Tuesday, 30 December 2014

Problems for measuring social inequality in illness (not mortality)

Inspired by a Twitter exchange with some medical colleagues here is a re-cap of a paper that we published many years ago now on some of the problems that can arise when you try to get an accurate measure of social inequality in ill-health.

The overall term for these in medical sociology is "Illness Behaviour". You can divide this general idea up into 4 more concrete categories

1. The lay referral network. Almost everyone has one of these. It is the bunch of people you talk to when you have a health worry. "Do you think I should take the day off work?" "Should I take vitamins?" "Should I go to the GP/casualty?" "Do I need to call an ambulance?" are some of the questions that family and friends might be asked. We know that people with a more biologically knowledgeable lay referral network are less likely to turn up at A&E unless they really need to. They are also more likely to get medical advice when they do really need it. But there are also more subtle effects. Women whose lay networks are made up more of friends consult less often, those whose networks are more dominated by family consult more often. You get 2 guesses why this might be, answers to @melb4886.

2. The demands of everyday life. People with more arduous jobs will need to seek care (and get themselves defined as "ill") at a level of symptoms that might not affect people in other kinds of jobs. If you are a roofer with vertigo you will feel "ill", if you are a librarian with vertigo you will probably not. So there will be biases in our measures of inequality in this kind of condition. There are plenty of other examples of this, and they have most intriguing implications for measuring social class differences in mortality but I won't go into that just now.

3. The sick role. Some groups of people need to be defined as ill in order to legitimately be excused certain kinds of role obligations (my favorite is "Not tonight, Josephine"). An academic (in my younger days) would not have to get a medical diagnosis and sick certificate in order to work at home for a day with a headache, period pains or a hangover.In some studies this results in people in middle class type jobs appearing to have less illness (and a lower consultation rate) than people in more routine types of jobs. When measuring social differences in consultation, you need to keep in mind that doctors are gatekeepers of the sick role, i.e. legitimate non-performance of various obligations. This varies with the type of obligation, and with its observability and the intensity with which it is policed. This kind of thing is pretty variable in place and time. For example, at UCL for some years now, after 12 days' sickness absence you get called for a disciplinary meeting even with a doctors' certificate. The the role of GPs in signing people off for long term sickness has totally changed in the UK in the past 5 years or so.

4. Quality of the Doctor-Patient relationship. GPs who know their patients and communicate will with them will tend to understand about illness behaviour. Although Phil Strong and others wrote about the ways in which many GPs (and other doctors) communicated less well with working class than middle class patients. In fact, looking back at the classical work on illness behaviour, we probably might not agree with all of it today. It was thought that a good GP screened for high blood pressure for example, on an opportunistic basis, and treated it. This would mean more people would tell a survey that they "had an illness". If GPs took more care of their middle class patients on the other hand this would produce a bias in the class specific rates of reported hypertension.I am not sure everyone is so keen on this kind of screening today, as there is little evidence of long term effectiveness. You could say the same of hypercholesterolaemia. I suspect an example everyone would still agree with would be high blood sugar. Although I have not seen much up to date evidence on this, I would not be surprised if screening surveys showed that more working class people had undiagnosed type 2 diabetes than middle class people.

You can see from these very quick examples that illness behaviour -produced bias does not all go in the same direction. Some factors will make inequalities in illness look bigger than they are and some will make them look smaller. When David Blane, Chris Power and I gave this paper to the RSS about 20 years ago, Derek Cook commented that we had "opened a can of worms that no one wants to think about".

Monday, 15 December 2014

Can we bring sanity into academic work?

A couple of tweets I sent today may have annoyed some people. They were only meant to suggest that we might be able to organize ourselves as academic Departments (or other types of "cost center") in a slightly more rational way. For example, what is the relative contribution to the Departmental budget of (1) 7 hours of admin and academic time spent revising expense forms that result in the saving of £5 versus (2) admin staff being able to deal more promptly with research applications so that deadlines are not missed. You need to take into account of course that the £5 is a bird in the hand whereas the application may fail. But it is worth thinking about. Admittedly, this very idea is an acceptance of the commercialization of the university that many people so hate (I do too). But since we are not succeeding in fighting commercialization all that well, trying to deal with it openly might save some gray hairs. The other reason I suggest this approach is that it was my experience that in fact university managers (both senior administrators and academics turned manager) absolutely hate it when you do this. It seems to take away some of their latitude for bullying made possible by ever shifting goalposts.

I have learned a great deal from the Project Manager of our ESRC center (ICLS). To spare her blushes I will call her PM. To the horror of many of the older center members, PM insists that we evaluate all of our initiatives. When we organize a meeting we ask attendees to say how helpful it has been, for example. Our first attempt to organize a Summer School was so poorly evaluated by our students that we spared ourselves the effort of doing it again. PM's track record of building up seminar series and other forms of science communication is, basically, fantastic. So much as we sometimes disliked it, we usually took her advice.

PM has an MBA. Now, once again, I would not be regarded by those who know me as the kind of person who would thrive in a Business School. But one thing I think they teach you to do is the 'business plan' (another detested phrase). At the moment, I have this idea that Departments could formulate business plans, which could be totally transparent. It would consist, at the simplest level, of figuring out a budget for our work by adding up the amount that comes in from teaching, research and the "QE". Does teaching bring in enough to pay the wages and overheads of everyone with a HEFC post? If so, then they can be left in peace when not teaching to concentrate on intellectual work, which may well result in some additional funds via the QE when it results in good publications. But the main contributors to the QE will be academics who teach less and put more effort into writing. The QE accruing to the Department must be enough to cover this cost.

Then there is research money. Well, first of all it needs to be understood that not all research money is equal. Research Council money covers (in theory) 80% of the total cost of the work including rent, building maintenance, heat, lights, water and so on. Universities are free to set the level of these costs. At top places it can be as much as £55,000 per year per full time post (no matter what the post holder is paid). So the lead applicant on a RC grant is bringing in, lets say to be moderate, 0.8*£35,000 per post (including a proportion added to her own time buy-out so if she spends 20% time on the project it is 0.8*£7,000). There are other funding bodies like drug companies who pay "100% overheads". Then there are the charities and foundations like Wellcome and Cancer Research UK. Many charities, not unreasonably, say that their benefactors do not expect their donations to be used to run the fabric of the universities and will not pay "overheads" at all. So although this money may buy out some academic time from teaching, it will not pay the running costs for the replacement person, nor for any additional staff needed for the project.

But all this can be calculated. What seems to me increasingly important nowadays is that there is more money out there to do a type of market research for government bodies. I am not sure what "overheads" are paid by, e.g. National Institute of Health Research. But deciding to apply for these research contracts throws another factor into the mix. The work still requires skill and effort, but is less likely to address the kinds of intellectual questions that will get papers that add to the QE. I have heard rumours that this kind of work is going spare and the funding bodies have trouble commissioning it. Should academic departments go for it? To me it would depend on a rational calculation. The money gained may pay for staff and their notional running costs, and thus help to retain people on short contracts, whose wages are not covered by other grants, QE money or teaching money. The ideal state would be to have enough coming in from the latter 3 sources that everyone can keep going by doing more classical types of academic work. But if this has not been achieved then people may need to turn their hands to less glamorous toil.

None of this is an different to what any small business has to do. The first priority needs to go to the tasks that bring in the most money. Unfortunate as this may be, it is not the fault of those who manage Departments (or other cost centres), who can be totally transparent about the whole thing. This would actually mean that everyone in the Department would be able to take joint responsibility for a common effort.