• Andrew Hutchings, Mary Alison Durand, Richard Grieve, David Harrison, Kathy Rowan, Judith Green, John Cairns, and Nick Black.
• Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT. andrew.hutchings@lshtm.ac.uk
• BMJ. 2009 Jan 1; 339: b4353.

ObjectiveTo evaluate the impact and cost effectiveness of a programme to transform adult critical care throughout England initiated in late 2000.DesignEvaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6.Setting96 critical care units in England.Participants349,817 admissions to critical care units.InterventionsAdoption 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 MeasuresTrends 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 pound20,000 ($33,170, euro22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000.ResultsIn 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 pound402 ($667, euro445) to pound1096 ($1810, euro1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear.ConclusionSubstantial 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.

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