Cruel and inefficient
Equality means good health outcomes, inequality bad health outcomes. Ian Spencer savages Labour’s Singapore plans
Labour’s shadow health secretary, Wes Streeting, on a visit to Singapore, has spoken admiringly of its healthcare system.1 Of course, it may be natural for a Labour rightwinger to admire a tax haven - that is, one of the most unequal countries in the world, with limited democracy, high levels of imprisonment and no right to jury trial. However, it is an interesting choice.
On the face of it, Singapore seems to be something of an ‘outlier’. Very unequal countries generally have poor healthcare outcomes.2 Yet, at first glance, that is not true of Singapore. For example, a study of
disability-adjusted life years and health-adjusted life expectancy across 193 countries between 1990 and 2017 found that Singapore had the highest life expectancy for women (87.6 years) and men (81.9 years) … the probability of dying from non-communicable disease between the ages of 30 and 70 is 10.1%, which compares favourably with the UK (11%), the USA (13.6%), Denmark (11.6%).3
And all of this on a relatively low level of expenditure - 4.47% of gross domestic product. So is Streeting’s admiration for the Singapore health system a change of direction to that followed by Conservative and Labour administrations since 1979? I doubt it, but there is cause for concern.
All is not what it seems. The statistics leave out nearly a quarter of its population and 37% of its workforce; migrant workers, who are excluded from Singapore’s universal healthcare system. Health insurance for migrant workers is the responsibility of employers, covering injuries at work and other unforeseen circumstances, but chronic conditions are omitted and long-term illness, even from industrial injury, can result in deportation.4 Migrant workers are generally young and fit; after all, they are those who can make the journey and work the average of 60-70 hours a week that many face. There is no need to provide for the diseases of old age in these workers, as they will have returned to their home countries by then.
Rich and poor
In international comparisons, poverty accounts for the world’s worst health outcomes. The major threats to life are communicable disease, poor sanitation and water quality, and nutritional insecurity. Once societies become developed enough to minimise these threats, then inequality, the gap between rich and poor, exerts an influence independently of poverty. This is in large part because of stress hormones, such as cortisol and adrenaline, on workers who have little control over their lives, but are aware of wide inequality.5
This produces a well-documented pattern, where the USA, for example, spends more on healthcare as a proportion of GDP than any other country in the world, but achieves worse health outcomes than many far poorer countries, including some developing ones. In addition, many workers in the USA have no health insurance at all. Comparing the health outcomes of different countries, epidemiologists will usually consider a wide range of indicators, from suicide rates to teenage pregnancy and from narcotic use to deaths from gun violence. Almost all of them are worse, the more unequal the country.6
In countries with the best health outcomes - eg, in recent history Japan and Spain, the gap between rich and poor is far narrower than in the USA, which has very poor health outcomes at great cost, socially and economically. Put differently, any society wishing to improve health across the board would be better placed using its wealth to reduce inequalities. Social differences have a far greater impact on the likelihood of getting some life-threatening disease than the quality of medical care has of preventing or treating it.7
The UK, which closely follows the USA as one of the most unequal countries in the world, has been moving closer to the US model of healthcare. This has led to significant investment in British private medicine by US healthcare companies. It has also led to Wes Streeting being given substantial donations by supporters with links to private health corporations.8 But he is not alone: Sir Keir Starmer and Yvette Cooper have also received hundreds of thousands of pounds from donors with connections to private health companies.9
Singapore is an island state of 5.7 million people, where only 4.2 million are “citizens and permanent residents”. Effectively, it imports its working class from the Philippines and south Asia, which endures low-paid work in construction, maritime services, manufacture and domestic service. The health profile of these migrant workers is very different from those of citizens and permanent residents. Many suffer high levels of significant mental illness owing to stress related to debt, the threat of deportation and poor accommodation. The fact that migrant workers are often housed in dormitories had a devastating impact during the Covid pandemic.
Tens of thousands effectively work under conditions of debt bondage due to high recruitment agency fees and the fact that they must surrender their passports to their employers and require permission to change jobs, under threat of deportation.10 Migrant workers are also excluded from political representation. The so-called People’s Action Party (PAP) has governed continuously since 1959, when Singapore was an autonomous part of Malaysia. The only opposition in parliament is the so-called Workers Party, which claims to represent a “constructive opposition” to the PAP - but certainly not to capitalism or the miserable status of migrant workers.
The healthcare system has been subject to several reforms in recent years to address some of the difficulties it has been facing, due in large part to an ageing population. These have included a shortage of acute hospital beds and the moving of health professionals away from the publicly funded sector to the private sector. Singapore has a system of widespread private healthcare and a safety-net provision for those who cannot afford to pay. There is an emphasis on personal responsibility for preventing illness and reliance on MediShield and MediFund insurance schemes as a long-stop provision for those on low incomes. Around 70-80% of Singaporeans obtain medical care within the public health system.
There is, of course, a well-developed private system for the very wealthy. Workers who are citizens and permanent residents, who can afford to pay, must contribute a proportion of the cost of care and this has led to a system with significant upfront costs for patients. Around 60% of Singaporeans have no general practitioner, as these are almost wholly engaged in private business. The majority of those seeking outpatient primary care obtain it through publicly subsidised polyclinics. It may be that Wes Streeting was unaware or indifferent to this when he stated that he would “bring back the family doctor system, if he became health secretary”.11 That certainly is not happening in Singapore!
Where Streeting may draw some inspiration is that citizens and permanent residents must contribute compulsory savings toward their healthcare - effectively 20% of their income. If admitted to hospital, Singaporeans must contribute to the cost of treatment, on a sliding scale, according to their earnings. If Singapore has inspired Streeting, it will be to find new ways of making the working class pay more for their care, while ensuring that it is private medical companies which make the biggest gains.
Streeting was also clearly impressed by the level of technology in Singaporean hospitals, or at least one of them - the vast Singapore General Hospital. Here, “They use fixed machines to measure their own blood pressure, weight and height and receive a printed plan of their day at the hospital, including timings for scans, tests and appointments to see doctors.”12 We have seen the fetish for technological solutions many times before. From the Horizon scandal in the Post Office to the debacle of ‘test and trace’, each successive government has tried to portray technology as providing a pain-free solution to the difficulty of solving problems without the cumbersome business of employing people, particularly when the National Health Service is haemorrhaging staff.
Of course, technology does have an important place in healthcare. For example, an ultrasound machine can provide relatively cheap, non-invasive, diagnosis at a fraction of the cost of an invasive laparotomy. However, that is a far cry from computer systems whose objective is to provide a system of surveillance over barely trained staff, which is, I suspect, closer to Streeting’s objective. After all, Streeting’s response to the NHS Long Term Workforce plan is to suggest that the Tories had stolen his idea and that he would have put the plan in place sooner! Yet the plan is unrealistic - based on the deskilling of nursing and medicine, in favour of ‘associate’ nurses and physicians, with shorter training and, of course, lower pay.13 Streeting and Starmer have both refused to say that they would make any significant improvement in NHS pay.
The NHS did not come into being like a shiny new pin in 1948. Nor is it an island of socialism in a hostile capitalist sea. It was the nationalisation - and rationalisation - of private, Poor Law, local authority and charitable provision. Its hospital stock was ageing and in a particularly bad way. In 1948, 45% of hospitals in England and Wales were built before 1891 and 21% before 1861. It was a “ramshackle and largely bankrupt edifice”.14 However, it has remained extremely popular - in no small part because it embodies some very important aspects of what a genuinely socialist society would have at its heart. Distribution is, for the most part, according to need. It was also, at inception, to all intents and purposes, free and universal. Moreover, if looked at from the point of view of the cost of administration, it was efficient. As the market has become a more dominant part of NHS expenditure, the proportion that is spent on administration has steadily risen - almost to the levels of US healthcare.
The NHS was achieved despite post-war austerity, the opposition of the Tory Party and senior doctors, who resisted the loss of income from private medicine. However, Labour’s record in office of defending the universal provision of health and social care after 1948 is not a good one. The Blair years saw a continuity of Margaret Thatcher’s move towards the piecemeal privatisation of the NHS. For example, The Health and Social Care Act (2003) provided the basis for NHS hospitals and primary care trusts to become eligible for ‘foundation’ status and start the process of becoming not merely independent, but incorporated into an increasingly privatised system. Private companies effectively ‘brand’ themselves as NHS components and many patients today are treated in private facilities paid for from public funds - including the dividends paid to the shareholders.
The recent history of the dismantling of the NHS owes far more to a move in the direction of US-style, insurance-funded, two-tiered healthcare than it does to Singapore. Streeting’s visit was a piece of political grandstanding in advance of the general election to appeal to staff writers at The Times, etc. The example of Singapore has been manipulated by commentators, who choose to ignore the fact that the healthcare system there is extremely expensive, when one considers the proportion of it paid for by relatively privileged citizens and permanent residents. These in turn enjoy their precarious privileges at the expense of a significant proportion of the population with no access to universal healthcare at all, unless it is provided for through employer contributions to insurance.
What we would be left with if we followed this route would be, like the US model - as cruel as it is inefficient.
The Sunday Times December 9 2023.↩︎
R Wilkinson and K Pickett The spirit level London 2009.↩︎
N Rajaraman et al ‘Exclusion of migrant workers from national UHC systems’ - perspectives from HealthServe, a non-profit organisation in Singapore Asian Bioethics Review Vol 12, pp363-74.↩︎
M Marmot The status syndrome: how social standing affects our health and longevity Bloomsbury 2015.↩︎
R Wilkinson and K Pickett The inner level: how more equal societies reduce stress, restore sanity and improve everyone’s wellbeing London 2019.↩︎
N Harrigan and Koh Chiu Yee, ‘Vital yet vulnerable: mental and emotional health of South Asian migrant workers in Singapore’, Lien Centre for Social Innovation, Social Insight Research Series, 2015.↩︎
The Sunday Times December 9 2023.↩︎
‘Road leading nowhere’ Weekly Worker July 6 2023: weeklyworker.co.uk/worker/1450/road-leading-nowhere.↩︎
A Pollock NHS plc: the privatisation of our healthcare London 2004.↩︎