Peter Lapsley: I know my place

Peter Lapsley Hraztan Jebejian is an Armenian doctor, and a very good one. He studied hard, keeps his CPD up-to-date, ensuring that he is fully abreast of developments in his speciality, is utterly reliable, and much in demand. He works very hard and makes a good living.

He is the physician who resolves the ailments in our household plumbing system. No job is too big or too small for him; he carried out a full heart transplant last year when he removed the old central heating boiler and installed a new one that provides us with constant hot water and has halved our gas bills; he installed an attractive water feature in our garden; and he came round immediately on receiving our call to replace the burned out element in the immersion heater that serves the bathroom in our loft conversion.

I have long been uncomfortable with the way in which society differentiates between skilled craftspeople and those with degrees, and with successive governments’ blind determination to send as many people as possible to university. Some people are more practical than cerebral, and vice versa, and thank heavens for that. What is the difference between a skilled plumber, electrician, carpenter, bricklayer, cabinet maker, thatcher or stone mason on the one hand, and a doctor, a nurse, a lawyer, an accountant, an architect, or a diplomat on the other – apart from the fact that the first group undertook apprenticeships or spent many years training “on the job” and that the second obtained their qualifications at universities?

While it would be extremely difficult for society ever to rid itself of these inherent ideas about “status” (call it “intellectual snobbery” if you like), at least “tradesmen’s entrances” have largely been consigned to history. And it is why, with no particular affiliation to any political party, I welcome so warmly the coalition government’s drive greatly to increase the number of apprenticeships available to young people.

There is a strong medical component to all this, evidenced in two fascinating papers, Whitehall I and II. The Whitehall I study examined mortality rates over 10 years among male British civil servants aged 20-64. It was an attempt to avoid some of the problems created by the use of general social class groupings, that is, the heterogeneity of occupations within a single class leaves room for differing interpretations. Instead, it concentrated on one “industry” in which there is little heterogeneity within occupational grades and in which there are clear social divisions between grades (Marmot, Kogevinas and Elston, 1987).

It showed a clear inverse association between grade (level) of employment and mortality from CHD and a range of other causes. Men in the lowest grade (messengers, doorkeepers, etc.) had a three-fold higher mortality rate than men in the highest grade (administrators) (Marmot, Shipley and Rose, 1984).

Grade is also associated with other specific causes of death (Marmot, Kogevinas and Elston, 1987). While low status was associated with obesity, smoking, less leisure time physical activity, more baseline illness, higher blood pressure, and shorter height, controlling for all of these risk factors accounted for no more than 40% of the grade difference in CHD mortality (Marmot, Shipley and Rose, 1984; Marmot, Kogevinas and Elston, 1987).

After controlling for standard risk factors, the lowest grade still had a relative risk of 2.1 for CHD mortality compared to the highest grade (Marmot, 1994).

The second study, Whitehall II,  also of British civil servants, was initiated to investigate occupational and other social influences on health and disease (Marmot, 1994). The final sample was 6900 men and 3414 women aged 35-55 in the London offices of 20 civil service departments (Marmot et al, 1991). Employment grade was strongly associated with work control and varied work (measures of decision latitude) as well as fast pace (a measure of job demands) (Marmot et al., 1991; Marmot, 1994). Lack of control on the job is related to long spells of absence (> 6 days) (Marmot, 1994).

In addition, there was no decrease in the difference in prevalence of ischemia depending upon employment category over the 20 years separating Whitehall I and Whitehall II (Marmot et al.,1991). Plasma cholesterol concentrations did not differ by job category, and the small inverse association between job status and blood pressure in men was reduced from that seen in the Whitehall I study. There was a significant inverse relation between BMI and job status but, especially in men, the differences were small. The risk factor that differed most between employment categories was smoking. Moderate or vigorous exercise was less common among subjects in lower status jobs (Marmot et al., 1991).

It is not difficult to relate all this to the wider society and to people’s status within it, or to the well-known differences in longevity between various parts of the United Kingdom and of the world. What would be extremely difficult, perhaps to the point of near impossibility, would be to resolve the issues involved.

It might be achievable, though. Consider how apparent public indifference to the armed forces has been transformed into something verging on hero-worship since the beginning of the war in Iraq.

There is a separate “medical” problem here, too. The Royal College of Nursing’s demographic profile of the nursing profession makes clear that an ageing workforce, reductions in funding and the collapse in international recruitment, are going to make it increasingly difficult to maintain nursing numbers.

Much of the publicity surrounding this has had to do with hospital nursing, but primary care has similar problems. I suspect that a part of this, at least, has to do with nursing having become a degree-based profession. I suspect also that there are substantial numbers of ex-nurses who left the profession to raise families and who would consider returning to nursing if it did not require them to climb on to an academic treadmill or to become too deeply embroiled in NHS bureaucracy. The answer may lie in a two-pronged approach.

The police service, directly comparable to nursing in many ways, resolved this long ago. Police officers are at liberty either to remain as constables throughout their working lives or to take the succession of examinations that will see them being promoted to more senior ranks. Nobody within the service thinks worse of those who elect to follow either course; a long-serving constable is as respected for his or her experience as a senior officer is for having taken and passed the exams. If a similar culture were to be introduced to the nursing profession, it would solve the “status” issue at a stroke, and might well solve the retention and re-recruitment ones, too.

Peter Lapsley is patient editor, BMJ (apologies to John Cleese, Ronnie Barker, and Ronnie Corbett).