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  • Author or Editor: Martin J. Smith x
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Tsars are increasingly being used in government to coordinate policy, to deal with complex problems and to implement government goals. However, there is almost no extant literature on the role of tsars who occupy a curious position in Britain's constitutional framework. The aim of this article is to examine the role and impact of tsars. The article attempts to define tsars and examines the extent to which they are bureaucratic entrepreneurs. Focusing on tsars in the Department of Health, where they have been most systematically used, the article examines the resources that they have to shape policy outcomes. The article highlights the way in which leadership is being used to fill in the holes created by new forms of governance.

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The growth of domestic private security in advanced democratic countries has resulted in a paradox. While the market is seen to provide a solution to the inefficient production of a key public service, it simultaneously challenges the liberal belief in a universal and publicly guaranteed social order. The argument of this article is twofold: first, that this paradox has created tensions within the sphere of regulatory governance; and second, that these tensions have given rise to a distinctive politics of security regulation. Through this argument, the article makes important new connections between the security governance and regulation literatures.

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The potential reduction in mortality that could be achieved through reductions in smoking behaviour has often been calculated on the assumption that smokers would reduce their mortality rate to that of the ex-smokers in the population if they quit, or would have the mortality rates of lifetime non-smokers if they had never started smoking.1-3 In a recent contribution to this journal, Sterling and Weinkam4 have pointed out that since smoking is strongly related to occupation and to socioeconomic position, these assumptions do not hold. The smoking group within a population will over-represent the working class, whose mortality exceeds that of the middle classes independently of smoking. Thus a more appropriate comparison would be between the mortality rates of smokers, ex-smokers and non-smokers within the same socioeconomic groups.

In this chapter we demonstrate the effects of making such appropriate comparisons when predicting the benefits of non-smoking. We use data from the Whitehall Study of London civil servants, in which both occupational grade and smoking have been shown to be strongly associated with mortality rates.5,6 The extent of confounding due to the relationship between smoking and employment grade is examined.

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Study objective: The aim was to explore the magnitude and causes of the differences in mortality rates according to socioeconomic position in a cohort of civil servants.

Design: This was a prospective observational study of civil servants followed up for 10 years after baseline data collection.

Setting: Civil service office in London.

Participants: 11,678 male civil servants were studied, aged 40-64 at baseline screening between 1967 and 1969. Two indices of socioeconomic position were available on these participants – employment grade (categorised into four levels) and ownership of a car.

Measurement and main results: Main outcome measures were all-cause and cause-specific mortality, with cause of death taken from death certificates coded according to the Eighth Revision of the International Classification of Diseases (ICD). Employment grade and car ownership were independently related to total mortality and to mortality from the major cause groups. Combining the indices further improved definition of mortality risk and the age-adjusted relative rate between the highest grade car owners and the lowest grade non-owners of 4.3 is considerably larger than the social class differentials seen in the British population. Factors potentially involved in the production of these mortality differentials were examined. Smoking, plasma cholesterol concentration, blood pressure and glucose intolerance did not appear to account for them. The pattern of differentials was the same in the group who reported no ill health at baseline as it was in the whole sample, which suggests that health selection associated with frank illness was not a major determinant. The contribution of height, a marker for environmental factors acting in early life, was also investigated. Whereas adjustment for employment grade and car ownership attenuated the association between short stature and mortality, height differences within employment grade and car ownership groups explained little of the differential mortality.

Conclusion: The use of social class as an index of socioeconomic position leads to underestimation of the association between social factors and mortality, which may be reflected in public health initiatives and priorities. Known risk factors could not be shown to account for the differentials in mortality, although the degree to which this can be explored with single measurements is limited.

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The relationship between cancer and socioeconomic position is examined for men using data from three sources – the Whitehall Study of London civil servants, the OPCS Longitudinal Study and the Registrar General’s Decennial Supplement. Mortality from, or registration for, malignant neoplasms was higher overall in lower socioeconomic groups. There was considerable variation in the strength, and to a lesser extent direction, of the association of specific cancer sites and socioeconomic position within each of the studies. However, between the studies the relationships between socioeconomic and the particular cancers were very similar.

The similarity in results, taken in conjunction with the differences in design and methods of the three studies, makes it very unlikely that these consistent associations are due to artefacts. The heterogeneity in relationships between specific cancer sites and socioeconomic position suggests that no single factor – such as differences in general susceptibility or differences in smoking behaviour – can account for these associations. However, socioeconomic differentials displayed by a particular malignancy do offer clues to its aetiology, and provide an indication of the scope that exists for reducing the burden of cancer within a population.

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