Limited public home-care provision and the expanding role of the voluntary sector

Since the 1970s, Japan has been grappling with an unprecedented demand for home care in the context of a rapidly ageing population, social change and slow economic growth (Kono Reference Kono2000; Peng Reference Peng2002); however, alternative resources beyond traditional family care remained limited (Hayashi Reference Hayashi2011). Recognising this, the Japanese government had, in the early 1970s, envisaged an expanded public provision but this was aborted after the widespread impact across the economy of the 1973 oil price-rise shock. Instead, post-1974 governments championed a ‘Japanese-style welfare society’, proposing supplementary state involvement with an enhanced role for individuals, the family and the community – emphasising distinctive Japanese traditions and cultural norms (Lee Reference Lee, Friedmann, Gilbert and Sherer1987; Hayashi Reference Hayashi2013).

The two key features of the resulting home-care arrangements were the disappointingly slow development in statutory home-care provision and a greatly expanded role for the voluntary sector in both statutory and non-statutory home-care arrangements (Kawai Reference Kawai1990; Fujimura Reference Fujimura1999). While expansion of statutory home-care provision remained limited, its delivery mechanism changed. Local authorities increasingly outsourced their home care, with 40 per cent of 3,200 authorities doing so in 1981, but over 90 per cent by 1999 (Kawai Reference Kawai1990; Ministry of Health and Welfare (MHW) 2001). They outsourced exclusively to local ‘welfare councils’ – technically not-for-profit organisations (NPOs) but in effect quasi-public quangos, with legal recognition and corporate status. Established in each locality and working under strict guidelines, they received public funding and also benefited from tax allowances (Adachi Reference Adachi and Long2000; Yamaguchi Reference Yamaguchi2000). Other voluntary organisations and private enterprises were largely excluded from the statutory home-care market before 2000. The shift achieved cost-savings, with hourly home help in the quasi-public sector a third cheaper than local authority rates (Kanaya Reference Kanaya and Yamauchi1999). Furthermore, welfare councils and other newly established quangos played an important role in developing their own supplementary home-care services to fill the growing shortfall in statutory home-care provision.

The voluntary sector's response to provide supplementary home care

Facing continuing fiscal constraints, central government saw ‘active participation and contributions of residents’ as a viable and economical extension to existing limited statutory home-care provision (MHW 1975: 87). To achieve this, from the 1980s, urban local authorities started to deliver their own home-care services by utilising existing quangos (e.g. welfare councils) or establishing ‘welfare corporations’ (another form of quango) (Coulmas Reference Coulmas2007; Totsuka Reference Totsuka, Life and Foundation1992). These operated on a mutual help ethos, recruiting and deploying local residents, predominantly middle-aged housewives, as ‘paid volunteers’, who offered modestly priced home care for payment at or below minimum wage or market rates (or sometimes receiving time credits redeemable to buy care later in life or for relatives living elsewhere) (Adachi Reference Adachi and Long2000; Hayashi Reference Hayashi2012). These quango-led initiatives operated outside the statutory home-care system. They were funded through membership fees and service-charges, supplemented by public subsidies (Fujimura Reference Fujimura1999).

In areas lacking such quangos, such as dormitory towns, outer suburbs and relatively remoter rural regions, new citizen-led voluntary groups and co-operatives spontaneously emerged, and became the seedbed of the later (as will be discussed) NPOs and LNPOs, to deliver similar services based upon principles of mutual help and independence involving paid volunteers (Adachi Reference Adachi and Long2000; Yamaguchi and Takahashi Reference Yamaguchi and Takahashi1993).

The concept of paid volunteers – paid less than conventional workers – generated debate over their utilisation as a cheaper alternative to paid care workers and the inevitable blurring of boundaries between voluntary and paid work (Ito Reference Ito1996; Morikawa Reference Morikawa1999; Noguchi Reference Noguchi and Kawai1990). Yet it was this concept that helped to expand the workforce for home care, which involved a demanding and regular commitment. Payment attracted different, more varied participants, including highly motivated recruits who could not afford to participate without payment to cover expenses not usually provided by voluntary organisations in Japan (Takano Reference Takano1993; Takechi Reference Takechi and Imamura1993). This became important as conventional volunteers remained scarce in the area of home care (Takagi Reference Takagi1992). Moreover, payment seemingly equalised the relationship between paid volunteers and older recipients who may possibly have felt some embarrassment at receiving free help from conventional volunteers (Tanaka Reference Tanaka1996). Above all, lower payment to paid volunteers kept service-fees low, another key cost-efficient consideration (Yamaguchi and Takahashi Reference Yamaguchi and Takahashi1993). For many service-users, private-sector home-care services, on average three times as expensive, were simply not an option, with less than 10 per cent of older people being able to afford such private provision (Kase Reference Kase1993).

Both quangos and citizen-led groups who fulfilled supplementary home care were given the generic term ‘resident participatory-type home-care provider organisation’ (Jumin Sanka-gata Zaitaku-fukushi Sabisu Dantai Zenkoku Renraku-kai (JSZSDZR) 2006). Central government, endorsing paid volunteers and regarding these organisations as the key to its ‘resident participatory-type welfare society’ vision, encouraged further expansion (MHW 1993a, 1993b, 1996). With such organisations, particularly citizen-led ones, requiring little or no public money, they appeared to be economically attractive. The number of these organisations increased significantly, from just 138 in 1987 to over 1,900 by 2000 (JSZSDZR 2006).

The onset of this large-scale citizen-involved initiative by the voluntary sector attracted considerable interest from government, researchers and the sector's own proponents, resulting in substantial research (Adachi Reference Adachi and Long2000, Reference Adachi2008; MHW 1993a; Totsuka Reference Totsuka, Life and Foundation1992). Verdicts were mixed, but a shared conclusion was that the grouping of diverse and different organisations under such a generic term risked blurring important differences between these bodies, particularly between quangos and citizen-led groups in terms of size, finance, priorities and the relationship with the public sector (Totsuka Reference Totsuka, Life and Foundation1992).

The term also risked minimising distinctive and positive features of the citizen-led bodies. Unlike quangos, these were typically small, local, independent and without legal recognition, all of which had benefits and disadvantages (Adachi Reference Adachi2008; Totsuka Reference Totsuka, Life and Foundation1992). They enjoyed maximum autonomy, thereby enabling them to offer user-led services flexibly. As such, they could pursue robust voluntarism with less professionalism and bureaucracy. Yet independence from the public sector meant that they struggled financially, lacking public subsidies. In addition, they failed to win the credibility among the general public which quangos continued to enjoy (Totsuka Reference Totsuka, Life and Foundation1992).

Emergence of hybrid organisations – LNPOs delivering home care – since 2000

Government responses to the challenges faced by citizen-led groups delivering supplementary home care were crystallised in legislation from the late 1990s. Firstly, the Act to Promote Specified Non-Profit Activities, introduced in 1998, gave citizen-led groups legal recognition and corporate status, thereby facilitating and promoting wide-ranging not-for-profit activities and volunteering, and so contributing to an enhanced public wellbeing (Kingston Reference Kingston2004). Subsequently, some groups became corporate NPOs, while others continued as voluntary groups without corporate status (Pekkanen and Simon Reference Pekkanen, Simon and Osborne2003). Secondly, the prospects for financial independence and stability crystallised with the public LTCI Act of 1997, introduced in 2000. The aim of LTCI was both to expand and further diversify existing quango-dominated statutory home care (Campbell and Ikegami Reference Campbell and Ikegami2003).

Accordingly, NPOs, but not non-corporate voluntary groups, along with other types of agencies (i.e. local authority, quango and commercial enterprise), could become licensed agencies, authorised to provide statutory home-care provision for eligible older people by using paid care workers. In return, licensed home-care agencies earn officially determined service-fees (e.g. 2,350 yen=£13.50 for 45-minute domestic support and 2,540 yen (£14.60) for 30-minute personal care in 2013), 90 per cent of this coming from LTCI funds and the remaining 10 per cent paid by service-users themselves. Importantly, service-fees boosted financial resources for licensed home-care NPOs (LNPOs), giving them self-sufficiency; conceivably, LNPOs might even make a modest surplus. Indeed, the ‘entrepreneurial’ scope for LNPOs has increased considerably, compared with that of voluntary groups and NPOs which chose not to become licensed home-care agencies (Tanaka, Asakawa and Adachi Reference Tanaka, Asakawa and Adachi2003; Adachi Reference Adachi2008).

However, the narrative changes as the LNPOs' relative share of LTCI home-care providers is examined in comparison with that of other licensed agencies in the new competitive LTCI home-care market. The overall size of this market expanded massively, with the number of licensed home-care agencies rising from 9,800 in 2000 to over 28,000 by 2011 (MHLW 2002, 2012b). Of the 28,000 agencies, nearly 60 per cent were in the private sector, up from 30 per cent in 2000. The reverse trend was witnessed in the public and quasi-public sectors, their combined shares dropping from 60 per cent in 2000 to 32 per cent by 2011. The LNPOs increased incrementally in both absolute numbers and relative terms, but this growth was relatively modest. In 2011, some 1,600 LNPOs accounted for 5.6 per cent of all licensed home-care providers (MHLW 2012b).

Despite their relatively modest position within the LTCI home-care market, LNPOs attracted disproportionate attention from government, commentators and their own proponents (Adachi Reference Adachi2008; Hashimoto Reference Hashimoto, Jichitai and Kenkyujo2000; Tanaka, Asakawa and Adachi Reference Tanaka, Asakawa and Adachi2003). This attention intensified throughout the aftermath of the range of reforms from 2005 onwards, as the government continued to foster expectations that the LNPOs would fill the widening provision gap (MHLW 2012a, 2013) – a gap represented in the substantial 40 per cent reduction in the delivery of LTCI domestic support hours in 2006 (Mori Reference Mori2008; Okifuji Reference Okifuji2010).

Behind these growing expectations was the prevailing perception of the earlier successes of voluntary agencies in the 1980s and 1990s, as discussed above. These agencies delivered supplementary home care, deploying volunteer or semi-volunteer workforces and therefore providing modestly priced home-care provision to local elderly – and often financially constrained – clients, significantly undercutting the private sector. Much of this was recorded in a body of literature (Adachi Reference Adachi and Long2000; Cyoju Shakai Bunka Kyokai Reference Cyoju and Bunka1998; Kawai Reference Kawai1990; Shibukawa Reference Shibukawa2001; Tanaka, Asakawa and Adachi Reference Tanaka, Asakawa and Adachi2003; Totsuka Reference Totsuka, Life and Foundation1992; Yamaguchi and Takahashi Reference Yamaguchi and Takahashi1993). Most contributions, however, concentrated on the 1990s and the early 2000s and highlighted pioneers or proponents of ‘good’ practice. Some literature has provided quantitative data which, although useful, does not differentiate the role of providing supplementary home care from other forms of provision or different types of voluntary organisations (National Welfare Council (NWC) 2011; Hongo et al. Reference Hongo, Araki, Matsuoka and Sodei2011).

In short, there has been little investigation particularly into the grassroots experiences and realities of individual organisations across the current, diversified voluntary sector, specifically the new LNPOs. As a result, we do not know the extent to which the current voluntary sector is able to respond to the government's growing expectations. Nor do we know the nature, manner or extent of the sector's responses – particularly those of LNPOs.

Constraints on LNPOs' capacity to deliver supplementary home care

Interviews with the selected LNPO managers cast considerable doubt on the fundamental assumption about their organisations' capacity and capabilities to deliver supplementary home care, in addition to their commitments to provide statutory home care under LTCI. One manager responded by saying that ‘I just don't have the staff to take on these extra duties’ (A) and another manager observed that ‘We are just able to co-ordinate and deliver our core [LTCI] business obligations’ (C). All respondents understood clearly the expectations placed on them by government and others, but they considered such expectations ‘unreasonable’ (E). One noted that ‘The basis of their [i.e. the government's] assumption that we [i.e. the organisation] should deliver the extras [supplementary home care] is unrealistic’ (F).

The prevailing reason expressed by respondents was their overstretched LTCI business commitments. For example, ‘The money [funding for supplementary home care] is just not there’ (C). Preoccupied with fulfilling this duty, they generally felt pessimistic about undertaking any further responsibilities (C, E). Compounding this was the deterioration of the core business, specifically the drop in income from reduced official service-fees for LTCI home care. This loss of revenue-stream affected staff working conditions, payment and the strategic investment in staff (B) and so further impacted on staff recruitment and the retention of stable and contented workforces (D). One manager said,

Staffing is a serious problem facing home-care provider agencies of all sectors in Japan (Hotta Reference Hotta2007). In these circumstances, the respondents explained that any surpluses accruing from their business were being increasingly eroded, leaving little scope to invest in any additional activities (C). None of the LNPOs in the study were planning to apply a cross-subsidisation strategy to undertake additional tasks: they typically believed that any such activity must be financially self-sufficient, either breaking even or making a modest profit, ‘Because to maintain our organisation is our top priority, so any deficit must be avoided at all costs’ (D). In addition, another manager observed, ‘Extra money [i.e. profit on turn-over] made by our [LTCI] business should be put back into our business … for example, we need to keep our staff’ (E). In the same mode, a third manager said ‘We've invested much of our surplus in staff training’ (B). In her responses, it emerged that she had organised many staff support programmes, to which experts were invited.

Generally, respondents concluded that the risks associated with financial diversification into supplementary provision should be avoided wherever possible (B, D–F), although in reality cross-subsidisation, albeit limited, did occur in larger or multi-business LNPOs, including three in the study (B, D, F), resonating with the findings of recent surveys (Hyogon Fukushi Net 2010). These findings undermine the common assumption that LNPOs are financially sound to take up additional roles because of their involvement in LTCI business which would generate surpluses and these surpluses can then be reinvested into supplementary activities (Tanaka, Asakawa and Adachi Reference Tanaka, Asakawa and Adachi2003).

LNPOs' responses to growing unmet home-care demand

Although overstretched by LTCI business, all respondents, through their routine work with clients, recognised that the scope of LTCI home-care provision was increasingly failing to address or resolve the growing needs of older people. One manager declared, ‘We just can't keep up with the ever-increasing demands from our customers … or their families’ (A). They accepted that the situation has deteriorated in recent years because of cuts in provision enshrined in the reforms from 2005 onwards (A, D). Significantly, they raised concerns about cuts in domestic support, ‘We know about the cuts [i.e. for domestic support] our customers have experienced … particularly those on low-level needs … and those whose families are out [i.e. at work] all day’ (G).

Accordingly, all LNPOs in the study undertook some kind of extra services. All except one engaged in providing supplementary home care. However, none of the LNPOs in the study had a volunteer workforce involved in delivering this specific service, although volunteers were used to a limited extent in other activities, such as in day centres (A, B, D–H) and to operate meal services (D, H). One reason given was ‘day-centre provision is a communal experience [i.e. team work] but home care is lone-working … and isn't popular with our volunteers’ (D).

The absence of a significant volunteer workforce requires two key explanations. First, respondents felt that their organisations simply lacked the resources to develop new volunteer workforces, involving recruitment, training and on-going support, in addition to their existing paid workforces (A, C, D, G). Secondly, and perhaps more importantly, they considered the use of volunteers for the delivery of home care (perceived as highly demanding, involving regular commitments and wide-ranging skills), ‘inappropriate’ (F), ‘unrealistic’ (C) and therefore ‘unfeasible’ (C, D, F).

It might be assumed that paid or semi-volunteers (volunteers in spirit but receiving below minimum or market rates of pay) could form an alternative to conventional volunteers to perform the supplementary care function (Tanaka, Asakawa and Adachi Reference Tanaka, Asakawa and Adachi2003). As already observed, paid volunteers were highly controversial when widely used by resident participatory-type home-care provider organisations during the 1980s and 1990s. Typically, LNPOs established before 2000 had their origins in these organisations and thus had a paid or semi-volunteer workforce. However, none of the LNPOs in this study, including three which had such origins, retained paid volunteers or had any intention of recruiting them.

The reasons for this are the same as those already noted, but a further fundamental obstacle to the use of paid volunteers is the precarious relationship between paid volunteers and conventional, paid care workers. As one manager put it, ‘Paid volunteers are likely to perceive themselves or be perceived by others as being in some sense “inferior” to our conventionally paid employees’ (B). Another noted, ‘Those recruited as helpers [paid volunteers] but having a care qualification would soon want to work as paid carers within the LTCI system … the helpers will thus flow into the LTCI business’ (D). In addition, it was further remarked by two managers:

As discussed later, this did not, however, prevent other non-hybrid voluntary organisations, not engaged in LTCI business and thus having no paid care workers, from employing paid volunteers to provide supplementary home care. This distinction further emphasises the large cultural difference between hybrids (LNPOs) and non-hybrids, and illustrates the impracticability of deploying paid care staff alongside semi-volunteers within the same organisation.

Given this perplexing range of difficulties, LNPOs in the study unsurprisingly saw no option but to rely on their existing care worker employees to deliver supplementary home care. Accordingly, they experimented to find ways which were feasible and cost-efficient to encourage their existing workforce to help deliver the required function. This revealed further complexities, but also helped to rectify and refine their operational methods – particularly supply mechanisms – identifying factors which promote or hinder success in fulfilling this role. We can now consider the three strategies (identified during interview data analysis) trialled by the seven LNPOs.

Supply strategy 1: Encouraging employees to undertake voluntary work

First, to cope with their core LTCI business, some LNPOs in the study have applied subtle moral pressure on their care staff to perform additional, voluntary duties, stressing their organisation's voluntary-minded status and mission: ‘As our organisation is run on non-profit lines, we should all buy into the voluntary ethic’ (E). The danger here is that roles and motivations can become blurred. Care workers, predominantly middle-aged and older women on zero-hour contracts, may find themselves effectively fulfilling both paid and voluntary roles. The perceived pressure to take on a subsidiary ‘voluntary’ role was understandably often resented by otherwise dedicated workers, as reflected in poor staff retention in at least one LNPO in the study. Here, the manager reported, ‘We've lost nearly half of our staff … because of all of this [i.e. volunteer working]’ (D). Another manager was slightly more guarded in her response, but did admit in confidence that ‘We are aware of several complaints about this issue of voluntary working’ (G).

Significantly, those workers most likely to leave LNPOs tended to be those themselves under greatest financial pressure, needing to work the maximum possible hours, and unable to afford what they saw as the ‘luxury’ of donating time voluntarily, according to one manager (H). In contrast, those employees most amenable to undertaking voluntary work tended, broadly speaking, to be experienced and longer-serving, coming from more privileged sections of society, with secure financial resources from their husbands in the form of salaries or occupational pensions (B, D), resonant with the findings of recent publications (Ueno Reference Ueno2011). As for the expectation of a voluntary additional role, one manager said,

Not only LNPOs but older ‘consumers’ themselves sometimes encouraged care workers to do work voluntarily. The respondents described these consumers variably as ‘highly consumerised’ (B), ‘incredibly sharp’ (A) or even ‘demanding’ and ‘cheeky’ (D). One manager noted, ‘They are unbelievably clever … they know exactly how to manipulate our care staff to do extra time and additional work for free’ (G).

Another expressed a range of rather more ambivalent feelings,

Some workers have expressed their unhappiness by leaving for employment with other agencies, often choosing day centres and the for-profit private sector, where rules and management practices designed to protect care workers from abuse were applied (F). Meanwhile, those remaining and doing ‘voluntary’ work appeared to be increasingly disconsolate: ‘We did start to notice that in some cases certain staff started to avoid the more demanding customers’ (D). Accordingly, managers increasingly recognised the importance of protecting their workers as well as responding to older clients' needs (B, D–G). Equally, they acknowledged the importance of demarcating clearly the roles of paid workers and volunteers and delineating the content of statutory home care and that of supplementary home care (A, F, G). This, in turn, underscores the complex and diverse nature of home care and the difficulties of providing flexible, informal and voluntaristic care within the regulated, standardised statutory framework.

Equally striking from the interviews is the extent to which older Japanese recipients cared about their rights as consumers. For example, one manager reported that ‘They are so quick to phone us these days … if the care worker is a few minutes late, they complain … or they demand a change of care worker for no real reason’ (A). These views contradict the common view that Japan lags behind in practice of individuals' rights and person-centred care (Nakanishi and Ueno Reference Nakanishi and Ueno2003).

An additional complication is that LNPOs faced pressure to operate within strict financial margins, not least because they had invested their business surpluses in staff training and support programmes (A, B, G). This encouraged LNPOs, including four in the study, to pay relatively low wages, at rates which were, ironically, below those paid in the private sector (Ueno Reference Ueno2011). As typically small, locally based organisations, LNPOs simply cannot compete with the private sector. One manager said, ‘We haven't been able to raise the hourly rate of pay for care workers for at least four years and so we cannot compete with the private-sector employers … we simply don't know how they manage to do this…’ (H). Using economies of scale, sizeable capital and cross-subsidisation between various for-profit businesses, private agencies appear more cost-efficient and financially viable, enabling them to offer more attractive rates of pay. LNPO managers regarded these private agencies as ‘financially better-positioned’ (B) and thus a ‘threat’ to them (F).

This apparently confirms the belief of many respondents that considerably more public support and intervention is required to enable LNPOs to perform their business role in the competitive statutory care market, let alone the delivery of supplementary home care (A–D, F). Yet some studies reported the importance of ‘a level playing field’ and thus the irrelevance or unacceptability of privileging LNPOs within the statutory care market (Kanaya Reference Kanaya2003). This might, in part, be justified by the finding that LNPOs were no better than the private sector, in terms of the quality of care provided under LTCI (Shimizutani and Suzuki Reference Shimizutani and Suzuki2007; Suda Reference Suda2011).

Supply strategy 2: Deploying employees at cheap rates

Recognising the difficulties associated with inducing paid care workers to do voluntary work unwillingly, some LNPOs investigated yet another financial strategy to deliver supplementary home care. One initiative is for LNPOs to attempt to persuade their staff to discharge this duty at lower rates of pay than the rates paid for delivering core LTCI activities. If successful, this would enable LNPOs to increase their capacity to do this. Moreover, as not-for-profit organisations, LNPOs could, in theory, afford to pass on the resulting savings to their service-users through lower charges. This would extend the organisations' reach and include in the scope of their provision those sections of society in more need of help.

However, in practice, this strategy soon proved unrealistic and inappropriate on two grounds. First, managers felt that ‘We have to use standard hourly rates of pay as an incentive to our workforce’ (D). Secondly, they recognised both the demanding nature of discharging these duties and their staffs' high skills (B, D). In other words, as one manager observed, ‘There is not much difference between statutory and supplementary duties so both should be done by skilled paid staff at the same rates’ (B). This finding challenges the widespread traditional interpretation of the earlier model (delivering supplementary home care) based on non-hybrid, conventional voluntary groups in the 1980s and 1990s, involving typically unskilled (semi- or paid) volunteers. This in turn underscores contrasting views and methods towards the delivery of supplementary home care between new hybrid LNPOs and other non-hybrid voluntary bodies.

Supply strategy 3: Utilising employees at proper rates – a solution?

Accordingly, all seven LNPOs engaged in supplementary home care resulted in paying the same or standard wages for both tasks. But this extra financial outlay was inevitably reflected in increased service-charges, which in turn limited the reach and impact of the LNPOs' role. Most seriously, potential users may, on financial grounds, be deterred from seeking this service which LNPOs would like to offer, a point confirmed by respondents in the study:

The hourly service-charge for supplementary home care set by LNPOs in the study varied from 1,300 to 2,500 yen (£7.50 to £14.40), considerably higher than the ten per cent user-fees of 259 yen (£1.50) for hourly statutory domestic support under LTCI, subject to eligibility, with the amount being capped according to an individual's care needs. Drawing on data from ten voluntary-sector organisations, one study found the average cost of an hour's similar service to be 1,200 yen (£6.90) (Hyogon Fukushi Net 2010). This is still cheaper than the average service-charges of 2,000 yen (£11.50), set by private-sector providers, but using economies of scale and a larger workforce, private-sector providers now match or even undercut the LNPOs (Silver Service Shinkokai 2009). In short, LNPOs face challenges in the evolving competitive supplementary home-care market, as well as in the still more competitive statutory home-care market under LTCI.

Yet, as previously noted, LNPO care workers are already working at full capacity in their core business roles, leaving little scope for them to engage in supplementary home care. One manager noted, ‘We don't advertise our non-statutory [supplementary] services to the public, but only take requests [directly] from our existing customers' (B). Recent cuts in LTCI provision forced LNPOs to prioritise their LTCI business commitments. Indeed, one manager lamented, ‘We recently had to stop our own domestic support service due to the lack of staff who could engage in the service’ (C). In summary, when compared with the core LTCI business, the supplementary home-care supply was negligible. One manager reported it to be ‘less than 10 per cent’ (F); another said ‘at most 20 per cent’ (G) and a third manager – who originally delivered 100 per cent – currently delivered ‘40 or 50 per cent’ (B). In a study it has been reported that about one-third of 864 LNPOs surveyed provide no supplementary services whatsoever and the scope and nature of the involvement of the remaining two-thirds await evaluation (Hongo et al. Reference Hongo, Araki, Matsuoka and Sodei2011).

Supplementary home care – non-hybrid voluntary organisations' responses

In contrast, other non-hybrid voluntary organisations, not involved in LTCI business, were more successful in providing supplementary home care, mobilising a ‘cost-efficient’ workforce and hence with more affordable service-fees, resulting in a wider reach. The composition of this workforce differed among the seven organisations examined. One NPO utilises ‘volunteers with rewards’ who help older members with domestic support and in return earn ‘time credits’ for the hours they volunteer (I). They can use these credits to buy their own care in later life or buy care for their relatives living elsewhere. Those without time credits pay a 500 yen (£2.90) ‘donation’ for hourly domestic support, significantly undercutting other voluntary and private-sector providers. One unsurprising result has been an increase in registered service-users, which exceeds volunteers, and this difference has widened in recent years. It was reported that ‘We have so many members [who want help] on our waiting lists … including local authority referrals … but we just don't have enough members [who volunteer to help other members]’ (I). This reflects difficulties in recruiting and retaining volunteers to meet the increasing need of service-users, suggesting, perhaps, the limitations of time credits as a means to incentivise volunteers to undertake demanding activities like these (Hayashi Reference Hayashi2012).

This partly explains why all except one of the remaining non-hybrid organisations in the study continued to deploy paid volunteers – paid less than conventional workers, or what are now defined as ‘supporters’ (O), ‘members’ (I) or ‘helpers’ (M) (to avoid controversy or criticism). ‘We have to be careful … no, I mean sensitive … about the term “paid volunteers”…’ (M). Nationwide, some 2,000 organisations delivering supplementary home care (and other services) are reported to be using such a workforce (NWC 2011). However, a semi-paid workforce inevitably raised service-fees, currently about an average of 944 yen (£5.40) per hour (NWC 2011), which matches the findings from the managers interviewed for this study. This was more than double the perceived affordable or acceptable charge, according to one study (Yamada Reference Yamada2005).

Interestingly, these non-hybrid voluntary organisations excluded from the statutory home-care market were more likely to receive public subsidies, helping further development. ‘Public funding ensures two of our part-time admin posts, without which we really couldn't function’ (N). This underscores the fundamental perceived need for increased public funding of supplementary home-care activity, and acknowledges the financial constraints on potential service beneficiaries. ‘We get public funding … a subsidy … which covers 50 per cent of our service costs … which our customers benefit from directly’ (M). In contrast, LNPOs have no such support, perhaps because ‘We are seen as care providers to do business, not voluntary agencies’ (B). However, public funding is declining at a time of budget stringencies: ‘Recently, our local government subsidies have been cut … we had to cut our services’ (K). Moreover, recent government policy, specifically the raising of the retirement age, has affected volunteer recruitment, particularly among the ‘young old’ post-war baby-boomers, i.e. those born during 1947 and 1949, who are often compelled to choose continuing employment over opting for voluntary work, as expressed by one manager: ‘We are disappointed by just how few baby-boomers came to us as volunteers’ (J).