The following letter to the health secretary Alan Milburn has been leaked. It was copied to Scottish health minister Susan Deacon, who also had socialist tendencies once.

'Dear Alan, I appreciate that your background is one of radical advocacy as a trade union researcher and, it is said, a proprietor of a left-wing bookshop on Tyneside. Of necessity this radicalism has been 'blurred'by New Labour rhetoric.

However, I would like to appeal to you to augment your capitalist efficiency agenda with much more vigorous action on equity.

For decades the NHS has been obsessed by performance indicators related to things such as reference costs, activity levels and waiting times for outpatient care and inpatient procedures.

More recently you have had a 'bout' of national service frameworks, some of which are both efficient and timely. Many of these concerns are valid and, in part, a product of management failures, due to lack of quantitative analytic skills in managing enormous variations in consultant productivity and idleness in their resolution which you continue to condone.

Since you entered office there have been expressions of interest about health inequalities but all too little action. Tessa Jowell, when health minister, tried to get this issue onto the agenda but then health secretary Frank Dobson's response was muted: for example, health action zones which appear to have disappeared into the quagmire of public health inaction management.

The polls, and the prime minister's dreaded focus groups, continue to persuade you to concentrate on waiting and volumes. However, somewhere surely in the Department of Health you politicians must consider equity issues?

What should you do?

Everything in the NHS plan has equity implications, and you should establish speedily performance indicators for primary care trusts and hospital trusts so that they are obliged to chart their success in reducing inequality in access to proven cost-effective healthcare interventions.

What type of inequality are we concerned about? We know that children born in Virginia Bottomley's Surrey constituency will live longer than children born in your constituency of Darlington. We know that life expectation in Scotland is lower than in England and associated with dismal disability levels which the Scottish minister laments. Lamentation alone is not enough, my dears.

In England, Scotland and Wales resources are increasingly distributed according to quite sophisticated measures of need. We know you want to use the budget allocation formula to reduce health inequalities. Well done. The intent is excellent.

However, as money 'plops' into Darlington, Glasgow and the Rhonda, how will you avoid the middle classes scooping the benefits? The drains folk (public health medicine) will promise this won't happen but are clueless about how to avoid it.

It is known that whether we look at primary care or secondary care, there are marked socialclass gradients in the use of healthcare. Thus in Scotland, Arbuthnot measures of deprivation can be used to show that the use of statins (drugs which lower cholesterol) is less among the poor after heart attacks, than among the rich with the same health problem. We do not know why this is so, but where are the performance indicators which measure the skill of local purchasers in reducing such inequalities? We know similarly that the use of beta-blockers and aspirin are well below recommended doses (and so cheap, the drug barons do not deploy their marketing skills to increase use). No doubt similar social-class differences exist there.

As you know, general practice is a black box of ignorance and the inflated opinions of professional nincompoops. Primary care trusts, some of which are merely obsessed with empire-building outside their management competence, must urgently manage primary care providers, not just in terms of efficiency (or lack of it) but also in terms of equity: are they really getting effective intervention to the poor in volumes appropriate for their needs? If not, 'promote' them to the dole queue.

There are social-class profiles in use in all the areas where you have national service frameworks. You cluck on about more cancer care, more cardiac care, improved mental health care (about time too) and will soon announce diabetes and elderly service developments. Well done, comrade. But where are the equity performance indicators and how many chief executives have been 'managed' out of the NHS for failing to improve access for the poor?

Just look at the social-class utilisation differences for cancer, heart and stroke care.

Why do you condone consultant inaction and managerial failure to measure and improve performance? No doubt like Tony, you are scared of the doctors. Don't be. Giving the poor more care does not reduce their private practice income.

Until we have equity performance measures and the corpses of the deficient professionals littering the by-ways, we will continue to fear that your radical spirits are dead, or at least well buried, until you challenge for the leadership of the Labour Party. In the meantime remember what Chairman Mao TseTung told us: continuous revolution and the improvement of the condition of the masses. Stop faffing about, man, and help the poor.

Yours in true comradeship.

Nala Dranyam.

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