A critical care system in transition? — The Northern Ireland perspective

Northern Ireland has a population of approximately 1.7 million and occupies an area of 5456 square miles which is equivalent to the traditional county of Yorkshire. It has the youngest population in the United Kingdom (UK) with 23% under 16 years of age (20% in UK as a whole). Sixteen percent of the population are of pensionable age (Northern Ireland statistics and research agency, 2003). The NI Department of Health oversees Healthcare Social Services and Public safety (DHSSPSNI). There are four separate health boards which are collectively responsible for 18 trusts. At present, a review of the current structures is underway with significant organizational change related to health and local government anticipated in the next year. These changes include reducing the 18 trusts to five ‘super’ trusts by April 2007 and creating a strategic health and social services authority to replace the 4 boards (Health and Social Services reform announcement by Sean Woodward Parliamentary Under Secretary for Health Social Services and Public Safety, 2005). The two universities in the province provide pre- and post-registration nurse education. The annual intake of student nurses has increased since a review of workforce planning and is currently 750. While having a common border with the Republic of Ireland (RoI), there have been few links between the two health systems. The RoI has a separate government, Department of Health and a health system with many differences when compared with the NHS. This has begun to change in recent years as the two health systems collaborate on specific projects. There are a total of 103 Critical Care beds within 14 acute hospitals in NI (54 level 3 beds and 49 level 2 beds). Nine hospitals provide both level 2 and 3 facilities, while five hospitals provide only level 2 facilities. The largest unit in the region has 17 level 3 and 8 level 2 beds. Average costs for the financial year 2003–4 show that an ICU bed costs on average £1670 per day, and an HDU bed costs £610 per day (House of Commons Hansard Index, 2005). Thirty years of civil unrest has resulted in critical care units with significant experience in the care of victims of bomb blasts, gunshot wounds, burns and other trauma which, until recent years, were rare in the UK. Most large units contribute to Intensive Care National Audit and Research Centre (ICNARC) and have outcomes comparable to units elsewhere in the UK. Only 5–10 years ago, the NI version of the NHS was similar to that in the rest of UK. Recent developments in England and Wales have widened the gap between us. Documents such as Comprehensive Critical Care (Department of Health, 2000), standards set by the Intensive Care Society (ICS, 1997) and position statements on nurse–patient ratios in critical care (Pilcher and Odell, 2000) are well known to nursing and medical staff in NI, and we have watched with interest, the development of critical care networks in England and Wales. Unfortunately, such documents are not applicable in NI as they have not been officially endorsed by the DHSSPSNI and the NI office, which currently governs NI in lieu of the (suspended) NI assembly. However, when things go wrong in the clinical arena of critical care, the standard to which we will be held is that which applies in the NHS in general. In some respects, critical care in NI has many differences. As yet, there is no managed clinical network for critical care although there are many informal good practice networks. While many hospitals are developing and introducing early warning systems, there are no formal funded outreach services and no post-ICU follow-up clinics. There is one Nurse Consultant for critical care within the entire region, and only a few units have dedicated Clinical Educator posts. The majority of new recruits to critical care are newly qualified nurses in their first post. We do, however, have some advantages/unique features. These include supernumerary induction programmes for newly qualified nurses, which until recently were fully funded. The Northern Ireland Critical Care and Transfer Service (NICCaTS) was the first transfer service for critically ill adults to service all acute hospitals in a whole region. A development framework designed by the Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC), through which registrants in NI can best develop roles safe for the public, responsive to need and ethically sound (Barrowman et al., 2005). Within the Royal Hospitals Trust, the ‘Reach’ project – a clinical careers framework for nurses that integrates reflective appraisal, work-based learning, practice development with accreditation of learning is being established. The framework enables all nurses to learn through their practice and achieve academic and professional accreditation for that work (McCormack et al., 2004). The NI and RoI health systems are investigating ways of providing appropriate health care to rural areas on both sides of the border by reviewing the hospital system at this interface. To change practice and develop services, we must clearly articulate the need and demonstrate how service developments can benefit patients. There is a drive to move in these directions, and the ability to learn from others who have already undergone this process is an advantage. Many NI projects have used national/international models as their template and have been lucky enough to learn from the successes and difficulties of others. Strahan et al. (2003) evaluated the early follow-up of patients after ICU discharge. The experience of developing and implementing an early warning observation chart has been captured by McCormick (2005). The development of nurse-led protocolized weaning from mechanical ventilation began 7 years ago in 1998, and the views of ICU physicians regarding weaning have also been investigated (Blackwood, 2003; Blackwood et al., 2004). The setting up of a NI region of the BACCN in the last few years has provided the opportunity to network with the rest of the UK, take part in the development of position statements and plan for a joint study day with the RCN NI Critical Care Forum early in 2006. A managed clinical critical care network in NI is likely to develop over the next few years. With the pending reforms resulting from the Review of Public Administration, it is indeed a difficult, unclear and confusing environment at present. The NHS in NI is a system in transition. For those with determination, ambition and a longer-term view, it is a system filled with opportunity.