open space:

Today's political climate has created an NHS which has declared itself committed to tackling health inequalities. By signing up to agendas identified by health action zones and health improvement programmes it has adopted a core philosophy based on a sound economic argument: the most effective way to tackle health inequalities is to develop a multi- faceted anti-poverty programme.

The extent to which this has underpinned various HAZ programmes varies from region to region. But such an approach has long-standing advocates in the health research community.1,2,3,4

Research has suggested that health chances are clearly related to the widening economic differentials between rich and poor, and it is by reducing these that the real health benefits will accrue.4 Such a gap is reflected in the widening differentials in salaries and conditions between NHS employees.

The reorganisation of NHS structures and controlling payment bodies has provided some ominous precedents. Primary care pilot sites, primary care groups and the private finance initiative all suggest that the NHS is moving towards a private, decentralised and capitalist model.

The financial freedoms given to primary care pilot sites enable them to determine local pay and conditions. In some cases, this has meant that GPs have awarded themselves large pay rises while freezing the pay of nursing and support staff. The movement towards primary care trusts may intensify these trends.

In the acute sector, the widening economic differentials are reflected in the privatisation of domestic and ancillary services by the majority of trusts. This has resulted in poorer conditions and pay for this group.

The recent imperative to address recruitment and retention in nursing and professions allied to medicine has led to some improvement in pay and conditions. But recent pay awards and service payments offered to consultants make such improvements almost meaningless and perpetuate the economic power imbalance which permeates the NHS.

Many HAZs have adopted a second core philosophy based on the imperative to break down bureaucratic and power structures and to create an environment where individuals feel valued and empowered. But in reality, there is little indication of this democratising process in the NHS.

Unequal conditions persist, for example, in access to training, in career development and in the basic support services provided for staff, including creche facilities, car parking and residential accommodation.

While the medical profession remains omnipotent, support for more vulnerable employees has gradually been whittled away. Government policy has stripped away the power of the unions, and the privatisation of many NHS employing agencies has created a situation where there is no collective body to champion the cause of the most badly paid in the NHS.

The recent development of PFI suggests that the NHS will move rapidly along the capitalist path, now reflected in the design of hospital services and buildings. The impact of huge amounts of borrowed finance may ensure that, purely in order to escape financial ruin, services will be developed on the basis of a rapid cost return.

Are we therefore going to see the proliferation of day care, short-stay surgical services at the expense of services for those more vulnerable in society - poor people, elderly people and those who are mentally ill?

The competing priorities within which the NHS operates suggest an underlying contradiction. While publicly championing movements identified by HAZs and HImPs, the NHS is contributing to the perpetuation of health inequalities among its employees and the community at large.

Some internal reflection and husbandry are urgently warranted.

Shan Barcroft is a nurse and health promotion specialist for North Lakeland Healthcare trust.

REFERENCES

1 Townsend P, Davidson N. The Black Report. Penguin, 1980.

2 Graham H. Women, Health and the Family. Brighton: Wheatsheaf Books, 1984.

3 Whitehead M. The Health Divide. Penguin, 1988.

4 Wilkinson R. Income and Mortality (ed) Class and Health: research and longitudinal data. Tavistock, 1986.