SCTS BORs September 2017 Franco Ciulli

GPICS 2015 STANDARDS Care must be led by a consultant in Intensive Care Medicine. Consultant work patterns must deliver continuity of care In general, the consultant/patient ratio must not exceed a range between 1:8 to 1:15 and the ICU resident/patient ratio should not exceed 1:8.

GPICS 2015 Standards cont. There must be a designated Clinical Director and/or Lead consultant for Intensive Care. A consultant in Intensive Care Medicine must be immediately available 24/7, be able to attend within 30 minutes and must undertake twice daily ward rounds . Consultant intensivist led multi-disciplinary clinical ward rounds within Intensive Care must occur every day (including weekends and national holidays). The ward round must have daily input from nursing, microbiology, pharmacy and physiotherapy. All treatment plans must have clear objective outcomes identified within a specific time frame and discussed with the patient where appropriate, or relatives/carers if appropriate.

GPICS 2015: Cardiothoracic Surgery In the United Kingdom, cardiac surgery is mainly carried out in specialist units within teaching hospitals or specialist hospitals dedicated to cardiothoracic work. The nature of cardiac surgery demands that all patients should be cared for post-operatively in a unit that conforms to the standards of general Level 2 and 3 intensive care facilities1 . Some patients will progress in a few hours from Level 3 to Level 1 status, while others will remain at Level 2 or 3 for longer. Many units care for selected cardiac surgical patients in the immediate post-operative period in facilities other than designated ICUs. These are variously referred to as the High Dependency Unit (HDU), cardiac recovery, cardiac fast-track or by another similar name. They have in common the aim of selecting patients, minimising or abolishing the period of mechanical ventilation in the post-operative period, and preventing complications. The patient-monitoring and staff requirements of such a facility are no less than the essential monitoring requirements of patients cared for in ICU, and the governance arrangements should be the same.

Greenaway Report 2013 Doctors may want to enhance their career by gaining expertise in areas equivalent to some special interest areas in a specialty, and subspecialty training through formal and quality assured training programmes leading to a credential in that area (credentialing). These programmes would be driven by patient and workforce needs, and may be commissioned by employers as well as current postgraduate education organisers. These areas would need to be approved and quality assured by the GMC to ensure appropriate standards and portability

New IMC intake 2013 First dual CST output 2018- 19 So far most trainees aspire to dual training 93% The CCT in ICM (2011): This is the newly approved CCT curriculum in ICM. It will now be possible to train entirely as an intensivist. The new curriculum allows the accepted cores of Core Anaesthetic Training, Core Medical Training and Acute Care Common Stem (all branches) as entry routes to its higher programme. It is also possible to be appointed to more than one CCT programme – that is, to undertake Dual CCTs Programmes in ICM and in a partner specialty. Please note that there is no Dual CCT curriculum – there is only the new ICM programme, which can be undertaken in conjunction with another CCT programme, thus leading to the award of two independent CCTs

Stage 1 ICM and Core/Intermediate Anaesthesia Stage 1 must be 4 years minimum in duration (for all Dual CCTs trainees this will happen by default), of which 3 must consist of 12/12 each in ICM, Anaesthesia and Medicine (for ACCS trainees 6/12 each of Acute and Emergency Medicine may count toward the Medicine requirement). Core level Anaesthesia comprises the full 2 years of Core Anaesthetic Training, which includes 3 months of basic level ICM. At completion of CAT (including a pass in the FRCA Primary) trainees can apply for training posts leading to Dual CCTs in Anaesthesia and ICM. Intermediate level Anaesthesia then includes a further 3 months of ICM at ST3/4 level. Dual CCTs trainees entering from CAT will therefore need to complete a further 6 months of ICM and the required 12 months of medicine to complete Stage 1 ICM. Dual CCTs trainees entering from ACCS (Anaesthesia) will have completed the required 12 months of medicine and 12 months of anaesthesia as part of ACCS (Anaesthesia), along with generally 6 months of ICM. These trainees will therefore need to complete a further 6 months of ICM to complete Stage 1

Stage 2 ICM and Higher Anaesthesia Stage 2 ICM 2 years of ICM training in a variety of “special” areas including paediatric, neurosurgical and cardiothoracic ICM. Stage 2 also allows 12 months for the trainee to develop special skills that will “add value” to the service. The CCT in Anaesthetics requires trainees to complete 3 months of Higher level ICM, which can be dual counted toward the ICM CCT. o Paeds/Neuro/Cardio blocks: Stage 2 requires a 3 month block in each of these areas. The purpose of these attachments is not to produce specialist intensivists but to introduce trainees to these areas so that if and when they take up a consultant post in ICM they will be useful members of the team able to recognise, resuscitate, stabilise and transfer critically ill patients who require specialist care and treatment.

Stage 3 ICM and Advanced Anaesthesia The anaesthesia CCT programme allows for 12 months of ICM training as an anaesthetic Advanced module; this time can therefore be dual-counted to allow Dual CCTs trainees to undertake Stage 3 ICM without extension of their training. There is no further provision for subspecialty training such as Cardiothoracic at higher level is taken into consideration at present. A further 2 years after CST would need to be undertaken at present.

Dr Simon Gardner & Dr Jonathan Brand Workforce Survey 2016 Dr Simon Gardner & Dr Jonathan Brand

Q2 & Q3: “How many (a) Consultants do you have working & (b) Whole Time Equivalents have you funding for?” Average 10. Ideally more consultants than WTEs, Several centres still significantly understaffed

Q4: “How many Consultants working in CTA/CITU also undertake sessions in general anaesthesia or general ITU?” >70% have other sessions, aids on-call, job planning, ?private work, “reserves”

Q6: “Which of the following areas of clinical practice do you provide anaesthesia/ITU for?” ECMO & Transplant only in about 1/3 centres

Q8: “Do you have separate rotas for CTA / CITU?” >70% still have unified rota

10 units already on separate rotas 22 remaining units: Q9: “How many additional Consultant appointments are required to staff separate rotas, in order to achieve a minimum of 1/6 on-call frequency?” 10 units already on separate rotas 22 remaining units: Range of between 1 – 8 appointments required 78 new consultants required across UK for complete separation of CITU & CTA rotas! Assuming 1 in 6 as minimum acceptable Total shortfall = , Debate about acceptable minimum numbers, logistics

Q19: “Do you currently have consultant vacancies within CTA/CITU Q19: “Do you currently have consultant vacancies within CTA/CITU? If so, how many?” Almost 50% currently have vacancies

Q19: “Do you currently have consultant vacancies within CTA/CITU Q19: “Do you currently have consultant vacancies within CTA/CITU? If so, how many?”

Q20: “Are you currently employing a consultant locum within CTA/CITU, If so, how many?” More than 50% employing a locum

Q20: “Are you currently employing a consultant locum within CTA/CITU, If so, how many?” Almost 50% employing more than 1

Consultant Post Fill Rates Per Region Scotland = 89% North East = 40% Ireland = 100% North West = 88% Yorkshire = 57% Midlands = 75% Wales = 50% South East = 60% London = 90% South = 100%

Q26: “Do you employ non-EU doctors into your senior training/fellowship positions within your department? If so, how many?”

A Perfect Storm Pressure on Anaesthetic Workforce Changes to Anaesthesia and ICM training Changes to ICM Standards and working practices Local pressures for GA lists: OOHCA / Primary PCI TAVI et al. EP

Proceed to develop a single unified critical care unit Proposed option BHI / BRI 2017/18 Proceed to develop a single unified critical care unit The outputs of the capacity and demand modelling show a core need for 48-50 critical care beds, in the configuration of 30-32 L3 beds and 18-20 L2 beds. The initial proposal would be to build capacity for at least 50 bed (or as many more as can be accommodated), and to immediately plan to staff 48 beds from Y1. The preferred model for an integrated unit at this configuration would entail the development of: The space currently occupied by GICU primarily as a dedicated L3 area. The intention would be to run18-20 L3 beds here, with 6 L2 beds (20 L3 beds and 6 L2 beds used for modelling); The BHI end of the CICU would be an 10-12-bedded L3 fast track cardiac recovery area, potentially stretching onto ‘the bridge’ (10 L3 beds used for modelling); The existing cardiac HDU/SHDU would be reconfigured as a 12-bedded multipurpose L2 area (12 L2 beds used for modelling) At least 2 additional bed spaces to be included where possible 4 additional step-down/high care/HDU style beds within a new cardiac ward

Proposed bed model   Current (physical) Proposed (physical) Change GICU Level 2 8 0  Level 3 13 20 7  Total 21 28 CICU Level 0 4 -4  Level 1 2 12 10  14 10 24 22 -2  Other location Level 1-2 4  8  Total level 0 beds Total level 1-2 beds (on cardiac ward) Total level 2 beds 1 Total level 3 beds 27 30 Total beds 45 58 This bed model includes the assumption that 4 beds’ worth of L0 / “wardable” cardiac patients are accommodated on a cardiac ward. A further 4 beds are to be run as a high care L1-2 area on the cardiac ward. This would take the total critical care capacity to 50 on the unit, plus 4 on a cardiology ward.