The Nhs is running out of money -should we close all the intensive care units?

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The NHS is running out of money –should we close all the intensive care units?”


Much like the Greek myth of the Daughters of Danaus who were condemned to forever fill a bottomless basin, there is a fundamental struggle in the founding principles of the NHS. Since its creation in 1948, it has committed to providing comprehensive healthcare to all while remaining free at the point of care.(1) As such, finite public funds stretch in an attempt to satisfy an infinite healthcare need. The realities of this tug of war necessitate the rationing of funding in order to provide the best healthcare possible given the resources available. So core is resource allocation to the NHS that its very constitution stipulates the “effective, fair and sustainable use of taxpayer money.”(2)

Intertwined in this struggle is the political machine that drives policy within the NHS. With the 2015 general elections looming, the UK’s health service is once again a hot-topic for discussion amongst political candidates. Debate on austerity measures, healthcare costs, funding gaps and the question of privatization dominate the media. As such, the political and economic climate calls for ever-increasing scrutiny on the effective use of resources within the NHS. In times were cost-utility analysis underpins funding, the value of resource intensive services like intensive care units (ICUs) is put into question. A movement towards redirecting resources towards preventative medicine, primary care and community services has arisen. With the new NHS Five Year Forward View, the NHS once again faces a period of change and service restructuring. This essay hopes to examine the current and future state of funding in the NHS, to examine how intensive care fares in terms of its cost-effectiveness and to discuss some of the limitations in a purely financial approach, ultimately advocating for a more holistic look at service funding.

NHS Finances and the Five Year Forward View

First and foremost it is essential to root this discussion in the context of the NHS’s predicted funding gap. In 2013, NHS spending constituted 8.2% of the UKs GDP.(3) Although projections vary, the UK office for budget responsibility suggests this may be as high as 16.6% by 2060.(3) Funding on the other hand, hampered by the aftermath of the global recession, is projected to remain relatively flat in real terms until 2020. NHS England, Monitor and independent analysts have all come to the conclusion that this could result in a £30 billion pound funding gap by 2020/2021.(4)

This predicted gap has served as a driver for change with the 2014 NHS Five Year Forward View establishing future funding priorities in the NHS. Amongst other changes, it heralds a shift away from acute services, like intensive care, in favour of improved primary care and community services. It simultaneously promises a “radical upgrade” in preventative healthcare.(4) By means of these changes as well as further efficiency savings the plan hopes to allow for a future NHS that is free at point of care while remaining fully tax-funded.

Determining the Cost of Intensive Care

In lieu of this funding gap, the NHS is focusing on assessing its services for their cost-effectiveness. In 2004, an estimated 2% of the NHS hospital budget (£675 million pounds) was spent on Intensive Care(5, 6) with approximately half dedicated to staffing costs.(7). However, despite concerns about the rising costs of intensive care, these figures benefit from a comparison with neighbouring European nations. Interestingly, prior to the 2014 Five Year plan, the UK already spent considerably less on intensive care than most European nations. For example, compared to the UK’s 2%, the Netherlands spent upwards of 20% of its health budget on intensive care.(8) Reflective of this fact, the UK has the smallest proportion of acute hospital beds allocated to critical care within Europe.(9) Overall it has approximately three times fewer critical care beds when compared to the Netherlands and seven times fewer compared to Germany.(10)

Determining the cost-effectiveness of intensive care requires a calculation of cost per individual patient, a figure which has proved notoriously difficult to ascertain. (11). This relates in part to the heterogeneity of case-mix between and within different Intensive Care Units. As a result, inter-patient and inter-unit comparisons prove difficult, requiring large study numbers. In the past, top-down approaches, where the total cost of running a unit is divided by the total number of patients, has been used. In 1995, Singer et al. found the average cost per patient was £1149 per day.(12) However, this method fails to take into account the high variability in cost between different patients which can be as substantial as £100-£8000 per day. Bottom-down methodologies where individual patients are ascribed costs in relation to the resources they use are more accurate but are also time-consuming and costly to implement. Again in 1995, a study using a bottom-down methodology estimated costs at approximately £1152.(6) Although the dataset itself could not be obtained, the Intensive Care National Audit and Research Centre (ICNARC) which collects detailed data from intensive care units across the UK estimated the cost of an in-patient episode on ICU in 2006 as four times that of a patient on a normal ward. (13)

Cost-effectiveness of Intensive Care

The high mortality rates in intensive care raise concerns about its cost-effectiveness. With an ICU mortality of 15.2% and an overall hospital mortality of 22.2%,(14) a large volume of resources are used in patients who ultimately do not survive. Furthermore, a study on 3600 ICU admissions showed patients who die prior to discharge use disproportionately more resources with the 15% who did not survive accounting for 37% of the budget.(15) This problem is compounded when difficulties in establishing clear treatment objectives in ICU are explored. A study looking at 1136 patients across 5 ICUs reported 20% of patients were receiving “inappropriate or futile therapy” that was unlikely to achieve its treatment aim. (16) Inevitably, these factors reduce the cost-effectiveness of intensive care services. Better identification of patients who are unlikely to survive despite treatment as well as a better understanding of the reasons patients frequently receive treatment “inappropriate and futile treatment” may help alleviate these factors.

Despite these limitations, in 2007 Ridley et al. performed a cost-utility analysis using Quality of Life Adjusted Years (QALYs) with the express purpose of determining the cost-effectiveness of intensive care in the UK. (17) Using estimates of hospital mortality with and without intensive care, post-discharge QALY estimates and NHS reference costs, the study found intensive care to have an incremental cost per QALY gained of £7010 vs non-intensive care. This lies well-within the well-within the 20,000/QALY limit that is often cited by the National Institute for Clinical Excellence(NICE) cut-off for determining which interventions merit funding. In comparison to other interventions, it is similar to breast cancer screening (£6800/QALY) and performs significantly better than other NHS funded interventions such as coronary artery bypass graft vs. medical management (£26,000/QALY) and hospital haemodialysis vs. no treatment (£45000/QALY) (18)

It is also worth noting that intensive care is a new specialty, particularly as it is known in the UK today. As such it is still undergoing the process of service improvement and optimisation that other, more long-standing medical specialties have benefited from. The 2009 report by the National Institute for Health Research Service Delivery and Organisation programme showed that despite increasing cost of care, since the initial modernisation of Intensive Care brought by NHS England’s Comprehensive Critical Care: a review of adult critical care services published in 2000 the actual cost-effectiveness of intensive care is improving over time. (13) This further strengthens intensive care’s position as a cost-effective, worthwhile investment.

The limitations of cost-utility analysis

Although from a purely financial perspective, maximizing cost-effective interventions at the expense of less cost-effective ones makes sense, its indiscriminate use violates the principle of equity that underpins the NHS. That is to say, even if ICU was less cost-effective, a healthcare system that from its very beginnings has committed to providing comprehensive cover cannot simply ignore its sickest.

Equally, cost-utility analysis ignores a fundamental distinctions between different services, a good example of which can be found between intensive care and preventative medicine. Here, there is a fundamental difference that goes beyond incremental cost per QALY gained; while one deals with the ramifications of illness the other prevents illness all together.

ICU, while essential and life-saving, are by most accounts a traumatic experience. Data from the ICNARC database shows that over half of intensive care patients report serious psychological morbidity after discharge. (19) Families of patients on ICU are at increased risk of both physical and mental health disorders, with one study demonstrating a 20% increase risk in the death of a spouse after their partner dies.(20)

Preventative medicine on the other hand, spares the patient and his loved ones the more insidious, intangible aspects of ill health. It prevents, or at the least delays the often painful process of biographical disruption and narrative reconstruction described by Bury et al. (21) as patients challenge their own identity and try to adapt to their new “sick role”. What is more, it protects family members from the painful experience of seeing a loved one deteriorate and suffer. Additionally, as Hannay(22) first described in 1980 with his iceberg of illness, much of ill health lies below the surface. Diary studies have shown that as few as 2.5% of symptoms ever reach a medical consultation.(23) Preventative medicine remains a healthcare system’s most effective (and likely only) tool against this iceberg by chipping away at it under the surface.

For these reasons, this author believes the analysis of the cost-effectiveness of intensive care - and in fact the premise of solely using cost-utility analysis to determine funding- is excessively utilitarian and should not be used alone as the determinant of rationing decisions.


The NHS Five Year Forward View has been presented as a response to the 30 billion funding gap that is likely to arise in coming years. This has created a need to examine the NHS’ current services for their value and cost-effectiveness, a process from which intensive care is not exempt. That being said, when compared with other European nations, the UK spends relatively few resources on intensive care. Despite concerns about increasing ICU costs, it remains a cost-effective intervention that is likely to become increasingly so as the service matures.

Nevertheless, unlike the Daughter’s of Danaus and their bottomless basin, the efforts of the NHS to provide healthcare is not a futile exercise and cost-utility analysis alone is ultimately excessively one dimensional for this purpose. Using intensive care and preventative medicine as an example, each service presents unique differences which cannot be measured only in QALYs. As such, while mathematical analysis should inform the process of rationing resources, it should ultimately remain a human decision and not purely a financial exercise.


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2. The Handbook to The NHS Constitution Department of Health; 2013.

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4. Five Year Forward View. NHS England 2014.

5. Cronin E, Nielsen M, Spollen M, Edwards N. Adult Critical Care. Health Care Needs Assessment (HCNA): University of Birmingham 2007. p. 1-68.

6. Edbrooke DL, Stevens VG, Hibbert CL, Mann AJ, Wilson AJ. A new method of accurately identifying costs of individual patients in intensive care: the initial results. Intensive Care Medicine.23(6):645-50.

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11. Reis D, Ryan D. Organisation and Management of Intensive Care: A Prospective Study in 12 European Countries (Update in Intensive Care and Emergency Medicine): Springer; 1997.

12. Singer M, Myers S, Hall G, Cohen SL, Armstrong RF. The cost of intensive care: a comparison on one unit between 1988 and 1991. Intensive Care Medicine.20(8):542-9.

13. Hutchings A, Durand M, Grieve R. Evaluation of theModernisation of Adult Critical Care Services in England. National Institute for Health Research Service Delivery and Organisation programme, 2009.

14. Annual Quality Report for adult, general (ICU, ICU/HDU) critical care. Intensivee Care National Audit and Research Centre (ICNARC) 2013/2014.

15. Atkinson S, Bihari D, Smithies M, Daly K, Mason R, McColl I. Identification of futility in intensive care. Lancet.344(8931):1203-6.

16. Huynh TN, Kleerup EC, Wiley JF, Savitsky TD, Guse D, Garber BJ, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA internal medicine. 2013;173(20):1887-94.

17. Ridley S, Morris S. Cost effectiveness of adult intensive care in the UK. Anaesthesia. 2007;62(6):547-54.

18. Hope T, Savulescu J, Hendrick J. Medical Ethics and Law, the core curriculum. Churchill Livingstone; 2003.

19. Rowan K, Wade D, Mouncey P. Provision of Psycological support to People in Intensive Care. ICNARC, 2014.

20. Christakis NA, Allison PD. Mortality after the hospitalization of a spouse. The New England journal of medicine. 2006;354(7):719-30.

21. Bury M. Chronic illness as biographical disruption. Sociology of Health & Illness.4(2):167-82.

22. Hannay DR. The 'iceberg' of illness and 'trivial' consultations. The Journal of the Royal College of General Practitioners. 1980;30(218):551-4.

23. Freer CB. Self-care: a health diary study. Medical Care.18(8):853-61.

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