Published: 30/01/2003, Volume II3, No. 5840 Page 20 21
Emergency access czar Professor Sir George Alberti has some of the most high-profile, politically sensitive targets within his care.But for Sir George, this target or that target is not the issue: the challenge is 'to get an emergency system you are prepared to go through yourself '.And he believes It is achievable - eventually
Emergency access is the vanguard of this year's pack of targets - it is very visible and very dramatic and hitting it is touch and go.Good news, then, to find national clinical director Professor Sir George Alberti in a relaxed frame of mind last week.
Only four months into the job, following an outspoken presidency of the Royal College of Physicians, he must be keenly aware of the clinicians and managers - not to mention ministers - counting the days until the end of March when 90 per cent of accident and emergency patients must wait less than four hours for admission-transfer-discharge.
He remains resolutely undefensive in the face of questioning on targets, still preferring to concentrate on both progress made and the long-term future. 'My abiding impression of emergency access has been that people have been working very, very hard, but they've been continuing to do what they have always done.'
Sir George says he has tried to combine his 'hard-nosed clinical input' with softer skills, creating what he has called 'think time' through inspiration, a bit of nous and 'some oomph'. Broadly, that comes in three flavours - personal visits to health economies (very specifically not just A&E), working with collaborative teams to spread good practice and looking at inefficiencies in all parts of the system, including 'home and community'.
Officially he spends half his time as czar while also holding down posts as professor of medicine at Newcastle University and professor of metabolic medicine at Imperial College of Science, Technology and Medicine in London. But he estimates that his government job equates to four or five days a week. Typically, this involves a couple of days on the road ('touring, listening, talking') with the rest made up of meeting his own taskforce, groups of stakeholders and the inevitable ministerial briefings.
So far, so czar - the big difference, he feels, is that emergency care requires a more 'whole-system' approach. 'You need to analyse the whole pathway and there are blocks everywhere.'
'One of the things I said when I was appointed was that it was nice to finally get a real challenge, ' he jokes - in fact, one of his many successes has been helping to transform diabetes care in the North East over the last 25 years.
'But the real challenge is to get an emergency system you are prepared to go through yourself. I keep coming back to patients - shortening their worry time - and about quality, which is why getting clinicians involved is vital.
You could get through patients much more quickly if you didn't bother about quality.
'What has struck me going round the country is how many managers are really committed to good clinical care. Of course they are informed quite strongly if it looks like they are not hitting targets, but perhaps I am a little bit of a maverick - if they are working their butts off imaginatively in an effort to meet them I will not go round berating them.'
If Sir George clearly cares about targets, he does not feel bound by them. 'If we miss the target, the media will make a meal out of it, and I suspect ministers will feel very uncomfortable. It would be a pity, but an awful lot of places have reached it and quality has improved unrecognisably over the past couple of years; and we have only been hard at it in the last nine months.'
The problem is that if politicians ask to be judged on targets, that is what they will be judged on. 'I am not a politician. I am there to improve the quality and therefore the quantity of emergency care.
My own feelings of failure would depend on if we did not develop a good integrated system of emergency care. None of it requires more than three neurons to rub together - it is about logic, common sense and resource. It is a do-able job - eventually.'
But he adds: 'It is totally unacceptable to wait even two hours... In a slightly Machiavellian way, I think the target is a bloody good thing because it has finally brought the spotlight onto a piece of the system that was unacceptable.'
'When I was at the RCP I used to berate the government for having too many targets, and I wouldn't have that view any more.' He says that despite the burden of work, the A&E community is happier 'partly because they see the resources coming and partly because of the focus on them; that attitude that A&E is a carbuncle on the side of the hospital has changed'.
'People know the light at the end of tunnel is daylight, not a 20tonne truck'.
He does not say it, but it seems clear that he feels that long after this target or that target have been forgotten, history's judgment will depend on the 10-year plan on which he is currently working. It is still a couple of months away from public consultation and Sir George says there are 'growing patches of light amidst the fog'.He is working closely with the czars who deal with primary and intermediate care and is clear that implementation depends on creating a genuine emergency care network within a health economy, with a lead based in every trust. The problem is empowering those networks.
'One way would be give them a budget and effectively have an emergency care trust - that would be a dramatic move but one that needs to be looked at. We have mental health trusts that are working right across a sector. It is about focusing funding on a system of care rather than an institution and it is something we do talk about in chronic disease management more and more.'
For example, he is keen to cut down on the 'half of people who turn up at large hospitals' who would be more appropriately treated elsewhere. 'At the moment there are perverse incentives to increase activity - for ambulance trusts, for example. And of course ifless people with minor injuries come to A&E it makes it even more difficult to hit 90 per cent targets. It would help to work towards a community-delivered emergency care system if the networks had more budgetary influence.'
One criticism of government policy has been the lack of earmarked funding. Sir George stresses just how much progress can be, and has been, made with existing resource. He highlights the increase in the use of the 'see and treat' method to cut many steps in the treatment chain. 'We were hoping up to 20 departments would have adopted this by the end of the year, but it has been many more than that. But it does depend on having staff numbers.'
He also points to walk-in centres, discharge lounges and minor injury units within A&E run by nurses.
He stands by his pledge that his 10-year plan will require a doubling of A&E consultants. But extra staff will not necessarily mean the same sort of staff. 'Start with patients and what they need, then work out what skills you need to meet that.' A member of the workforce taskforce, he points to work on increasing the skills range of paramedics.
Asked whether the 2004 target of 100 per cent under four hours is achievable within current capacity, Sir George elects to 'dodge that question slightly'.
'I did not actually set that target.
I have never been a great believer in 100 per cent targets because I do not think you can ever achieve them. But if you divide up the workload between minors and majors, we can deal with well over 90 per cent of the former in well under four hours - and should do.
'The problems come with majors, particularly ones where you need the right beds, and I do not know whether we will have enough staff to achieve that. So I would use that same word 'challenging', but be a bit cautious about it - [in] some parts of the workload I think we can achieve it; other parts I do not know.'
He argues that future targets should step outside the door of the A&E department and look at the whole system. He gives examples of the time spent waiting for transport or advice from a GP or NHS Direct, accessibility of the site, preventive action in the community (for example, reducing falls for the elderly). 'These are the myriad steps towards A&E, and you pick out the ones that are creating problems and design targets round them.'
He will not be drawn on which are key but says: 'Though we will want to sustain progress on minors, I think the focus is on major illnesses, which is much, much more complex. It is not just waiting for beds, but also waiting for results from labs - one of the targets might be having a seven days a week, 14 hours a day investigative service, because that is a big problem.'
Ten trusts still had fewer than 60 per cent of patients waiting less than four hours in the second quarter of last year (news, pages 4-5,16 January). But Sir George denies that tougher reporting regulations on waiting times to prevent gaming have affected more than a handful of trusts. He also denies that all underperformers suffer from endemic problems, of which A&E is only one symptom and therefore untreatable in even the medium term. He argues that some 'have just not focused on A&E'.
'I am amazed at how quickly thinking has turned round in those places.'
Sir George does not welcome repeated references to March 2003, but pressed again he pauses carefully. 'My view is that the majority of trusts will meet the target and I am not particularly interested in numerical games after that.For me, targets are just a step in finding a cure for a very chronic disease.'
Unpretentious, thoughtful, engaging - the professor possesses the characteristics required to focus on that cure. 'I will feel we have succeeded when I can go to an emergency department and find a couple of members of staff sat down having a cup of coffee. That means they've got some headroom and that is when you get people actively further improving.'
'If emergency care hasn't quite yet woken up and smelled the coffee, Sir George gives every impression he thinks it will - eventually.