With a shortage of subspecialists, specially trained nurses and ICU beds, critical care in South Africa falls far short in addressing the needs of the 64m population, especially in the public sector, writes MedicalBrief.
Critical care beds across the country number only 4 719, with around 1 186 of these beds in the public sector, while the number of trained critical care nurses sits are just over 6 000. In addition, the exact number of critical care subspecialists is not known, but is considerably lower than comparable countries.
In an inaugural address at the University of Pretoria, newly appointed Professor Isabel Coetzee-Prinsloo outlined a transformative vision for the future of critical care in South Africa. She presented what she termed the “three pillars of excellence in critical care” – quality education, practice development and knowledge translation.
Her lecture, delivered at a time when healthcare systems worldwide continue to evolve in the wake of the Covid-19 pandemic, Coetzee-Prinsloo emphasised the indispensable role of specialised critical care nursing, says an IOL report.
She said critical care units were nurse-led, and critically ill patients were cared for and managed by highly skilled critical care nurses in collaboration with physicians and intensivists. This lived reality, she said, underscores the urgent need for a structured, multi-faceted approach to sustaining and enhancing excellence in the field.
Her call coincides with that of other experts who, in a recent study, highlighted the shortage of critical care subspecialists.
Critical care has been a recognised subspecialty in the Health Professions Council of South Africa (HPCSA) since 1992, with a formal examination to obtain the Certificate of Critical Care established in 1999 with the Colleges of Medicine of SA.
The recent study, published in the SA Medical Journal by U Gangen and I Joubert (University of Cape Town) and D Wagstaff (University College London), contributes new findings on the existing workforce by doing an official count as recognised by the HPCSA.
They write:
SA has an inadequate supply of critical care subspecialists per 100 000 population compared with similar upper-middle-income countries. There is also a maldistribution between provinces, with the more urbanised and densely populated provinces having a disproportionally higher number, leading to unequal access.
Critical care is a multidisciplinary, interprofessional field of medicine for patients with acute, life-threatening organ dysfunction requiring invasive support – critical illness being defined as “a state of ill health with vital organ dysfunction with a high risk of imminent death if care is not provided and the potential for reversibility”.
The Covid-19 pandemic revealed to the world the shortage of trained consultants in critical care.
Indeed, many specialists from other disciplines (surgery, anaesthesiology, internal medicine) were recruited into intensive care units (ICUs) during the pandemic. However, even afterwards, critical care remains under-prioritised, both globally and nationally.
In South Africa, it is a subspecialty, meaning doctors must first qualify as specialists in fields like anaesthesia, internal medicine, general surgery and emergency medicine, and can then complete a two-year fellowship programme in an accredited ICU.
But the subspecialty here is a young one: it was only in 1999 that the Certificate of Critical Care became a qualification under the Colleges of Medicine of SA (CMSA).
Since 2001, doctors have had to pass a written examination, a paper-based objective structured clinical examination and an oral examination after completing at least 18 months of their fellowship to obtain the qualification of critical care subspecialist (synonymous with intensivist).
Globally, it is estimated that there will be an 18m person shortfall in healthcare workers by 2030, predominantly in low- and middle-income countries,
In 2019, the Critical Care Society of Southern Africa (CCSSA) consensus statement on ICU triage and rationing (ConICTri) stated that the number of trained critical care subspecialists in this country was unknown, as many of the consultants had not registered their qualifications with the HPCSA or had chosen to emigrate.
A previous article published in 2013 attempted to count the number of such subspecialists in SA, but lacked detail.
An accurate account of their distribution would help the government to allocate adequate funding to these posts, and to increase the availability of fellowships.
The aim of this study was to quantify the number of critical care subspecialists in SA, including those with critical care certification as well as those ‘grandfathered’ into the subspecialty. The term ‘grandfathered’ is applied to individuals who are granted the same title and privileges as critical care subspecialists based on their expertise and experience in the field, despite never having taken the Certificate of Critical Care examination.
They are registered as subspecialists in critical care with the HPCSA.
The study also aims to quantify how many subspecialists practise in the public sector v the private sector, or both, to describe their provincial distribution, and to look at transformation in the demographic profile.
Critical care subspecialist profile
As of December 2023, the total number of adult critical care subspecialists registered with the HPCSA was 82 – almost double the 2010 number. However, the density per 100 000 population grew by only 28%, as the adult population has increased.
The distribution among the various disciplines for 2023 is as follows: 33 from anaesthesiology, nine from emergency medicine, 22 from medicine, one from neurosurgery, two from obstetrics and gynaecology and 15 from surgery.
Anaesthesiology has been a dominant presence since 2010, while neurosurgeons are the least represented in this subspecialty.
In 2023, 63% of the critical care subspecialists were male and 37% female. While there still exists a great discrepancy between the genders, the proportion of females entering the field has been on an upward trend since 2010.
A population group analysis of the workforce since 2010 revealed that 59% of the critical care workforce comprised white consultants, 26% Indian, 9% black, 2% coloured and 1% Chinese.
This distribution highlights the dominance of white consultants in this subspecialty. The most significant growth in representation has been in the Indian consultant population, although the sharp decrease in the unknown category over time should be noted, which distorts the data analysis pre-2019.
From 2019, however, the racial distribution has remained stable. Based upon the 2022 population statistics from Stats SA, most of the workforce is concentrated in the Western Cape and Gauteng.
Conversely, Limpopo, North West and Mpumalanga hold a disproportionately low ratio to population size.
Critical care capacity
Regarding the anonymous survey we sent to all 1 023 members of the CCSSA, only 82 responded – seemingly a low response rate of 8%, but, given that only a small proportion of the Society are doctors, the true response rate is probably higher.
Of the 49 specialists who answered yes to being a certified critical care subspecialist, 14 responded yes to working in the private sector exclusively, while 21 work in the public sector exclusively. Only five said they were not currently practising as a critical care subspecialist in SA.
This is the first study quantifying the number of critical care subspecialists in the country to look at their provincial distribution, the division between the public and private sectors, and the demographic composition of the workforce.
Despite transformation in the field, white males continue to dominate. Similarly, anaesthetists continue to be the main contributors to critical care medicine.
The workforce density was greatest in the Western Cape and Gauteng, and the more rural provinces like North West and Limpopo had no specialists at all. Additionally, ~29% of the workforce is in the private sector.
A meta-analysis and systematic review by Wilcox et al showed a consistent trend of increased efficiency and improved patient outcomes in ICUs managed daily by critical care subspecialists.
This reiterates what was published in the LeapFrog guidelines of November 2000,[20] stating that ICUs run by intensivists showed reduced ICU mortality and length of stay. The guidelines recommended that ICUs should be staffed by board-certified intensivists, that they should be available at work during the day for eight hours, seven days per week and that they should respond to >95% of calls for help within five minutes.
This study counted 82 critical care subspecialists in SA as of 2023. In contrast, the USA counted 20 000 full-time-equivalent intensivists in a 2015 audit. The UK estimated its whole-time-equivalent intensive care medicine consultant count to be <1 150 in 2022, while Australia counted 756 employed fully qualified intensivists in 2016.
To compare SA with similar upper-middle-income countries, Brazil estimated 6 500 intensivists in 2022, Mexico had 1 139 critical care in 2021 and in 2019, China had 20 985.
The data initially suggest that the number of critical care consultants per 100 000 adult population in SA is far below the numbers in comparable upper-middle-income countries.
However, this study may be under-counting the number because there are subspecialists who are certified in critical care but choose not to register as such with the HPCSA.
This decision is influenced by billing protocol within the private sector: consultants may avoid registering as critical care subspecialists to retain their billing capacity for procedures to do with their primary specialty, e.g, neurosurgical procedures, general surgical procedures and perioperative anaesthesia.
Evidence supporting this is an article in the Southern African Journal of Critical Care in 2019, which estimated that at least 113 critical care subspecialists had been certified by the Colleges of Medicine of SA since the birth of the subspecialty two decades ago.
Additionally, this study did not count specialists who have ICU experience but lack formal critical care qualifications, yet who help provide the population with greater access to ICU facilities.
Despite an under-representation in the HPCSA’s official count, however, the combined count of registered and unregistered critical care subspecialists is still probably well below comparable upper-middle-income countries and international standards, and even below the National Department of Health’s own recommended ratio of specialists per 100 000 population.
The Percept report of 2019 is the most comprehensive report looking at the supply of and need for medical specialists in SA, but it neglected to report on the subspecialty of critical care.
The evidence provided emphasises that the subspecialty of critical care is not prioritised sufficiently in this country, which additionally, appears not to be training enough critical care subspecialists to meet its needs.
There are few funded fellowship posts in critical care, but the exact number is beyond the scope of this article, as the number of posts is not publicly available. Future research into this is warranted.
A similar problem is being faced by the UK, which is now allowing doctors to train in intensive care medicine as a seven-year standalone specialty, meaning they do not need a base specialty.
Adopting a similar approach here could enhance the training and availability and address the shortfall. However, it may lead to a dearth in other specialties.
Funding more consultant and fellowship posts in critical care could alleviate the shortfall, and ease the burden of critical illness.
The distribution of ICU beds mirrors the inequality in the distribution of critical care subspecialists. Only 25% of ICU/high care beds are in the public sector.
The Western Cape has a public sector ICU bed:population ratio of 1:20 000 and Gauteng a ratio of 1:25 000, while Limpopo’s ratio is 1:150 000 and North West 1:110 000.
To effectively address the provincial maldistribution of critical care subspecialists, a multi-faceted approach can be adopted. Rural pay and increased benefits may attract and retain doctors in those areas, while increasing critical care fellowship posts in North West and Limpopo will attract more young doctors there.
The rollout of the National Health Insurance (NHI) aims to promote a fair distribution of resources and the ICU bed to population ratio would be 1:10 000, but there would still exist a large variation in this ratio between provinces.
Additionally, the NHI does not help in addressing the shortage of the number of critical care subspecialists needed to run these ICUs.
Telehealth is foreseen to play a crucial role in the delivery of medical services here, and can assist with the shortage by connecting patients in remote areas to critical care subspecialists in urban areas, enabling them to conduct virtual ward rounds in remote and peripheral hospitals.
Recommendations
(i) A national workforce strategy needs to be developed to improve the total number, representation and distribution of critical care subspecialists.
(ii) An official count of the number of fellowship posts in critical care needs to be conducted.
(iii) Telehealth should be investigated and evaluated as a cost-effective strategy for overcoming geographical maldistribution
Limitations
We must acknowledge the vital role played by specialists with years of experience in working in ICU but who lack formal training in critical care. They play an essential role in providing a greater proportion of the population with access to ICU facilities, but were not counted in this study.
Hence the real critical care workforce is under-estimated in this research.
The data gathered from the HPCSA do not consider that some subspecialists may still be registered with the HPCSA, despite having emigrated or retired. As mentioned, it is also believed that the number of subspecialists qualified in critical care is higher than the number provided by the HPCSA, as some may choose not to register their qualifications with the HPCSA.
The census on number of ICU beds was conducted almost a decade ago, and it is likely that there are now more ICU beds in SA, especially after the pandemic.
U Gangen,1 MB ChB, DA (SA); I Joubert,1 FCA (SA) Cert Crit Care; D Wagstaff, 2 FRCA, PhD
1Department of Critical Care, Faculty of Health Sciences, University of Cape Town
2Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, and Division of Surgery and Interventional Science, University College London
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