Written evidence submitted by the Faculty of Intensive Care Medicine (RTR0002)

Key recommendations:

1. Implementing measures to improve how critical care staff are and feel valued; include concrete measures to improve multi-disciplinary staff education and reward attained skills

2. Increase National Training Numbers allocated by NHSE to Intensive Care Medical Training

3. Planned, targeted increases in regional staffed critical care capacity; unmet demand places huge pressures on staff including moral distress

Introduction:

1. Intensive Care Medicine (ICM) was recognised by the General Medical Council as an independent medical specialty in the UK in 2010. COVID -19 has 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 providing health care in the 21st century.

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 Faculty includes the doctors (intensivists) who lead critical care services,  Advanced Critical Care Practitioners (ACCPs), and Critical Care Pharmacists are also members. It has close professional links with those bodies representing nurses and allied health professionals working in intensive care in the UK. The Faculty works on behalf of its members and other services to promote critical care education and standards, influence and define national policy, and, most importantly, improve patient outcomes.

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.

4. Critical Care lies at the heart of 21st century secondary care crucially underpinning all other areas of acute hospital care. When critical care capacity cannot meet demand, other services particularly elective surgical services will suffer as demand from this elective quarter can be cancelled whilst demand from emergencies cannot. The impact on other secondary care services of excess demand on critical care services was and continues to be clearly demonstrated by COVID-19.

Background:

5. Critical Care, not just in England but across the UK was at significant risk in the event of even minor increases in demand. Prior to the pandemic FICM produced a report called, Critical Condition in 2018, highlighted the issues of critical care capacity, demand and supply. Overall, the situation is now worse than 2018 due to loss of critical care staff from the workforce. The biggest issue facing units is nurse staffing; meeting critical care nurse recruitment and retaining them in critical care following a gruelling 20 months is increasingly challenging.

6. 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. https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/workforce_data_bank_2021_-_for_release.pdf

7. Critical care bed occupancy pre pandemic ran at over 87%; 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, and the more pressure the workforce is placed under.

8. 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. Population increase, ageing demographic, and increased public and professional expectations all account for increased demand.

Assessment:

9. The Faculty of Intensive Care Medicine surveyed its members in November 2020 “Voices from the Frontline” https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/voices_from_the_frontline_of_critical_care_medicine.pdf. The report highlights the efforts made to provide to provide an excellent critical care service. This however is not sustainable over successive pandemic waves.

10. Each successive wave brings additional pressures on an exhausted workforce making it harder to recruit and retain staff.

Recommendations:

11. The Covid-19 pandemic has placed enormous demands on critical care staff. Sadly, this has not been reciprocated in how they feel valued. Consequently, many units have seen a loss of critical care staff, particularly nursing staff. Staff education and attainment of key skills need pushed higher up the agenda. Attainment of skills should be financially rewarded.

12. Reduce demand on critical care services. In particular, improve services such as “enhanced care” for elective surgery, and long-term ventilation and weaning services outside of critical care units, staffed by non-critical care staff. https://www.ficm.ac.uk/standardssafetyguidelinescriticalfutures/enhanced-care

13. NHS Scotland and NHS Wales have seen yearly increases in National Training Numbers for Intensive Care Medicine. NHS England gave a welcome one-off increase in 2020, but no increase in 2021. Targeted regional increases in medical training places for intensive care specialists are needed now and in future if we are to prevent other secondary services (e.g anaesthesia) being drafted in and thereby severely impacting the service they provide.

14. The Intensive Care National Audit and Research Centre (ICNARC) data shows large regional variations in COVID admissions. This variation represents differences in supply of staffed critical care capacity. The more units struggle to admit, the more pressure the staff are under, and the greater the moral distress caused. Targeted regional investment in critical care workforce and staffed beds would help provide more equitable care and reduce workforce pressures, aid staff retention and future staff recruitment.

December 2021