In those moments of frustration between the patient, the rock of the NHS and a private referral (the ‘hard place’), have you ever thought, ‘let’s just start from scratch and provide compulsory health insurance for everyone’?
This is currently the system in Japan – although, as I recently discovered on a fascinating trip to Tokyo with the RCGP’s exchange programme for AITs and First 5s, ironically they are now aiming for a system more like ours in the UK.
I spent time at the Kawakita Family Medicine Centre, and not only had my eyes opened to the realities of such a healthcare system, but also, unexpectedly, gained more of an appreciation of our own history of general practice in the UK and the respect it engenders, but which is often forgotten at home.
Much like trying to navigate the Tokyo metro, ordering hot coffee in a can from a vending machine, and being given house slippers to wear on a nursing home visit, being faced with the complex insurance-based system was a culture shock. In Japan, there is a system of national health insurance, funded through premiums weighted according to income and age, in addition to significant contributions from employers and taxes. Numerous types of insurance exist, including coverage for social care and nursing needs, with patients under 65 contributing between 20-40% of the costs.
As a fee-for-service system, patients have open access to any specialist, with a small fee only recently introduced for patients attending tertary hospitals of over 500 beds without a referral from a primary care doctor.
With no established gatekeeper role in the system and easy access to investigations, time spent in hospital and the cost of care is escalating exponentially, particularly as the population ages. While old age is celebrated and respected in Japan, it also provides a dystopian insight into the impact on healthcare services, with data showing spending on elderly long-term care is expected to more than double by 2060.
In tackling this, the Japanese Ministry of Health, Labour and Welfare (MHLW) have highlighted primary care physicians as being fundamental to providing the efficiency and cost savings needed to make the system sustainable.
However, developing the identity of general practice is challenging in a system where gatekeeping is not a prerequisite. How do you even say GP in Japanese? There is no direct translation – nor an equivalent role. Traditionally family doctors have ranged from single handers in community clinics, to internal medicine specialists in hospital departments of family medicine, with no standardised training system such as the GP VTS scheme in the UK or equivalent of the MRCGP. Professional regulation since 2010 has come from the Japan Primary Care Association (JPCA); however in recognition of general practice as a specialty, the MHLW are introducing the term ‘board-certified GP’ this year with a framework of six competences that include patient-centred, community-orientated care and inter-professional team working.
Meeting Japanese GPs was a humbling experience. Without the security of a Royal College for over half a century, and without an identity ingrained into the social consciousness, they often find it hard to express their role to patients and families, including their own, despite having such a fundamental part in the future of the Japanese healthcare system. Pioneers such as Professor Ryuki Kassai, from the Department of Community and Family Medicine in Fukushima, are embracing these challenges and looking internationally to bring structure and changes to family medicine in Japan, whilst bringing a sense of identity and community to those in training.
When my Japanese exchange counterpart spent time sitting in on my clinics in the UK, our cultures could not have seemed more different. In Japan, clinics are based on local population needs, often set up by individuals with a specialist interest. As a former cardio-thoracic surgeon, he works for a clinic specialising in home visits in the more rural northern part of Japan which was itself set up by another cardio-thoracic surgeon; with a portable XR machine and blood gas analyser in the back of his car, he can perform lifesaving procedures for palliative patients without the need to transport them to hospital.
The patients themselves are different: the majority are ethnically Japanese, only speak Japanese and come with an instilled respect for the medical profession. Obesity is rare and there is still a culture of caring for elders, although society is undergoing significant shifts in expectations and cultural obligations.
However, bonding over patients and shared experiences, our cultures didn’t feel 6,000 miles apart. Despite my terrible Japanese, it was clear the common language of medicine is stronger and I fondly remember getting to know him and sharing our visions for the future of general practice both in the UK and Japan.
Throughout my time in Japan and through meeting the Japanese doctors who came to visit the UK, I was struck by their drive to develop family medicine at scale. Each I encountered was a pioneer working against social stereotypes and challenging the boundaries that have existed in their medical culture for generations, to improve care for patients. I couldn’t help being slightly envious of their journey in developing an identity for Japanese GPs that reflects who they are, without the negative stigma of the press or punitive government policies. However, I was struck by their respect for our history and tradition of general practice, which is something to be treasured and upheld.
It just sometimes takes a trip to Japan to realise this.
Dr Maham Stanyon is a GPST3 and academic clinical fellow at Imperial College London