EDITORIAL

© 2006 The Author. Journal compilation © 2006 British Association of Critical Care Nurses, Nursing in Critical Care 2006 • Vol 11 No 2 61

A critical care system in transition? — The Northern Ireland perspectiveNorthern Ireland has a population ofapproximately 1.7 million and occupiesan area of 5456 square miles which isequivalent to the traditional county ofYorkshire. It has the youngest popula-tion in the United Kingdom (UK) with23% under 16 years of age (20% in UKas a whole). Sixteen percent of thepopulation are of pensionable age(Northern Ireland statistics andresearch agency, 2003). The NI Depart-ment of Health oversees HealthcareSocial Services and Public safety(DHSSPSNI). There are four separatehealth boards which are collectivelyresponsible for 18 trusts. At present, areview of the current structures isunderway with significant organiza-tional change related to health andlocal government anticipated in thenext year. These changes includereducing the 18 trusts to five ‘super’trusts by April 2007 and creating a strat-egic health and social services author-ity to replace the 4 boards (Health andSocial Services reform announcementby Sean Woodward ParliamentaryUnder Secretary for Health Social Servi-ces and Public Safety, 2005).

The two universities in the provinceprovide pre- and post-registrationnurse education. The annual intake ofstudent nurses has increased since areview of workforce planning and iscurrently 750.

While having a common border withthe Republic of Ireland (RoI), therehave been few links between the twohealth systems. The RoI has a separategovernment, Department of Healthand a health system with many differ-ences when compared with the NHS.This has begun to change in recentyears as the two health systems collab-orate on specific projects.

There are a total of 103 Critical Carebeds within 14 acute hospitals in NI (54

level 3 beds and 49 level 2 beds). Ninehospitals provide both level 2 and 3facilities, while five hospitals provideonly level 2 facilities. The largest unitin the region has 17 level 3 and 8 level 2beds. Average costs for the financialyear 2003–4 show that an ICU bed costson average £1670 per day, and an HDUbed costs £610 per day (House of Com-mons Hansard Index, 2005).

Thirty years of civil unrest hasresulted in critical care units with sig-nificant experience in the care of vic-tims of bomb blasts, gunshot wounds,burns and other trauma which, untilrecent years, were rare in the UK. Mostlarge units contribute to Intensive CareNational Audit and Research Centre(ICNARC) and have outcomes compa-rable to units elsewhere in the UK.

Only 5–10 years ago, the NI versionof the NHS was similar to that in therest of UK. Recent developments inEngland and Wales have widened thegap between us. Documents such asComprehensive Critical Care (Depart-ment of Health, 2000), standards set bythe Intensive Care Society (ICS, 1997)and position statements on nurse–patient ratios in critical care (Pilcherand Odell, 2000) are well known tonursing and medical staff in NI, andwe have watched with interest, thedevelopment of critical care networksin England and Wales. Unfortunately,such documents are not applicable inNI as they have not been officiallyendorsed by the DHSSPSNI and the NIoffice, which currently governs NI inlieu of the (suspended) NI assembly.However, when things go wrong in theclinical arena of critical care, the stand-ard to which we will be held is thatwhich applies in the NHS in general.

In some respects, critical care in NIhas many differences. As yet, there isno managed clinical network for crit-

ical care although there are many infor-mal good practice networks. Whilemany hospitals are developing andintroducing early warning systems,there are no formal funded outreachservices and no post-ICU follow-upclinics. There is one Nurse Consultantfor critical care within the entireregion, and only a few units have dedi-cated Clinical Educator posts. The major-ity of new recruits to critical care arenewly qualified nurses in their first post.

We do, however, have some advan-tages/unique features. These includesupernumerary induction programmesfor newly qualified nurses, which untilrecently were fully funded. The North-ern Ireland Critical Care and TransferService (NICCaTS) was the first trans-fer service for critically ill adults to ser-vice all acute hospitals in a wholeregion. A development frameworkdesigned by the Northern Ireland Prac-tice and Education Council for Nursingand Midwifery (NIPEC), throughwhich registrants in NI can bestdevelop roles safe for the public,responsive to need and ethically sound(Barrowman et al., 2005). Within theRoyal Hospitals Trust, the ‘Reach’project – a clinical careers frameworkfor nurses that integrates reflectiveappraisal, work-based learning, prac-tice development with accreditation oflearning is being established. Theframework enables all nurses to learnthrough their practice and achieve aca-demic and professional accreditationfor that work (McCormack et al., 2004).The NI and RoI health systems areinvestigating ways of providing appro-priate health care to rural areas on bothsides of the border by reviewing thehospital system at this interface.

To change practice and developservices, we must clearly articulate theneed and demonstrate how service

Editorial

© 2006 The Author. Journal compilation © 2006 British Association of Critical Care Nurses62

developments can benefit patients.There is a drive to move in these direc-tions, and the ability to learn fromothers who have already undergonethis process is an advantage. Many NIprojects have used national/inter-national models as their template andhave been lucky enough to learn fromthe successes and difficulties of others.Strahan et al. (2003) evaluated the earlyfollow-up of patients after ICU dis-charge. The experience of developingand implementing an early warningobservation chart has been captured byMcCormick (2005). The developmentof nurse-led protocolized weaningfrom mechanical ventilation began 7years ago in 1998, and the views of ICUphysicians regarding weaning havealso been investigated (Blackwood,2003; Blackwood et al., 2004).

The setting up of a NI region of theBACCN in the last few years has pro-vided the opportunity to network withthe rest of the UK, take part in thedevelopment of position statementsand plan for a joint study day with theRCN NI Critical Care Forum early in

2006. A managed clinical critical care net-work in NI is likely to develop over thenext few years. With the pending reformsresulting from the Review of PublicAdministration, it is indeed a difficult,unclear and confusing environment atpresent. The NHS in NI is a system intransition. For those with determination,ambition and a longer-term view, it is asystem filled with opportunity.

Joanna McCormickNurse Consultant, Critical Care,

The Royal Hospitals, Belfast,E-mail: joanna.mccormick@royal

hospitals.n-i.nhs.uk

REFERENCESBarrowman L, McCance T, McCusker C.

(2005). Development Framework Consulta-tion Responses Report. Belfast: NorthernIreland Practice and Education Council forNursing and Midwifery (NIPEC).

Blackwood B. (2003). Can protocolized-weaningdeveloped in the United States transfer to theUnited Kingdom context: a discussion. Inten-sive and Critical Care Nursing; 19: 215–225.

Blackwood B, Wilson-Barnett J, Trinder J.(2004). Protocolized weaning from mechan-

ical ventilation: ICU physicians' views.Journal of Advanced Nursing; 48: 26–34.

Department of Health. (2000). ComprehensiveCritical Care – A review of adult critical careservices. London: Department of Health.

Health and Social Services reform announce-ment by Sean Woodward ParliamentaryUnder Secretary for Health SocialServices and Public Safety November22nd 2005.

House of Commons Hansard Index. (2005).10th October: column 263W.

Intensive Care Society. (1997). Standards forIntensive Care Units. London: Intensive CareSociety.

McCormack B, Devlin M, McIlrath C. (2004).REACH Pilot 1a Evaluation. Belfast: RoyalHospitals Trust and Royal College of Nurs-ing, Royal Hospitals Trust.

McCormick J. (2005). Design and implementa-tion of an observation chart with an inte-grated early warning score. PracticeDevelopment in Health Care; 4: 69–76.

Northern Ireland Statistics and ResearchAgency. (2003). www.nisra.gov.uk.

Pilcher T, Odell M. (2000). Position statementon nurse-patient ratios in critical care.Nursing Standard; 15: 38–41.

Strahan E, McCormick J, Uprichard E, Nixon S,Lavery G. (2003). Immediate follow upafter ICU discharge: establishment of a ser-vice and initial experiences. Nursing in Crit-ical Care; 8: 49–55.