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Health economics in the UK: Capacity, constraints and comparisons to US health economists
International Review of Economics Education 12 (2013) 1–11
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Health economics in the UK: Capacity, constraints and comparisons to US health economists Billingsley Kaambwa, Emma Frew * Health Economics Unit, Public Health Building, University of Birmingham, Birmingham B15 2TT, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Available online 18 April 2013
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. ß 2013 Elsevier Ltd. All rights reserved.
JEL classification: A11 A20 Keywords: Economists’ career decision Motivation Training
1. Introduction 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
* Corresponding author. E-mail address: [email protected] (E. Frew). 1477-3880/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.iree.2013.04.004
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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. 1.1. Data and methods The Health Economists’ Study Group (HESG) is an organisation of health economists that is based in the UK but membership is not restricted to the UK (90% of its members are within the UK). The organisation exists to support and promote the work of health economists and has been in existence since 1972 (Blaug, 1998). The HESG was selected as the forum to conduct the UK survey as the group presented the largest UK-based mailing list of health economists. At the time of the survey, the HESG had a mailing list that comprised 355 health economists working in different sectors (commercial, government and academia) which was created to enable the effective and quick transmission of health economics information (e.g. jobs, events, surveys, etc.). The online questionnaire used in the survey was first piloted among staff based at the Health Economics Unit within the University of Birmingham, UK in April 2008. Initially the survey replicated the US survey but in response to comments and suggestions revealed during the pilot work, questions were modified to give the survey more clarity and a UK-focus. The questionnaire comprised 25 multiple-choice and 10 open-ended questions. The questions were categorised into different themes: professional identify (whether respondents described themselves as health economists or not, professional organisation membership, views on accreditation); attraction to discipline (reasons for studying health economics, reasons for deciding to pursue a career in health economics, ideas on how to target potential health economists); training (highest qualification attained, timing of qualifications, appropriate training requirements for health economists); current job details (work sector, job title contract details, team arrangements, income generation policies); time allocation (split between research/administration, consultancy and teaching); areas of expertise (economic evaluation, government policies, etc.); and satisfaction with peer review process and employment environment (ease of collaboration both within and outside the discipline). The online survey was emailed to all members of the mailing list on the 16 May 2008. To encourage a good response, two follow-up email reminders were sent to members of the mailing list within the survey period.
2. Findings Out of a possible 355 individuals, 156 responded giving us a 44% response rate overall. About 79% were members of the HESG and 62% held joint membership of the HESG and the International Health Economics Association (iHEA). In line with the US survey we focused our analysis on the respondents
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that classed themselves either as ‘a health economist’ (115) or ‘an economist working in health’ (24) which left us with 139 respondents. 2.1. Motivation for joining the health economics profession Respondents were asked to provide the main reason for choosing to study health economics, the main reason for choosing to pursue a career in health economics and what could be done to encourage potential students to join the profession. Table 1 outlines the main responses provided to each question. In relation to the main reason for choosing to study health economics, 27% (38 respondents) of the sample revealed that they did not study health economics and were therefore removed from further analysis to this question. This left 101 respondents, of which 54 answered ‘other reason’. Respondents who ticked the ‘other reason’ box were also asked to specify this reason and their free text responses were then analysed by the authors before being put into broad categories. This analysis produced two further major categories: ‘interest in health economics’ and ‘needed in current job/ career progress’. When all responses were considered, availability of funding for Masters health economics programmes was given as the most prominent reason for studying health economics (for 22% of the sample), followed by health economics being taught at undergraduate level (17%) and sheer interest in health economics (15%). The perception that studying health economics would lead to career progression motivated 14% of the sample to study health economics while 13% cited having
Table 1 Options for main reason to study health economics and to pursue a career in health economics as well as ways of encouraging potential health economists to join the profession. Percentage Main reason that influenced decision to study health economics Availability of funding for MSc course Health economics was taught as part of my undergraduate degree Sheer interest in health economics Career progression Staff member from undergraduate department or another colleague encouraged you Exposed to health economics at work or attended external seminar delivered by health economist
a
22 17 15 14 13
12
Main reason that influenced decision to pursue a career as a health economista Job opportunities 38 Attended external seminar delivered 24 by a health economist 24 Having studied a Masters in health economics 13 Interest in health economics 10 Staff member from university department encouraged you or attended a health economics seminar What could be done to encourage potential students to join the health economics profession Teaching health economics at undergraduate 26 and postgraduate levels (on full or part-time basis as well as through distance learning) 18 Raising the profile of health economics or highlighting its role in decision making 15 Availability of funding for health economics teaching Increase exposure to health economics 12 e.g. through seminars and advertisements. a
Some respondents cited more than one reason for their decision to study health economics or to pursue a career as a health economist.
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been encouraged by others as the main reason for their decision to study health economics. Another 12% ascribed it to being exposed to health economics at their place of work, or through attending a seminar given by a health economist while disparate reasons were given from the rest of the sample. The majority of respondents (38%) revealed ‘job opportunities’ as the main reason for pursuing a career in health economics. Twenty-four percent said that it was because they had studied an MSc in health economics, whilst 10% revealed that it was due to encouragement from a member of staff within a university department or having listened to a health economics seminar. Thirty-four respondents indicated ‘other’ in response to this question and of these, most (18 or 13%) said ‘interest in health economics’ with the remaining ‘other’ reasons being evenly spread across a variety of reasons e.g. experience of health economics in home country, belief we can contribute to improving the health economy, personal reasons, family commitments and by chance. Respondents provided free-text responses to the question about what could be done to better encourage potential students to join the health economics profession. These responses were analysed by the authors and then grouped into broad categories which are also shown in Table 1. For 26% of the sample that answered this question, teaching health economics at either undergraduate or postgraduate level was seen as the way of achieving this goal. Respondents felt that this teaching should be on a full or part-time basis and could include distance learning as well. Other major reasons suggested included raising the profile of the profession through robust research as well as highlighting the role that health economics plays in decision making (18%); availability of funding for health economics teaching (15%); and increasing exposure to health economics, e.g. through seminars (12%). 2.2. Demographics Nineteen percent of our sample were below the age of 31 while 69% were aged between 31 and 60 (37% aged 31–40, 19% aged 41–50 and 12% aged 51–60). Fifty-one percent were female. The majority of respondents were white (80%) with about 4% and less than 1% being Asian and Black-African, respectively. 2.3. Education and training As shown in Table 2, 50% of our respondents had training up to Masters level (MSc, MA or MPhil) while 45% had training up to doctorate level (PhD or DPhil). Only two respondents had a medical degree while five had Bachelors degrees (BA or BSc). Eighty-four percent of the Masters degrees were in health economics compared to 56% of the PhDs. For the whole sample, the gap between obtaining a first degree and a PhD was on average 11 years, though shorter (about 6 years) for those in the 21–30 years age group. The majority of individuals who had health economics training received their highest qualification from a UK institution, with the University of York training most of the respondents in our sample (nearly 30%). More than half of the sample (53%) obtained their highest qualification after the year 2000. The survey also revealed that of the 115 who self-identified themselves as health economists, only 78% actually studied health economics. Table 2 Institution of training by highest qualification for UK health economists.a,b Institution
UK University Other UK University Non UK University Unspecified University Total a
Qualificationc
Total
BA/BSc
MPhil/MSc/MA
MD
DPhil/PhD
All degrees
3 2 0 0 5
57 5 5 2 69
0 0 1 1 2
29 21 8 4 62
89 28 14 7 138
(3) (7) (0) (0) (4)
(64) (18) (36) (29) (50)
(0) (0) (7) (14) (1)
(33) (75) (57) (57) (45)
(100) (100) (100) (100) (100)
Figures are n (row %). One individual did not indicate their highest qualification or university where the qualification was obtained and was therefore omitted from the table. c BA/BSc, Bachelor of Arts/Bachelor of Science; MPhil/MSc/MA, Master of Philosophy/Master of Science/Master of Arts; MD, Doctor of Medicine; DPhil/PhD, Doctor of Philosophy. b
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Table 3 Acceptable training for a senior lecturer or a similar level in health economicsa (%). Degree
Academia
FPOb
Government
NFPOc
Pharmaceutical
Other
All
PhD from an economics department: health economics topic PhD from a public policy/health policy/health services research department: health economics topic MD degree: health economics topic No PhD: Masters in health economics PhD from an economics department: non-health economics topic
95
100
100
100
89
100
95
82
67
100
100
89
83
83
51 45 58
67 89 33
100 100 67
100 100 72
83 82 28
67 83 67
61 59 53
a b c
The value in each cell equates to the percentage reporting ‘definitely acceptable’ and ‘acceptable’. FPO, for profit organisation. NFPO, not for profit organisation.
We asked about suitable training for the position of senior lecturer or a position at a similar level in health economics. We chose senior lecturer level (as opposed to a newly hired health economist level asked in the US survey) because in the UK, we would not expect a newly-trained health economist to possess a PhD. Specifically we asked: ‘Suppose your department/company had advertised for a senior lecturer or a similar level in health economics. How likely is your department/group to consider the following candidates acceptable?’ We listed 11 different degrees and asked the individual to indicate on a 5-point scale the degree of acceptability for each degree. Table 3 presents the responses for five of the main degrees. We found that overall, the most acceptable qualification for a senior lecturer in health economics is a ‘PhD from an economics department in a health economics topic’. This was a consistent finding across all types of employer (although ranked the same as a ‘PhD in a health services department: health economics topic’ for Government, not-for-profit organisations (NFPOs) and pharmaceutical employers). However, after this, acceptability differed by type of employer with other ‘lower’ degrees being deemed to be equally acceptable. In for-profit organisations (FPOs), for instance, a Masters level qualification in health economics (without a PhD) was considered to be more acceptable than a ‘PhD from a public policy/health policy/health services research department specialising in a health economics topic’ or an ‘MD on a health economics topic’. The responses were also stratified by type of academic (i.e. professors, readers, senior lecturers, etc.) and showed that the more senior an academic was, the more likely they were to accept qualifications other than a PhD in a health economics topic as suitable qualifications for the position in question. 2.4. Employment Sixty-five percent of the respondents worked in the academic field while about 14% percent were employed in the pharmaceutical or medical device industry. FPOs and NFPOs employed 6% and 4% of the respondents, respectively, while only 3% worked for the government. Among those in academia, most were research fellows or associates (23%), 16% were professors or readers, 11% were lecturers and 9% were senior lecturers. The rest of the sample did not state their job titles. Fourteen percent of academics also reported having a private sector role and 23% who worked in the private sector reported also having an academic position. Eighty-three percent were in full-time employment and about 60% had a permanent contract. About 18% of female health economists were in part-time employment compared to about 4% of male health economists. The size of the health economics teams varied: nearly 13% of respondents said that they were the only health economist in their work place, about 12% of the sample were part of teams with 3 or less people, 16% were in teams of between 4 and 5 people and over 50% were in teams of more than 5 health economists. The rest of the sample did not specify the team sizes. 2.5. How do health economists spend their time? On average, health economists spend 40.2 h a week on professional activities (median 40 h). A health economists’ time is typically spread across research (58%), administration (19%), consultancy
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Fig. 1. How UK health economists’ professional time is split by work sector (mean percentage of total).
(12%) and teaching (10%) although the time spent on research did differ by employment setting. Fig. 1 illustrates that UK Government health economists spend the most amount of time on research as did those in academia and NFPOs. We asked our sample about income generation policies and found that approximately half of the academic health economists were expected to raise part or all of their salary from external sources. This was compared to 33% in FPOs and 12.5% in NFPOs. Seventeen percent of the academic health economists had an annual target to raise (on average, 100% of salary) as did all of the health economists who worked in a FPO (on average, 175% of salary). 2.6. Research interests A third of our sample reported being principal investigators on a funded contract at the time of the survey; about 90% of these were in academia. The most common funder was the UK Department of Health (for 17% of the health economists). For 50% of the UK health economists, all of their research time was spent focusing on health economics. We also asked about subspecialty areas within health economics (allowing the option of providing more than one subspecialty); the results can be seen in Table 4. Most health economists (87%) spend their time focusing on Economic Evaluation (predominantly CEA and CUA), 39% worked on government policies whilst nearly 38% said their focus was on other outcomes research (including burden of disease). 2.7. Perceptions of professional life The final part of the survey sought to elicit information about how satisfied health economists were with peer-review processes, research constraints and the employment environment. Our survey Table 4 Subspecialisation among UK health economists.a Subspecialty
%
Economic evaluation (Cost-effectiveness/-utility/-benefit analysis – CEA/CUA/CBA) Other outcomes research (including burden of illness) Government policies (e.g. health economics based on public finance) Behaviour of individuals (e.g. health economics on labour economics) Behaviour of firms (e.g. health economics based on industrial organisation) Health insurance Other
87 38 39 19 11 5 23
a
Respondents could provide more than one subspecialty.
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found that 60% of health economists were satisfied with the peer review process utilised to choose papers for inclusion in health economics conferences, 54% were satisfied with the review process employed for publications in peer-reviewed health economics journals and 54% expressed satisfaction with the review process for grants. There is a perception that some health economists work in isolation as part of multi-disciplinary teams and as such we wanted to ask about ease of collaboration both across and within departments. We found that 50% of the sample felt that it was easy for them to collaborate across departments and an even greater proportion (61%) said it was easy to collaborate within departments and within teams. Whilst research output is a criterion used to assess promotion prospects for health economists working across all sectors, within academia (69% of our sample) it is an essential part of the job as UK higher education institutions are assessed on the basis of the Research Excellence Framework (REF), a new system for assessing the quality of research (it has replaced the UK Research Assessment Exercise). The UK REF informs the selective allocation of funding to UK higher education institutions. In light of this requirement of the discipline, we felt that it would be interesting to ask our sample about what makes a ‘good’ publication. We found that 35% felt that quality was better than quantity with respect to how peer-reviewed publications were viewed for promotion, however nearly half (42%) were unsure as to whether being one of two authors on a paper (compared to one of five) counted more for promotion. Overall, most of the UK sample (73%) expressed satisfaction with their employment. We asked our respondents for their views on accreditation of health economists and if this is required, what this accreditation would be based on. Responses revealed that within our sample (and remember these are self-classified health economists and economists working in health economics), 57% said ‘no’ to accreditation and 39% said ‘yes’ (4% were unsure). For those that said ‘yes’, the most commonly cited reason was that health economists should have, as a minimum, some form of formal economics training. Other suggestions were that there should be a certificate of training within certain subspecialties of health economics, e.g. modelling, outcome valuation, so that prospective employers have a clearer idea of individual skill sets. One health economist argued that accreditation would ensure professional integrity which would lead to economic evaluations (particularly in the pharmaceutical sector) being conducted responsibly. Some of the health economists that said ‘no’ to accreditation had strong views with the main feeling being that health economics is a discipline, not a profession. This was summarised well by one health economist who said: ‘‘I would strongly disagree with such accreditation, you do not need accreditation to be an economist, a statistician or an operational researcher, involvement and reputation through track record and input to professional bodies, such as HESG and iHEA, should act as a form of screen/signal, rather than heading off into a ‘controlling’ environment, accreditation seems to suggest a practitioner-based model, which is not the way forward’’ (anonymous responder). Other reasons for opposition to accreditation were perceptions of the diversity of the discipline making it difficult to decide what accreditation should be on the basis of, the resistance to become ‘elitist’, and the fact that we have postgraduate qualifications in health economics therefore we do not need accreditation, unlike ‘chartered’ professions such as accountancy.
3. Discussion 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 USbased survey so that ‘like-for-like’ comparisons could be made. Our study revealed that UK health
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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.
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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
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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. References Ammerman, A.S., Farrelly, M.A., Cavallo, D.N., Ickes, S.B., Hoerger, T.J., 2009. Health economics in public health. American Journal of Preventive Medicine 26 (3) 273–275. Biener, L., Garrett, C.A., Gilpin, E.A., Roman, A.M., Currivan, D.B., 2004. Consequences of declining survey response rates for smoking prevalence estimates. American Journal of Preventive Medicine 27 (3) 254–257. Blaug, M., 1998. Where are we now in British health economics? Health Economics 7 (Suppl. 1) S63–S78. Europe Unit, 2011. EU Policy-Education, Diploma supplement. http://www.europeunit.ac.uk/sites/europe_unit2?eu_policy_education/diploma_supplement.cfm.uk (accessed 2011). Gulacsi, L., 2007. The time for cost-effectiveness in the new European Union member states: the development and role of health economics and technology assessment in the mirror of the Hungarian experience. European Journal of Health Economics 8 (2) 83–88. Higher Education Funding Council for England, 2011. http://www.hefce.ac.uk/learning/diversity/achieve (accessed 2011). Madden, L., King, L., Shiell, A., 2009. How do government health departments in Australia access health economics advice to inform decisions for health? A survey. Australia and New Zealand Health Policy, http://dx.doi.org/10.1186/1743-8462-6-6.
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Morrisey, M.A., Cawley, J., 2008. US health economists: who we are and what we do. Health Economics 17 (4) 535–543. Newhouse, J., 1998. US and UK health economics: two disciplines separated by a common language? Health Economics 7 (Suppl. 1) S79–S92. Williams, I., McIver, S., Moore, D., Bryan, S., 2008. The use of economics evaluations in NHS decision-making: a review and empirical investigation. Health Technology Assessment 12 (7) .
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International Review of Economics Education journal homepage: www.elsevier.com/locate/iree
Health economics in the UK: Capacity, constraints and comparisons to US health economists Billingsley Kaambwa, Emma Frew * Health Economics Unit, Public Health Building, University of Birmingham, Birmingham B15 2TT, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Available online 18 April 2013
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. ß 2013 Elsevier Ltd. All rights reserved.
JEL classification: A11 A20 Keywords: Economists’ career decision Motivation Training
1. Introduction 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
* Corresponding author. E-mail address: [email protected] (E. Frew). 1477-3880/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.iree.2013.04.004
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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. 1.1. Data and methods The Health Economists’ Study Group (HESG) is an organisation of health economists that is based in the UK but membership is not restricted to the UK (90% of its members are within the UK). The organisation exists to support and promote the work of health economists and has been in existence since 1972 (Blaug, 1998). The HESG was selected as the forum to conduct the UK survey as the group presented the largest UK-based mailing list of health economists. At the time of the survey, the HESG had a mailing list that comprised 355 health economists working in different sectors (commercial, government and academia) which was created to enable the effective and quick transmission of health economics information (e.g. jobs, events, surveys, etc.). The online questionnaire used in the survey was first piloted among staff based at the Health Economics Unit within the University of Birmingham, UK in April 2008. Initially the survey replicated the US survey but in response to comments and suggestions revealed during the pilot work, questions were modified to give the survey more clarity and a UK-focus. The questionnaire comprised 25 multiple-choice and 10 open-ended questions. The questions were categorised into different themes: professional identify (whether respondents described themselves as health economists or not, professional organisation membership, views on accreditation); attraction to discipline (reasons for studying health economics, reasons for deciding to pursue a career in health economics, ideas on how to target potential health economists); training (highest qualification attained, timing of qualifications, appropriate training requirements for health economists); current job details (work sector, job title contract details, team arrangements, income generation policies); time allocation (split between research/administration, consultancy and teaching); areas of expertise (economic evaluation, government policies, etc.); and satisfaction with peer review process and employment environment (ease of collaboration both within and outside the discipline). The online survey was emailed to all members of the mailing list on the 16 May 2008. To encourage a good response, two follow-up email reminders were sent to members of the mailing list within the survey period.
2. Findings Out of a possible 355 individuals, 156 responded giving us a 44% response rate overall. About 79% were members of the HESG and 62% held joint membership of the HESG and the International Health Economics Association (iHEA). In line with the US survey we focused our analysis on the respondents
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that classed themselves either as ‘a health economist’ (115) or ‘an economist working in health’ (24) which left us with 139 respondents. 2.1. Motivation for joining the health economics profession Respondents were asked to provide the main reason for choosing to study health economics, the main reason for choosing to pursue a career in health economics and what could be done to encourage potential students to join the profession. Table 1 outlines the main responses provided to each question. In relation to the main reason for choosing to study health economics, 27% (38 respondents) of the sample revealed that they did not study health economics and were therefore removed from further analysis to this question. This left 101 respondents, of which 54 answered ‘other reason’. Respondents who ticked the ‘other reason’ box were also asked to specify this reason and their free text responses were then analysed by the authors before being put into broad categories. This analysis produced two further major categories: ‘interest in health economics’ and ‘needed in current job/ career progress’. When all responses were considered, availability of funding for Masters health economics programmes was given as the most prominent reason for studying health economics (for 22% of the sample), followed by health economics being taught at undergraduate level (17%) and sheer interest in health economics (15%). The perception that studying health economics would lead to career progression motivated 14% of the sample to study health economics while 13% cited having
Table 1 Options for main reason to study health economics and to pursue a career in health economics as well as ways of encouraging potential health economists to join the profession. Percentage Main reason that influenced decision to study health economics Availability of funding for MSc course Health economics was taught as part of my undergraduate degree Sheer interest in health economics Career progression Staff member from undergraduate department or another colleague encouraged you Exposed to health economics at work or attended external seminar delivered by health economist
a
22 17 15 14 13
12
Main reason that influenced decision to pursue a career as a health economista Job opportunities 38 Attended external seminar delivered 24 by a health economist 24 Having studied a Masters in health economics 13 Interest in health economics 10 Staff member from university department encouraged you or attended a health economics seminar What could be done to encourage potential students to join the health economics profession Teaching health economics at undergraduate 26 and postgraduate levels (on full or part-time basis as well as through distance learning) 18 Raising the profile of health economics or highlighting its role in decision making 15 Availability of funding for health economics teaching Increase exposure to health economics 12 e.g. through seminars and advertisements. a
Some respondents cited more than one reason for their decision to study health economics or to pursue a career as a health economist.
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been encouraged by others as the main reason for their decision to study health economics. Another 12% ascribed it to being exposed to health economics at their place of work, or through attending a seminar given by a health economist while disparate reasons were given from the rest of the sample. The majority of respondents (38%) revealed ‘job opportunities’ as the main reason for pursuing a career in health economics. Twenty-four percent said that it was because they had studied an MSc in health economics, whilst 10% revealed that it was due to encouragement from a member of staff within a university department or having listened to a health economics seminar. Thirty-four respondents indicated ‘other’ in response to this question and of these, most (18 or 13%) said ‘interest in health economics’ with the remaining ‘other’ reasons being evenly spread across a variety of reasons e.g. experience of health economics in home country, belief we can contribute to improving the health economy, personal reasons, family commitments and by chance. Respondents provided free-text responses to the question about what could be done to better encourage potential students to join the health economics profession. These responses were analysed by the authors and then grouped into broad categories which are also shown in Table 1. For 26% of the sample that answered this question, teaching health economics at either undergraduate or postgraduate level was seen as the way of achieving this goal. Respondents felt that this teaching should be on a full or part-time basis and could include distance learning as well. Other major reasons suggested included raising the profile of the profession through robust research as well as highlighting the role that health economics plays in decision making (18%); availability of funding for health economics teaching (15%); and increasing exposure to health economics, e.g. through seminars (12%). 2.2. Demographics Nineteen percent of our sample were below the age of 31 while 69% were aged between 31 and 60 (37% aged 31–40, 19% aged 41–50 and 12% aged 51–60). Fifty-one percent were female. The majority of respondents were white (80%) with about 4% and less than 1% being Asian and Black-African, respectively. 2.3. Education and training As shown in Table 2, 50% of our respondents had training up to Masters level (MSc, MA or MPhil) while 45% had training up to doctorate level (PhD or DPhil). Only two respondents had a medical degree while five had Bachelors degrees (BA or BSc). Eighty-four percent of the Masters degrees were in health economics compared to 56% of the PhDs. For the whole sample, the gap between obtaining a first degree and a PhD was on average 11 years, though shorter (about 6 years) for those in the 21–30 years age group. The majority of individuals who had health economics training received their highest qualification from a UK institution, with the University of York training most of the respondents in our sample (nearly 30%). More than half of the sample (53%) obtained their highest qualification after the year 2000. The survey also revealed that of the 115 who self-identified themselves as health economists, only 78% actually studied health economics. Table 2 Institution of training by highest qualification for UK health economists.a,b Institution
UK University Other UK University Non UK University Unspecified University Total a
Qualificationc
Total
BA/BSc
MPhil/MSc/MA
MD
DPhil/PhD
All degrees
3 2 0 0 5
57 5 5 2 69
0 0 1 1 2
29 21 8 4 62
89 28 14 7 138
(3) (7) (0) (0) (4)
(64) (18) (36) (29) (50)
(0) (0) (7) (14) (1)
(33) (75) (57) (57) (45)
(100) (100) (100) (100) (100)
Figures are n (row %). One individual did not indicate their highest qualification or university where the qualification was obtained and was therefore omitted from the table. c BA/BSc, Bachelor of Arts/Bachelor of Science; MPhil/MSc/MA, Master of Philosophy/Master of Science/Master of Arts; MD, Doctor of Medicine; DPhil/PhD, Doctor of Philosophy. b
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Table 3 Acceptable training for a senior lecturer or a similar level in health economicsa (%). Degree
Academia
FPOb
Government
NFPOc
Pharmaceutical
Other
All
PhD from an economics department: health economics topic PhD from a public policy/health policy/health services research department: health economics topic MD degree: health economics topic No PhD: Masters in health economics PhD from an economics department: non-health economics topic
95
100
100
100
89
100
95
82
67
100
100
89
83
83
51 45 58
67 89 33
100 100 67
100 100 72
83 82 28
67 83 67
61 59 53
a b c
The value in each cell equates to the percentage reporting ‘definitely acceptable’ and ‘acceptable’. FPO, for profit organisation. NFPO, not for profit organisation.
We asked about suitable training for the position of senior lecturer or a position at a similar level in health economics. We chose senior lecturer level (as opposed to a newly hired health economist level asked in the US survey) because in the UK, we would not expect a newly-trained health economist to possess a PhD. Specifically we asked: ‘Suppose your department/company had advertised for a senior lecturer or a similar level in health economics. How likely is your department/group to consider the following candidates acceptable?’ We listed 11 different degrees and asked the individual to indicate on a 5-point scale the degree of acceptability for each degree. Table 3 presents the responses for five of the main degrees. We found that overall, the most acceptable qualification for a senior lecturer in health economics is a ‘PhD from an economics department in a health economics topic’. This was a consistent finding across all types of employer (although ranked the same as a ‘PhD in a health services department: health economics topic’ for Government, not-for-profit organisations (NFPOs) and pharmaceutical employers). However, after this, acceptability differed by type of employer with other ‘lower’ degrees being deemed to be equally acceptable. In for-profit organisations (FPOs), for instance, a Masters level qualification in health economics (without a PhD) was considered to be more acceptable than a ‘PhD from a public policy/health policy/health services research department specialising in a health economics topic’ or an ‘MD on a health economics topic’. The responses were also stratified by type of academic (i.e. professors, readers, senior lecturers, etc.) and showed that the more senior an academic was, the more likely they were to accept qualifications other than a PhD in a health economics topic as suitable qualifications for the position in question. 2.4. Employment Sixty-five percent of the respondents worked in the academic field while about 14% percent were employed in the pharmaceutical or medical device industry. FPOs and NFPOs employed 6% and 4% of the respondents, respectively, while only 3% worked for the government. Among those in academia, most were research fellows or associates (23%), 16% were professors or readers, 11% were lecturers and 9% were senior lecturers. The rest of the sample did not state their job titles. Fourteen percent of academics also reported having a private sector role and 23% who worked in the private sector reported also having an academic position. Eighty-three percent were in full-time employment and about 60% had a permanent contract. About 18% of female health economists were in part-time employment compared to about 4% of male health economists. The size of the health economics teams varied: nearly 13% of respondents said that they were the only health economist in their work place, about 12% of the sample were part of teams with 3 or less people, 16% were in teams of between 4 and 5 people and over 50% were in teams of more than 5 health economists. The rest of the sample did not specify the team sizes. 2.5. How do health economists spend their time? On average, health economists spend 40.2 h a week on professional activities (median 40 h). A health economists’ time is typically spread across research (58%), administration (19%), consultancy
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Fig. 1. How UK health economists’ professional time is split by work sector (mean percentage of total).
(12%) and teaching (10%) although the time spent on research did differ by employment setting. Fig. 1 illustrates that UK Government health economists spend the most amount of time on research as did those in academia and NFPOs. We asked our sample about income generation policies and found that approximately half of the academic health economists were expected to raise part or all of their salary from external sources. This was compared to 33% in FPOs and 12.5% in NFPOs. Seventeen percent of the academic health economists had an annual target to raise (on average, 100% of salary) as did all of the health economists who worked in a FPO (on average, 175% of salary). 2.6. Research interests A third of our sample reported being principal investigators on a funded contract at the time of the survey; about 90% of these were in academia. The most common funder was the UK Department of Health (for 17% of the health economists). For 50% of the UK health economists, all of their research time was spent focusing on health economics. We also asked about subspecialty areas within health economics (allowing the option of providing more than one subspecialty); the results can be seen in Table 4. Most health economists (87%) spend their time focusing on Economic Evaluation (predominantly CEA and CUA), 39% worked on government policies whilst nearly 38% said their focus was on other outcomes research (including burden of disease). 2.7. Perceptions of professional life The final part of the survey sought to elicit information about how satisfied health economists were with peer-review processes, research constraints and the employment environment. Our survey Table 4 Subspecialisation among UK health economists.a Subspecialty
%
Economic evaluation (Cost-effectiveness/-utility/-benefit analysis – CEA/CUA/CBA) Other outcomes research (including burden of illness) Government policies (e.g. health economics based on public finance) Behaviour of individuals (e.g. health economics on labour economics) Behaviour of firms (e.g. health economics based on industrial organisation) Health insurance Other
87 38 39 19 11 5 23
a
Respondents could provide more than one subspecialty.
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found that 60% of health economists were satisfied with the peer review process utilised to choose papers for inclusion in health economics conferences, 54% were satisfied with the review process employed for publications in peer-reviewed health economics journals and 54% expressed satisfaction with the review process for grants. There is a perception that some health economists work in isolation as part of multi-disciplinary teams and as such we wanted to ask about ease of collaboration both across and within departments. We found that 50% of the sample felt that it was easy for them to collaborate across departments and an even greater proportion (61%) said it was easy to collaborate within departments and within teams. Whilst research output is a criterion used to assess promotion prospects for health economists working across all sectors, within academia (69% of our sample) it is an essential part of the job as UK higher education institutions are assessed on the basis of the Research Excellence Framework (REF), a new system for assessing the quality of research (it has replaced the UK Research Assessment Exercise). The UK REF informs the selective allocation of funding to UK higher education institutions. In light of this requirement of the discipline, we felt that it would be interesting to ask our sample about what makes a ‘good’ publication. We found that 35% felt that quality was better than quantity with respect to how peer-reviewed publications were viewed for promotion, however nearly half (42%) were unsure as to whether being one of two authors on a paper (compared to one of five) counted more for promotion. Overall, most of the UK sample (73%) expressed satisfaction with their employment. We asked our respondents for their views on accreditation of health economists and if this is required, what this accreditation would be based on. Responses revealed that within our sample (and remember these are self-classified health economists and economists working in health economics), 57% said ‘no’ to accreditation and 39% said ‘yes’ (4% were unsure). For those that said ‘yes’, the most commonly cited reason was that health economists should have, as a minimum, some form of formal economics training. Other suggestions were that there should be a certificate of training within certain subspecialties of health economics, e.g. modelling, outcome valuation, so that prospective employers have a clearer idea of individual skill sets. One health economist argued that accreditation would ensure professional integrity which would lead to economic evaluations (particularly in the pharmaceutical sector) being conducted responsibly. Some of the health economists that said ‘no’ to accreditation had strong views with the main feeling being that health economics is a discipline, not a profession. This was summarised well by one health economist who said: ‘‘I would strongly disagree with such accreditation, you do not need accreditation to be an economist, a statistician or an operational researcher, involvement and reputation through track record and input to professional bodies, such as HESG and iHEA, should act as a form of screen/signal, rather than heading off into a ‘controlling’ environment, accreditation seems to suggest a practitioner-based model, which is not the way forward’’ (anonymous responder). Other reasons for opposition to accreditation were perceptions of the diversity of the discipline making it difficult to decide what accreditation should be on the basis of, the resistance to become ‘elitist’, and the fact that we have postgraduate qualifications in health economics therefore we do not need accreditation, unlike ‘chartered’ professions such as accountancy.
3. Discussion 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 USbased survey so that ‘like-for-like’ comparisons could be made. Our study revealed that UK health
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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.
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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
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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. References Ammerman, A.S., Farrelly, M.A., Cavallo, D.N., Ickes, S.B., Hoerger, T.J., 2009. Health economics in public health. American Journal of Preventive Medicine 26 (3) 273–275. Biener, L., Garrett, C.A., Gilpin, E.A., Roman, A.M., Currivan, D.B., 2004. Consequences of declining survey response rates for smoking prevalence estimates. American Journal of Preventive Medicine 27 (3) 254–257. Blaug, M., 1998. Where are we now in British health economics? Health Economics 7 (Suppl. 1) S63–S78. Europe Unit, 2011. EU Policy-Education, Diploma supplement. http://www.europeunit.ac.uk/sites/europe_unit2?eu_policy_education/diploma_supplement.cfm.uk (accessed 2011). Gulacsi, L., 2007. The time for cost-effectiveness in the new European Union member states: the development and role of health economics and technology assessment in the mirror of the Hungarian experience. European Journal of Health Economics 8 (2) 83–88. Higher Education Funding Council for England, 2011. http://www.hefce.ac.uk/learning/diversity/achieve (accessed 2011). Madden, L., King, L., Shiell, A., 2009. How do government health departments in Australia access health economics advice to inform decisions for health? A survey. Australia and New Zealand Health Policy, http://dx.doi.org/10.1186/1743-8462-6-6.
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Morrisey, M.A., Cawley, J., 2008. US health economists: who we are and what we do. Health Economics 17 (4) 535–543. Newhouse, J., 1998. US and UK health economics: two disciplines separated by a common language? Health Economics 7 (Suppl. 1) S79–S92. Williams, I., McIver, S., Moore, D., Bryan, S., 2008. The use of economics evaluations in NHS decision-making: a review and empirical investigation. Health Technology Assessment 12 (7) .