Together with the the Association of Anaesthetists and the Royal College of Anaesthetists (RCoA), the Faculty is a Core Participant in Module 3 of the UK Covid-19 Inquiry, which is looking into the impact of the pandemic on healthcare systems, patients and healthcare workers in the four nations of the UK. We are participating to represent our members, who comprise over 24,000 doctors and healthcare workers who played a direct and significant role in the UK's response to the pandemic. Our evidence draws on the extensive data and member testimony collected at the time and we thank all those who contributed. 

The statement below is our joint opening submission to the Inquiry. A summarised version was presented in person at a Preliminary Hearing for Module 3 on the 10 September 2024.
 

1. Introduction

Our organisations and their members

1.1. The Faculty of Intensive Care Medicine (FICM), the Association of Anaesthetists, and the Royal College of Anaesthetists (RCoA) represent staff including anaesthetists, doctors in intensive care medicine (intensivists), advanced critical care practitioners (ACCPs), and critical care pharmacists. 

• 1.1.1. RCoA is the UK professional and statutory body for anaesthesia, with a combined membership of more than 24,000 fellows and members across the four nations of the UK. RCoA is responsible for supporting its fellows' and members' careers, setting standards of clinical care, overseeing training, examinations and recruitment and acts as the voice of the specialty on behalf of the membership.
• 1.1.2. FICM is the UK professional and statutory body for the medical specialty of Intensive Care Medicine (ICM), intensivists, ACCPs, and Critical Care Pharmacists, with around 4,500 members across the four nations of the UK. FICM is responsible for training, examination and recruitment of intensivists and ACCPs and promotes education, produces standards and guidelines, and influences national policy.
• 1.1.3. The Association of Anaesthetists is a professional organisation made up of over 10,000 anaesthetists in the UK, Republic of Ireland and internationally. Its main aims are to improve patient safety, to improve patient care, to provide education for anaesthetists, to support the wellbeing and interests of anaesthetists, and to support research in anaesthesia.

1.2 For clarity, unless otherwise specified, the organisations will be referred to as "we" throughout this submission.

Acknowledgements

1.3. Before we continue, we would first like to give our thoughts to all those impacted by the Covid-19 pandemic (the pandemic): those who died, their families and loved-ones; those who suffer from long Covid; and everyone whose lives were affected, disrupted, or even torn apart by the pandemic.

1.4. We would like to further acknowledge the huge stresses our members faced, and the incredible sacrifices made. The healthcare workers our organisations represent stood on the front line of the pandemic, treating the most ill patients. Others worked in other vital hospital services, such as, for example, urgent and emergency care, maternity services and elective surgery. Their skills, dedication, resilience and ingenuity played a key role in saving huge numbers of lives. It is their experiences that we wish to share with the Inquiry.

1.5. We would further like to thank the Inquiry for accepting our organisations as Core Participants in Module 3 and for enabling us to voice our members' experiences and achievements. We also thank the Inquiry for its diligent work to date. Given our members' experience, we welcome the opportunity to contribute to the Module 3 hearings. We subsequently look forward to reviewing the Inquiry's reports and further recommendations.

Our role during the pandemic

1.6. The primary story that our organisations wish to tell is that of our fellows and members. Nevertheless, as organisations, we took on proactive leadership roles during the pandemic which included creating resources for clinicians and hospitals, providing clinical expertise to policy makers, advising government, signposting and interpreting official NHS guidance and educating the public. 

1.7. The organisations and the Intensive Care Society also worked together to produce a single hub of information for clinicians, NHS departments, NHS England, and devolved nation equivalents, and received 665,000 visits and 1.4 million page views. Together, we produced guidance on topics such as how to cross-skill staff, deal with increasing ICU demand, and restart elective surgery. The alignment and collaboration between our respective organisations enabled us to synthesise the vast and disparate guidance that could have otherwise confused and overwhelmed clinicians.

Key summary

1.8. In this opening submission and with reference to the scope of Module 3, we wish to make a number of observations regarding the impact of the pandemic on the UK's healthcare systems:

• 1.8.1. The experience of individuals from our organisations mirror and reinforce the findings from Module 1 of this Inquiry, namely that funding constrained the ability of the NHS to ‘surge up’ capacity during the pandemic as the system faced severe staff shortages and under-resourcing.
• 1.8.2. Intensive care capacity in terms of staffing, beds and equipment were already perilously under-resourced pre-pandemic and continues to be.
• 1.8.3. Healthcare provision for patients with Covid-19 resulted in the significant scaling up of working hours for many ICU staff and redeployment of other staff, including anaesthetists, to support intensive care.
• 1.8.4. There was a significant impact on non-Covid related healthcare, such as elective surgery, due to the reallocation of resources towards Covid-19 related needs.
• 1.8.5. The pandemic took a great toll on the mental health and wellbeing of healthcare staff.
• 1.8.6. Communication with patients and their loved ones in the pandemic setting was particularly difficult to manage, witness and experience.
• 1.8.7. The PPE shortages faced by healthcare staff were a significant burden and dramatically affected the overall healthcare provided.
• 1.8.8. The implementation of infection prevention and control measures produced challenges to normal ways of working and sometimes proved difficult to implement in the current hospital infrastructure.

2. Pre-pandemic status

Intensive Care

2.1. Intensive care units (ICUs) are vital for hospital functioning. ICUs are where the most critically ill patients are treated and supported. ICUs are fitted with specialised equipment to closely monitor patients, maintain vital bodily functions, and provide treatment for failing organs. Their staffing includes intensivists, intensive care nurses, and other specially trained professional groups such as ACCPs and critical care pharmacists.

2.2. Even before the pandemic, ICUs in the UK were significantly under-resourced in terms of funding, staffing, bed capacity, infrastructure, and equipment and lagged behind other comparable nations.

2.3. The highest level recommended for intensive care bed fill rate for safe and efficient patient care is 85%. Prior to the pandemic, NHS England data put the critical care bed fill rate at 87%,¹ and the Faculty of Intensive Care Medicine (FICM) collected survey data in 2018 that showed the bed fill rate for Northern Ireland and Wales was estimated to be at least 95%, and 84% in Scotland.² Additionally, the OECD estimated that England had 10.5 ICU beds per 100,000 population in 2020, which was lower than the OECD average of 12. It was also substantially lower than other comparator nations, such as France (with 16.3), the United States (25.8), and Germany (33.9). There is also large regional variation of capacity within the UK.³

2.4. ICU capacity is not just an issue of numbers of beds but also staffing, which was also overstretched pre-pandemic. FICM’s data showed that some larger units were lacking sufficient resident staff to support the recommended ratio of one doctor caring for eight patients, and 62% of units lacking a full critical care nursing complement.⁴ This was leading to cancelled operations, reduced quality of care, and potentially negative impacts on patient safety. 40% of units had to close one or more beds on a weekly basis due to lack of staff. To cope with demand patients were transferred between hospitals in at least 80% of units, and this occurred at least monthly in 21% of units.⁵

Anaesthesia

2.5. The role of the anaesthetist is also vital to the functioning of the NHS. Anaesthetists are highly trained specialist doctors: most operations cannot take place without one. Anaesthetists not only administer the anaesthetic, they monitor and respond to changes in patients’ vital functions to ensure they remain stable and comfortable during their operation.

2.6. Anaesthetists' skills and expertise are needed for patients of all ages in a large range of settings where resuscitation, anaesthesia, and pain relief are needed, including pre-hospital care, emergency departments, maternity wards, interventional radiology suites, acute and chronic pain services, gastroenterology, dentistry, and psychiatry.

2.7. Similar to the issues affecting ICUs, prior to the pandemic there was also a shortfall of 1,400 anaesthetists across the UK. The RCoA estimates that shortfall may have prevented 1 million operations and procedures from taking place each year.⁶ The shortfall has now grown to at least 1,900 this year.⁷

2.8. The World Federation of Societies of Anaesthesiologists (WFSA) estimates that there 14.2 anaesthetists per 100,000 population in the UK, compared 15.9 in the United States, 17 in France, and 37.4 in Germany.⁸

3. The pandemic

3.1. The pandemic took a significant toll on the already constrained healthcare system. Almost 50,000 of the very sickest Covid-19 patients were seen in ICU, who needed substantial and prolonged support.⁹

3.2. The following sets out the key areas of impact from the perspective of our organisations' members, namely: staffing; procedures and guidance; infrastructure; resourcing (i.e medicine and equipment); and non-Covid related healthcare.

Staffing

Working patterns

3.3. ICU capacity had to be rapidly expanded in terms of space, staff, beds, and equipment. Due to the enormous efforts of NHS staff this was largely achieved, but at considerable cost, most notably to the health and wellbeing of staff, the education of doctors in training and on other NHS services.

3.4. Staffing capacity was increased by introducing longer working hours, cancelling leave, suspending other duties, and redeployment. In a FICM survey of intensivists in November 2020, 80% of respondents reported increasing their working hours during the first wave of the pandemic, and 88% reported leave cancellation. 63% reported redeployment of colleagues from partner specialties to support either ICM work or other work.¹⁰

3.5. All additional work undertaken by existing intensive care staff, such as teaching, training, supporting professional activities and other clinical activities, was cancelled. This had a subsequent impact on wellbeing and morale.

Training

3.6. The experiences of doctors in training during the pandemic deserve particular mention – including anaesthetists in training (AiTs) and intensivists in training (IiTs). Doctors in training provide vital clinical service to the NHS, while balancing the need to reach important educational milestones. This balance was hindered by the demanding nature of the pandemic measures and the dramatic change to the types of cases being addressed. Exams were disrupted or even cancelled, leading to difficulty with training progression.

3.7. AiTs were particularly affected by redeployment. Our survey work shows that in July 2020, 89% reported that AiT training opportunities had been affected and 76% had lost out on clinical learning.¹¹

3.2. IiTs also likely suffered similarly due to the situation they found themselves in with reduced clinical exposure to conditions other than Covid-19 for a considerable period.  This may have impacted on exam performance given the anomalously low exam scores in ICM in October 2021.

Redeployments

3.9. A great many anaesthetists were redeployed to intensive care, as anaesthetists do some work in intensive care as part of their training, and many intensivists are also anaesthetists. Redeployments included reallocating staff from their usual theatre duties, as well as recalling other staff with intensive care training who had been working in other services, such as resuscitation, oncology, and community services. In a survey of anaesthetists conducted in June-July 2020, 43% of respondents reported being redeployed to support intensive care during the first wave. This provided a vital supplement to intensivist doctors.¹²

3.10. Redeployment increased the intensive care workforce by approximately 38% in October 2020, rising to an approximately 125% increase of the workforce by January 2021. This came at severe cost to other hospital services that had formerly relied on those staff, such as in elective surgery.¹³

3.11. Despite the efforts to increase staffing levels, the situation remained incredibly stretched. This resulted in a relaxation of nationally recognised safety / best practice staffing ratios and working practices for intensive care. Despite this, ICUs still only had resources to deal with Covid-19 and lifesaving emergencies during the peaks of the pandemic, leading to other services and patients suffering from lack of intensive care support. For example, some major elective surgery requires ICUs to care for and monitor critically ill patients after operations – but during the pandemic, this was limited.

3.12. Where anaesthetists were not redeployed, many continued to work in other hospital areas, such as maternity services and operating theatres. Urgent and emergency surgery still occurred and a degree of elective surgery continued, despite changes to scheduling and resourcing shortages.

Mental health

3.13. It is clear the stresses of the pandemic harmed the mental health of many doctors and healthcare workers. Evidence showed that the percentage of ICU staff reporting probable mental health disorders increased from 51% to 64% before and during the 2020/2021 winter surge, respectively.¹⁴

3.14. An RCoA survey from April 2020 showed that over 40% of respondents suffered mental distress as a result of Covid-19, while over a third felt physically unwell.¹⁵ By July 2020, those reporting mental distress rose again to 64% in July.¹⁶

3.15. A big challenge faced primarily by patients and their families, but also by clinicians, during the pandemic was the fact that relatives could not usually attend in person in hospital. This meant that news had to be communicated either via telephone or, where allowed, video calling. These factors made both communicating treatment plans and breaking bad news more difficult as relatives could not attend the hospital or see their loved one in a video call enabling them to contextualise the severity of the illness and treatments being given. Understandably, clinicians found it hard to watch families while on video calls to ventilated patients, where they may be watching them die remotely. Some staff tell us they have not fully recovered from the psychological effects.

3.16. Clinicians with sick relatives sometimes found themselves in this situation themselves as they were unable to visit their loved ones even if they were being treated in the same hospital where they worked.

Procedures and Guidance

3.17. The pandemic resulted in a vast range of new measures, protocols and guidance to deal with the significant increase in demand on the healthcare system. From the perspective of our members, key areas of impact included Covid testing, triaging, and Infection Prevention and Control (IPC), including those related to Aerosol Generating Procedures (AGP) measures.

Testing

3.18. Testing for Covid-19 was vital for the functioning of the healthcare system, however, in April 2020, nearly 40% of anaesthetists were unable to access the testing they need for themselves and 50% couldn’t access the testing they needed for household members. Furthermore, the self-isolation measures due to limited testing abilities meant that the workforce was restricted at a time of high demand.¹⁷

3.19. By May 2020 matters had improved slightly, but the availability of testing remained challenging. Around one in 10 anaesthetists were still self-isolating due to suspected Covid-19 in either themselves or a household member. By July 2020, 38% of anaesthetists report that rapid testing was either not available, or only available to only a small extent for staff and the figure was 26% for patients.¹⁸

3.20. Wider and earlier availability of testing, especially rapid testing, could increase workforce availability and help stop infections in any future pandemic.

Triaging

3.21. In early 2020, some clinicians were concerned that intensive care services would exceed capacity as had been observed in parts of Northern Italy. Understandably, many wanted guidance to be developed to enable patient triage if that situation arose and clarity around when to start triaging. However, no official national guidance was produced by NICE, NHSE, or the devolved nations. This led to some clinicians feeling extremely exposed and vulnerable in the early weeks of the pandemic – unsure of what life or death decisions they might be required to make, or their legal exposure if they did so.

3.22. While there was some debate about whether professional bodies should produce such guidance – ultimately, it was our view that to be credible, authoritative, and legally robust any guidance, if required, must be produced by a statutory body such as NICE.

Infection Prevention and Control (IPC) and Aerosol Generating Procedures (AGP) measures

3.23. IPC measures, while necessary in many respects, also created stressful working environments: staff could be required to anaesthetise for long cases where they would normally have had breaks but were unable to do so due to the need to reduce movement in and out of theatre and to conserve PPE.

3.24. AGPs are medical procedures that produce minute particles that become suspended in the air (i.e. aerosols). AGP measures involve introducing aerosol clearance times to reduce the risk of spreading infections. Such measures cause delays to procedures as it requires giving time for the air to clear and therefore prevents operating theatre doors from being opened. Early in the pandemic, tracheal intubation (i.e. inserting a breathing tube) was classified as an AGP. This added time to operations, required additional staff and resulted in a significant decrease in efficiency.

3.25. Eventually a body of research was formed that showed tracheal intubation did not lead to aerosol generation. The experience and evidence amassed during this pandemic must be remembered and applied in future.

Infrastructure

3.26. When creating new estate, or modifying existing space, the infrastructure needs to be designed to cope with pandemic situations. The following provides some key examples of the difficulties faced regarding hospital infrastructure during the pandemic and the need to rapidly expand ICUs and create separation to reduce the spread of infection.  

Bed capacity

3.27. The pandemic did not just require increased staffing in ICU, but also extra bed capacity, which we have noted was already reaching its limit prior to the pandemic. At the start of March 2020, bed capacity was around 4,100 adult intensive care beds available across England.¹⁹ At the peak of the second wave at the end of January 2021, reported capacity increased to over 6,000 beds. In many cases this was achieved by taking over ward space, or operating theatre space – which again had consequences for other hospital services.²⁰

ICU structure and expansion

3.28. During the pandemic, patients with and without Covid-19 had to be separated. In addition, isolation measures were crucial for both patients with Covid-19 or those who did not but were critically ill. The resulting measures resulted in many of our members witnessing first-hand how the physical infrastructure of some hospitals was not fit for purpose. The position varied greatly depending on the specific hospital, which also meant that guidance could not be applied easily or consistently.

3.29. Pre-existing ICUs were not structured in ways that allowed national recommendations around safe patient isolation set out in the NHS Health Building Note 04-02, which provided that 20% of bed capacity should be single room occupancy. Without such capacity in ICUs, there was a greater need for ICUs to expand into other hospital areas so that isolation could be achieved.

3.30. Repurposing rooms came with challenges, such as bed spaces being too small for ICU beds and equipment. It also resulted in knock on effects for other services.

3.31. The separation of wards or pathways made travelling between different hospital areas time-consuming and complicated, reducing the efficiency of the working environment.

3.32. Some hospitals used off-site or isolated facilities (such as independent sector hospitals) to help provide capacity for elective operating but were still constrained by lack of staff in many cases.

Oxygen supply and distribution

3.33. The potential for a condition like Covid-19 to increase the demand for oxygen in hospitals had not been properly considered before the pandemic. As a result, oxygen supplies were at risk of running out due to high usage and old infrastructure.

3.34. A particular issue was ice build-up on oxygen evaporators due to the volume of use. There were also issues in the design of some hospital buildings, and the capacity of the piping, which impacted on the ability to deliver high flow oxygen through the pipes.

3.35. We are also aware of other examples, such as in January 2021 at Southend Hospital, where the hospital had to restrict the amount of oxygen it provided per patient due to the sheer level of demand. This involved reducing the target range for oxygen levels that should be in patients' blood from 92% to 88-92%.²¹

Resourcing: Medicine, PPE and Equipment

Medicine

3.36. Shortage of drugs was also a major issue during the pandemic. It is vital that supply and/or availability of drugs must be considered in preparedness for any future pandemic.

3.37. In intensive care and anaesthesia, drugs such as propofol, rocuronium, atracurium, and fentanyl were in high demand but with limited supply. In April 2020, RCoA survey work found that 14% of anaesthetists did not have access to all their usual drugs.²² In May 2020, 13% were still unable to access the anaesthetic drugs they needed.²³

3.38. Propofol, opioid pain-relieving drugs, and muscle relaxants, needed to be conserved for sedation, pain relief and to facilitate ventilation in Covid-19 patients in intensive care. This reduced their availability for non-Covid related medical care such as elective surgery. As such, anaesthetists needed to adapt rapidly (during an already stressful situation) and were forced to use unfamiliar drugs and techniques. For example, thiopental was used for induction of anaesthesia in place of propofol, which some anaesthetists would never have used before.  This change in practice did not impact the safety of patient care but some of these drugs lead to side effects such as taking longer to wake up after an operation or experiencing muscle pains so the quality of the patient experience was reduced.

PPE

3.39. The availability of PPE was of huge concern to all staff in the early stages of the pandemic. In a survey of anaesthetists in April 2020, 71% cited PPE as their top priority and 73% stated they were concerned for their health due to shortages. At the time of the survey 17% were unable to access the PPE they needed.²⁴ Even by July 2020, 15% reported that stocks remained insufficient. Many clinicians had concerns that PPE was sometimes poorly distributed, out-of-date, and not always received on the front-line in a timely fashion. This meant the PPE did not always fit correctly, reducing its effectiveness, and increasing the potential for viral transmission.²⁵

3.40. In some areas where there were early shortages of PPE, measures to conserve PPE were used. For example, actions were bundled up so that one person wearing PPE could do them all. This meant that individual staff had longer periods of time in PPE and fewer breaks in a shift. In other cases, PPE was reused after cleaning due to shortages or concerns about shortages.

3.41. Some healthcare workers were told to work remotely, leading to deficiencies in care. For example, critical care dietitians worked remotely were not able to collect basic patient information such as height and weight which were critical for determining patients’ energy and protein needs.

3.42. Fundamentally, shortages of staff PPE likely increased staff infections and reduced the functionality of ICUs, operating theatres, maternity wards, and other hospital services.

3.43. Guidance issued at the end of February 2020 on appropriate PPE for intensive care was slow to come out. This caused some consternation. There was a lack of clear leadership on this issue. When official guidance was forthcoming, our organisations, along with the Intensive Care Society had to produce a guide on how to interpret it in an easily accessible format.

Ventilators

3.44. Another aspect of ICU capacity during the pandemic was the availability of ventilators. Prior to the pandemic most ICUs had just enough ventilators to provide one per bedspace, occasionally with a small number of spares. During the pandemic, demand exceeded supply. Ventilators require a long lead-in time to manufacture, and it is challenging to scale up supply quickly. As a result, there was a shortage of suitable equipment. This led to the redeployment of other pieces of equipment, such as anaesthetic machines, which provide short term ventilation for operations.

3.45. As reduced levels of surgery were occurring there were thousands of anaesthetic machines sitting idle. One of the functions performed by anaesthetic machines is ventilation. However, these machines are not designed for continuous use over several days, in contrast to ICU ventilators.

3.46. Also, the use of new and different pieces of equipment became problematic for some members of staff as they may have been unfamiliar with the nuances of how they should be operated and maintained. We believe this may have contributed to patient harm in some cases.

3.47. Increased capacity planning requires identification of suitable surplus equipment that can be rapidly brought into use if required alongside sufficient staff to facilitate this.

Treatment for non-Covid-19 patients

3.48. While the pandemic's impact affected many aspects of the UK's healthcare services, two areas that, from the perspective of our members, were particularly adversely affected (although this is not exhaustive but merely illustrative) were elective surgery and maternity services.

Elective surgery

3.49. As ICU capacity increased, elective surgery had to slow down or stop. The reasons behind this were numerous, including national directives; redeployment of anaesthetists; intensive care expanding into operating theatres; the lack of additional intensive care capacity to care for patients who had undergone surgery; and additional IPC measures.

3.50. National surgical activity reduced by 54% between January 2020 and January 2021, equivalent to 9,770 operations lost per day.²⁶ In England, while waiting lists were already large and growing prior to the pandemic and had reached 4.2 million people by its eve, they grew even further during the pandemic. By the end of the pandemic, numbers had risen to 6.7 million.²⁷

3.51. These are not just statistics - real people are behind every story. Huge numbers of people continued to suffer, wait, and in some cases deteriorate while the hospitals that were there to treat them were focused on pandemic efforts.

3.52. The elective surgery backlog has not been tackled and has continued to grow, with 7.6 million people waiting in England. While lack of preparedness for the pandemic was not the only cause of this - waiting lists were growing even before the pandemic hit - the pandemic undoubtedly accelerated the rise.

Maternity services

3.53. Anaesthetists are vital to maternity services, providing pain relief and anaesthesia during labour and childbirth. During the pandemic, practice had to be changed to protect both staff and patients.

3.54. Patient flow through maternity services was greatly affected by the separation of infected patients. Birth partners could not be accommodated in the same way they were before the pandemic and in particular in operating theatres due to the constraints on the movement of infected individuals. The use of PPE also hindered communication. 

3.55. The constraints caused distress for the women involved, during such a critical moment of their lives. It further created stress for the staff providing care and treatment to those women, day in and day out.

4. Preparing for the future

4.1. Overall, we believe the lessons of the pandemic need to be learned and channelled into better preparation. We have touched on what we consider to be some, but not all, areas of focus. We are concerned that in many respects we are little better prepared now than we were in 2020.

4.2. In particular, intensive care capacity should be viewed as a national resource. Improving that capacity, in-line with other economically comparable countries, would provide much more resilience in the event of a crisis. This requires investment in staff, beds, infrastructure, PPE and equipment.

4.3. Commensurate investment is also needed to increase anaesthetist numbers, which would in turn help to address some of the backlog in healthcare services.

4.4. Our organisations consider that staffing is a key area to address the concerns addressed in this submission. We consider that training is key to this. Capacity in intensive care and anaesthesia could be rapidly increased if funding were allocated to allow doctors currently at foundation level to enter speciality training. In anaesthesia, for instance, a doctor starting core training can start to provide a degree of independent patient care within 6 months. However, well over half of doctors who have finished foundation training and have applied to start speciality training have no place to progress to.

4.5. The NHS Long Term Workforce Plan in England did not address this urgency regarding speciality training. To provide some figures from our internal sources, the number of training posts available for intensivists is around 175 posts per year which is considerably fewer than is needed to meet existing service demands and insufficient to allow for any expansion of service. For anaesthesia, the number of higher posts was increased by 70 in 2022, recurring for 3 years, however, there is no guarantee this increase will be made permanent.

4.6. We would like to conclude by reiterating our thanks to all involved, the sacrifices and contributions made and reemphasise our thoughts and condolences to all victims, their families and loved ones.
 

References

1. Report from The Faculty of Intensive Care Medicine titled Critical Capacity: A Short Research Survey on Critical Care Bed Capacity, dated March 2018.
2. Report from The Faculty of Intensive Care Medicine titled Critical Capacity: A Short Research Survey on Critical Care Bed Capacity, dated March 2018.
3. Report from the Organisation for Economic Co-operation and Development titled Intensive care beds capacity, dated 20/04/2020.
4. Report from The Faculty of Intensive Care Medicine titled Critical Capacity: A Short Research Survey on Critical Care Bed Capacity, dated March 2018.
5. Report from The Faculty of Intensive Care Medicine titled Critical Capacity: A Short Research Survey on Critical Care Bed Capacity, dated March 2018.
6. Written evidence submitted by the Royal College of Anaesthetists, dated September 2021.
7. RCoA Manifesto, Anaesthesia: solutions for an NHS in crisis, dated 8 May 2024
8. World Federation of Societies of Anaesthesiologists: World Anaesthesiology Workforce Map (data collected between 2021 and 2023).
9. Intensive care national audit & research centre, overview of key statistics gathered, dated 23 May 2024
10. Report from the Faculty of Intensive Care Medicine titled Voices from the Frontline of Critical Care Medicine, dated November 2020.
11. Report from RCoA titled View from the frontline of anaesthesia during COVID-19, May 2020 survey results, dated May 2020.
12. Report from RCoA titled View from the frontline of anaesthesia during COVID-19, July 2020 survey results, dated July 2020.
13. Article from E. Kursumovic published in Anaesthesia titled 'The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation', dated 27/04/2021.
14. Article by Charlotte E. Hall and others titled 'The mental health of staff working on intensive care units over the Covid-19 winter surge of 2020 in England: a cross sectional survey', published in the British Journal of Anaesthesia, dated 24/03/2022.
15. Briefing from RCoA titled View from the frontline of anaesthesia during COVID-19, dated April 2020.
16. Report from RCoA titled View from the frontline of anaesthesia during COVID-19, July 2020 survey results, dated July 2020.
17. Briefing from RCoA titled View from the frontline of anaesthesia during COVID-19, dated April 2020.
18. Report from RCoA titled View from the frontline of anaesthesia during COVID-19, July 2020 survey results, dated July 2020.
19. Web Article from the King's Fund titled Critical care services in the English NHS, dated 25/11/2020.
20. Oral briefing by NHSE
21. Web Article from the BBC titled Covid-19: Southend Hospital oxygen supply reaches 'critical' situation, dated 11/01/2021.
22. Briefing from RCoA titled View from the frontline of anaesthesia during COVID-19, dated April 2020.
23. Report from RCoA titled View from the frontline of anaesthesia during COVID-19, May 2020 survey results, dated May 2020.
24. Briefing from RCoA titled View from the frontline of anaesthesia during COVID-19, dated April 2020.
25. Report from RCoA titled View from the frontline of anaesthesia during COVID-19, July 2020 survey results, dated July 2020.
26. Article from E. Kursumovic published in Anaesthesia titled The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation, dated 27/04/2021.
27. NHSE Consultant-led Referral to Treatment (RTT) Waiting Times Data, 2019-2020 and 2022-2023