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Dr Gary Masterson, President of the Society, reflects on how changes in the way critical care is commissioned may impact on critical care bed provision.

There have always been (and always will be) bed pressures in critical care. I don’t know about you, but I find this the most stressful aspect of my job. However, over the last 20 years of my working life as a consultant, when I have had the misfortune of stumping around my hospital’s general wards, I am always extremely glad to return home to my critical care unit. The general wards struggle: they’re jam-packed with elderly and frail patients with nowhere else to go, grossly understaffed, chaotic and little in the way of continuity of care. You know what I mean. In critical care, we don’t suffer these problems to the same extent and, since the advent of critical care networks and a more regional approach to managing critical care beds, we can usually cope when bed are short.

We have enjoyed a long period of critical care having high profile amongst both provider trust executive teams and commissioners. We have fought hard for this over the years, and I think collectively we have done very well. Twenty years ago we were a covert and undervalued sub-speciality. That’s no longer the case.

quote2Twenty years ago we were a covert and undervalued sub-speciality. That’s no longer the case

So why may our honeymoon period be about to end? In my part of the world the Clinical Commissioning Groups, who have up to now taken the bulk of criticism and stress for the NHS’ financial woes, have been clever.  They have decided to push the risk further down the line to the acute providers by talking the trusts into accepting the (bad) old-fashioned Block Contract for a variety of services including critical care.

For years we have been working towards developing a tariff based system where the demand in activity (which we have little control over) is remunerated fairly and appropriately. Such a system is potentially open to dishonest gaming in some specialities perhaps but not in critical care. The CCGs don’t like this because it makes planning for the future financially tricky. With the unscientific (but financially safer for the CCG) Block Contract the provider is given a lump of cash to deliver a service and, because they are in financial dire straits themselves, they look for every opportunity to save money. For critical care this means closing beds with a hope and a prayer that they can get away with it. They won’t get away with it all the time because they can’t. Our fluctuation in activity will make this a certainty.

The downstream effects will be cancellation of high risk elective cases, a decrease in tertiary service capacity and, worst of all, a likely increase in non-clinical patient transfers to (hopefully) neighbouring trusts. The latter is acceptable to all if it’s only an occasional occurrence, however when it becomes frequent it’s tantamount to asking your colleagues in neighbouring trusts to do your work for you! It’s not much fun for the patient or families either.

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The downstream effects will be cancellation of high risk elective cases, a decrease in tertiary service capacity and, worst of all, a likely increase in non-clinical patient transfers to (hopefully) neighbouring trusts

My antennae tell me this pattern of CCGs moving to Block Contracts is spreading malignantly throughout the system. Why the providers have been so keen to sign up to this so naively is something I don’t currently understand. I suspect the they weren’t given a choice. Beware, the pressure to close beds to enhance efficiency (but we all know the truth) is upon us. I don’t blame the CCGs or the provider trusts. This is a direct result of central government’s continued failure to fund the NHS (and social care) properly.

The Intensive Care Society will do all it can to support our members. Speak to us and let us know what’s happening in your patch.

 

3 thoughts on “The Beginning of the End?

  1. Well said Gary! We need to centralise adult Intensive Care, hub and spoke, with peripheral units stabilising and transferring with a dedicated transfer service, ie like paeds ICU. In effect, we will soon be doing it anyway, but all over the region and not to one or two centres of excellence.
    How has it come to this? It’s a mad mad world!

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    1. Sean, good to hear from you and glad you liked my slightly depressing blog. Your suggestion for the future of critical care service delivery (“Hub & Spoke”) is certainly one option on the table that might look good value for money, at least superficially. I’m not sure that patients, relatives or even critical care professionals would be so enthusiastic though. Keen to hear others’ views. – Gary Masterson

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  2. I would also be concerned at hub and spoke. As someone who started life in a DGH and is now at a teaching hospital ( hub for vascular liver and kidneys ) it can be a real issue getting patients out and back to their initial source. As someone who was previously at the spoke, the site team regarded the repatriation as very low priority anyway, so never allowed discharges from ICU to allow a bed to be provided. Also, if you dumb down the peripheral hospitals, then work that they do, normally as well as the centres will have to move to the centre, resulting in loss of expertise and destabilisation of the DGH. Been there, seen that. Don’t do it.

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