Written Statement - Provision of Critical Care Services in Wales

Today, I am publishing “Together for Health – Delivery Plan for the Critically ill: A Delivery Plan up to 2016 for NHS Wales”.  It builds on the progress we have already made improving critical care services in Wales.  It is a framework which challenges the NHS to innovate and sets out clearly the Welsh Government’s expectations on outcomes to be delivered.  

The Delivery Plan, which has been developed by a NHS Task and Finish Group, seeks to address challenges facing critical care services in Wales. It has five delivery themes with clear expectations:

• Delivering Appropriate, Effective Ward-Based Care
• Timely Admissions to Critical Care 
• Effective Critical Care Provision and Utilisation 
• Timely Discharge from Critical Care 
• Improving Information and Research

It seeks to ensure that those who require critical care receive it in an appropriate environment, cared for by sufficient numbers of suitably qualified and experienced staff.

The Task and Finish Group has also agreed a Consensus Statement on Critical Care in Wales and a report on the relationship between organ donation and critical care services.  

The nature of the intensive therapy provided means critical care beds are amongst the most costly resource within a secondary care service.  For example a level three bed is about 4½ times more expensive than a normal ward bed. Therefore, when a “critical care episode” is complete, it is important that patients are moved on to an environment more appropriate for their needs and rehabilitation as soon as possible.

Critical care units need to be able to respond to fluctuations in emergency admissions as well as cope with planned demand. All units in Wales report occupancy rates of greater than 80%, with many at times operating at over 100% occupancy, when patients are sometimes being cared for in areas other than critical care.  This unsatisfactory situation is something I want to address.

At the same time, many patients on critical care units may not require that level of care. National critical care data shows that, in 2012/2013, 111,377 critical care bed hours were lost due to patients awaiting discharge to ward beds; this equates to almost thirteen years or thirteen lost beds across Wales.

NHS Wales has an average of 3.2 intensive care beds per 100,000 people. As we are all aware, this is lower than the number of beds provided for the population in the rest of the UK.  Such a level of beds makes it all the more important that they are used to maximum efficiency and effectiveness by minimising avoidable or unnecessary admissions and ensuring timely discharge.

I therefore fully endorse the approach set out in the Delivery Plan.  The focus must be on improving the efficiency of critical care.  This must be tackled as a priority by Local Health Boards. I also accept that efficiencies alone will not be enough to cater for the increasing demand and further investment to increase critical care capacity is necessary. Work to address the issues highlighted will be undertaken alongside further work required to quantify the additional number of critical care beds required in Wales.

There are clear parallels to be drawn between the issues identified relating to the provision of critical care services and the issues which I have previously highlighted affecting unscheduled care.  As I stated in my oral statement to the Assembly on unscheduled care, I believe we need a new national conversation about the way in which our care services best meet the needs of an ageing population. Critical care will always be a finite resource and must be used for those who need it, when they need it.  Critical care is not appropriate for all patients, so we must support patients and clinicians to have open and honest conversations about escalation of treatment, appropriateness of critical care and the anticipation of death.

Finally, I should mention the relationship between organ donation and critical care services, since it was the work on the Human Transplantation (Wales) Bill which put the provision of critical care services into the spotlight.  The work of the Task and Finish Group shows success will come from focussing our actions on the wider aspects of critical care rather than the specific needs of organ donation.  Critical care is the most appropriate environment for organ retrieval and support of donor families. I accept the group’s view that the current high occupancies of Welsh critical care units makes immediate access to critical care often difficult and could reduce our ability to accept potential donors. The Group’s clear advice is that, independent of any change in organ donation legislation; there is a need to address both the efficiency in critical care bed utilisation and capacity.  This will reduce critical care as a constraint to organ donation in Wales.

I am determined action must be taken to tackle the inefficient use of resources highlighted within this plan. I firmly believe that the actions together with those I have previously highlighted to tackle unscheduled care pressures will improve our critical care services for those who use it and for those who work in it. It is now for Local Health Boards to plan and deliver services in line with these expectations.

I would like to thank all the members of the Task and Finish Group on Critical Care, drawn from professionals in this field from across Wales, for developing the plan.  This plan represents the start, not the finish, of a programme of action.  I anticipate receiving recommendations quantifying the additional critical care capacity required in Wales next year.  At that time I will provide you with a full update on progress.