it was recently revealed that one quarter of paediatric intensive care beds in holland are closed   and that many critically ill children have to be transferred to receive care .
problems organizing paediatric intensive care exist in most health care systems . if we are to avoid crises such as this then we have to solve two fundamental problems : the way in which we staff the intensive care units with nurses ; and the lack of information that we have regarding the service that we are trying to commission .
first , they are usually required to have specific higher postgraduate training in order to work at a basic grade .
such training may not enhance their pay as compared with other nurses in other disciplines .
second , their career structure is pyramidal , which limits the opportunities for individual progression and increases the appeal of lateral career moves into less stressful environments such as community nursing or ( in the uk ) national health service direct . from the nurse 's perspective , salary progression
is usually linked purely to administrative responsibility and often fails to recognise significant additional practical and intellectual skills , such as intensive care training itself or additional experience ( e.g. in techniques such as haemofiltration or extracorporeal membrane oxygenation ) .
even when additional recurrent funds are identified to commission a paediatric intensive care service , it can thus prove prohibitively difficult to open intensive care beds .
furthermore , when service provision is inadequate , problems with recruitment suffer from negative reinforcement .
centralization of care in large high volume units enables the best return from any limited resource , and it is tempting to assume that nurses will be the same as any other resource in this respect .
nurses are unlikely to commute large distances to find work in intensive care in preference to a local change in specialty .
effective planning and commissioning of a paediatric intensive care service requires close audit of activity , which we lack . in many cases
the capacity of a paediatric intensive care service can be described in terms of the number of physical bed spaces present , but this does not reassure us that the beds are accessible .
variations in patient dependency , the numbers of nurses available and their skill mix all have to be taken into account when deciding whether a bed can be used at a given time .
even knowledge of the number of accessible beds tells us nothing about the amount of work being done .
such information can only be gained by looking at patient flow ( admission rate , duration of stay , occupancy , readmission rate ) and intervention rates . even then , information regarding quality of care is lacking .
a limited view of the quality of care ( its effectiveness ) can be inferred from standardized mortality ratios generated using mortality prediction models .
however , the use of mortality data in this way has been questioned in paediatric intensive care , where survival rates are greater than 90% and morbidity may be of increased relevance because of the potential longevity of survivors .
most literature and research using standardized mortality is based on the performance of individual units or groups of units . from an epidemiological perspective , however , it is preferable to know what happened to every child from a defined population who received intensive care ( irrespective of where it was provided ) and whether a lack of resources meant that some children were denied intensive care .
there is evidence that increasing numbers of children are receiving or are expected to receive intensive care . in the uk ( or at least in birmingham ) this is occurring without a change in the intubation rate , implying that the change could represent partial resolution of an asserted shortage .
where there are ample resources there is a tendency to provide high dependency care and ' observation ' on the intensive care unit , whereas triage otherwise limits this tendency .
hence , when great variation in the incidence of intubation is observed within   or between   health care systems , one can infer variation in resource provision .
the greatest concern must be when refused admissions occur in units with high intubation rates .
the appropriateness of intensive care admission or intervention ultimately still has to be judged on a case review basis .
the development of the mortality prediction model ' pim ' ( paediatric index of mortality )   has involved a collaboration that has , among others , incorporated all paediatric intensive care delivered in australia .
the epidemiological superiority of these data will increase the influence of the conclusions drawn from it . in the uk , where we have long suffered from similar problems to those currently affecting holland
first , this is being achieved through a study designed to assess the relevant mortality prediction models , which is to include morbidity ( united kingdon paediatric intensive care outcome study , ukpicos ) .
the study has recruited all the major providers of paediatric intensive care in the uk .
second , the english department of health has commissioned a continuous audit of paediatric intensive care to follow on from that study called ' picanet ' ( paediatric intensive care audit network ) , which will include the successful severity model .
hence , commissioners will have access to comparative , risk adjusted , performance data on which to make their decisions .
 problems with commissioning paediatric intensive care stem both from difficulties in recruitment and retention of nurses , and from incoherent or nonexistent national audit . 
 pyramidal career structures and patterns of remuneration that concentrate on administrative responsibility over clinical skills underlie the former , whereas poor audit conceals variations in both service quality and demand . 
 epidemiologically superior data are required if we are to solve commissioning problems . 
 we need to know what happened to every child from a defined population receiving intensive care and whether a lack of resources means that some children are denied intensive care . 
Introduction
Nurse recruitment, retention and funding
Lack of information
Change and variation in standards
Comprehensive audit
Competing interests
Abbreviations