اقتصاد سلامت در بریتانیا: ظرفیت، محدودیت ها و مقایسه ها برای اقتصاددانان بهداشتی ایالات متحده

This paper presents the results of a survey of the demographics, appropriate training and professional perceptions of UK health economists. In addition, information on what motivates health economists to enter the discipline and views on how to motivate individuals to study health economics were obtained. This was done with the intention of contributing to the debate on ways of increasing capacity for health economics across the UK. Information on appropriate training, the working environment and working activities was revealed by this survey. Where possible, the results are compared to a similar survey (Morrisey and Cawley, 2008) of US health economists

In the current economic climate in which many European and other developed countries have announced public sector funding cuts, demand for health economics skills has never been greater. To analyse economic data, decision making bodies such as the UK National Institute for Health and Clinical Excellence (NICE) require well-trained health economists to work with them (Williams et al., 2008). Often, health economists’ skills are sought to help with decisions over the fair and most efficient use of limited health care resources. A survey of public health researchers and practitioners in the US revealed that one of the barriers to using health economics in decision making was a lack of health economics expertise (Ammerman et al., 2009). Gulacsi also reports that the numbers of essential health economics research institutions or professionals are not sufficient in the new European Union member states (Gulacsi, 2007). Similarly, most would agree that within the UK, demand for health economists far outweighs supply. Health economics, relative to mainstream economics is a new discipline (Madden et al., 2009). There are many potential career pathways for a graduate in health economics and this is testament to the diversity of skills that a health economist can possess. Within academia, health economists often find themselves in the ‘middle ground’ positioned between the discipline of mainstream economics and Medical Schools/Public Health departments. Health economists can enter into the discipline from a variety of backgrounds, for example, from mainstream economics, public health or from operational research. Outside academia, health economists might be based within Government departments, work for consultancy firms or have chosen a career within the pharmaceutical industry. This can lead to a situation where there are many health economists from a variety of backgrounds, working across different sectors doing very different roles. Similar to the US setting reported by Morrisey and Cawley in their survey published in 2008 (hereafter simply referred to as ‘the US survey’), in the UK, little is known about the demographic characteristics and other features of health economists. This paper presents the results of an online UK-based survey of health economists undertaken between 16 May and 30 June 2008. Results on demographics, training and professional perceptions are presented. Attention is also given to what motivates health economists to enter the discipline and therefore how we can motivate undergraduate students to undertake a postgraduate degree and choose health economics as a potential career. Where possible, the results are compared to the US survey

This survey has elicited information from health economists in the UK with respect to professional identity, training, attraction to discipline, job details, job expectations, areas of expertise, satisfaction with peer review and employment environment and compared these, where applicable, to the US survey. To our knowledge, this is the first study of its kind to be done in the UK. Another study compared views of UK and US health economists but focused on levels of agreement on ‘positive’ and ‘policy’ questions (Newhouse, 1998). Our analysis focused on 139 individuals who classified themselves as either a health economist or an economist working in health economics. The reason for the exclusion criteria was to follow the protocol adopted by Morrisey and Crawley in the similar US-based survey so that ‘like-for-like’ comparisons could be made. Our study revealed that UK health economists are motivated to study health economics through exposure to health economics at the undergraduate level, the availability of funding for Masters programmes, sheer interest in the subject, the need to progress careers and encouragement from colleagues. Therefore, one way to attract more people into the profession would be through initiatives to teach health economics at both undergraduate and postgraduate levels. In addition to institutions that already train health economists increasing their numbers of students, there is also need to encourage those not currently teaching health economics to do so. Initiatives such the Health Economics education (HEe) website, hosted by the Economics Network and led by the Health Economics Unit at the University of Birmingham, that collates online resources for teaching health economics will go a long way in achieving this goal. Another way to expand capacity is through increased availability of studentships for Masters programmes in health economics. In January 2008, for instance, the Economics and Social Research Council (ESRC), the Medical Research Council (MRC) and the National Institute for Health Research (NIHR) jointly launched an invitation to tender for Masters studentships in Economics of Health. Four institutions were successful in obtaining these studentships. In 2011, this was repeated and three institutions were successful. This should go some way towards increasing the capacity for health economics within the UK but given that the competition for these studentships is high, and a third of Masters students go on to pursue an academic career, capacity could be further enhanced if more Masters studentships were to be made available. There is also a need to create more PhD opportunities so that training does not stop at the Masters level. Encouraging or developing other subspecialties, such as CBA, in the UK may help health economics have a more holistic outlook which could attract more individuals to join. In addition to the presentation of seminars in work places and academic institutions, conducting robust health economics research for high profile bodies such as NICE and the UK Department of Health will raise the profile of health economics thereby attracting more research funding and with it, more jobs. It however needs to be said that there will be challenges in translating the results of our survey into actionable policy undertakings as the level of consensus on policy issues among UK health economists is low, lower than that of US health economists for instance (Newhouse, 1998). The response rate in our survey was 44% which is higher than the 32% reported in the US survey. Morrisey and Cawley discuss the reasons for the low response rates and deduce that it is consistent with general downward trends in survey response rates (Biener et al., 2004). They also surmise that it may be an artefact of growth in the discipline in that more people are joining health-economics professional organisations who work in ‘multiple fields of economics or health’ but as they are only operating in health economics at the periphery, they are less likely to respond to surveys of this type. Further comparisons with the US survey will reveal how the UK survey compared in terms of demographics and characteristics. Most UK health economists (88%) were aged between 21 and 60 years and within this age group, 19% were below the age of 31. These results show that our sample was relatively young as seen when compared to results from the US survey where 90% were aged between 31 and 60 years with a higher proportion in the 41–50 and 51–60 year age groups (29% and 27%, respectively). Overall within our survey we had a slightly higher proportion of females (51%) to males which was in contrast to the US survey which had more males (62%) compared to females. Exploring the data in more detail however also revealed that in our older age group, we had more males to females. This result could of course be attributed to the manner in which we captured the data in terms of survey design but may have revealed a general trend that the older generation of health economists is male-dominated and that it is only recently (within the last 10–15 years) that more females have entered the profession. The majority of respondents were white (similar to the US study) but with less Asian respondents in the UK (4%) than in the US (11%). Overall therefore, compared to the US sample, the UK sample had a lower representation in the 41–60 year band category, a higher proportion of females and a similar proportion of white respondents but less Asian respondents. Similar to the US survey, the majority of respondents felt that the most suitable training for the position of senior lecturer or a position at a similar level in health economics was a ‘PhD from an economics department in a health economics topic’. It appears that despite the option of studying for a doctorate degree in health economics within a variety of schools/departments, the majority of established health economists agree that gaining a PhD from an economics department is the superior option. There was almost an even split between respondents that had had training up to Masters level (50%) and those that were doctorally trained (45%). This is in contrast to the US findings where only 3% had training up to Masters degree level and up to 93% had doctorate degrees. This may reflect the difference in age distribution between the two samples (as the US sample were older) or the sizeable pharmaceutical health-economist workforce in the UK for whom a PhD is rarely a requirement. However, it might also be due to the natural progression for a US health economics graduate being to study for a PhD immediately following a Masters or an undergraduate degree. In the UK, we feel that the general trend is to work for some years as a junior health economist following a Masters degree before progressing to study for a PhD. In fact, our study revealed that for the whole sample, the gap between obtaining a first degree and a PhD was on average 11 years, though shorter for those in the 21–30 years age group. It also appears that UK health economists choose to have a gap of at least a few years between Masters study and a doctoral degree. Within the UK sample, interestingly, the largest proportion of Masters degrees were in health economics (84%) but of those that did have a PhD, a lower proportion were ‘classed’ as being within this discipline (56%). In the US survey, 57% chose to specialise in a health economics topic for their PhD. This may be due to a terminology issue in that in the UK, PhDs majoring in health economics can be taken within a variety of departments/schools such as departments of economics, social sciences, health services research and public health or medical schools. Quite often the ‘title’ of your PhD reflects the place that your PhD was registered rather than the research topic. These results also highlight the fact that most UK-based health economists were trained locally within the UK, mainly at the University of York. However, a number of universities have in recent years been training health economists as well. The results of this survey underscore the fact that academia employs the majority of health economists in the UK (65%) which is comparable to the figures in the US (64%). This may however be reflective of the sample we used in that most of the activities of the HESG tend to have an academic bias to them. Compared to the UK, there were comparatively more individuals working for NFPOs, FPOs and the Government in the US (15% vs. 6%, 9% vs. 4% and 12% vs. 3%, respectively). The high proportion of individuals working in NFPOs in the US is certainly striking and it not clear why this is case. In addition, only 25% of UK academic respondents were professors, readers or senior lecturers compared to 57% in the US (we assumed that assistant and associate professors in the US were equivalent to UK lecturers and senior lecturers, respectively). Therefore compared to the UK survey, the US survey sampled health economists operating at more senior levels, which result is consistent with that on the level of training. Fewer academics reported having a private sector role compared to those in the private sector who also had an academic position. As expected, there were more female health economists who were in part-time employment. The size of the UK health economics teams varied but was relatively bigger than those reported in the US survey where 13% of respondents indicated that they were the only health economist in their department, 40% were in teams of 3 or 4 people and 23% were in teams of more than 5. On average, UK health economists spend 10 h less than that of their US counterparts on professional activities. Overall, though, our UK sample reported equivalent time spent on research to the US sample (58% vs. 56%), although the time spent on research did differ by employment setting. The amount of time academic health economists spent on teaching (14%) was fairly low. In the US, for instance, the corresponding percentage was 30%. This reflects the big role that research plays among UK academic health economists (occupying nearly 70% of their time). The expectation of covering salary costs was found to be far higher in the UK compared to the US, with the US survey reporting that health economists were only expected to cover 48% of salaries from external sources (if working in academic departments of public health and medicine) and 13% (elsewhere in academia). In terms of research for the UK survey, we split the US term ‘Outcomes research’ into two categories: ‘Economic evaluation (CEA, CUA and CBA)’ and ‘Other outcomes research (including burden of illness)’ as we felt that these terms produce a more detailed picture of where UK health economists focus their research. In terms of areas of specialisations, there seems to be more of an emphasis on economic evaluation for UK health economists compared to those in the US study (85% vs. 50%). Other specialisations that were prominent in the US study do not appear to be well represented in the UK sample (e.g. health insurance). This is a logical result given the difference in the health care systems of the two countries, i.e. the UK system is predominantly funded through general taxes with an emphasis on economic evaluation as a means of informing resource allocation decisions while this is not the case for the US where private health insurance is the major source of health care funding. Further and among the UK health economists, we found that the majority are working within CEA and CUA spectrums, which may reflect the lack of popularity, or the underdeveloped nature, of CBA within the UK. Our UK survey found similar proportions to the US survey for health economists who are satisfied with the peer-review process for papers for inclusion in health economics journals (60%), for publications in peer-reviewed health economics journals (54%) and for the review process for research grants (38%). A slightly smaller proportion of the UK sample (73%) expressed satisfied with their employment compared to the US sample (85%). The majority in our sample felt that health economists should not be accredited. With respect to this issue of accreditation, there has been a movement within the Europe Unit (a sector-wide body which aims to raise awareness of the European issues affecting UK higher education) for all UK higher education institutions to issue a ‘Diploma supplement’ (Europe Unit, 2011). This supplement would act as a further explanation of the qualification received and detail all modules completed as part of the degree. It is similar to a ‘transcript’ but presents the information in a different format. This initiative ties in closely with the Bologna process, that is, making all degrees and qualifications transparent and comparable. If all health economics graduates were issued with a document of this type this would make it much easier for employers to seek out graduates with the appropriate skills for the role that they are appointing to (from both within and outside the UK). According to a 2007 survey, 60% of UK higher education institutions currently issue Diploma supplements. On a similar note, the Higher Education funding council are issuing funding to support the development of the Higher Education Achievement Report (HEAR) that will provide more details about the students’ learning and achievement (Higher Education Academy, 2011). The intention is for all graduates from 2011 to 2012 to be issued an HEAR alongside an academic transcript and the European Diploma supplement. With this extra documentation expected to become the norm in the UK, this will increase future employers’ insights into the ‘knowledge sets’ of potential applicants compared to just a degree classification. One key limitation of our findings within this paper is that the UK and US surveys were not designed to be directly compared but rather were ‘stand-alone’ research surveys designed to elicit similar types of information from health economists. Whilst we accept this is a limitation, we do not believe that this renders the comparisons unmeaningful but rather our findings need to be viewed with this in mind. Chronologically, the UK survey was conducted after the US survey was published but a number of the questions were adapted for a UK focus. By using the HESG mailing list as the largest mailing list of health economists in the UK, we have attempted to try and capture as many health economists as we can operating in different settings but accept that the majority of our responders were academics and this brings with it an inherent underrepresentation of ‘other’ health economists operating within different sectors in the UK. In addition, some questions such as what individuals who did not study health economics studied would be helpful in further understanding career pathways in health economics. We invite researchers to re-administer our survey with more of such questions and also perhaps with more of a pharmaceutical or government focus in mind and would be interested to see how the results compare, and indeed how they compare to the US findings.