Masuda: In June, the Japan Policy Council published a strategy for avoiding a crisis in the elderly population in the Tokyo area. In the future, the elderly population in the Tokyo metropolitan area (Tokyo, and Saitama, Chiba and Kanagawa Prefectures) is expected to increase rapidly. I must apologize for repeating things that the governor is already well aware of, but the population aged 75 and older is expected to increase by 1.75 million in the next ten years up to 2025. This would hammer the medical and nursing care field. The shortage of facilities for medical and nursing care would assume more serious proportions, but this problem is actually not limited to the Tokyo metropolitan area because any strengthening of the medical and nursing care capacity in the metropolis will place a very large burden on the national economy. No matter how you look at it, the price of land in Tokyo is so high that providing nursing care facilities would cost twice as much as in, for example, Akita Prefecture. Since there would also be a 20% premium on salary costs for nursing staff, the metropolitan area would account for more than half of the current premium payment of 170 billion yen nationwide. Another big problem is what to do about nursing staff. According to our calculations, the Tokyo metropolitan area alone will need to increase the number of medical and nursing staff by at least 800,000 or 900,000 persons. If we try to cover this shortage with an influx from rural areas as has been customary in the past, we will only accelerate the demise of the regional cities. In this sense, the demise of the regions and the elderly population crisis in Tokyo are one and the same problem.
Masuzoe: Since people ask me my opinion of the “Masuda report” in all sorts of places, I have said some critical things. That relocating people from Tokyo because of a shortage of facilities is an outrage, for example. This is an issue that I would like to discuss in more detail. I do share the awareness of the problems and what might happen as a result of the increasing number of elderly people.
Masuda: So, what should we do? We came up with the following four recommendations: (1) lower the degree of reliance on human resources for medical and nursing services, (2) integrate regional medical and nursing facilities into collective housing for the elderly, (3) cooperation and broad-based support between Tokyo and the three prefectures, (4) prepare to move the elderly out of the Tokyo metropolitan area to regional areas. This was the order of priority we had in mind, but the fourth recommendation that you criticized is also the one that got the most press coverage. To us it was only a proposed alternative.
First of all, what are your thoughts on the serious shortage of nursing staff due to the rising numbers of elderly people? Secondly, what kind of policies would put an end to the influx of human resources from the regional areas?
Masuzoe: I have an experience of nursing my mother and I was also Minister of Health, Labour and Welfare. Of course, as governor, I also have to deal with these issues.
Ever since my time as minister, I have been saying that we need to prepare a range of alternatives and to be flexible where nursing is concerned. The Japan Policy Council arrived at its conclusions based on the number of beds in medical and nursing care facilities, but the Ministry of Health, Labour and Welfare focuses its policy on care in the home. But, it is not a question of choosing between institutions or care in the home. We have to consider both otherwise we won’t be able to make judgments. From the viewpoint of the family that provides the care, putting someone into long-term care at an institution seems pitiable, but they have jobs to go to. So, in our case, my mother spent weekdays at a facility for the elderly and on the weekends we brought her home. However, to deliver this kind of flexibility, a huge number of facilities would be required in extreme instances because everyone wants to take their summer holiday at the same time, and work at the same time. When we think about the increase in the number of caregivers needed, we should not make the number of facilities the issue. We have to make changes to our lifestyle to introduce more flexibility. I believe that what defines a truly affluent welfare society is the possibility to opt for home care services or institutional services when you need them and according to the family configuration.
Masuda: Yes, that’s certainly true.
Masuzoe: We don’t have enough nursing staff at present. Salaries for nurses are too low and there is no career progression. It is hardly surprising that so few people are attracted to nursing as a lifelong career option when they can’t even plan for their future in the same way as the average company employee. We have to do something to improve the way we treat nurses. As an aside, we also need to reverse our ideas. The number of female medical doctors is on the rise, but once they have children to look after, they are no longer able to come to the hospital. When I was Minister of Health, Labour and Welfare, I asked female doctors what they would need to be able to return to work at the hospital after they have children. It turns out that what they need is not daycare on the hospital premises, but flex time. Night shifts or evenings are out, but they can work from ten in the morning to three in the afternoon. They said that they wanted to work those hours. If they worked those hours at hospitals, we would add substantial potential. I think the same is true for nursing. There is no absolute need for full-time nurses only. We already have a substantial number of people with nursing qualifications. If we could get the qualified nurses who are now on leave to work part-time, I think we could substantially reduce the shortage of nurses.
Masuda: I don’t think that is enough of a solution, but it is an idea.
Masuzoe: When I was looking after my mother I thought about getting some qualifications. Getting the lowest level of qualification seems doable.
Masuda: There are all sorts of qualifications, including national ones like certified care worker or care manager, or grade one or grade two certification for home care workers.
Masuzoe: We need to operate the system for qualifications in a more flexible manner. My barber is studying to qualify as a nurse. The reason is that among the elderly there is a growing need for barbers who can do home visits to cut hair, so being a barber with a nursing qualification is a big advantage. It made sense to me when I heard about it. If barbers, gardeners, dog trainers, and people in other occupations were able to spend ten percent of their working time on nursing, we should be able to secure substantial numbers of people.
Masuda: You are suggesting that we should do more to integrate qualifications. But the reality is that you would need incentives for someone to channel part of their job to nursing.
Masuzoe: Some people who have reached the mandatory retirement age enjoy working as gardeners, or dog minders. For such people, nursing offers good prospects for work. We should do this first before we start using robots or bring in foreign nursing staff.
Masuda: You are saying that we should first unlock the untapped workforce. What do you think about using ICT and robots?
Masuzoe: I was actually in hospital for a hip operation in April this year and my left hip joint is now artificial. When I was in the hospital I realized that the robots cannot carry on a conversation. This is something you miss.
Masuda: But technology is making progress and robots who are able to have conversations are not so far off.
Masuzoe: Of course, if they can be used we should use them. But I prefer a human being to a robot (laughs). Also, in my experience, it is important not to ignore dialects when thinking about conversation. If they get dementia, your average grandpa or granny who was born somewhere in the countryside will forget standard Japanese and speak the dialect they knew as children. The progression of dementia is completely different depending on whether there is someone who understands that dialect or not. My mother had left a rural community to move to Kita-Kyushu and occasionally she would have a nurse who came from the same area. She really came alive at those times and together the two of them constructed a world that not even the family members could enter. I am pessimistic about both robots and foreign nurses because even if they know Japanese and can carry on conversations, I doubt that it is communication in the true sense. It is my theory that we could reduce nursing expenditure in the long term if grandpa and granny received their care in places where they can communicate in their own dialects.
Masuda: Ultimately, the place where you are born is the place where you can use your own dialect. When we considered the services that support the elderly in their daily life as well as medical and nursing care, I couldn’t help wondering if Tokyo will cope. Collective housing is a very difficult topic, but actually, if we can bring people together within walking distance to services, it is easy to provide care in the home. The number of vacant houses is increasing and this is something we need to leverage to make sure people are not so scattered. People living in large-scale condominiums are also aging en masse. The buildings are also deteriorating, the surrounding shopping streets are shuttered, and the ones living there are old people with nowhere to go. There are also cases of people dying alone at home. I believe Tokyo is already taking measures to deal with this situation, but how will you revitalize these areas?
Masuzoe: In the case of Tokyo, I don’t think there is any need to think about collective housing because the whole area is covered by regional comprehensive care.
Masuda: But regional comprehensive care is quite a difficult issue, isn’t it? It seems obvious, but you will require more manpower than you need if people live collectively. As you already pointed out, you would need a structure for increasing the number of part-time nurses and leveraging healthy elderly people.
Masuzoe: Apropos large-scale condominiums, the renovation of Tama New Town is going ahead with the help of private capital. If you have, for example, a four or five-storey building with no elevator or provisions for accessibility, demolition is the only choice. But in a ten-storey building you can create space by building facilities for the elderly, daycare centers, and shops on the first floor, and turning the upper floors into housing.
Masuda: It is important to build both daycare centers and facilities for the elderly to create places where different generations live side by side. The streets will not come alive unless you build for everyone, including young people and the elderly.
Masuzoe: We are building the athletes’ village for the 2020 Olympics in Harumi, but when the Olympic Games are over we will have a new town of condominiums with 6,000 apartments, which we will turn into a multi-generational town with facilities for the elderly and for daycare. Another concept is to turn it into a “hydrogen town” where electricity and hot water are generated from hydrogen. So, we are building new towns and we are also revitalizing existing large-scale condominiums.
Masuda: What about measures to deal with vacant houses? If you’re thinking about converting vacant houses into medical clinics or nursing centers, there are all sorts of regulatory barriers. Since the elderly are at risk from accidental fires, the Fire Services Act would require you to install facilities of some kind or another.
Masuzoe: Yes, you’re right. At the moment, we are extremely hard-pressed over measures to deal with vacant houses. We think that they could be adapted and converted into group homes. But it is not only a matter of vacant housing, the whole concept of the home is turning into a very big problem. I think the idea of “my home” to be the biggest obstacle to the alternative of relocating people to the regions.
Masuda: If you are not renting, but own your home.
Masuzoe: Yes. I think there will never be any movement on relocation to regional areas unless the government switches from a policy of home ownership to a tenancy policy. I am sure we all understand that people should not be relocated once they are elderly and in need of care, but they should relocate while they are in their fifties and still healthy. But people in their fifties probably still have mortgages. Even if they have paid off their mortgages, they would have to let go of the homes that they have worked so hard for. Even if they sold their homes, they wouldn’t get enough money to fund a relocation, so the whole thing is absurd. It will not change until we have a market for homes that is similar to the second-hand market for cars. Years ago when the Socialist Party still had influence, Miyazawa Kiichi said (former Prime Miniseter), “All the guys waving to people from the Socialist Party election campaign cars live in rental housing. As soon as they move into a condominium, they will change into LDP supporters.” This is the kind of thinking we have to change. Both the government and government policy have to make a U-turn, but people will also have to liberate themselves from the idea of home ownership. We are trying to raise taxes on vacant houses, but I am not sure how far this will go toward a solution.
Masuda: The Nomura Research Institute published some figures a few days ago. There are now 8.2 million vacant houses nationwide, but by 2033 this figure will exceed twenty million. This is a terrible situation. You are quite right to say that we need to change the basics of housing policy to solve the problem of vacant housing.
Masuzoe: There is also the problem of inheritance. It’s not at all easy.
Masuda: The elderly population is not just an issue for Tokyo, so cooperation with the other three prefectures is essential. I understand that Ishiba Shigeru, Minister in charge of Overcoming Population Decline and Vitalizing the Local Economy in Japan, chaired the Regional Revitalization Liaison Council for Tokyo, Saitama, Chiba and Kanagawa Prefectures on June 2.
Masuzoe: Mr. Ishiba and I discussed this issue and we agreed that there are some issues where we have to join forces and to consider the whole Tokyo area, so I spoke to the heads of the three prefectures. Governor Kuroiwa Yuji of Kanagawa Prefecture was able to find time in his schedule, but Chiba and Saitama sent their deputy governors to participate in the meeting. It was decided that from now on the deputy governors will attend on a regular basis and the governors will attend when recommendations are made.
Masuda: In any case, I think it is of great significance that there is some coherence in the Tokyo area and that people are concerned about the problems with an aging population. I look forward to the outcomes.
Masuzoe: From the viewpoint of the nation, the Tokyo area is also a region, but what can one region do? Take the example of the problems with the roads. We are building the Ken-O expressway, an external ring road outside the metropolitan expressways. But what do you about road tolls when an expressway crosses one of the prefectures? Unless we make it cheaper to take the outer ring road or the Ken-O expressway, cars will converge on the city center. We should also work together on such problems. As was pointed out in the recommendations from the Regional Revitalization Council, the problems with medical care are not limited to Tokyo. People are moving out of the city to the adjacent prefectures in search of care facilities, and people from Saitama, Chiba and Kanagawa come to Tokyo if there are good hospitals.
Masuda: In that sense, patients are considering hospitals carefully and then making choices out of their own free will.
Masuzoe: The high price of land in Tokyo creates bottlenecks for everything. The only way to create space is to build high–although this not the case at Tama New Town mentioned just now. The policy should be to charge extremely low rents for land to make it easy for the private sector to get a foot in the door and to somehow remedy the situation where no one can build medical or nursing facilities. We need to make skillful use of deregulation in this sense.
Masuda: No other local governments find themselves squeezed into as tight a spot as Tokyo, so where would you like to see openings in the regulations?
Masuzoe: People say that Tokyo does not build medical or nursing facilities, but that is not true. The city of Tokyo is converting its unused warehouse space into welfare facilities. There is room for improvement like making sure that there is no waiting list for childcare.
Masuda: Among the recommendations we made in our report, relocation to regional areas triggered the most discussion in the newspapers. We were extremely cautious when we wrote the report. Of course, we were not thinking about forced relocation and we are definitely not suggesting compulsory relocation for any required nursing staff.
To be honest, we were mostly thinking about people returning to their birthplace, or moving to somewhere that is familiar because they lived there for four or five years while working. If an individual wants to relocate, it is important that the state is supportive, but the intention behind the recommendation was to broaden the alternatives, not to impose relocation even if the system is overhauled.
Incidentally, last year the Cabinet Office conducted a poll of Tokyo residents asking about their intentions to relocate in the future. According to the results, approximately forty percent of respondents said they were considering relocation. With this much interest and a ratio that increases as the years pass, why does it not lead to relocation? It is understandable in the case of young people because life will be hard for them if there are no job openings in the destination area. People in their fifties and sixties say they are worried about medical and nursing care. Both viewpoints are perfectly understandable. To start with, it is important to set up a one-stop point of contact to provide information to people who are interested. The issue of cost is probably also an important point that influences the decisions of people who are interested in relocation. I wonder if it would not be possible to start by trialing relocation for two or three years.
Masuzoe: If this is what you meant, I think it’s fine. As for the reasons why people who are interested in moving don’t go through with it? If we drop down to the level of the individual, there is, first of all, the problem of opposition from the spouse or children, then there is employment and home ownership. From the viewpoint of the family, another obstacle for our generation is that people have many siblings. Since I am the youngest, I wouldn’t have anywhere to live if I wanted to move back to Kita-Kyushu. If we think about the reasons why people moved to Tokyo in the first place, some people came here to get away from troublesome siblings or relatives. The atmosphere in the capital liberated us. I understand why you would say that moving back to the place you were born is the easiest option, but there are good reasons why some people left their birthplace.
Masuda: Yes, you have a good point. It seems there is often opposition from the spouse.
Masuzoe: If the wife tells the husband to go ahead and move, the truth is that many men of our generation don’t have any life skills and we would die early if we lived alone. (Laughs)
Masuda: Many people who have not been able to persuade the family and have relocated on their own tend to return after a few years. Conversely, in families where the wife agrees to relocation, none of them return. It goes to show that the women are in charge. (Laughs)
Masuzoe: Another big factor is the reception at the destination. Based on my experience of living in Germany and France when I was young, the Germans complicated things too much and the interventions were irritating. In France, on the other hand, I only had to do the minimum necessary and then they let me be. I wonder if the same doesn’t apply here.
Masuda: I see. So, the towns that have successfully incorporated newcomers are doing something right. I think that warm relations between people are necessary, but it’s also important not to intervene in clumsy ways.
Masuzoe: Including the young, the number of people who want to live in the regional areas is fixed. But no matter where you move, once you have lived in Tokyo, you will sometimes feel like returning. I am sure there are people who want to visit the Kabukiza once a year. At such times, the bottleneck is the cost of transportation. Generally speaking, transportation is expensive in Japan. Whenever I went to Kyushu together with my wife and two children to look after my mother, a single trip set us back 100,000 yen, an amount that is roughly equal to a month’s pension. You will hesitate if you think your monthly pension will be used up for a return trip to Tokyo. Even if you start by trialing relocation, it will not happen unless there is some leeway on time and money. The Democratic Party failed to do it, but if you ask me, we should implement policies to make all the expressways toll-free.
Apropos, leeway on time, I think the lack of time in the modern lifestyle has contributed to the shrinking population. You already sounded the warning bells on this, but young women from the regions come to the Tokyo area where birthrates are low. As long as this is the case, nothing will improve unless we reform the approach to work nationwide, including the men. There will be no solution unless we as a nation find a way to be more relaxed, to do things more slowly, and do other things than work.
Masuda: I couldn’t agree more about valuing relaxation.
Masuzoe: I think that Japan is really impoverished. Even though everyone is so frantic about working, why are we not more affluent than we are? I would like to suggest that we make Japan the first country in the world with a three-day work week where we do our work quickly and create wealth quickly.
Masuda: Yes. Since we have finally got to the point where we can enjoy a long life expectancy, we should not be so downbeat and get stuck on the problems around healthcare and nursing, but we should have a broader debate around life after retirement.
Translated from “Tokushu –Chiho Iju wa ‘Ubasuteyama ka’/ Taidan: Tochiji, Koreisha no Zoka wo Uketomekiremasuka? (Special Feature: Is Relocation to Regional Cities the Equivalent of Abandoning Old people in the Mountains to Die? / Dialog: Governor Masuzoe, is it possible to come to grips with the increase in the elderly Population?),” Chuokoron, August 2015, pp. 34–41. (Courtesy of Chuo Koron Shinsha) [August 2015]