INTERNATIONAL NEWS
An overview of the provision of Neuro-anaesthesia and Neurocritical Care in Great Britain and Northern Ireland, 2023
Sally Wilson
President of the Neuroanaesthesia and Neurocritical Care Society
Consultant in Neuroanaesthesia and Neurocritical Care
The National Hospital for Neurology and Neurosurgery
London
Jessie Welbourne
Member of Council Neuroanaesthesia and Neurocritical Care Society
Consultant in Intensive Care Medicine and Neuro-anaesthesia
Associate Honorary Professor, University of Plymouth
Healthcare in Great Britain
The United Kingdom has a population of approximately 67 million spread across the British Isles. Great Britain and Northern Ireland and health care is provided free at the point of delivery, by the National Health Service (NHS). While there is the option of private health care, the majority of the population are fully reliant on the NHS for their health care. Acute and emergency care is only available via the NHS and so the majority of neuroanaesthesia and neurocritical care is fundamentally provided via the NHS. The NHS is funded by general taxation plus national insurance and it is organised centrally, although the NHS in Scotland, Wales and Northern Ireland manage their individual areas . Provision of care is organised into primary community care, secondary general hospital based care and tertiary specialist hospital based care. There are also some ‘quaternary’ services, for example extracorporeal membrane oxygenation (ECMO) and for neurosurgical based specialties there are a small group of super-specialised units nationally.
Neuro-science centres
There are 40 Neuroscience centres in Great Britain and Northern Ireland. These are tertiary centres where neurosurgical and specialist neurology services are provided. Each centre has a surrounding network of local hospitals or ‘district generals ‘in its catchment area. There are a variety of transfer arrangements from the district general hospitals to the hospitals offering neurology and neurosurgery. These largely depend on the ambulance service to provide transfer. An increasing number of regions now have specialised secondary transfer services for critically ill patients, those that fall in the category of ICU care. These services may also provide rapid transfer for patients who require endovascular mechanical thrombectomy for stroke. The majority of neuro centres are also Major Trauma Centres that provide specialist care to trauma patients. These hospitals have commissioned services for care of patients with major trauma or injury to more than two major organ systems. They require input from teams in other specialties including orthopaedic trauma, cardiothoracic surgery, general surgery, vascular, maxillofacial and ophthalmic surgery. Where all of these specialties are not co-located on the same site, clear arrangements exist for working with a hospital that does provide these specialties. The majority of neuro centres are located in major cities.
Neuro Critical care is provided in 2 main models. The most common arrangement is that the neurocritical care patient is cared for within a general ICU. The staff who work there are commonly neuro trained ICU nurses with medical cover from intensivists who may work in both general ICU and neurocritical care. A minority of ICUs have stand alone neurocritical care units who are staffed by intensivists who do not cover general ICU. These neurocritical care units will have significant links to neuroradiology, neurosurgery, neurology and neurophysiology. The use of intracranial pressure monitoring is universal, with care being provided in keeping with the Brain Trauma Foundation recommendations and other international standards. Multimodal monitoring is common, but used to varying degrees dependant on local practice.
Standard speciality delivery
All UK Neuro centres provide neurosurgery and neuroradiology for acute care, including coiling and clipping of intracranial aneurysms after subarachnoid haemorrhage. There is a rapid expansion in the provision of neurointerventional radiology, particularly to accommodate the delivery of mechanical thrombectomy for stroke. Meeting the challenge of staffing this specialist service is an ongoing concern. Neuroscience centres across the UK will also provide care for patients with traumatic brain injury, intracerebral haemorrhage, acute spinal cord injury and neuro medical disorders.
Quaternary neuroscience care.
There are a few sub-specialty centres in the UK, for example the National Hospital for Neurosurgery and Neurology at Queen Square in London. These units do not take trauma patients, but do provide specialised care for rare diseases, for example immune mediated and new onset refractory status epilepticus (NORSE) and deep brain stimulation for anorexia nervosa which is nationally commissioned. Some units also offer dedicated paediatric neurosurgery such as Great Ormond Street Hospital in London. Other specialist services include intra-operative MRI which is not universally provided in UK neuro centres, although the number if units is increasing.
Training for doctors in neuroanaesthesia and neurocritical care
The standard training program for doctors in the UK begins with 5 -6 years of medical school. Medical graduates then work for 2 ‘foundation years’ before entering more specialised training. For our specialties, this is commonly first the ‘Acute care common stem’ (ACCS) program which includes acute medicine, emergency medicine, anaesthesia and intensive care medicine. There is a competitive national process of application for this. Following ACCS, Specialty Training Programs in anaesthesia or intensive care medicine are provided nationally. The curriculum for these is governed by the Royal Collage of Anaesthetists (RCoA) and the Faculty of Intensive Care Medicine (FICM) respectively. Many ICM trainees ‘dual train’, that is compete for specialist training in both ICM and another specialty. The second specialty may be anaesthesia, acute medicine, or emergency medicine. These doctors in training fulfil training program requirements including vigorous national exams. This specialty training takes 5 years full time, which means that the minimum time taken to train from qualification to joining the specialist register is 9 years. For neuro training, there a specified training objectives in the RCoA and FICM curricula and further specialised training may be undertaken if the individual has a specialist interest in the area. In addition, many neuro specialists chose to do optional fellowships in neuroanaesthesia and neurocritical care, which may be in the UK or overseas.
There is huge competition for places on training programs. However, the option to train on a more individualised programme while employed as a specialty doctor by a hospital is also possible. This involves effectively experiencing the same training opportunities in clinical practice and taking the same post graduate exams with the FRCA or FICM, but then completing training via the certificate of eligibility for specialist registration (CESR) route. These specialist doctors are then eligible for specialist consultant jobs in competition with those who have completed training rotations.
Role of the Neuroanaesthesia and Neurocritical Care Society (NACCS)
The main roles for NACCS are focused on providing national standards, enabling excellent education for neuroanaesthesia and neurocritical care in the UK, in addition to supporting research and quality improvement in these areas.
Recent NACCS educational meetings
NACCS runs two educational meetings per year, which are the two day annual scientific meeting which is held face to face and a one day webinar. The scientific meeting is hosted by a different neuro centre each year, to enable rotation of the location and a variety of overviews. The 2022 meeting was held in Birmingham and included specialist sessions for both neuroanaesthesia and neurocritical care. The November live webinar featured UK teams discussing awake spinal surgery, the use of intra operative monitoring and a live link to Prof Lori Shutter in Pittsburgh discussing the BOOST-3 clinical trial. NACCS has also collaborated in educational events from associated societies, including the Society of British Neurological Surgeons and a recent meeting with the Obstetric Anaesthetists Association. We have an upcoming session at the State of the Art meeting in June 2023 run by the Intensive Care Society.
Research areas by UK teams
The UK has a strong tradition of delivering excellent medical research and the areas of neuroanaesthesia and neurocritical care are no exception to this. The major university centres for example Cambridge and Manchester have large and active research departments. There are significant trial groups in other centres for example the Southampton team with a special focus on subarachnoid haemorrhage research. Funding for research may come from the National Institute for Healthcare Research (NIHR) UK or international funds and NACCS provides some financial backing for specific neurorelated research activities.
Upcoming events with NACCS
In May 2023, the annual Scientific meeting will be held in Nottingham and includes two days of clinical and research topics, delivered by international speakers. We are looking forward to welcoming Alana Flaxman, President of SNACC as one of our keynote speakers. There will be a November webinar. We welcome delegates from overseas offering members rates to our affiliated societies.
