It was a profoundly sad and moving occasion last Saturday when hundreds of us met in the damp chill of a January morning to pay our respects to the late Al Liddell. What a shock to have heard of his sudden and untimely death, aged just 63.
There will be many of you reading this wondering, who was this man? Why did so many senior figures from the NHS of the 1980s and 90s feel the need to drive from all over the country to be at that North London crematorium? Let me try and explain.
Al was way ahead of his time in the NHS in promoting outcomes rather than activity. To a management cadre in East Anglia in the 1980s where he was CEO of the then regional health authority (think of it as the SHA of its day), this was a profound shock. Where there had been precious little real accountability of any kind, it was tough enough to consider becoming accountable for quantity of service delivered, but for outcomes? What business was it of the management of the NHS to actually improve the health of the population? How could they be held to account for something so difficult to measure?
But Al persisted. He devised a set of outcome values which he relentlessly promoted on his travels across the region. Those of us on his team at HQ also had to do this on pain of death. So ingrained they became that even now, after the passing of so many decades, I can recite them parrot fashion: efficiency, effectiveness, equity, accessibility, appropriateness and responsiveness.
The radicalism was promoting the idea that in the delivery of health services it was never possible to satisfy all people all the time, and that trade-offs between these values were necessary. This challenged conventional thinking of the time that put the value of clinical effectiveness above all the others.
It led Al to have terrible battles with many senior clinicians who could not accept anything other than the primacy of the value of clinical effectiveness. But this was not pie in the sky stuff – it was essentially practical. When later in my own career I found myself confronted with my own difficult choice issues to deal with, including the infamous Child ‘B’ case, I readily followed Al’s frame of reference. My Director of Public Health, Ron Zimmern, and I came to our decision as to what course of action to take by making explicit and transparent reference to this set of values.
Al was not one to accept government policy on the NHS at face value. Despite the then Secretary of State Ken Clarke’s public statement that the internal market would be introduced with no prior experimentation (‘no pilots’ he had said in Parliament), Al ran some pilots. I was proud to be part of making them happen. The result was the seminal ‘Rubber Windmill’ simulation exercise in 1990.
We assembled the best brains we could, devised an elaborate (and expensive for the time) simulated health economy and then brought everyone together over three days to test what would happen. The Guardian, to Al’s embarrassment, headlined it ‘The Day the Market Crashed’ but of course that’s what we did deliberately – we tested it to destruction.
The big learning point – which may now seem a bit naive but back then was radical – was that when people who have otherwise only operated in a command economy operate in a market, their behaviour changes. Competition is not just a new management technique like quality circles or management by walking around (both fashionable at the time). No, it had a dynamic of its own. It changed the way people thought, acted and behaved, be that for good or ill. At the time we were shocked by what we saw happen on the floor of the simulation room.
Then when he moved to the Department of Health as Director of Planning, he took the lead in writing the White Paper ‘A Service with Ambitions’ in 1996. Let me remind you of the context: a dying government beset by sex and sleaze, with Blair about to be elected with a landslide majority. Yet Al laboured on and produced what I still think is the best government White Paper on healthcare.
It was not full of rhetoric or empty promises. It was a realistic account of reality. It used the then rather novel concept of a set of cameos describing what good care looked and felt like for different categories of patient. It stressed the importance of making information available to patients and carers for them to make decisions. It had a much more sophisticated sense of what responsiveness to patient needs was rather than the simplistic market notion of choice of provider. In that sense it presaged much of the current agenda of shared decision making and patient-centred care.
So, Al was not just the best boss I ever had, not just a remarkable visionary, but a man who made a real difference to the way health services are delivered today. It's such a tragedy that he will no longer be around to continue to help us make sense of what is to come. All the more reason why there remains a continuing need for leaders who are able to hold and deliver on such straightforward and coherent principles in an ever increasing complex healthcare landscape.
Stephen is Chief Executive of the Health Foundation, www.twitter.com/THFstephen