The future workforce of our Intensive Care Units – Doctor,physician assistant or no-one?

Critical care is an essential cog in the functioning of all acute hospitals. A major emphasis on professionalism with the launch of the Faculty of Intensive Care Medicine (FICM), and training, with the evolution of a new accredited training program, has resulted in the recognition of Intensive Care as a stand-alone specialty. A governance framework under the auspices of FICM and the Intensive Care Society Joint Standards Committee has defined Core Standards ¹ ; commissioning can be structured around these and the Guidelines for the Provision of Intensive Care Services. ²

Intensive Care Medicine would be expected to have a rosy future, but is this so? With an ageing population and increasing expectations, many of which are defined as core standards, Intensive Care Units (ICUs) continue to expand. Between 2000 and 2006, critical care beds in England increased by 40% ³ followed by an expansion in the consultant workforce by 25% ⁴ from 2005 to 2010. The baseline demand for intensivists is expected to further increase 25% by 2033 based on demographic changes alone. ⁵

Are we fully prepared to staff these changes? Is Intensive Care Medicine an attractive option for the trainee doctor? Can a job be structured that allows the Intensivist to work in a satisfactory manner throughout their career? At the time of writing, we can see the threat posed to our specialty by the misunderstanding of the impact of working in antisocial hours. Contracts that disadvantage those working unsocial hours and remove safeguards around maximum hours worked, putting doctors and their patients at risk, are unlikely to generate interest in a specialty where this type of work is a requirement for good patient care.

Where are we now?

Intensivist led care results in more appropriate, efficient, higher quality care with better outcomes for critically unwell patients, and this has driven the change in the organisational structure of ICUs from open to closed.^6,7 Mortality benefits are demonstrable in many patient cohorts including sepsis, ⁸ major trauma, ⁹ neurological injury ¹⁰ or high risk surgery.^7,11 The improved outcomes in high risk surgical patients is part of the rationale behind the Royal College of Anaesthetists’ Perioperative Medicine Programme, a vision to reduce variation, improve outcome and meet public and political expectations. ¹² The sickest patients with high APACHE scores ⁹ or those that require mechanical ventilation have most to benefit from Intensive Care delivered by trained Intensivists. ¹³

Intensivists also have an impact on the financial burden of critical illness with a higher admittance threshold than doctors without specific training and a reduction in the number of unnecessary admissions and unnecessary investigations. ¹⁴ Lengths of stay are reduced as a result of lower complication rates and recognising opportunities for prompt discharge. ¹¹

However these evident benefits of Intensivist led care come at possible personal cost. A recent survey of consultant workload in Intensive Care demonstrated significant pressures. Nearly a quarter of ICUs have consultant to patient ratios in excess of 1:14, with potential to compromise patient care, consultant wellbeing and training. Many consultants work more than the base contract of 10 PAs but with an average of only 2.14 SPAs; ¹⁵ less than the current Consultant Contract’s requirement of 2.5. Other surveys have shown a significant burden of ill health related to job intensity, ¹⁶ stress^17,18 and burn out syndrome.^19,20

Provision of support for ICM consultants from trainees is problematic. A third of ICUs regularly have insufficient trainee daytime cover and nearly 80% of ICUs consistently have insufficient trainee cover overnight. ¹⁵ Trainee experience and competence, particularly related to advanced airway management, are important challenges many units face. Furthermore the number of ICM trainees achieving a CCT in ICM is already projected to fall significantly over the next four years largely due to the transition from the old to the new training program. ²¹

In common with the UK, other countries face increasing demand for critical care services. In America, a shortfall in Intensivists leading to a crisis was predicted 20 years ago.^22,23 In response, the Society of Critical Care Medicine taskforce abolished formal nurse to patient, and doctor to patient ratios and suggested collaborating with emergency physicians, ²⁴ increasing the number of training pathways resulting in accreditation, ²⁵ greater use of computerised protocols, regionalisation of intensive care units, telemedicine ²⁶ and physician assistants. ²⁷ Despite this, America still has a projected 22% shortfall of supply for intensivist hours by 2020, increasing to 35% by 2030. ²⁸

Issues with providing sustainable, high quality Intensive Care seem to be International, but are there any solutions? We suggest 3 possible approaches:

A – Support consultants to maintain skills, commit to a career in ICM and remain fulfilled and happy in their work

B – Attract and retain high caliber trainees to ICM and give them the skills and learning that allow them to flourish throughout a lifelong career in ICM

C – Restructure how ICM is delivered in the UK

Solution A

There are many ways to improve consultant retention and satisfaction in ICM, based largely around job planning, managerial changes within Critical Care Directorates and joined up thinking about how the ICU flow of patients can be optimised. These can and should all be delivered locally and need to be supported by central initiatives sponsored by FICM, the ICS and the Workforce groups of these organisations. In the first instance, there needs to be a focus on the consultants job plan; all too often job plans for new consultants are based around a vague priority to reduce on-call frequency, and manage that within a defined, and hard-fought, cost limit. Little attention is given to how the new job can be used to promote values well known to provide a good and stable workplace. Priorities in job planning should improve team working by scheduling team SPA time for regular meetings, providing a level of clinical support to avoid isolated working, and giving goals and support for other SPA activity in which colleagues can transparently see the progress in activity in the ICU. As well as this, meeting the recommended ICS DCC commitments, providing medium on call frequencies of 1 in 5 to 1 in 8 and appropriate, regularly reviewed SPA time as outlined by the 2003 Consultant’s Contract is essential. ²⁹ More recently, posts are being advertised with only one SPA. Protecting SPA time is important as it is during this time that new consultants have the opportunity to specifically engage in management and service development, along with training of the next generation of Intensivists. These are factors that not only impact on the efficiency of ICUs but also personal fulfillment and sustainability of posts.

It is well accepted that medical continuity of ICM care improves outcomes, ³⁰ but providing this within a consultant job plan can be difficult. There is clearly a balance between continuity of work and adequate breaks. This needs regularly reassessing and with care can be managed on an individual basis to some extent. It is rare to find the European Working Time Directive (EWTD) used for anything other than limiting total working time and most consultants waive this right; however, the EWTD also gives direction on how extended spells of work can be compensated by giving rest time within the paid contract. This can greatly improve work life balance and is rarely implemented. ¹⁵ The 2003 Consultant Contract is also currently under some threat with proposed plans to change the definition of Premium Time. This too will have a significant negative impact on our specialty and departments will need to carefully manage this and make sure other clauses are used for the protection of colleagues.

One of the biggest stressors influencing job satisfaction is bed availably. ¹⁷ Most published audits suggest that this is infrequently due to the ICUs being full of critically ill L3 patients, something that would, of course, be hard to resolve. More frequently there are patients on the ICU who are awaiting placement in a ward bed, or even hospital discharge. Organisational factors, bed allocation and prioritisation can all help here. ICM departments need to be fully involved in developing Operating Procedures for bed management. ³¹

It remains an exciting time for intensive care medicine, although sometimes this can be difficult to spot in the welter of moaning and complaining that emanates from a gathering of senior colleagues. Working in the NHS as an ICM consultant is a privilege that colleagues forget at their peril. ICM offers a continually exciting and interesting job, it is comparatively well paid in international terms with good security.^32,33

Solution B

Intensive care, like most hospital specialties, already faces a shortage in trainee numbers. This will only worsen over the immediate future as the need for critical care increases but the number of trainees fails to follow the same trajectory. In part, this is due to the recent changes in the training program and success in establishing Intensive Care as a stand-alone specialty. More so it is a result of the political drive to focus NHS funding on community based care and the recruitment drive in general practice. There has also been a reduction in the number of applicants enrolling on to medical undergraduate courses following the rise in tuition fees and the anticipated debts facing medical graduates in excess of £70,000. ³⁴

The GMC Shape of Training Review ³⁵ will reduce the training time required to deliver generalists but can it deliver the experienced, competent and confident Intensivists we desire? There is a real risk that future trainees will have reduced exposure and hence a limited chance to see role models prior to achieving a junior consultant post. Prior to even considering the impact of imposing the 2016 new junior doctor contract there was already concern that recruitment into a specialty with unsociable hours, facing ever-increasing pressures would become more difficult.

If a fair junior contract is negotiated, Intensive Care is in a good position to tackle this workforce challenge. The specialty has an established identity with demonstrable value in improving outcome for patients. It has a clear vision in the form of quality standards, a new curriculum and an assessment process to be proud of. Most importantly it has a motivated and enthused consultant workforce, factors that correlate strongly with satisfaction in current GMC trainee surveys.

As a consultant led service, ICM continues to provide an apprenticeship model with trainees benefiting from direct consultant interaction almost 24/7. There is a clear link between supervision, patient safety, enhanced quality of care and more rapid acquisition of trainee skills and professional attitudes, which supports the consideration of mentorship programmes. ³⁶

There are numerous exciting training opportunities associated with critical care; including the development of skills in echocardiography and ultrasound, or the opportunity to engage in education, research, quality improvement projects, leadership roles and management. FICM also accredits some overseas placements as contributing towards overall training, thus enhancing an exciting training experience.

Looking to other professions for inspiration, product exposure and promotion are crucial in order to remain competitive within the market place. This should be targeted at both undergraduate and postgraduate level. With the Five Year Forward View report ³⁷ in mind it is important to continue to support training opportunities in Intensive Care for anaesthetists but also the “generalists” who can only benefit from skills gained when faced with an acutely unwell patient presenting to a care centre which may not have direct physical access to Intensive Care.

Individuals are also more likely to stay with organisations if they are proud of what is being delivered but also when they have a share in the organisation or sense of ownership. This translates to delivering high quality care and actively engaging trainees in service improvement. In support of delivering 24/7 care, rotas should correlate with predictable busy periods on ICUs. The Health and Social Care Information Centre has critical care data for admission times and patterns over the course of the year. Nearly 50% of critical care admissions occur between 8:00 and 17:59, but 18:00−18:59 is the busiest hour in the day with 7.9% of admissions, ³⁸ ideally rotas should reflect this.

Alongside high quality training there needs to be flexibility. Whilst there is a male preponderance to the current Intensive Care consultant workforce, two thirds of medical graduates are female and an increasing number are likely to be attracted to the challenges and subtlety of Intensive Care Medicine. Consultant posts can be compatible with family life; however, shift work during training years can often prove difficult for trainee workforce with children. Women must not be penalized for taking time out if they have a baby or if they train less than full time.

Lastly, accurate workforce modeling is essential in order to avoid the unlikely position where we have a surplus of trainees for whom there are no jobs. This can happen; a workforce survey conducted in Australia highlighted a relatively young consultant workforce and a potential oversupply of trainees for whom there are few consultant posts available on completion of Intensive care training. ³⁹

Solution C

Many of our ICUs are in the process of expanding or recognise a need to expand, as they function close to maximal capacity but are constrained by inadequate resources and problems elsewhere within trusts. We regularly face overflowing emergency departments and medical patients occupying outlier beds; impacting on patient flow, timeliness of admissions, discharges and our ability to deliver on key quality indicators. ICM can be in a pivotal position to improve on acute care generally and this will impact at a hospital and regional level as well as in Intensive Care itself.

ICM has always been in the forefront of the use of technology, for example, it was the first area to start computerised charting, prescription and ordering. ⁴⁰ Electronic tracking systems that incorporate programs identifying patients at risk of organ failure will highlight the location of patients requiring intensive care input and timely intervention to reduce the need for, or facilitate, appropriate admissions. The potential need for a bed will electronically be relayed to the bed management hub.

We have already reached an era where our phones and watches can capture and record physiological parameters, sleep and activity patterns along with investigation results and organ donation decisions. Intensive Care Medicine should be helping to work towards these more generally and this will also improve local health care. Intensivists are well placed to help other physicians and managers in understanding ethical and legal choices and have been vital in mapping resuscitation and Do Not Resuscitate pathways. Early decision making and reenrollment of General Practitioners and others will improve patient care and will also cut down on inappropriate resource use.

Intensive Care research has clearly demonstrated that although different models for the provision of services can all give excellent results a number of core principles have always been key. These include specialists providing daily Intensive Care, a ‘closed’ Intensive Care environment, continuity of care, as well as an adequate case load to gain and maintain experience.

ICM consultants are key to helping deliver a good and safe model of Intensive Care locally. However, it is likely that Specialist ICUs will be centralised with opportunity for hub and spoke delivery of care through established networks to maintain skill mixes. All units should be optimised in terms of size to deliver safe care at cost effective ratios. ⁴¹ Together with this, proven therapeutics can be protocolised and largely delivered electronically. Telemedicine may have a role both within the units for Intensivists but also external referrals and consultations.

Advanced Critical Care Practitioners (ACCPS) can help address the current shortage in trainee numbers and provide continuity. This has already been supported by the development of the ACCP curriculum and assessment system along with the award of approved FICM Associate Membership for existing practitioners meeting the necessary requirements. ⁴²

Conclusion

One of us has just started a career as a consultant in Intensive Care and one of us first walked on to an Intensive Care Unit as a doctor 26 years ago. We enjoy the specialty for all its challenges, rewards, opportunities and the fantastic teams we are fortunate to be part of.

So where do we go from here? We think that Intensive Care is in a powerful position and our future is not bleak. We have a better understanding of where we are, NHS acute trusts cannot exist without Intensive Care specialists. Through FICM, ICS and SICS, we are a strong body with a progressive agenda and a voice to be heard. We just need to ensure we collectively deliver the solutions to realise this and avoid falling into a future of poor staffing, poor morale, and failing health.

We have to continue to support and protect our medical, nursing and allied workforce whom in recent months has highlighted the incredible level of passion, dedication and commitment that exists within Critical Care − a specialty most still feel proud and privileged to be part of.