Intended for healthcare professionals

CCBYNC Open access

Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis

BMJ 2009; 339 doi: (Published 12 November 2009) Cite this as: BMJ 2009;339:b4353
  1. Andrew Hutchings, lecturer1,
  2. Mary Alison Durand, research fellow1,
  3. Richard Grieve, senior lecturer in health economics1,
  4. David Harrison, statistician2,
  5. Kathy Rowan, director2,
  6. Judith Green, reader in medical sociology1,
  7. John Cairns, professor of health economics1,
  8. Nick Black, professor of health services research1
  1. 1Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. 2Intensive Care National Audit and Research Centre, Tavistock House, London WC1H 9HR
  1. Correspondence to: A Hutchings andrew.hutchings{at}
  • Accepted 26 June 2009


Objective To evaluate the impact and cost effectiveness of a programme to transform adult critical care throughout England initiated in late 2000.

Design Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6.

Setting 96 critical care units in England.

Participants 349 817 admissions to critical care units.

Interventions Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity.

Main outcome measures Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at £20 000 ($33 170, €22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000.

Results In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from £402 ($667, €445) to £1096 ($1810, €1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear.

Conclusion Substantial improvements in NHS critical care have occurred in England since 2000. While it is unclear which factors were responsible, collectively the interventions represented a highly cost effective use of NHS resources.


  • We thank all patients and staff in the participating units in the ICNARC case mix programme, members of the adult critical care stakeholders’ forum, and members of the study reference group: Deborah Dawson, Lisa Hinton, Sue MacFarlane, Mick Nielsen, Mike Pepperman, Sue Shepherd, and Keith Young. We are grateful for administrative support and assistance provided by Carolyn Knipe, Emma North, Keryn Vella, Cathy Welch, and Emma Wood.

  • Contributors: All authors took part in planning the study. AH and RG analysed the data. All authors took part in interpreting the results and reporting the research. AH is guarantor.

  • Funding: The study was funded by the NIHR SDO research and development programme (grant SDO/133/2006). AH was supported by a MRC special training fellowship in health services research. The study funders had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The researchers were independent from the funders

  • Competing interests: None declared.

  • Ethical approval: Not required

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

View Full Text