«Edited by ANNE MASON Research Fellow, Centre for Health Economics University of York and ADRIAN TOWSE Director, Ofﬁce of Health Economics Radcliffe ...»
The effects can also be experienced many times, as in the case of repeat victimisation (or just by vividly recalling the episode as some PTSD sufferers do). On the basis of existing evidence, it is difﬁcult to predict the direction for multiple victimisations. Additional injuries might have an increasing marginal
142 THE IDEAS AND INFLUENCE OF ALAN WILLIAMSeffect, but the UK criminal compensation tariff seems to take the opposite view, where the most severe injury is taken as a reference point and additional injuries are included at reduced rates. Therefore, we need to elicit valuations from those with repeated (real or perceived) exposure to crime.
There is also the need to consider the effect that the criminal justice system may have on how people react to criminal victimisation. There are parallels here with health, where the process of health care may affect people’s response to treatment, but the effects would again seem to be more pronounced in the context of crime, where the sentence given to the perpetrator of the crime can have an important effect on how well the victim deals with the crime. This is recognised by the increasing interest in ‘restorative justice’, which brings victims and offenders together in order to allow victims greater voice in the criminal justice system.
Once robust measures of the individual losses in well-being from crime and the fear of crime have been developed, there will be the need to determine the social value of these losses. There are again strong parallels to health here, where the development and use of QALYs has led to questions about whether it is appropriate for policy purposes to assume that ‘a QALY is a QALY is a QALY’, irrespective of the characteristics of its recipient. While this represents the default position adopted by the National Institute for Health and Clinical Excellence (NICE) in its evaluation of healthcare technologies, there is ongoing empirical research into its validity. Developing an equity-weighted measure of public safety will be particularly important given the very unequal distribution of the effects of crime across society. While most of us can expect to get ill and need health care at some point in our lives, crime is heavily concentrated in certain geographical areas, and within those areas on certain households and individuals (Pease, 2001).
But the primary need is to develop a robust measure of public safety. In short, what is required is an ‘EQ-5D for crime’. We have recently co-ordinated an ESRC-funded seminar series on ‘Crime, insecurity and well-being: an economic approach’, which has many parallels to the EuroQol group in that it has brought together academics from a range of disciplines, and policy makers, to consider how best to describe and value the losses in well-being from crime in order to inform public sector resource-allocation decisions. Alan attended some of the earlier seminars and we believe he would be pleased to hear that we are planning to take the empirical research forward through grant proposals.
ACKNOWLEDGEMENTSWe would like to acknowledge Alan Williams for inspiring our (academic) interest in crime in the ﬁrst place. Many of the ideas in the paper are the result of working with Graham Loomes and Tessa Peasgood on two Home Ofﬁce reports on the intangible costs of crime and the fear of crime. We have
THE MEASUREMENT AND VALUATION OF PUBLIC SAFETY 143also been inﬂuenced by discussions as part of an ESRC seminar series on crime, insecurity and well-being, where the input of Simon Moore and Joanna Shapland has been particularly helpful. The usual disclaimers apply.
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THE MEASUREMENT AND VALUATION OF PUBLIC SAFETY 145
APPENDIX: EXAMPLE CRIME STATE CLASSIFICATION SYSTEMWe will describe some states that you may ﬁnd yourself in because of crime.
When we say ‘because of crime’, this can be caused by being a victim of a criminal offence, or by witnessing a criminal act ﬁrst hand, or by simply hearing about a crime on television. Also, the crime can be violent and cause injuries, or non-violent and only involve loss in property. Such experiences will affect people in different ways. Here we are just describing the effects of the experience.
The ﬁrst is physical health problems A No physical health problems B Mild problems with physical health (e.g. difﬁculty running fast; limited hearing) C Moderate problems with physical health (e.g. use a stick to walk around;
moderate intermittent pain) D Extreme problems with physical health (e.g. use a wheelchair; severe pain) The second one is mental health problems A No mental health problems B Mild problems with mental health (e.g. feel somewhat anxious; mild depression) C Moderate problems with mental health (e.g. occasional anxiousness;
persistent mild irritability) D Extreme problems with mental health (e.g. severe depression;
hallucination) The third is constraints on behaviour A No constraints on behaviour (e.g. I can do what I want and go where I want) B Mild constraints on behaviour (e.g. there are some constraints on what I do and there are a few places I cannot go) C Moderate problems with control (e.g. there are many things I cannot do and a number of places I cannot go) D Extreme problems with control (e.g. I can do hardly anything I would like to and there are very few places I can go) The fourth is how you relate to others A No relational problems B Mild relational problems (e.g. feel that other people will let me down) C Moderate relational problems (e.g. mistrust of strangers; unease when out and about in the community) D Extreme relational problems (e.g. mistrust of intimate family members; feel completely alone all the time)
146 THE IDEAS AND INFLUENCE OF ALAN WILLIAMSThe ﬁfth is how vulnerable you feel A No vulnerability problems B Mild vulnerability because of crime (e.g. sometimes just worry about getting things wrong) C Moderate vulnerability problems because of crime (e.g. occasionally worry that everything could be lost) D Extreme vulnerability problems because of crime (e.g. feel strongly that something is bound to go seriously wrong and nothing can be done about it) CHAPTER 13 Discussion of Paul Dolan and Aki Tsuchiya’s paper: ‘The measurement and valuation of public safety’... Martin Buxton As the authors suggest, this paper would almost certainly have pleased Alan Williams in the way it takes the concept of the QALY and begins to explore how it, or something like it, might be applied to an area of public spending other than health care. Alan’s early involvement with the Treasury meant that he was well aware of the need to consider value for money in all aspects of the public sector. However, I suggest, that he, like me, would have wanted to contextualise this work as part of a wider, more ambitious agenda that could lead to a methodology for comparing cost-effectiveness across a variety of areas of public sector spending.
As it stands, the preliminary descriptive system proposed by Dolan and Tsuchiya (and set out in the Appendix to their paper) for what Alan Williams called their SALY (safety-adjusted life year) bears a strong family resemblance to the EQ-5D health-related quality of life descriptive system.* It sets out to provide a classiﬁcation system that ‘allows the different attributes of well-being that are affected by crime to be combined into overall “crime states”’. In this paper setting out early ideas, many of the details of the valuation process are still unclear. They do however propose a familiar process for the valuation of states relative both to each other and to the anchor points of, at the top end, no problems related to any of the dimensions characterising the effects of crime and, at the other end, death. They suggest that this may have to be ‘a natural death’, to allow for the likely possibility that death as a result of crime is perceived as worse than death by illness or accident.
The precise relationship of this new measure to the EQ-5D (or other existing QALY measures used in health) is unclear. Indeed it is not explicit * For a description of the EQ-5D system, and its development, see for example Williams (1997).