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Social inequalities: a home front? SIR,-In the second interview with Mr William Waldegrave he talked about inequalities and low pay in the NHS.' The National Health Service is the largest public employer in the United Kingdom, with just over a million full time equivalent staff. Brown and Rowthorn of the industrial relations and economics departments at Cambridge have produced an authoritative review of pay in the public sector during the 1980s.1 This covers the 10 years since the publication of the official report on social inequalities in health.3 The table gives their main relevant findings. Two baselines are needed to correct for the Clegg award of 1979/80 intended to reduce anomalies between public and price sectors. The contrast between higher and lower paid employees in the NHS highlights the growth in material inequalities described elsewhere.4'8 Brown and Rowthorn comment that the position of "portering and hospital orderly staff has deteriorated far more than that of the unskilled in the economy as a whole . . . [those] who have fared worse throughout the public services are the least educated." Differentials in male mortality between social classes during the period 1970-2 to 1979-83 have increased more in NHS staff than in the general population. The standardised mortality ratio of hospital porters in 1979-83 was over twice that of doctors, dentists, and opticians.' The question has been raised before whether organised medicine should become more involved in these inevitably "political" issues.4 Laissez faire market economics and current social defences evidently are not adequate. Two possible, relatively uncontroversial, areas where medicine might be able to contribute are child poverty and, in a long tradition, the crisis in housing.4 Does this issue of pay in the NHS present another opportunity for a useful contribution? The latest, 1990, figures of pay for male NHS "ancillaries" as a whole are again strikingly low, among the lowest of full time manual workers. The regular hourly pay of hospital porters, for Pay in the NHS during the 1980s

example, was £3.60, the lowest 10% of them earning £112.10 per week, against the average for all "manual" males of £5.10 and £139.40 respectively.'0 May some, or many, of such NHS workers (particularly those with several!children) be in serious difficulties at too low a standard of living? The situation is aggravated now by "competitive tendering" (privatisation) of ancillary services. Low pay tends to be overlooked as a possible source .of poverty and deprivation, in the face of more obviously vulncrable groups like those chronically unemployed, single parents, seriously disabled people, old people without additional pensions, and so on. Could this be an appropriate issue for official public health medicine, its skills and concerns? It would be complex and delicate, entailing as it does sexist national pay policies, massive labour turnover, and fragmented trades unions. Nevertheless, stronger advocacy by the BMA, too, of the cause of their low paid colleagues could bring benefits for the whole of the NHS far beyond these particular aspects. A deepening recession of uncertain duration makes such questions especially timely. J N MORRIS Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC I E 7HT 1 Smith R. William Waldegrave: thinking beyond the new NHS. BMJ 1991;302:711-4. (23 March.) 2 Brown W, Rowthorn B. A public services pay policy. London: Fabian Society, 1990. (Fabian Tract 542.) 3 Department of Health and Social Security. Inequalities in health. Report of a research working group. London: DHSS, 1980. (Black report.) 4 Morris JN. Inequalities in health: ten years and little further on. Lancet 1990;336:491-3. 5 Department of Social Security. Households belouw average income. A statistical analysis 1981-7. London: Government Statistical

Service, 1990. 6 Johnson P, Webb S. Poverre in official statistics: tno reports. Part 1. London: Institute for Fiscal Studies, 1990. 7 Barr N, Coulter F. Social security: solution or problem? In: Hills J, ed. The state of welfare. Oxford: Clarendon Press,

1990:274-337. 8 Anonymous. Mr Major's dream: is social mobility enough? [editorial]. Lancet 1990;336:1547-8. 9 Balarajan R. Inequalities in health within the health sector. BMIj 1989;299:822-5. 10 Department of Employment. Nuew earnings surves' 1990. London: Government Statistical Service, 1990.

% Change in real weekly earnings

Male employees: Medical practitioners Ambulancemen Hospital porters Female employees: Nurses, etc Ancillaries Hospital orderlies All male employees All female employees

1979-89

1981-9

55 25 4

26 11 4*

57

38 8 3* 25 29

11 0 24 31

*Comparable change in "unskilled private employees): 8% in 1979-89 and 14% in 1981-9.

sector" (male

BMJ

1991

VOLUME

302

13

APRIL

Thinking beyond the new NHS SIR,-Mr William Waldegrave exhibits a refreshing change of direction from his predecessor in his interview with Richard Smith,' 2 particularly with respect to his views on preventive care and the forthcoming national health strategy document. Sadly, he aLso exhibits a degree of naivety in his understanding of the relevance and importance of interdepartmental collaboration on these issues. Developing a coherent government health policy on alcohol or tobacco (or indeed an entire

national health strategy) requires a clear commitment from all relevant government departments. Such commitment to health needs to achieve appropriate status alongside the other aims of individual departments in order that the overall health aims can be achieved. Historically, this has not happened because the priorities of the Treasury, the Department of Transport, the Ministry of Agriculture, Fisheries, and Foods, etc, are bound up with the missions of each department's ministers and civil servants, many of which are clearly in conflict with the aims of such health policies.3 Mr Waldegrave's mission should now be to ensure that the government (and not just the Department of Health) has a clear commitment to improving health through its new strategy. Until that comes about the existing conflict between the interests of different government departments will ensure that no real progress is made. This would be a tragedy because the substantial efforts currently being made by communities and individuals throughout the country to work collaboratively towards achieving the aims of Health For All45 will always therefore be limited in their success. Health For All requires collaboration at all levels, from central government outwards. The British government has repeatedly indicated its commitment to the WHO Health For All targets and this was reiterated by William Waldegrave. The opportunity now exists for this commitment to be taken beyond rhetoric with the launching of a national health strategy. The challenge for Mr Waldegrave is to convince the rest of government that this requires health to be placed high enough on the agendas of all departments. Unless this is achieved, his new public health initiative seems unlikely to reach very far beyond the new NHS. MARTIN WHITE

Division of Epidemiology and Public Health, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH 1 Smith R. William Waldegrave: thinking on the new NHS. BMJ7 1991;302:634-40. (16 March.) 2 Smith R. William Waldegrave: thinking beyond the new NHS.

BMJ 1991,302:711-4. (23 March,) 3 Maynard A, Tether P, eds. Preventing alcohol and tobacco problens. Vol 1. The addiction market: consumption, production and policy development. Aldershot: Avebury, 1990. 4 World Health Organisation. Regional strategy for attaining health for all by the year 2000. Copenhagen: World Health Organisation, European Regional Office, 1981. 5 World Health Organisation. Targets for health for all by the year 2000 in the European region. Copenhagen: World Health Organisation, European Regional Office, 1985.

SIR,-In his interview with Dr Richard Smith, the Secretary of State for Health, Mr William Waldegrave, admitted that under the new arrangements he expected that there would be teething troubles (although his predecessor was adamant in

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Social inequalities: a home front?

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