpatient/in-patient care
Regular health care:• PCP, clinics with in-patient facilities• Regional affiliate hospitals• Dental care, pharmacies

Handles consultation andservice coordination

Visits/ Moving in

Home• One’s own residence• Senior residences offering services, etc.

■ In-home services:■ Facility /Residence services:• Home-visit long-term care,• Nursing care homes
home-visit nursing, outpatient day long-term care
• Geriatric health services• Multifunctional long-term care in a small group homefacilities• Short-term admission for daily life long-term care
• Communal-living care for• Equipment for long-term care covered by public aid
dementia patients• 24-hour home-visit service• Living care for persons at• Combined multiple service (multifunctional long-term
government-designatedcare in a small group home & home-visit nursing)facilities,
etc.
■ Preventive long-term care services

Livelihood support/preventing long-term care
So that seniors can continue active, healthy living[Provision of Community-Based Integrated Care System]
Formulating a structure that ensures integrated medical,
long-term care, housing, preventative care and livelihood
support services in a familiar community.

Senior clubs, residents’ associations, volunteer groups, NPOs, etc.
Source: “Regarding formulation of community-based integrated care system”, Section 3, Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare

required from a car-centric society to a people-centric one.
Equally important are the roles played by day service centerswhich provide a place for the elderly (in particular men) to get out
and about. Elderly people are prone to staying cooped up in theirhomes, drinking alcohol from the morning and living a hermit-likeexistence which then robs them of their health. Getting out andenjoying a chat with other people brings enormous benefits both
physical and mental. To allow this to happen, there must be anemphasis on a transition to compact cities, including the provision ofstreets that are conducive to walking, such as parks and green
pathways. Streets should be widened and adorned with plants andstreet furniture to better cater to elderly people who find walking fora long time difficult. Elderly people are often very attached to theland passed down to them from their ancestors, and many simply do
not wish to uproot. However, they are now faced with the choice of
uprooting to live in a “compact” town, or to remain where they are
and to put up with the inconvenience. While a case example that
could serve as a model is yet to emerge, there are several budding
initiatives which I will introduce next.

Pioneering Initiatives
Firstly, “Share Kanazawa” (Kanazawa city in Ishikawa Prefecture),
which is seen as the model for the Japanese version of a Continuing
Care Retirement Community (CCRC) and where not only the elderly
but also people with disabilities, students, and various other people
from multiple generations live altogether with the aim of creating a

coexisting community. The spacious grounds and one-story houses
inspire a sense of calm. The Japanese version of CCRC is partiallybased on the US version, aiming to achieve a Japanese-style multigeneration community with an emphasis on the elderly moving into
the community while they are still in relatively good health.
The second is “Nakama Well Park Hills” (Nakama city, Fukuoka
Prefecture), which successfully combines a hospital, nursing carehomes, recuperative facilities, and private old people’s home with asupermarket, sports club, and other services – all within the heart ofa regional city. All services are combined in one space, allowing
anybody who goes there to access shopping, health and leisure.
The third example worthy of mention is “Gifu City Tower 43” (Gifucity in Gifu Prefecture), developed next to the train station. This is an
example of a redevelopment project next to a station in a regional
city, incorporating medical and welfare functions in one space. The
43-floor condominium offers both family-type and elderly-oriented
rental accommodation, with the lower floors housing a clinic, dayservice, private old people’s home, home-visit nursing center andnursery. This provides an example of taking the various functions
scattered around a town and integrating them in a vertical space. The
projects created in these regions constitute an attractive option to
the baby-boomer generation who will become very elderly in 2025,
and wish to move to another area at an early stage due to a lack ofavailable care facilities in the Tokyo metropolitan area after 2025.

Japan SPOTLIGHT • July / August 201919

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Present & Future Issues
While various issues exist, I will focus here on the three issues ofpeople, information and money. First of all is the lack of personnel toprovide long-term care, a problem that afflicts both the Tokyo
metropolitan area and other regions equally. Even if it is possible toconstruct the buildings that provide the “hard” element, a huge issue
remains of there not being enough caregiver human resources who
can provide the crux of the “soft” operations. While the lack ofhuman resources is becoming a prominent issue in various
occupations outside of the welfare domain, people working in caregiving and welfare services require specialist knowledge andtraining, and therefore cannot be quickly sourced and put to work.
The second issue is the unifying of information. I have previously
outlined how a system is already in place to support the livelihoodsof people even if their family composition or economic
circumstances change. However, going to hospital, day service orcare facilities every time they take a turn for the worse can be amajor source of inconvenience for the individual, who receives
multiple types of medical and caregiving information from thevarious bodies providing the services that they require. Whensomeone is looking to learn the optimal course of action for theirsituation from a wide variety of experts, if information is not unified
then it is not possible to respond accordingly, including the correct
administration of medicines.
The third issue is the limits of public finance. The rising number of
elderly persons requiring nursing care is massively increasing thecosts associated with medical and nursing care. According to the
Ministry of Health, Labour and Welfare, Japan is expected to have inexcess of ¥140 trillion in social welfare liabilities by 2025. Despite
being told to begin with that individual premiums for long-term careinsurance would not be that high, rising demand is seeing insurance
premiums rise steadily. In addition to the long-term care insurance
premiums paid by those enrolled in the program, tax monies are also
being funneled into the financial resources behind long-term careinsurance, and the increase in social insurance costs is putting
serious pressure on the public purse. We are surely overdue arethink of the relationship between the financial burden shoulderedby individuals and the services provided.

Community Building Toward 2040
While the picture I have painted above depicts the society of 2025
when baby-boomers become elderly aged 75 and over (Advanced
Elderly), initiatives are in fact under way for the year 2040 when thechildren of baby boomers become Advanced Elderly themselves.
Preparations are being made for 2040 which is the next turning point
after 2025 when baby boomers join the ranks of the very elderly.
The year 2040 will be one in which IoT, AI, drones and driverlesscars are all part of daily life, amid predictions that the structure of
20 Japan SPOTLIGHT • July / August 2019industry will undergo enormous changes. AI will make it possible for
medical diagnosis and treatment by robots, and will also help
support determinations related to health promotion to prediction andprevention of illness. The aim for 2040 is to realize a “community
coexistent society” where the elderly and persons with disabilities
can live together. To make this a reality, the basic strategy revolves
around community integrated care, which allows those requiringsupport and nursing care to continue living in their communities, anda transition to compact regional cities with a Community-Based
Integrated Care System. In any case, the challenges presented by an
ultra-aging society cannot be surmounted unless systems and laws
are put in place to provide facilities that act as a safety net, andunless we reconfigure the awareness of elderly people themselves
regarding their lifestyles and community bonds, based upon aconcept of community building that moves away from seeing
medical and welfare facilities as being separate entities. This will
require a completely new approach to how towns are designed
overall.
Japan cannot escape the fact that its population will continue todecline. Solutions will not be found by continuing on the same
trajectory of the systems and plans that were formulated during the20th century which saw the population undergo growth. It is hightime to consolidate systems and approaches that are in line with theelderly of the 21st century, and the care compact city is one concrete
choice available to us. Up until now, we have attempted to create an
in-home welfare system to meet the considerably high needs ofelderly people who wish to remain living in their homes. However,this approach has evidently not resulted in the materialization of an
in-home centered system. We built care facilities across the nation,and then private operators entered the market. We implemented thelong-term care insurance system, and over time built up a system tosupport communities by making reference to other welfaredeveloped nations. Put simply, it was not built in the course of a day.
For other countries in Asia facing a greying population, one would
like to see the construction of systems, policies and customs that
correspond to the particular circumstances of each nation, and that
fit well with their respective situations. I fervently hope that when
doing so, these nations will be able to draw on valuable examples ofsystems and policies provided by Japan, a veritable front-runner in
confronting an ultra-aging society.

Satoru Yamazaki is CEO of Toshi-Yamasaki City Planning Research Instituteand adjunct lecturer at Kanagawa University of Human Services.