Written evidence submitted by the Faculty of Intensive Care Medicine (CBP0012)

 

1.              About the Faculty of Intensive Care Medicine (FICM)

1.1.              Intensive Care Medicine (ICM) was recognised by the General Medical Council as an independent medical specialty in the UK in 2010. The Covid-19 pandemic illustrated the unique expertise of the specialty in treating the critically ill. Whilst understanding of the specialty has increased, considerable knowledge gaps as to how ICM is integral to wider healthcare delivery remain. Understanding the role of ICM in the acute hospital environment is fundamental to addressing the current backlog in elective surgical demand, as well as providing a more resilient NHS service in future.

1.2.              The Faculty of Intensive Care Medicine was founded in 2010 and currently has 4,254 members, making it the largest organisation of critical care medical professionals in the UK. The Faculty is the professional and statutory body for the specialty of Intensive Care Medicine, the doctors who lead critical care services and Advanced Critical Care Practitioners, and includes Critical Care Pharmacists as members. It has close professional links with the bodies representing nurses and allied health professionals working in intensive care in the UK. The Faculty works on behalf of its members and our wider services to promote education and standards, influence and define national policy, and, most importantly, improve patient outcomes.

1.3.              Intensive Care (often used interchangeably with Critical Care) treats patients, with, at risk of, or recovering from life-threatening failure of one or more of the body’s organ systems.  It includes the provision of organ support, the investigation, diagnosis, and treatment of acute illness, systems management and patient safety, ethics, end-of-life care, through to support of patients and families in their mental and physical recovery from critical illness. Treatment can be delivered in a physical space (intensive care unit, high dependency unit or critical care unit) or as an outreach service to the rest of the hospital. Where the intensive care team provides outreach support to the hospital, the intention is to prevent further patient deterioration or to support the recovery of those who have been critically ill.

1.4.              Patients are admitted to Critical Care as emergencies from multiple sources including the Emergency Department, medicine, surgery, cancer, haematology and obstetric wards.

1.5.              The Critical Care team provides advanced organ support and monitoring for patients who are at high risk of deterioration following surgery.

1.6.              Critical Care lies at the heart of 21st century secondary care underpinning all other areas of acute hospital care. When critical care capacity cannot meet demand, other services particularly elective services will suffer as demand from this quarter can be cancelled whilst demand from emergencies cannot.

 

2.              What is the anticipated size of the backlog and pent-up demand from patients for different healthcare services including, for example, elective surgery; mental health services; cancer services; GP services; and more widely across the healthcare system?

 

2.1.              FICM would refer to work done by the Institute for Fiscal Studies and the submissions from the Royal College of Anaesthetists and Royal College of Surgeons of England as to the factors impacting on likely demand for surgical procedures: https://ifs.org.uk/publications/15557

2.2.              Critical Care provides a crucial safety net for planned elective surgery (cardiac, neurosurgery, and cancer). This vital role was illustrated during the first and second waves of the Covid-19 pandemic when the necessary expansion of critical care bed capacity for patients with Covid-19 brought many other hospital services to a standstill due to the lack of critical care capacity for almost anything other than patients with Covid-19 infection.

2.3.              The current surgical backlog in demand is in part a consequence of that necessary expansion of critical care services; both in terms of physical hospital bed capacity lost to critical care expansion, but also the staffing necessary for that increase in capacity; staffing from other areas of the hospital including anaesthesia and elective surgical theatre staff were necessary because the increased workload could not be met by ICM trained staff alone. A larger critical care capacity with trained staff would provide more resilience to future surges in demand and is a vital element of addressing unmet surgical and cancer treatment needs resulting from the pandemic.

2.4.              Patients having elective surgery carrying higher risk due to the nature of the operation, or because of co-morbidities and patient frailty, also require planned admission to critical care for supportive care. In essence these elective cases “compete” for critical care capacity with critical care emergencies. Where demand exceeds supply of critical care beds, elective cases risk cancellation, thereby worsening the backlog.

2.5.              Covid-19 also illustrates two other issues: Firstly, an elective high risk surgical patient may only require a critical care stay of 1 to 2 days, whilst 25% of patients ventilated with Covid-19 had a critical care stay of more than 25 days. One patient critically ill with Covid-19 could therefore result in more than 25 elective cases being cancelled. Secondly, patients with Covid have to be isolated from elective high risk cases to ensure patient safety which reduces critical care capacity for elective work. The more patients critically ill with an infectious disease such as Covid that need critical care, the fewer staffed critical care beds there are for elective cases.

3.              What capacity is available within the NHS to deal with the current backlog? To what extent are the required resources in place, including the right number of staff with the right skills mix, to address the backlog?

3.1.              There is extremely limited capacity within critical care services in England to deal with the current backlog without significant increases in staffed critical care bed capacity. Increases in elective surgery will inevitably lead to an increase in complications and place an additional demand on critical care services.

3.2.              Prior to the pandemic FICM produced a report called, Critical Condition in 2018, highlighting the issues of critical care capacity, demand and supply. Overall the situation is worse than 2018 due to loss of critical care staff from the workforce. This compounds historical deficiencies, and lack of isolation facilities often within ageing unit infrastructure which do not have the necessary isolation rooms for managing an endemic infectious disease. The biggest issue facing units is nurse staffing; meeting critical care nurse recruitment and retaining them in critical care following a grueling 18 months is challenging.

3.3.              There are around 3756 staffed critical care beds in England. The number of critical care beds per capita is amongst the lowest in Europe (Germany 27 beds/100,000 population, versus England 8 beds/100,000 population). The figure for England hides a wide regional variation in staffed critical care bed capacity per capita. The impact of this can be seen within the regional Covid-19 critical care admission data.

Critical care bed occupancy pre pandemic ran at over 87% which is more than 10% over the recommended 75% occupancy. The higher the bed occupancy the more likely elective cases will be cancelled due to lack of critical care bed. The bed fill rate for Northern Ireland and Wales was estimated to be at least 95%. Scotland was 84%. NHS England data put the critical care bed capacity rate at 87%, but a number of units responded to express doubt that the rate entered for their Trusts was a true reflection of their real capacity

3.4.              In the 2017 Critical Futures report the Faculty reported that:

3.5.              Even without Covid-19, the Intensive Care National Audit and Research Centre (ICNARC) and the Centre for Workforce Intelligence (CfWI) both projected an annual increase in demand for critical care services of around 4% per annum. There is no reason why Covid-19 will reduce this and more likely it will increase bed use due to long critical care stays.

The increasing population, ageing demographic, and increased public and professional expectations all account for this increased demand. Different demands were simulated (as seen below). There was already a call for a significant increase in staffed critical care capacity alongside more efficient use of existing critical care capacity. 

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This lack of critical care capacity needs to be addressed. The key issues are firstly increased staffing across the multidisciplinary team and secondly critical care infrastructure. If capacity is not increased, services dependent on critical care support will suffer including trying to meet the demand for elective higher risk surgery rates and outcomes from cancer.

 

4.              How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term?

4.1.              Acute critical care capacity needs to increase: A phased expansion in critical care services is required irrespective of the pandemic and need to address the current backlog. This requires the recruitment of nursing, medical and allied health professionals to meet National standards. Without capacity, surges in demand will continue to require staffing from outside critical care such as anaesthesia, theatre staff, and recovery areas. This will at best hinder meeting any increase in elective surgery, and at worse increase the size of the backlog.

4.2.              The Faculty suggests a focus on the right patient, in the right place at the right time for treatment. Critical Care is a precious resource and should be equally available for those who need it, when they need it. There are two key patient groups whose care could be delivered outside of acute critical care units. With appropriate system re-organisation and targeted investment, Enhanced Care Units and Long Term Ventilation units alongside a necessary expansion in critical care provision for acute hospitals could significantly ease capacity constraints. The Health Inequalities highlighted in the CMO’s recent 2021 report also occur in ICM. Access to critical care is not equal across regions; critical care bed provision per 100,000 population varies from 5.6 to 13 beds/100,000 population.

4.3.              Enhanced Perioperative Care Units: Much high risk elective surgery traditionally thought to need critical care support could in fact be better and more efficiently delivered by an Enhanced Care service. This would free up acute critical care beds for those critically ill and provide a more efficient elective service for those requiring supportive care. In most hospitals the Enhanced Perioperative Care Service would be geographically separate from critical care, only take elective surgical cases (non-covid patients), whilst being staffed more efficiently by an elective surgical/anaesthetic team. The Faculty has developed specific guidance for the staffing and standards required to develop such a service.

4.4.              Long term ventilation and weaning units: Some ventilated patients are stabilised and no longer critically ill. These patients’ needs would be better met in units designed for the purpose; either long term weaning from ventilatory support, or providing lifelong invasive ventilation in a long term ventilation setting as a step towards either home ventilation or ventilation in specific care homes. Currently many of these patients are still cared for in acute critical care units as there is no other suitable local service. If long term invasive ventilation and weaning services were expanded this would free up acute critical care beds as well as providing more appropriate care to this patient group.

4.5.              Infrastructure of Critical Care services: Many units do not meet the recommendation that 20% of their bed capacity is single room occupancy (NHS Health Building Note 04-02). Covid-19 highlighted the impact of an infectious disease and the necessary Infection, Prevention and Control measures necessary. This infrastructure needs addressing with changes to estates. If modernisation does not occur, many units will continue to need to expand into other areas of the hospital at times of increased community prevalence of infectious diseases e.g. influenza or SARS CoV-2 and thereby impact on elective services. There is a risk that elective surgery will be impacted by seasonal winter pressures and on-going SARS CoV-2 waves.

 

5.              What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic? How could this support the future work of the NHS and care services?

5.1.              The pandemic has shown that NHS services can respond faster and more efficiently than thought previously. Critical Care pandemic capacity planning was planned for a doubling of capacity for a period of 6 weeks. During the pandemic all units have met this requirement and many units increased capacity up to 4 fold for many months. 

5.2.              Critical Care services have historically been under resourced and any increases usually done in an unplanned fashion. There is now better public and political understanding of the importance of critical care to secondary care services. This understanding needs to include a planned expansion of capacity to meet routine demand, alongside an increase in resilience to the inevitable waves of this pandemic and others in future.

5.3.              Critical Care capacity should be viewed as a national resource. Improving UK Critical Care capacity in-line with other economically comparable countries would provide much more resilience in the event of a crisis. It would help prevent a backlog of demand from other NHS services, improve standards of care and outcomes across a range of NHS services, as well as improving the physical and mental health of staff in critical care.

 

5.4.              The importance of the multi-disciplinary team has been very strongly illustrated during the pandemic response. Services, including critical care and high risk surgical care are completely dependent on staffing; access to a ventilator, or a bed without appropriate staff is meaningless. Critical care and enhanced care for high risk surgery need to be staffed by a multi-disciplinary team. These staffing standards are available (link to GPICS 2 and FICM Enhanced perioperative care documents) and include; pharmacists, psychologists, physiotherapists, and occupational therapists. Skills that have been acquired by other members of the healthcare team during Covid should not be lost.

 

6.              What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges?

6.1.              Recognition of Advanced Critical Care Practitioners (ACCPs). ACCPs are clinical professionals that form part of the multidisciplinary team responsible for patient care during their critical care admission. The ACCP role is a way of working for health professionals, which crosses professional boundaries. They are highly experienced and educated practitioners who have developed their skills and theoretical knowledge to a very high standard. They are empowered to make high-level clinical decisions to ensure that patients receive timely, personal, and effective care. The Department for Health and Social care review of Medical Associate Professionals (MAPs) in 2019 did not include ACCPs. ACCPs are currently developed from experienced nurses, physiotherapists, paramedics or other related health care professionals: this further denudes a critical care and acute hospital workforce. If the DHSC recognised ACCPs as MAPs it is envisaged that ACCPs may also be drawn from other emerging healthcare roles including those entering healthcare from science backgrounds.

6.2.              Advance Care Planning and End of Life Care. Educating the public is necessary around expectations at the end of life. The pandemic has illustrated the importance of individuals being included in decisions regarding their care, including the elderly, frail or those with significant medical co-morbidities; those most at risk of complications following major surgery. Shared decision-making is regarded as best practice but an individual’s lack of capacity, when critically unwell often precludes their involvement in decisions about treatment. Information about patients’ wishes and beliefs needs to be embedded earlier into considerations around planning for surgery thereby minimising confusion and conflict due to clear communications about advance care planning and whether treatment involving intensive care admission is likely to achieve a desired outcome.

6.3.              Life after Critical Illness and Intensive Care Services. Historically, there has been no national and limited local investment in managing the aftermath of complex critical illness. This has meant patients with no clear avenue to help them with the physical, psychological, cognitive and social consequences of critical illness. It has also led to progressive inequality for patients dependent on where they happen to fall critically ill. As a result, they struggle to return to their previous quality of life. Appropriate help could have improved their outcome, if provided by those with an understanding of their recovery. This is in stark contrast to single organ disease, such as heart, respiratory, head injury or stroke, which all have well defined rehabilitation pathways.

The pandemic will be responsible for a large unmet need in the recovery phase of the illness, as to date over 120,000 patients have been treated on intensive care units in England, Wales and Northern Ireland for Covid. The Faculty has produced guidance on how intensive care recovery services can be developed.

6.4.              Building a sustainable future for the sickest patients in the hospital. Reasonable investment in expanding intensive care provision, attention to making sustainable careers for those working in ICM and proactive service configuration as illustrated can present positive solutions to the needs of the sickest patients in the hospital and helping to address the backlog in elective surgery and cancer treatment. The Faculty’s Critical Condition report in 2018 illustrated these issues for commissioners of services and national stakeholders.

6.5.              There was already a deficit in trained Intensive care doctors (intensivists) which the SARS CoV-2 pandemic highlighted. Additional medical staff were pulled in, particularly from Anaesthesia who had some of the necessary skills to fill this deficit. We need to see an expansion of intensivist workforce such that critical care needs are not so reliant on other services. We can’t continue to deplete other services of their workforce when they are needed for the own work and any surge in demand. National Training Numbers (NTNs) are allocated by Health Education England. ICM saw a one off increase in NTNs in 2020 but this has not been repeated in 2021. NHS Wales and NHS Scotland did increase their NTN numbers. In future we need an increase in ICM NTNs to staff an increase in routine ICM capacity, provide more ICM workforce resilience and reduce demand on other services for surges in demand.

6.6.              The mental wellbeing of NHS staff during the pandemic has been well documented. The impact on critical care staff has been particularly harsh. Efforts to support staff and address mental health have been made and on-going support from NHSE will help recruit and retain staff in the critical care workforce. 

 

More details on workforce and demand is available at:

https://www.ficm.ac.uk/sites/default/files/workforce_data_bank_2021_-_for_release.pdf

 

Enhanced Care:

https://www.ficm.ac.uk/news-events-education/news/enhanced-care-guidance-service-development-hospital-setting

 

Sept 2021