Setting health priorities: the development of cost-effectiveness league tables.

Alan Williams’s web site describes him as a ‘‘pseudoretired professor of economics still active in promoting more explicit priority-setting based on cost-effectiveness approaches to both health maximisation and the reduction of health inequalities’’. He is widely acknowledged as the most influential of British health economists and indeed the father of the sub-discipline in the United Kingdom, as evidenced by respondents to a survey of British health economists who, when asked about the paper deemed most influential on both the discipline and policy, answered ‘‘anything written byAlanWilliams’’ (1) and specifically his 1985 paper reproduced here. At first sight it may appear odd that economists should choose as ‘‘most influential’’ a paper about coronary artery bypass grafting (CABG), and moreover one published in a medical journal. We believe that the following features account for the seminal nature of the paper: the collection of methodological aspects that were innovative at that time; the close relationship between analysis and policy; the frank acknowledgement of the limitations in data quality; and the vision of a future research agenda. However, the active involvement of its author in proselytising and arguing for his overall vision that ‘‘an explicit approach based on cost-effectiveness reasoning is on stronger moral ground than any other approach’’ has also been a key reason for the paper’s success in stimulating the research and policy directions of many others (including economists). Williams’s paper introduced four specific methodological ideas to the context of decisionmaking in the UK National Health Service (NHS): application of the quality-adjusted life year (QALY) as a measure of effectiveness of interventions; calculation of ratios of cost per QALY gained from interventions; presentation of the first ‘league table’ comparing the relative cost-effectiveness of different interventions; and recognition that sub-groups of patients may have differential cost-effectiveness ratios. Parts of these ideas had been developed and applied in earlier publications in the USA (2, 3) but never in the UK. The approach of combining quantity and quality of life across different health interventions in the league table was particularly influential in moving cost-effectiveness analysis away from only piecemeal decision-making to broader sectoral planning (4). In terms of policy implications, the paper concluded that CABG compared extremely favourably with heart transplants and treatment of end-stage renal failure, favourably with valve replacement for aortic stenosis and implantation of pacemakers for heart block, and less favourably with hip replacements. The more severe a case of angina, the more costeffective it was to treat with CABG, and only the most severe cases were judged to be ‘‘a fairly strong claimant’’ on any extra resources. These were controversial conclusions aimed at stimulating further debate. The paper was published at an important point: a consensus conference had recommended a large increase in CABG operations; the UK Department of Health and Social Security had just significantly extended the heart transplant programme; and a detailed report on the costs and benefits of the heart transplantation programme had been completed (5). The paper was the first to compare directly the efficiency of very different types of health care interventions and, by so doing, to challenge UK government policy.However, it was also important for the future acceptance of the approach that several key people involved in these debates had been part of the 1 Senior Lecturer in Health Economics, Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England (email: [email protected]). 2 Professor of Health Economics and Policy and Head, Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, London, England. 3 Research Fellow in Health Economics, Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, London, England.