Carers UK – Written evidence (SOC0046)
1.1 Carers UK is a charity set up to help the 6.5 million people who care for family or friends, unpaid. At some point in our lives every one of us will either need care or be involved in looking after an older relative, a sick friend or a disabled family member. Whilst caring is part and parcel of life, without the right support the personal costs can be high as it can affect your job, your health and your finances.
1.2 Carers UK is a membership organisation of carers, run by carers, for carers. We have over 20,000 members and a reach of many more. We provide information and advice about caring alongside practical and emotional support for carers. Carers UK also campaigns to make life better for carers and influences policy makers, employers and service providers, to help them improve carers' lives.
1.3 Carers UK’s advice and information services answer around 20,000 queries from carers and professionals every year. Our website is viewed by over 100,000 people every month, 27,000 subscribe to our monthly email newsletters, and the combined reach of our online communities and social networks exceeds 38,000. We’re in regular contact with around 1,500 local organisations, including many run by carers, who are in touch with around 950,000 carers. Carers UK has offices in Wales, Scotland and Northern Ireland.
1.4 Carers UK and major businesses have set up Employers for Carers offering help to employers to retain the 1 in 9 employees who are caring for a family member. Employers for Carers is a forum of employers – large and small – supported by the specialist knowledge of Carers UK. Our Employers for Carers network is over 130 businesses which cover over 1 million employees.
1.5 The evidence provided by Carers UK comes directly from carers’ own experiences of the health and care system, including their experience at work and how it is impacted by social care changes. We also look at other external sources of key evidence.
Summary
2.1 To be sustainable, any long term settlement for social care must have support for unpaid care at its heart. Carers play a vital role providing unpaid care which is currently worth £132bn each year[1], but they cannot increasingly prop up a social care system in crisis as this brings with it significant costs in health, well-being and employment.
2.2 The rationing of social care services due to funding cuts is resulting in extreme and unsustainable pressure being placed on carers, who are providing more care, for more hours than ever before. Since 2001, the growth in the number of carers has outstripped population growth by 16.5% and the number of people providing 20-49 hours of care a week has increased by 43%[2].
2.3 Carers UK has argued for over a decade that social care is both a condition of employment and an economic enabler and we welcome the focus of the Economic Affairs Committee on social care. There is strong evidence to show that carers give up work to care. Carers UK research estimates that over 2 million people have given up work at some point to care for loved ones and 3 million have reduced working hours[3]. The current impact of staff turnover, absenteeism and stress as a result of juggling work with caring is already having a huge impact on business, estimated to be costing UK businesses over £3.5 billion every year[4]. This will be contributing to the lower rate of UK productivity which will become increasingly worse unless action is taken.
2.4 Care services need to be recognised as a vital part of economic productivity, a ‘condition for employment’ as essential to employers’ thinking of locating their business as good transport links and a decent housing supply. As well as addressing these barriers, stimulating a vibrant care market to meet this growing demand can turn the challenges of an ageing population and an ageing workforce into a driver for economic growth.
2.5 Social care should be seen as an industry with potential for growth and for creation of better paid and higher status jobs. Current trends of high turnover, low pay, low skills and low status must be reversed and social care work recognised as an enabler of growth.
2.6 In addition to the challenges facing for business and caring, there are avoidable costs in terms of the impact on carers’ health and wellbeing.
2.7 Technology to support caring and more flexible working is both a means of supporting the wellbeing and employment prospects of carers and in itself is an area of economic growth that should be fostered and incentivised.
2.8 Carers UK is extremely concerned that we are storing up a far greater crisis in care if carers face more widespread and greater health risks and do not feel able to care in the future. The costs of this to the state are unquantified and could be very significant.
2.9 Carers UK wants to see the following provisions for carers in any long term funding settlement for social care:
Evidence of the impact of funding challenges on carers
1.1 The rationing of social care services due to funding cuts is resulting in extreme and unsustainable pressure being placed on carers, who are providing more care, for more hours than ever before. Since 2001, the growth in the number of carers has outstripped population growth by 16.5% and the number of people providing 20-49 hours of care a week has increased by 43%[5].
1.2 Carers UK’s own research with carers found that 1 in 5 carers who are providing 50 hours or more of care each week are receiving no practical support with their caring role[6]. The impact of providing care without the right support is vast, affecting carers’ health, finances and ability to have a life outside caring, as well as their ability to continue caring.
1.3 Almost three quarters (72%) of the respondents to our most recent State of Caring 2018 survey who are currently providing care said they had suffered mental ill health such as stress or depression as a result of caring, while well over half (61%) said their physical health had worsened as a result of caring[7].
1.4 Over a third of carers (37%) responding to our survey described their financial situation as ‘struggling to make ends meet, while a further 20% said they are or have been in debt as a result of caring. Under half of carers (48%) said that they could afford their bills without struggling. For those who care for 50 hours or more per week, almost 2 in 5 carers (29%) said they were struggling to make ends meet, nearly a quarter (23%) said they are in or have been in debt as a result of caring, and 45% said they could afford their bills without struggling.
Accessing support
1.5 Many carers are caring without the support they need or are seeing reductions in the amount of support provided. The latest 2016-2017 data from NHS Digital on Adult Social Care Spending in England that the number of carers getting support or being assessed from local authorities has dropped by 5% since last year with spending on carers dropping by 6%.Spending on the respite services that give carers’ a much needed break from their caring has also decreased.
1.6 The evidence from carers is that they are seeing cuts in the care packages that the person they support receives, that they are finding it harder to access the breaks they need to look after their own health and well-being, they are unable to access the kinds of support that enables them to work as much as they would choose to do.
1.7 1 in 7 carers reported they/those they care for received less care or support during the previous year[8] and 40% of carers haven’t had a break for a year[9].
1.8 The care and support system remains complex and hard to navigate with people still taking a long time to identify the support that is available for them and their family. 24% took over 5 years to identify as a carer[10].
Experiences of services
1.9 We know that in some instances carers refuse health and care support because of concerns over quality. Disappointingly, over one fifth of carers (23%) who responded to the State of Caring 2018 survey this year said that they had refused support because of this. This was reported most strongly by those caring for someone at the end of life, over a third (37%) of whom stated they had refused support because of concerns over quality[11].
Concerns for the future if adult social care continues to be underfunded
2.1 Carers UK is extremely concerned that we are storing up a far greater crisis in care if carers face more widespread and greater health risks and do not feel able to care in the future. The costs of this to the state are unquantified and could be very significant.
2.2 The evidence from families is that they and those they support are deeply worried about the future of the services they rely on and that social care support won’t keep pace with their changing needs. In terms of practical support with caring, as many as 1 in 4 carers (25%) said they are worried that the support they currently buy or receive might be reduced, while almost two thirds of carers said that they do not know what might happen with the support they currently buy or receive (65%). Only 1 in 10 carers (10%) said that they felt confident that the support they receive and rely upon will continue[12].
2.3 Carers worry too about their own ability to continue caring in the future, particularly given the significant mental and physical impacts they’re seeing on their own health. When asked about the future, worryingly, the majority (58%) of carers said that they expect their physical health to get worse in the next two years. Only 3% said they thought their health and well-being would improve.
2.4 Carers’ expectations for their mental health and well-being were similarly discouraging, with over half of carers (57%) saying they expect their mental health to get worse in the next two years and only 4% saying they expect it to improve. Carers who said they were struggling financially to make ends meet and those who were over the age of 65 years old or providing round the clock care were more likely than other groups to say they expect their physical health to get worse in the next two years, with between 63% and 66% of these groups reporting this. Carers who said they were struggling financially to make ends meet, were the most likely group to expect their mental health to get worse in the next two years (65%).
2.5 A carer’s health and well-being can have a significant impact upon their ability to provide support for the person they care for. We asked carers whether they thought their physical and mental health would affect their ability to care in the future. Worryingly, almost half of carers responding to our survey (43%) said they expect that they will be able to provide less or no care in the future because of poor current or future physical health, while over one third (35%) of carers said they expect that they will be able to provide less or no care in the future because of poor current or future mental health[13].
2.6 Our evidence from carers shows that any economic modelling which is predicated on the unpaid support of families and friends continuing to care in good health, or being able provide the same level of care in the future, would be deeply flawed. We have already set out our concerns about modelling which does not factor in the challenges of having to remain in work longer because of a rise in pension age and a shortage of skilled labour in the wider labour market.
Reaching political and public consensus on a solution
1.1 There are a number of factors that have made it difficult to make progress in the area of social care funding. Many of these are common features of any long-term policy making. For example, legislative change and investment that needs to take place across electoral terms. Across a number of policy areas the UK has not been prepared for the changes needed to adapt to an ageing society and the costs of doing so have grown as successive Governments have been unable to make decisions.
1.2 The complexity, inconsistency and lack of understanding of the existing social care system are all important barriers to public and political engagement with the issues. This lack of public engagement and clear support has made it more difficult for policy makers to confidently put forward the significant spending commitments required.
1.3 Until they come in contact with the social care system, most people do not realise the differences between NHS and social care provision. The availability of NHS Continuing Care funding for some conditions and a diverse approach from local authorities to the free or subsidised services offered all make it hard for the public to understand how the system works.
1.4 Proposals to make small changes to the system often expose the inherent unfairness and inconsistencies that already exist and make it difficult to make a case for change. Bigger, more fundamental changes that could make the system fairer are costly and will require political and public consensus to achieve.
Political consensus:
1.5 To reach a political consensus on solution that will provide enough funding for a sustainably funded fair system for the long term, we need shared clarity and openness about the scale of the issue and that this will only be achieved with successive Parliaments working towards a common goal. To achieve this goal and start from a shared position we need to be clear about all of the following:
Public consensus:
1.6 A great deal of deliberate work was undertaken for the pension changes as part of the Turner Review which were significant and far reaching. Significant deliberate work was done by Government in 2009 and 2010 with the public on social care. More deliberative work with the public has been undertaken since by the Dilnot Commission and independently by others such as the Health Foundation, Kings Fund and the Nuffield Trust. There is already significant evidence on which a public consensus could be built.
1.7 Government needs to take forward action and not delay tackling social care funding in the short and medium term. Whilst the medium term will be discussed in the Green Paper on social care, the question of short term funding must be acted on. We cannot continue with the current situation of underfunding in social care where the poorest get increasingly less or nothing at all, and those with means above the threshold are facing ever increasing charges and payments – facing a limitless bill for care costs, whilst families are also under intolerable pressures.
Carers UK’s view on funding options
1.1 To be sustainable, any long term settlement must have support for unpaid care at its heart and actively support families and friends to do the following:
1.2 To achieve this we need a social care system that:
1.2.1 Recognises the huge existing contribution of unpaid care and the existing pressures on the sustainability of current levels of unpaid caring: Failure to understand competing pressures on people to work longer and the propensity of people to provide unpaid care will result in more pressure on the health and care system and on families.
1.2.2 Is Well-funded: By this we mean that there is sufficient funding in the system to ensure that people who need publically funded social care and their families and friends get it.
1.2.3 Is Sustainable: By this we mean that we can plan for the future knowing that the social care system will be there in the future to support us and anyone who relies on us for support.
1.2.4 Extends eligibility: Addresses unmet need by extending the right to publicly funded support to those with more moderate needs for care or support and raises the means test floor to enable more people to get support with the costs of care.
1.2.5 Pools risk: We need a social care system that pools risk between different groups of people. At the moment, those carers most at risk of catastrophic direct and indirect costs are:
1.2.6 Recognises that care services are a pre-condition for work - part of the infrastructure needed for participation in the labour market: Without a sustainable funding settlement the ability of the workforce to juggle work and care will decrease, with the likelihood of early exit from the labour market or reduced working hours and income. Our evidence suggests that carers leaving the workforce and having difficulties juggling work and care negatively affects the UK productivity rate.
1.2.7 Has sufficient resources to enable the delivery of consistent high quality care: by this we mean care that is defined by families and the people that they care for as good quality – well trained staff, appropriate care, punctual support, in order to lead a fulfilling life. The care needs to be readily available and affordable to families.
1.2.8 Funds the young as well as older people needing care: We need a social care system that looks at care across the life-course from people who have a disability from birth or childhood through to people developing disabilities later in life.
1.2.9 Harnesses the power of technology to support caring where it can and where this is desirable.
1.2.10 Invests in community capacity: The capacity of small and medium community voluntary sector organisations has been hit by spending cuts and a lower capacity of the public to donate in the economic downturn. According to the NCVO’s current projections, charities will be faced with a £4.6bn shortfall in income by 2018/19 - the result of cuts to government contract and grant income, low growth in donations from the public, and inflation. Small and medium-sized organisations saw an overall fall of 38% in their income from government sources between 2007/8 and 2012/13[14]. Without a healthy and resilient voluntary sector, people are less able to access low level support which can prevent support needs from developing or developing as quickly. For example, access to lunch clubs which can provide a break for a carer.
1.3 Potential measures that could have a negative impact on carers
Social care as an economic enabler
Social care – a pre-condition for work
1.1 Support in the workplace through a stronger statutory rights base and greater awareness of caring and informal support from employers themselves have a huge contribution to make to supporting people to manage caring alongside paid work and creating a more productive workforce. But without access to flexible, affordable, reliable and high quality care services people will increasingly take the difficult decision to give up work. 46% of carers responding to our research who have left work to care cited problems with care services as a contributing factor[15].
1.2 The combination of childcare and care for others, particularly ‘distance caring’ – supporting older parents or disabled derivatives at the other end of a motorway – is significantly adding to workplace stress and absence at a cost to individuals, business and the economy.
1.3 A study by the London School of Economics has estimated the public expenditure cost in England of people leaving their jobs to care as £1.3 billion a year in carers’ benefits and lost tax revenues. If you add to that the impact of lost income and pensions for individuals and families and the figure given in a report by Age UK is a staggering £5.3 billion UK-wide. Add to that again losses to employers in terms of recruitment and retention and lost productivity and the figure would be higher still[16].
1.4 The work that Carers UK has done with employers shows that the loss to the company of an employee is roughly equivalent to a year’s salary, if not more. Centrica (which chairs the Employers for Carers forum) estimates potential costs savings of £2.5 million through increased staff retention and £4.5 million through reduced unplanned absenteeism[17]. Whilst there is good evidence that Employers for Carers members are moving towards ever better practice, and flexible working as an issue across all employers is improving, the evidence from carers shows that the issue still remains largely hidden in the workplace. For example, implementation of rights could be improved, and businesses are not aware that they need to maximise the potential of their employees, because they are not aware of the impact of caring.
1.5 Carers who have given up or reduced hours to care were asked to name the top three things they felt would have helped them stay in work. More support from care workers coming to the home of the person they care for was the top choice of most carers (28%) and 54% of carers put it in their top three. 45% of carers put support with household chores such as help with shopping as a top three priority and one third (34%) put support for managing or coordinating care in their top three[18]. This underlines that it isn’t only those providing personal care that are seeing an impact on their ability to stay in work but also those arranging and organising care for loved ones.
1.6 This is a particular issue for women’s participation in the labour market. 1 in 4 women aged 50-64 have caring responsibilities, compared to 1 in 6 men[19]. Women have a 50:50 chance of providing care by the time they are 59; compared with men who have the same chance by the time they are 75 years old[20]. Women are more likely to be sandwich carers (combining eldercare and childcare) are also more likely to give up work in order to care.
1.7 Provision of childcare has long been recognised as a condition for women and men to participate in the labour market with Government and legislative interventions that seek to ensure parents have sufficient access to affordable and reliable childcare services.
1.8 Investment in childcare in the 1990s – through the tax system, through business incentives – enabled new players to come into the childcare market, and increased the supply of childcare to families. We want the same strategy for care, providing the right leadership and the right opportunity for growth.
1.9 Care services for children and adults with disabilities, long term mental or physical health conditions or needs that result from being older must urgently be recognised as pre-conditions for work both for people with disabilities themselves as well as for families and friends providing support to them.
1.10 There must also be a focus on reskilling those who have taken time out of the labour market. Having given up work, many carers wish to return. This may be after a short period of time, or may be after many years. Skills audits with carers show that they feel disempowered, disconnected, outdated and a long way from the labour market.
Care as a growth industry
1.11 Care has the potential to be a good news story of economic growth. If the need for more care is inevitable, then guaranteeing the supply of that care is an opportunity for growth in the care business.
1.12 There is increasing demand for better and more flexible services from families willing and able to buy care, from service-users with personal budgets, and from employers who want services that enable their employees to work without stress. Most people who use care services - and that includes the low level preventive services often paid ‘cash in hand’ such as cleaning, gardening or shopping - are ‘self-funders’, paying for it themselves.
1.13 These care services could come from a range of providers; from social enterprises, the voluntary sector, micro businesses, big businesses. Services need to be affordable, so that families can use them as much as they need to, creating a virtuous circle of demand and supply. They must be flexible and reliable, so they meet real needs.
Skilling up social care
1.14 The care sector is already a significant part of our economy. Around 1.5 million people work in social care in England alone, and demand for care workers is increasing all the time as our population ages. The value of the UK care home market is estimated at £15.9 billion[21] and Skills for Care calculated that the adult social care sector in England is worth £40.4 billion to the economy in direct, indirect and induced effects[22]. It is clearly an industry with problems, many relating to the under-funding of care by successive governments.
1.15 Uncertainty over future migration rules following Britain’s exit from the European Union could also have an impact on the availability of care work staff. In the first part of 2016 alone, over 80% of all migrant care workers who moved to England to take on a social care role were from Europe[23]. The Department of Health and Social Care’s own evidence to the Migration Advisory Committee suggested that a shortage of care workers would impact significantly on women who provided unpaid care and who also worked.
1.16 Driving up the availability and quality of care that is needed cannot be achieved without a plan to improve the skills, status and pay of the care workforce. The current social care staff turnover rate of 27% - nearly twice the average for other professions in the UK is not sustainable and must be reversed. Without reliable back up from care professionals, families and society will continue to see a negative impact on their ability to care without negative effects on their health, well-being and livelihoods.
Investment in innovation to support caring and flexible working
1.17 Innovation and technology have a significant role to play in supporting families to care – protecting their health and wellbeing, reducing stress and addressing the social isolation that is often associated with caring. Technology has huge potential to support people to combine work and care by enabling them to work flexibly and to help with caring.
Embedding support for carers in the NHS
2.1 Without a more integrated approach to supporting carers and their families, funding will not be sustainable. Whilst local government has a clear duty to identify and support carers, no parallel duty currently exists for the NHS. Carers UK believes that this is a significant barrier to the proper implementation of duties under the Care Act 2014 to support carers. Carers UK believes that a legal duty and systematic identification and support of carers by the NHS would support a joined up approach to supporting carers better and prevent carers from missing out on vital information and advice.
2.2 To support the contribution to the health and care system of those that wish to care unpaid and for the NHS Long Term Plan to succeed, we need a significant step up in the approach from NHS England. Carers need to be separately identified at every stage through the NHS journey across all settings. This is critical to ensure that data is collected, carer experience of services is clearly monitored and their own outcomes evaluated against health, ability to work, wellbeing, knowledge and resilience around caring, etc. This is to ensure that we have objective evaluation and a robust basis for continuous service learning and improvement.
2.3 In addition, there are several areas where NHS funding could be best spent to deliver better support for carers and those they support.
Investment into community health services
2.4 Carers UK’s research with carers in 2015 on the reasons for use of acute services revealed that a lack of community health services was a huge factor in causing them to turn to acute NHS services for the person they support. Carers identified serious difficulties accessing primary and community support services, with 1 in 5 saying they had no option but to take their loved one to A&E because it was impossible to see a district nurse or a GP out of hours, and 1 in 10 saying they didn’t know where else to go.
2.5 The report, Pressure Points, found that of the 4 in 10 carers who have taken their loved one to A&E in the previous 12 months believe their admission could have been prevented. Carers believed these admissions could have been prevented with more (55%) or higher quality support (50%) for the person they care for, more local support for them as a carer (32%) or access to a district nurse (25%)[24].
Breaks under NHS Continuing Care
2.6 The NHS is responsible for ensuring that cares of people under NHS Continuing Care are able to access breaks from their caring role.
Personalisation
2.7 Because of the disparity between the NHS and local authority legal duties towards carers, Carers UK has some concerns about the extension of personalisation in joint health and social care assessments and care planning. It is vital that these processes look properly at the role of unpaid care and how carers can be supported.
Digital interface between NHS and local authorities
2.8 Carers UK agrees that the development and delivery of digital activity needs to work across health and social care to create a smooth journey without carers having to repeat information. It is hugely important too in order to stop negative health outcomes because information has not been transferred, read or shared between professionals.
Lessons from elsewhere
Free Personal Care
2.9 The House of Commons Health and Social Care and Housing, Communities and Local Government Committee joint report recommended free personal care and it has also been proposed by a number of organisations working in health and social care.
2.10 Carers UK would also urge the Government to look at the Scottish model which delivers free personal care and which could bring great improvements to the affordability of care and support services in England.
Family Care Leave in Japan
2.11 With Japan’s ageing and declining population, the Ministry of Health, Labour and Welfare (MHLW) has taken steps to improve carers’ employment situation and allow more flexibility for employees to, for example, take care of their parents while retaining their jobs. In March 2016, the Government of Japan reviewed the Act on the Welfare of Workers Who Take Care of Children or Other Family Members Including Childcare and Family Care Leave (“Act”), coming into effect on January 1, 2017.[25]
Flexibility in Taking Long-Term Family Care Leave (Kaigo Kyugyo)
2.12 Under the prior Act, employees were entitled to take long-term family care leave (kaigo kyugyo) for a family member up to a period of 93 days. Under the amended Act, such employees can now take such leave but divide the 93 days into three separate occasions. Also, since there are no restrictions as to when the leave should be taken, employees are allowed to take leave, for example, for 31 days each year during a three-year period. This is paid at 67 percent of earnings.[26]
Flexibility in Time to Take Short-Term Family Care Leave
2.13 Employees are entitled to five days (or 10 days if nursing two family members in need of care or more) of short-term family care leave per year, and similar to the amendments made to childcare leave, an employee can take half-day increments of leave instead of the previous full-day increments..
Measures to Shorten Prescribed Working Hours, Etc.
2.14 An employer is required to implement one of the following measures (based on its discretion) for employees taking care of a family member:
2.15 Now, employees are allowed to use, separately from the family care leave, these measures on at least two occasions during a three-year period starting from when they first began using the measures.
Extended Scope of Family Members in Need of Care
2.16 Previously, the Act referred to co-habitants and dependents, however this has now expanded and simplified to include those family members who live outside of the employee’s household and/or who are not considered the employee’s dependent.
Payment and funding
2.17 Japan’s leave and employment support is funded under the Employees’ Health Insurance system and financed by equal contributions from employees and employers. The system includes a variety of insurers, and although there is a statutory requirement of (at least) equal contributions from employers and employees, contributions by employer can be higher by collective agreements etc. Depending on the type of insurers, the state subsidises a small proportion of payments and/or administrative expenses.[27]
9 October 2018
[1] Carers UK (2015) Valuing Carers 2015
[2] Carers UK (2015) Valuing Carers 2015
[3] Carers UK and YouGov (2013) as part of Caring & Family Finances Inquiry UK Report (2014)
[4] Carers UK (2014) Care Leave, Impact on Business
[5] Carers UK (2015) Valuing Carers 2015
[6] Carers UK (2016) State of Caring 2017
[7] Carers Week (2018) Health and Connected research for Carers Week 2018
[8] Carers UK (2018) State of Caring 2018
[9] Carers UK (2017) State of Caring 2017
[10] Carers UK (2016) Missing Out
[11] Carers UK (2018) State of Caring 2018
[12] Carers UK (2018) State of Caring 2018
[13] Carers Week (2018) Healthy and Connected, Research for Carers Week 2018
[14] NCVO (2015) A financial sustainability review: Change and adaptation in the voluntary sector as the economy recovers (PDF, 830kb)
[15] Carers UK (2014) Quality of Care and Carers
[16] Age UK (2012) Care crisis wipes over £5.3 billion from the economy
[17] Centrica Best for Carers and Eldercare, Top Employers for Working Families Special Awards 2015
[18] Carers UK (2016), State of Caring 2016 Report
[19] Census 2011
[20] Census 2011
[21] Laing Buisson, ‘Care of Older People UK Market Report’, 27th edition, September 2015
[22] Skills for Care, The state of the adult social care sector and workforce in England 2016
[23] Independent Age (2016), Brexit and the future of migrants in the social care workforce
[24] Carers UK(2016) Pressure Points
[25] Sonderhoff & Einsel News Update: Law Newsletter (January 2017)
https://se1910.com/wpdata/wp-content/uploads/2017/01/2017.1-Law-Newsletter-E-1.pdf
[26] Nakazato, H. and Nishimura, J. (2017) ‘Japan country note’, in: Blum S., Koslowski A., and Moss P. (eds.) International Review of Leave Policies and Research 2017. Available at: http://www.leavenetwork.org/fileadmin/Leavenetwork/Annual_reviews/2017_Leave_Review_2017_final.pdf
[27] Nakazato, H. and Nishimura, J. (2017) ‘Japan country note’, in: Blum S., Koslowski A., and Moss P. (eds.) International Review of Leave Policies and Research 2017. Available at: http://www.leavenetwork.org/fileadmin/Leavenetwork/Annual_reviews/2017_Leave_Review_2017_final.pdf