Alan Williams

Short abstract

Economist who transformed the delivery of health care to patients

Alan Williams was a professor of economics at the University of York for over 40 years. He was driven by the ambition to challenge the orthodoxy and improve the way in which health care is delivered to patients. Those entering his office were immediately struck by a notice on his desk. This declared (only partly humorously), “Be reasonable, do it my way.” Here was a man of principle with an evangelical urge to work collaboratively with other disciplines and practitioners in the medical profession to ensure not only that healthcare resources were used to maximum effect in improving population health, but also that the benefits of health care were equitably distributed among all sections of the population.

He graduated from Birmingham University, and his first academic post was in Exeter, where he taught innovatively in public finance. After sabbaticals at the Massachusetts Institute of Technology and Princeton University, he was recruited to the then new University of York in 1964, where he again focused on the teaching of public finance.

In 1966 he was seconded to the Treasury, where it was decided that, in addition to designing courses in economics for civil servants, he should be sent off to the Ministry of Health. The immediate issue was hospital planning, or as Alan found at the ministry, an absence of such planning.

As he engaged with the ministry's policy issues, he encountered some intriguing characters that became lifelong friends, in particular Professor Archie Cochrane (obituary BMJ >1988;297: 63) and Sir Douglas Black (obituary BMJ >2002;325: 661). With these and other eminent leaders of the medical profession, Alan realised that here was a significant “industry” largely untouched by economic analysis, where both medical practice and healthcare policy making were almost entirely evidence free. With allies such as Cochrane and Black he was set on a new career of creating and applying intellectual capacity in economics to the challenging problems of funding and providing health care, as well as the production of health by redistributive social programmes and policies that complemented the NHS.

Figure 1.

The products of his work manifest themselves in many ways. His own writings were prolific and he led the subdiscipline of health economics for decades. He was a father figure to health economists in York, in the United Kingdom, and around the world. But he also influenced the thinking and writing of many others. As Archie Cochrane drafted his famous Effectiveness and Efficiency book (review BMJ >2004;328: 529), Alan converted this wonderful character from the narrow path of concern about clinical effectiveness of interventions (or rather, as Archie emphasised, the absence of such evidence) to the centrality of the economic component of decision making. Costs of treating one patient, as Alan so eloquently explained over many years, always represent benefits forgone by other patients or potential patients, and to ignore costs is to ignore the sacrifices of others. This unarguable perspective on health economics is why Alan referred to the subdiscipline as “the cheerful face of the dismal science.”

Williams was intrigued by what “health” is, and how it is valued by individuals. In addition to arguing the case for the application of techniques of economic evaluation to health and health care in provocatively titled articles such as “Cost benefit analysis: bastard science and/or insidious poison in the body politick,” he embarked on a substantial research programme, initially much stimulated by the late Professor Rachel Rosser, that explored the attributes of health and led to the production of a generic quality of life measure EQ5D (www.euorqol.org). This measure has since been used in thousands of clinical trials and may in future be used routinely in the NHS to appraise the success of clinical activities.

Like all economists, Williams argued that the policy issue was not whether there was rationing in health care but what principles should decide who should get access to care. Rationing, he argued, involved depriving patients of care from which they could benefit and which they wished to consume. If the objective of the NHS is to increase population health to the maximum extent from a limited budget, prioritisation should be determined by the relative cost effectiveness of competing interventions.

The challenge, given the poor evidence base about clinical effectiveness, was to improve clinical and economic knowledge so that bodies such as the National Institute for Health and Clinical Excellence (NICE) can inform rationing efficiently. Williams's advocacy of the concept of the Quality Adjusted Life Year (QALY) as the instrument for rationing decisions is now implemented clearly in NICE guidance.

Williams was also concerned with the issues of inequality in health and health care and the integration of equity concerns into cost effectiveness analysis. In his later years he strongly advocated the concept of the “fair innings,” arguing that greater weight should be given to the young who had not had such a good life (BMJ >1997;314: 8209081009). In his 70s he argued at public meetings with older people that it was their responsibility to accept some discrimination in favour of the young when they had had a fair innings.

He leaves a wife, June, and three children.

Alan Harold Williams, professor of economics University of York (b Birmingham 1927; BCom Birmingham, hon DPhil Lund, FBA), died from cancer on 2 June 2005.

Alan Williams' landmark BMJ paper on the economics of coronary artery bypass grafting (BMJ >1985;291: 3263160430) is available in PDF format on bmj.com.