A tribute to our friend and colleague, Alan Williams.
The sign on Alan Williams’ desk revealed his sense of humour, a man who invited and relished debate, but always recognising that intellectual pursuits were a means to a practical end.
Alan was a man of principles: as Bob Sugden notes, Alan was not interested in “cookbook” economics, but in developing guiding principles that embraced and encouraged active intellectual engagement and development. Many of the authors of the papers contained within this book testify to their encounters with Alan – their intellectual journeys. Bob Sugden recalls his student days and attributes his chosen career path to Alan’s influence; Ben van Hout reminisces about the impact Alan had upon Dutch efforts to develop quality of life measures; Bengt Jönsson echoes these sentiments, remembering how Alan’s courageous intellectual battles within Europe paved the way for younger academics; and Alan Maynard reminds us of the debate that raged (and perhaps rages still) between egalitarians and libertarians, both parties guilty, Williams observed, of comparing the ideal characteristics of their own ideology with the actual characteristics of the opposing ideology. As intellectual journeys criss-crossed, new ideas were born and principles were refined or revised; for Alan, principles were never meant to be followed slavishly or unthinkingly.
However, Alan was also a practical man: intellectual debates were not an end in themselves, but were for the purpose of tackling real-world issues. He wanted to help decision makers engage with the issues facing them; the role of the health economist, as he saw it, was to provide a clear framework through which important factors informing the decision-making process were made accessible and transparent. Thus Alan continued, well into his retirement, to propound applications for his work. Always an egalitarian, he argued that there were equity grounds for discriminating against older people who had had their “fair innings”, and that these grounds had important implications for the way in which scarce resources were allocated within tightly squeezed healthcare budgets. In recent years, Alan worked with Aki Tsuchiya on broader issues of equity and fairness, exploring the implications of discriminating on the basis of gender or socio-economic status.
Alan will perhaps best be remembered for his work within cost–benefit analysis. The quality-adjusted life year (QALY), born of his desire to find a generic outcome measure that would enable an assessment of the opportunity costs of healthcare interventions, synthesised the principled and the practical: life years added by a health intervention, adjusted for the quality of that life – not an end in itself but a means to achieving equitable health outcomes for all in the real world of limited resources. The role of the QALY as a tool for decision makers, enabling them to break out of the artificial constraints of “welfarist” or “Paretian” approaches, is discussed by Tony Culyer, who sets out the key dividing points between Paretian and decision-making approaches to the application of economics in the allocation of resources in health care.
Within the healthcare sector, debates over the derivation and application of the QALY continue. Paul Kind reminds us that the quality element (“Q”) of the QALY is critical: whose values should be used, how should values be combined, and who should decide these issues? Kind argues that scope remains for methodological development, and that failure to address this has serious practical implications. Bob Sugden echoes these sentiments, questioning whether decision makers should decide, on behalf of the community, what the collective objective should be. Alan Maynard focuses on the failure of healthcare systems to measure treatment effects, and advocates a system-wide application of patient-related outcome measures (PROMs) as a way forward.
Alan’s work on the QALYs also inspired methodological work on outcome measurement in other fields. Paul Dolan and Aki Tsuchiya’s work on quality of life measurement in crime is in its early stages of development, with the SALY (safety-adjusted life year) proposed as a tool for measuring public safety. Their discussant, Martin Buxton, discusses the potential for a “super-QALY” to embrace outcome measurement across different parts of the public sector, or even across multiple sectors.
Alan vigorously contested charges that cost–benefit analysis was a “pseudo-science”. However, modern economic evaluation is not immune to the same allegations. Peggy and Richard Musgrave, who open this book with a tribute to Alan, reflect on his concern with the philosophical and ethical issues that underpin decision making, issues that must still be faced. To recognise and appreciate Alan’s legacy, the task falls to the health economics community to ensure that we do not shirk our responsibilities: the need to be intellectually rigorous without being rigid; to keep in sight the practical implications of our work; to acknowledge the shortcomings within our discipline; and to move forward in the spirit of the Williams’ way.