(My wife Anne has made a research on her home country Denmark's eldercare system, visiting some of elderly care houses. Then she compares it with the Japanese system, with which she is also acquainted. Here is the result of her work.)

The Nordic solution October, 2010
Anne Kawato
A couple of years ago mass media all over the world proclaimed the Danes the world's happiest people and everybody scrambled to explain why. Was it the laid-back, easygoing ways of the Danes, was it the rolling hills and mild climate, was it the Danes' clear enjoyment of filling their houses with the beautiful, simple designs of their nation, or was it, and I for one think this is a very important part of their proclaimed happiness, the Danish welfare system that embraces every citizen form cradle to grave?
In many countries (even Japan) old age and infirmity is a nightmarish specter that haunts people from the beginning of middle age.

In Denmark, elderly people might not live in luxury and opulence, but they will always have a place to stay and satisfaction of their immediate needs.
However, the idea that the state has to look after the old and infirm is even in Denmark a comparatively new phenomenon. Only in 1891 did the Danish Folketing pass a law, the so-called "fattiglov", that gave all needy over the age of 60 a small annuity from the state. Up until then they had had to fend for themselves or rely on the charity of relatives or others. From the mid 19th century there had existed a system of so-called "fattiggårde" the number of which increased sharply around 1870 when the industrialization lured people from the countryside into towns for an insecure future of badly paid jobs and poor housing. In 1885 there were between 350 and 375 "fattiggårde" that housed approximately 6.500 of Denmark's poorest citizens. Living at a poor house was seen as the last solution. It was a life of hardship, work, humiliation and the forfeit of civil rights.

For those a little better off there were the cramped spaces of tenement attics or tiny rooms in rooming houses or pensions. Statistics show that these were overwhelmingly rented by singles over 60. Some pensions (so-called hvilehjem) catered especially to the elderly and offered a measureless though poorly paid service to old people.
Only at the beginning of the 20th century did some foresighted counties start building homes for the elderly. Up until then such homes had been built by private organizations, mostly to secure the old age of widows of artisans or officials.
In 1933 Karl Kristian Steincke and Thorvald Stauning secured a social reform that removed the stigma of poverty, and made it a right for needy citizens who through no fault of their own had become insolvent to receive financial help from the state.
The ideas expressed in the 1933 social reform are the basis for today's welfare system.

Today's welfare for the elderly in Denmark is envied all over the world. There have been several trends in elder care, but the leading opinion today is that the elderly as far as possible shall stay in their own homes, and if need be receive help to do household chores or help from a health care worker if they are ill. Only if they need help with everyday needs such as getting out of bed, getting dressed, or going to the toilet, they are offered a room in a residence for the elderly.

During August I had the opportunity to visit several "plejehjem" (homes for the elderly and infirm) in Odense, Denmark's number three city, Munkemose Plejehjem a short walk from Odense center, Sukkerkogeriet, likewise near the city center, and Egmont, which is located on the outskirt of the city, but easy to get to by public transportation.
These 3 institutions represent two trends within eldercare, the centralized homes of the late 20th century and the new ideas of dividing up the elderly in small family like units the so-called "leve-bomiljøer".

The cost for an apartment at any of these institutions are usually regulated so an elderly person receiving only a state pension can pay for everything and still retain a small amount of money as pocket money.

The average state pension consists of a basic sum of 63.048 kr. plus extra 63.486 for singles, 29,640 kr. for married people. (Sociale Ydelser 2009) The elderly have to pay taxes of their income, but still they usually have a couple of thousand left after paying for rent, board and services at the institution. They can often also obtain rent subsidy from the state. Payment at different centers varies, however. The newer the building the more the elderly have to pay. The difference in rent between an old facility such as Munke Mose and a newly built institution such as Sukkerkogeriet, which was built in 2004, is 1858,26 kr. There are still differences for board and other services. Thus whereas the inhabitants at Munke Mose have money left to spend, at Sukkerkogeriet relatives sometime have to support the old.

At all the centers I visited managers put an emphasis on creating living conditions as close to the life the elderly had had as possible. The elderly must not feel institutionalized. They must feel they are still independent humans beings, responsible for themselves. They have their own small apartments Though Munke Mose is the oldest center, the apartments are the most comfortably designed. Each person has two rooms, dining kitchen, bath and a small entrance. (67square m) They can opt out of the boarding option and cook their own food, but hardly anybody does that.

At the other two centers there are only small kitchenettes, or rather a small counter where they can put a coffeemaker or the like, but no real cooking facilities. Though Munke Mose is not a real leve-bomiljø, the elderly are taking part in decision making e.g. through the inhabitant council, and with everyday decisions about activities. In Egmont participation in decision taking also goes for deciding on the menu in each unit. Food is prepared by the staff in each unit. Thus people in each unit might have different menus.

At Sukkerkogeriet, decision making by the elderly seemed less developed, probably because this institution housed more demented elderly. Of the three though the newest this was the least comfortable institution. Food was brought in from outside prepared in individual plastic trays but arranged on plates by the staff. At both Munke Mose and Egmont staff had made an effort to make common rooms cozy decorating with old-fashioned furniture, things and pictures. At Egmont this goes for the corridors also. They were wider than at the other institutions which made it easier to decorate them without breaking any rules.

On the other hand Sukkerkogeriet seemed to be designed by somebody who didn't really understand the functions of a home for the elderly. The institution was part of a complex around an inner court, only one wing housing the center. Unfortunately the designer had placed the large common balconies facing north towards the inner court. As the court was surrounding by tall buildings the balconies were rather windy and shady. I went there on a day when it was about 22 C, and it felt cold on the balconies. It seemed they weren't used very often. The common rooms were furnished with modern, comfortable furniture, but they lack the homely, cozy feel that was evident at the two other institutions.

Though Sukkerkogeriet was located near the center and very close to a big shopping center the lack of greenery around the buildings gave it a barren, forlorn appearance. The small courtyard in the complex center was created for the inhabitants of the general residential apartments. This year, however, Sukkerkogeriet's manager told us, they had negotiated at least a temporary right to use the space. One more thing that struck me was that doors at Sukkerkogeriet were locked. This was a necessity, we were told, because the center housed many demented elderly. However, all the inhabitants had their own keys, we were assured. At Egmont doors were not locked, but the large windowed management office was on the first floor right next to the exit. If somebody tried to get away, they could be apprehended. There had been some instances, when somebody had walked away, but the staff had always located them immediately. It would not be right to lock up people, they are free individuals, the manager said. At Munke Mose few of the inhabitants are demented, but occasionally the staff has had to lock the door. From all apartments at Egmont and Munke Mose there is a pretty view over gardens or green areas. Munke Mose is located near the beautiful park of the same name, so it's easy for relatives to take wheelchair bound elderly for a ride along Odense River.

At all the centers there are lots of physical training programs, activities and excursions for the elderly, and they generally seem happy.
Approximately 80.000 elderly live in nursing homes, residences for the elderly or assisted living facilities in Denmark. 20.000 received permanent domestic help. This number is more than twice the number 30 years ago. In Denmark as well as in Japan we are seeing a graying of society that is going the challenge the existing welfare system.

Though there might exist some unresolved problems in Danish eldercare, it still seems so much better than what is offered the elderly in Japan, and so much more affordable. In Japan it would probably be unthinkable that an elderly person, surviving on only a state pension, could in a 67square m 2DK with and still have pocket money left. In Japan, even with a huge amount of head money at a private institution, the elderly can not expect more than one small room.

In Japan the tradition of caring for the elderly at home has slowly been eroded the last couple of decades. Surveys among young people show that many don't intend to take care of elderly parents. Today's caretakers might be the last generation to accept this responsibility as their duty. Statistics show that most caretakers are over 60 and more than two thirds of caretakers over 50. Elderly people are taking care of those who are even older or more infirm than themselves. Even people in their 70ies are looking after spouses or elderly parents. With the rising number of senior citizens this phenomenon will also increase. The Japanese has been looking to the Nordic solution to find a way out.

However, in Japan the sheer number of elderly and the cramped living conditions in most major cities make nursing care reform a huge challenge.
2002 saw an introduction of the so-called Long-Term Care Insurance. On paper it looks excellent. But even in expensive private institutions the elderly have no more than a small 6 mat room to call their own. It is therefore of essential to make common facilities cozy with familiar objects. One concern of mine is that when elderly in Japan go into a nursing home, they lose their familiar surroundings. When you visit a nursing home in Denmark, all the small apartments are filled with many of the things that surrounded the elderly throughout their lives, their furniture, their pictures, their books and their knickknacks. I think this makes a transition to a nursing facility less traumatic. Elderly residents of nursing homes in Japan can bring very little with them from their former lives. As mentioned above, nursing homes in Denmark encourage the elderly to decorate common rooms with some of the familiar object they don't have room for in their own apartments. This is so much more important in Japan where the elderly have room for very little in their private rooms. It is important that nursing homes are not just seen as places to stove away the elderly with adequate physical care. They need to live out their lives in an environment that is also mentally supportive.

In most nursing homes in Japan you see the same dull pastel colors on walls, furniture, and curtains. Everything seems almost colorless and impersonal. However, we have lately seen a trend at some private facilities to bring in young designers with a keen interest in enlivening the everyday lives of the elderly by bringing warm and soothing colors to common rooms in nursing homes and to day service centers. Changing interior design in nursing homes is a way a bettering the lives of the elderly that demands neither extra space nor an exorbitant amount of money.

Another problem in Japan is the disproportionate number of bedridden elderly. Insufficient nursing-care services cause many elderly patients to resort to long-term, medically unnecessary "social hospitalization" instead. This is a burden on the finances of the health insurance system and an insult to the dignity and self-respect of an elderly person. Unless nursing services are expanded, this situation will only be exacerbated in the coming years. Understaffing is a serious problem. At some facilities there is not enough time to get people out of bed and they are left in diapers all day. Developing the system of care helpers and home care helpers is an absolute must. At the moment many middle aged women see an opportunity in this field, but the work must be made more attractive for a larger group of people. Many young people steer away from a carrier in nursing care, because it is seen as hard and unattractive work. With unemployment or underemployment among the young there is a pool of potential health care worker in Japan. Nursing care must be made an attractive and respected profession.

The Nordic solution can not be transferred to Japan directly. Here are too many people and too little space, but changes can be made, so it will be easier for the elderly to live out their lives in physical and mental comfort.