The Analysis of Small Area Statistics and Planning for Health

Author(s): Colin Thunhurst

Source: Journal of the Royal Statistical Society. Series D (The Statistician), Vol. 34, No. 1,
Statistics in Health (1985), pp. 93-106
Published by: Wiley for the Royal Statistical Society
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The Statistician (1985) 34, pp. 93-106

The analysis of small area statistics and planning for

health

COLIN THUNHURST

Department of Applied Statistics & Operational Research, Sheffield City Polytechnic,

Pond Street, Sheffield S I WB, UT.K

Abstract: Recent years have seen a focussing of attention on the social and geographic
variations that exist in the need for health care in the U.K., the social and geographic
variations that exist in the provision of health care and the tendency for these
variations to coincide inversely. Of the two sides of the needs-provision equation it
has, necessarily, been the former that has proved most difficult to determine with any
measure of general agreement. Over the last year, the British Medical Journal has
published two competing census-based indices, each of which claims to measure the
level of need for primary care. This paper reviews and assesses the merits of each and
suggests that a more illuminating analytic approach might be found by applying
clustering techniques.

Introduction

Recognition of the failure of the U.K. National Health Service to distribute health
care services and health care resources in direct proportion to the need for those
services and resources has been relatively long-standing. As long ago as 1971 Welsh
General Practitioner, Julian Tudor Hart, argued that the converse was in fact the case
and coined the now familiar 'Inverse Care Law':

In areas of most sickness and death, general practitioners have more work,
larger lists, less hospital support, and inherit more clinically ineffective
traditions of consultation, than in the healthiest areas; and hospital doctors
shoulder heavier case-loads with less staff and equipment, more obsolete
buildings, and suffer recurrent crises in the availability of beds and replace-
ment staff. These trends can be summed up as the Inverse Care Law: that the
availability of good medical care tends to vary inversely with the need of the
population served. Hart (1971)

For many years, successive governments failed to acknowledge this most important
contravention of one of the founding principles of the National Health Service. Either
out of ignorance, or because they felt that they lacked the necessary power to effect
significant change, the condition of mis-match was allowed to persist or, arguably,
ever to worsen.
It took until 1975 for official recognition of the problem to be secured. That year
saw the establishment of the Resource Allocation Working Party, which was set up
with the following terms of reference:

To review the arrangements for distributing NHS capital and revenue to

RHAs, AHAs and Districts respectively with a view to establishing a method
of securing, as soon as practicable, a pattern of distribution responsive

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94 Colin Thunhurst

objectively, equitably and efficiently to relative need and to make recom-

mendations.
The following year saw the publication of the Working Party's report, 'Sharing
resources for health in England' (DHSS, 1976) which contained the now infamous
RAWP formula, which is used extensively, both at regional and district level, for the
distribution of resources throughout the NHS. The RAWP procedure has been
criticised for various reasons, not least for its undue concentration on measures of
mortality and morbidity and its failure to identify and incorporate the distribution of
social deprivation. This is seen as the foundation from which the observed differences
in health outcome originate.
A quite contrasting approach was adopted by the members of the subsequent
working party, established in 1977 under the chairmanship of Sir Douglas Black, to
investigate 'Inequalities in Health'. The report of this working party-commonly
termed 'The Black Report'-contained a comprehensive programme of anti-poverty
measures which stretched well throughout and well beyond the National Health
Service to encompass social reforms in the areas of housing, education, child benefits,
tobacco consumption, etc. The publication of the report had seen a change of
Government, and the new Secretary of State for Social Services, Patrick Jenkin,
rejected its conclusions out of hand, arguing that the implementation of its recommen-
dations would be too costly. Unpalatable to the Government as the findings of the
Black Working Party may have been, they have changed the nature of the debate
about health and inequality to a dramatic degree. No study in the area can now be
published without reference to the social variations underlying variations in health
experiences. And the number of such studies now being published has increased
dramatically.
For example, focussing on primary care in Inner London, the Royal College of
General Practitioners reported a survey which has been conducted on the need for
and provision of general practice throughout the 16 Area Health Authorities of inner
and outer London. The same year, 1981, saw the publication of the Acheson
Report-the report of a study group established by the London Health Planning
Consortium-which contained 115 recommendations 'designed to improve primary
health care services by providing a framework within which the problems of indi-
vidual communities can be tackled'.
For some years the DHSS/General Medical Services Working Party on Underdoc-
tored Areas has been searching for a way to identify those areas where the difficulties
are greatest (the underprivileged areas) with a view to improving services.
The shift in the debate that has taken place can be well characterised by the 'fable'
of the physician on the river bank told by Irving Zola:
You know", she said, "sometimes it feels like this. There I am standing by
the shore of a swiftly flowing river and I hear the cry of a drowning man. So
I jump into the river, put my arms around him, pull him to the shore and
apply artificial respiration. Just when he begins to breathe, there is another
cry for help. So I jump into the river reach him, pull him to the shore, apply
artificial respiration, and then just as he begins to breathe, another cry for
help. So back in the river again, reaching, pulling, applying, breathing and
then another yell. Again and again, without end, goes the sequence. You
know, I am so busy jumping in, pulling them to shore, applying artificial
respiration, that I have no time to see who the hell is upstream pushing them
all in.

Recent attempts to move from simple measures of morbidity and mortality to an

analysis of social conditions do, one can argue, constitute a serious shift in the focus
upstream.

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 Analysis of small area statistics 95

Indices of need for primary care

The Jarman Index

The task of trying to develop a measure of the need for primary care has been taken
up most vehemently by the Underprivileged Areas Sub-committee of the General
Medical Services Committee-in particular, by one of its members Professor Brian
Jarman. Last year, Jarman (1983) published in the British Medical Journal the details
of an index that he had been using.
Jarman relied on the response to a general practitioner workload survey to identify
13 'Social Factors' and 8 'Service Factors' (see Table 1) which were identified by GPs
as 'contributing to the pressure of work on general practitioners'. He discarded
'Service Factors' from his index for the following reasons:
(a) Social factors are not amenable to alteration by those responsible for primary
health services;
(b) Service factors are not recorded for sufficiently small areas;
(c) Service factors tend to cancel each other out.
Of the 13 'Social Factors', three were then pruned out-population over 65 years,
crime rate, difficulty in visiting-leaving a short list of 10 social variables.

Table 1. Social factors and service factors contributing to the pressure of work on
general practitioners-Jarman (1983)

Social factors
1. Older people (aged 65 and over)
2. Children (aged under 5)
3. Unemployment
4. Poor housing
5. Ethnic Minorities (people born outside United Kingdom)
6. Single Parent Households
7. Elderly Living Alone
8. Overcrowding
9. Lower Social Classes
10. Highly Mobile People (% changing house in a year)
11. Non-married Couple Families (less stable family groups)
12. Crime and Vandalism
13. Difficulties Visiting (long distances, traffic, etc.)

Service factors
1. Long Outpatient Waiting Times
2. Low % Area Health Authority Expenditure on Community Services, More on
Hospital Services
3. Low % Local Authority Expenditure on Home Helps, Meals on Wheels
4. Low % Area Health Authority Nurses Attached to General Practices
5. High % Elderly GPs (aged 70+) in Area
6. High % Single Handed GPs in Area
7. High % GPs' lists over 3000
8. High % GPs' lists under 1000

To each of these an arcsine transformation was applied-to reduce the extent of

skewness. The standardised values of the transformed variables were weighted-by a
weighting given by the scores for each variable in the GP survey (see Table 2). They

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96 Colin Thunhurst

were then combined to form a composite index-for details, see Irving (1983).
The publication of the Jarman Index provoked a number of criticisms-particularly
from Scott Samuel (1983), who accused Jarman of 'expediency' and creating 'an
impression that the health needs of deprived areas can be acknowledged only via a
statistical edifice with foundations of medicopolitical clay'. Specifically, he criticised
Jarman for the process by which the factors were selected in the first place-the
representativeness of the GP sample survey-and the criteria employed for excluding
the service factors and rejecting three of the social factors. At a subsequent seminar on
the Need for Health Services in London, held at the King's Fund Centre, he claimed
that he could produce his own 'back of the envelope' index which would have far
greater objective value than Jarman's and which wouldn't involve the complex process
of conducting practitioner surveys.

Table 2. Variables included and weights used in under-

privileged area (UPA) score-Irving (1983)

Over 65 2-5
Pensioners alone 2-6
Under 5 19
One-parent families 1-2
Unskilled workers 1-5
Unemployment 1-3
Lack of amenity 14
Overcrowding 1 2
Change of address 1 1
Ethnic minorities 1-0

N.B. In it's preliminary version the 'Unemployment' variable was

double weighted as a substitute for the 'Unskilled workers' variable
which was not then available.
In a subsequent version both the 'Over 65' and the 'Lack of amenity'
variables have been removed.

The Scott Samuel Index

Scott Samuel's own 'objective indicator' of the need for primary health care was
published in the British Medical Journal earlier this year (Scott Samuel, 1984). For
this, he took, as an 'objective measure of an area's need for primary health care', 'the
proportion of the population not in employment due to permanent sickness, as
recorded in the national census'. From a range of census indicators for the local
government districts of Merseyside and Cheshire he identified 10 variables 'that
explained independently 25% or more of the variance in permanent sickness rates (as
defined above)'. From these 10 variables he employed identical methods as those used
by Jarman in terms of transformation and standardisation and then weighted them
according to their correlation with the permanent sickness variable. This produced a
competing index the performance of which was compared with that of Jarman.
It seems an obvious question to ask why, if as Scott Samuel states permanent
sickness rates provide an 'objective indicator' of the need for primary health care in
the first place, it is necessary to enter the rather circular process of deriving a more
complex indicator out of correlated variables. Why not just use the permanent
sickness rates as they stand?

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 Analysis of small area statistics 97

Table 3. Ten indicators which explained independently 25% or more of the permanent
sickness rate for the Mersey RHA-Scott-Samuel (1984)

Persons Aged Over 15 with Temporary Sickness

Households Overcrowded
Households Severely Overcrowded
Households Owner Occupied
Households Rented from Local Authority
Households with no Car
Men aged 16-64 out of Employment
Women aged 16-59 out of Employment
Private Households with Three or More Dependent Children
Households with One Person Aged Over 15, with One or More Children

Table 4. Indicators of health and material and

social deprivation-Townsend, Simpson & Tibbs
(1984)

Health indicators
Deaths per 100,000 adults aged 15-64
Stillbirths and Infant deaths per 1000
Low birth weight (under 2800 g)
Deaths per 10 000 adults aged 65 +
Indicators of material and social deprivation
Fewer rooms than persons
Households without a car
Unemployed
Children receiving free school meals
Electricity disconnected

N.B. In the study of Townsend, Simpson & Tibbs indices

of health and material and social deprivation were produced
for the 28 wards in the City of Bristol by respectively
cumulatively ranking each set of indicators.

Reading between the lines, one would deduce that Scott Samuel is anxious not to
subject himself to the same criticism as that levelled at the RAWP formula-that
simply using measures of mortality and morbidity ignores the variations in social and
economic environments that underlie them and produces an essentially 'downstream'
index. However, in achieving the marginal shift of focus that lies behind the
derivation of what is in fact little more than a technically more complex surrogate for
the one-dimensional permanent sickness indicator, Scott Samuel has done well to
expose the rather shaky foundations on which the whole enterprise is founded.

Why an index in the first place?

The reasons for wanting a single 'objective indicator' in the first place are a little
unclear. The implications of doing so are clearer and are well illustrated in the
potentially endless argument that could pass between Jarman and Scott Samuel, and
expanded to include many more besides.

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98 Colin Thunhurst

Jarman's initial decision to produce a weighted index at the outset appears to be

based upon a rejection of the use of principal component analysis. For this, he cited
and repeated the arguments of Craig & Driver (1972). It is important to be clear
precisely what it was, though, that Craig & Driver were rejecting-and why. There
has grown up a tradition, still unfortunately not laid to rest, within geographically
related studies of employing principal component analysis as a methodological
majician's wand to be waved over a large-the larger the better-set of indiscrimi-
nately collected variables and declaring the resultant 'principal component' as 'the'
index. Throughout the 1960's and 1970's the literature is peppered with just such
exercises claiming to produce 'indices of rurality', 'indices of deprivation', etc.
In rejecting the adoption of such a method for producing an 'index of need for
primary care' one would have great sympathy with Jarman. But the problem only
arises if the point of the exercise is to produce 'the' objective index at the end of the
day. In eliminating the use of principal component analysis as a method to be
employed altogether, he is perhaps throwing out the baby with the bath water. With
other ends in mind principal component analysis might be used, together with other
appropriate techniques, as a powerful method for exposing underlying data structure.

Problems of multi-collinearity

Principal Component Analysis can be used as a methodological black box aimed at

trying to tease out the dimension underpinning a particular data set, but more
generally, and more appropriately, it is a means of trying to tackle the severe multi-
collinearity that invariably bedevils data sets such as those employed by Jarman and
Scott Samuel. The straight index approach ignores the presence of and the effect of
multi-collinearity. Elsewhere, Thunhurst (1982), I have examined a data set similar to
that employed by Jarman and Scott Samuel, one originally used by the London
Health Planning Consortium (1979) when looking at the need for acute hospital
services in London. It comprised five variables: standardised mortality ratio; the
percentage of households lacking exclusive use of basic amenities; the percentage of
households with more than one person per room; the percentage of pensioners living
alone; and, the percentage of New Commonwealth immigrants, recorded for each of
the 32 London boroughs. Each of the last four variables had high correlations with the
first and would thus, by Scott Samuel's criterion, be prime candidates for an 'index of
need for acute services'. However, I went on to show that when we examine the partial
correlation coefficients, the signs of the last two variables, controlling for the effects of
the other three turn from positive to negative. I went on to argue:
An interpretation, based solely upon this data set, would seem to be that each
of the individual variables can be taken on their own as good indicators of
the existence of health problems, as measured by a high value of the SMR.
However, only two of the variables, the housing variables, can be taken as
direct indicators. The other two are surrogates. Pensioners living on their
own and New Commonwealth immigrants will tend to live in areas of poor
housing but will not, of themselves, experience 'excess' health problems-in
fact there is some indication of the reverse.

Problems of skew

Furthermore, in opting for a single index created as a weighted combination of

variables-as both Jarman and Scott Samuel do-no consideration is given to the

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 Analysis of small area statistics 99

nature of the distribution of the variables so combined. Irving (1983) in the technical
paper describing the construction of the Jarman Index identifies the variables as
having been transformed using an Arcsin transformation. Scott Samuel employs
'identical methods as those used by Jarman' and thus presumably does the same. Now
the Arcsin transformation will generally lessen the extent of skewness, particularly
where this is initially quite extreme-as is often the case with census variables-but it
doesn't remove all skewness, nor does it equalise the skewness between all variables.
To retain skewed variables asthe basis of a weighted combined index may be no bad
thing, if done purposefully; but if done indiscriminately it will have the effect of
creating an additional unknown weighting factor, particularly at the extremities of the
distribution of the index, precisely that part of its' range with which we are normally
most concerned. To put it another way a single skewed variable, say typically the
percentage of heads of households born in the New Commonwealth or Pakistan, may
dominate the index by virtue of its' distribution; high scoring areas on the index may
be simply high scoring areas on this variable.

More fundamental problems

These are technical concerns and may be overcome by a greater degree of technical
sophistication; but there is a more fundamental concern which would question the
whole exercise of trying to produce a one-dimensional index in the first place. Needs
are multidimensional-particularly needs for health care. Wouldn't it be better to
approach the general problem of identifying areas of need for primary health care in a
way that retains this essential multi-dimensionality of the way that these needs exist
within the community? The process of 'trade-off between dimensions, which has been
performed via general practitioner responses to questionnaires by Jarman, via weight-
ing the variables according to their correlations with permanent sickness by Scott
Samuel, can be avoided-or rather transformed to the political process where it
rightly belongs-if we adopt analytic techniques which retain the essential multi-
dimensionality of the problem space. An example of such a contrasting approach can
be found in an exercise that I was involved in defining areas of poverty for Sheffield,
more details of which can be found in Crabtree, Rogers & Thunhurst (in press).

A Different Approach-Defining Areas of Poverty for Sheffield

The analysis conducted using 1981 census data to revise Sheffield's 'priority areas of
deprivation' contains a number of features which are now quite standard in such
social area analyses. Others were relatively new and, for obvious reasons, it is these
that will be concentrated on here.
First, in this analysis we adopted a purposeful approach to the selection of census
indicators. Rather than throwing everything into a statistical melting pot and expect-
ing it to produce 'an answer' we proceded along more parsimonious, less indiscrimi-
nating lines. This meant thinking more clearly about the concept we were trying to
operationalise-'deprivation'. Over the last century, but more intensively over the last
two decades, a number of competing explanations have been produced for the
phenomenon that is generally known as 'urban deprivation'.
The nature of these explanations, and the dimensions of their diversity, are well
captured in Table 5. It shows, on the vertical axis, a continuum of explanation, from
social pathology to structural functioning, accounting for the existence of this pheno-
menon. Within this continuum, specific examples of explanations are located. On the
horizontal axis, important features of each explanation are portrayed. The table

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100 Colin Thunhurst

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 Analysis of small area statistics 101

clearly highlights how differing explanation determines differing choice of analytic

features, and in the context of census-based analyses differing choice of census
variables. The choice of explanation is, of course, an acutely political one, reflecting
broadly speaking an 'individualist' or 'collectivist' view of the world. Choice of a
particular set of census variables thus reflects a particular political view of the world,
and that view is no less present simply because the choice is not made explicitly. The
political philosophy of the Sheffield City Council dictates that such choices should be
made explicitly and, under its current direction, that such choices should reflect its
collectivist/structural view of the world. In keeping with this, we adopted a working
definition of deprivation that lay to the structural end of the continuum. Translated
into census variables, this indicated three distinct sets of 'candidate' variables' which
need representing in the study:
(i) First, there are direct indicators. These consist of deprivations in themselves.
Examples of these are severe overcrowding, single parent families, unemployment
variables and variables concerned with social class.
(ii) Second, there are indirect indicators. These enable the existence of deprivation
to be inferred, but do not necessarily constitute deprivations in themselves. Such
variables are: households without a car; large households; numbers of children and
pensioners. These variables can crudely be viewed as either proxy measures of
possible lack of income; factors which might make poor households poorer, or
measures of people particularly likely to be discriminated against (e.g. New Common-
wealth or Pakistan households).
(iii) Third, there are interpretative indicators. These are not measures of deprivation,
but aid the geographical analysis of the distribution of direct and indirect indicators.
These include: the number of in-migrants during the previous year; the number of
council rented houses; the number of students; the amount of furnished and unfur-
nished rented accommodation.
This differentiation of variable type proved an important factor in the interpretation
of analytic results.
Initial identification of variables, performed prior to the availability of 10% data
on social class, produced a set of 21 variables. These were analysed, using primarily
the CLUSTAN clustering package, and revised in a number of directions-to remove
redundant variables, and to remove an undesirable emphasis on demographic
structure-and extended to include 10% data on social class, giving a final list of 18
variables, see Table 6.
This second set of 18 variables was analysed using the CCP (Census Clustering
Package) developed by Stan Openshaw at the University of Newcastle Upon Tyne
(Openshaw, 1982) for precisely the type of exercise in which we were engaged. (For
details of the relative merits of the CLUSTAN and ccp clustering packages see Crabtree
et al. (1984).) This produced an initial definition of two dozen areas exhibiting serious
evidence of deprivation.

Grassroot survey

Census analyses have a strong tendency to produce a partial view of the world. Areas
of deprivation do not necessarily fall into the neat geographical areas employed by the
census-even when working at a level as detailed as enumeration districts. Also, the
coverage of topics in the census gives a far from complete perspective. For example,
much of the post-war high rise and deck access housing is objectively good quality
housing as defined in terms of census variables. Unfortunately the experience on the
ground-or rather in the air-is a little different. For reasons that are too complex to

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102 Colin Thunhurst

Table 6. Indicators employed to define Sheffield's 'areas of poverty'

Direct indicators
Proportion of economically active population seeking work-men
Proportion of economically active population seeking work-women
Proportion of economically active persons under 25 years being unemployed
Proportion of all households being lone parents with dependent children
Proportion of households being severely overcrowded (more than 1P5 p.p.r.)
Proportion of head of households in Social Class IV (semi-skilled)
Proportion of head of households in Social Class V (unskilled)
Proportion of households lacking a bath and/or w.c.
Indirect indicators
Proportion of households with 6 or more persons
Proportion of households lacking a car
Proportion of the population aged 0-15 years
Proportion of the population over 60/65
Proportion of the population in households with head of New Commonwealth or
Pakistan origin
Interpretative indicators
Proportion of in-migrants during the previous year
Proportion of households renting council accommodation
Proportion of persons aged 18-24 being students
Proportion of households renting furnished accommodation
Proportion of households renting unfurnished accommodation

Table 7. Grassroots survey: Details of questionnaires distributed and returned

Questionnaires Questionnaires
returned distributed

Departments within the local authority:

Careers Service 27 60
Cleansing Services 10 10
Education 130 499
Environmental Health 19 20
Family and Community Services 38 116
Housing Services 5 30
City Libraries 31 40
Planning and Design 8 12
Recreation 30 280
City Council Members 17 87
South Yorkshire County Members 4 43
South Yorkshire Police 105 109
South Yorkshire Probation Service 10 30
Area Health Authority 78 100
South Sheffield Project 9 35
Voluntary Sector 7 31
Totals 528 1502

Questionnaires returned = 528

Questionnaires distributed = 1502
Response rate =35%

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 Analysis of small area statistics 103

Table 8. Breakdown of most deprived cluster groups into areas of poverty identified

Cluster 7: Areas of Acute Poverty-mainly areas of Council flats. Exceptionally high

scores on all direct poverty indicators.
Area 1 -Hyde Park
Area 2 -Broomhall Flats
Area 3 -Kelvin
Area 4 -Pyebank
Area 5 -Cromford Street
Area 6 -Townhead Street

Cluster 8: Areas of Poverty-high proportion of furnished rented accommodation

with high population turnover.
Area 8 -Havelock (part Cluster 17 also)
Area 17 -Crookesmoor
Area 29 -Machon Bank

Cluster 17: Area of Poverty-predominantly low rise Council housing.

Area 7 -Park Hill
Area 9 -Manor
Area 10 -Wybourn
Area 12 -Flower Estate
Area 14*-Moorfield Flats
Area 15 -Ellesmere
Area 16 -Greenland, Darnall
Area 18 -Woodthorpe
Area 19*-Edward Street
Area 20 -Parsons Cross
Area 23 -Brushes Estate
Area 24 -Hallyburton Road
Area 28*-Winn Gardens

Cluster 16: Areas of Poverty-high proportion of unfurnished rented accommodation

and housing lacking basic amenities. Large immigrant population.
Area 13*-Staniforth Road (part Cluster 12 also)
Area 21-Tinsley (part Cluster 12 also)

Cluster 12: Areas of Poverty-mainly owner occupied housing. High proportion of

immigrants.
Area 11 -Nottingham Street (part Cluster 17 also)
Area 22*-Sharrow Street
Area 25*-Abbeyfield
Area 26*-Wolseley Road
Area 27 -Albert Road (part Cluster 7 also)
Area 30*-Firvale

These areas were added after analysis of the Grassroots Survey results.

be discussed here, many of these blocks have failed socially rather than structurally or
in terms of amenity-provision.
In order not to miss out on any such areas the results of the census analysis were
checked and augmented using a 'grassroots survey', 1500 grassroots workers through-

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104 Colin Thunhurst

out the City, from teachers, social workers, councillors to the police, were circulated
with details of the draft definition of areas, as produced by the census analysis,
together with a questionnaire in two broad sections 'issues not covered in the 1981
Census' and 'provision of services and facilities'. The pattern of response was itself
interesting-see Table 8.
As a consequence of the grassroots survey the 24 areas initially defined were
extended to give 30 in all, which allowed for a much more discriminating definition of
'priority areas' than the undifferentiating 'inner city boundary' that had previously
been employed-see Fig. 1.
The newly defined priority areas have already been adopted for policy formation by
a number of departments throughout the City Council. The Education Department,
for example, has made it a matter of priority that all families within the defined areas
should have access to nursery education facilities; and they are being used as priority
areas for the deployment of this year's Urban Programme Expenditure.

Guidelines for health planning

The tradition of census analyses as important components in urban, and rural,

planning is much longer-standing than it is for health planning. Advocacy for, and
application in, health policy formation are relatively recent-see, in the U.K., Skrim-
shire (1976), Scott Samuel (1977) and Carstairs (1981) and, in the U.S., Struening
(1974). It is perhaps then not surprising that health planners should find themselves
publicly casting about in the rather indiscriminate fashion that characterised the more
early applications to general social policy.
If health planners are not to spend the next 30 years rediscovering afresh, in health
planning, what has already been learnt in social planning, we would do well to
examine critically the social scientists' experience and develop general guidelines
accordingly.
The first of these that I would suggest is to think clearly about the initial selection of
variables. This, in turn, necessitates a clear theoretical understanding of the under-
lying process at work. In this, health planners have been greatly assisted by the
deliberations of the Black Working Party. The Black Report considered four 'explana-
tions' for the existence of social inequalities in health: (i) Artefact explanations; (ii)
Theories of natural or social selection; (iii) Materialist or Structural explanations; (iv)
Cultural/behavioural explanations. The first two were, for good reasons, dismissed out
of hand. The latter two were considered worthy of more detailed examination.
It would seem to me that in establishing, for more detailed consideration, these two
particular explanations the Black Working Party has also established two polarities of
the health deprivation explanation continuum equivalent to the social pathology-
structural continuum of Table 5, above. Cultural/behavioural explanations of health
inequalities will emphasise the bad health behaviour of the 'lower' social classes
poor dietary habits, incautious supervision of children at play, etc. Material or
structural explanations will argue that the root causes of social inequalities (as well as
the features highlighted by advocates of cultural/behavioural explanations) lie in the
functioning of our society, particularly the uneven distribution of power and com-
mand over resources. These explanations will stress the unequal distribution of wealth
and suggest that other characteristics are derivative. Between these polarities I would
suggest that there is a parallel continuum which, if properly developed, would mirror
that offered for explanations of urban deprivation.
Having established a theoretically sound framework for the study of health inequal-
ity, the next step is to match this with an analytic rigour. Problems such as skew and
multi-collinearity are an inherent feature of the subject matter at hand. They cannot,

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 Analysis of small area statistics 105

Ik'. Ho rfB-N

INNER CUALTEATIO90NSAR

Fig. 1.
Areas of acute poverty 8. Havelock 19. Edward Street
1. Hyde Park 9. Manor 20. Parsons Cross
2. Broomhall Flats 10. Wyboumn 21. Tinsley
3. Kelvin 11. Nottingham Street 22. Sharrow Street
4. Pye Bank 12. Flower Estate 23. Brushes Estate
5. Cromford Street 13. Staniforth Road 24. Hallyburton Road
14. Moorfields Flats! 25. Abbeyfield
Areas of poverty Gibraltar Buildings 26. Wolseley Road
6. Crofts Buildings! 15. Ellesmere 27. Albert Road
Townhead/ 16. Greenland-Darnall 28. Winn Gardens
Hawley Street 17. Crookesmoor 29. Machon Bank
7. Park Hill 18. Woodthorpe 30. Firvale

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 106 Colin Thunhurst

neither should they, be wished away. We have the techniques to expose the underlying
structure; these should be used and the data analysed appropriately in the light of this
with purpose and consideration.
My last two guidelines are perhaps, as those already identified, veering to the
obvious, but no less worth stating all the same. Census data provides a powerful and
reliable glance into social structure; as mortality patterns do for the structure of the
distribution of ill-health. But both views are partial views. Wherever possible they
should be extended, as illustrated by the grassroots survey; and, above all, interpreta-
tion of 'results' should be fully informed by these and other deficiencies such as those
identified above.

Acknowledgements

The study described, identifying Priority Areas for the City of Sheffield, was con-
ducted in collaboration with Janet Crabtree and Mike Rogers of the Sheffield City
Council's Department of Planning and Design. Much of the description of the study
offered above-particularly that relating to the theoretical foundations-relies heavily
on expositions developed by them.

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