In this work we found marked heterogeneity in the numbers of critical care beds between European countries, even when corrected for population size and age distribution, gross domestic product, expenditure on healthcare and numbers of total acute care beds. The differences in provision can be exemplified by the fact the Germany has 6.9 times the number of intensive care beds compared with Portugal per head of population.

The artificial split of critical care beds into either intermediate or intensive care varies widely across Europe despite the move to standardize descriptions across the region [12, 13]. This lack of a consistent definition reduces our ability to compare clinical practice and organizational models across borders and therefore will not help individual countries to build the case for additional capacity in future years. We believe that it would be beneficial to have a European standard definition of exactly what an intensive care bed is, which could then be implemented within the different countries. This definition could include factors related to the unit’s ability to address organ dysfunction/failure, availability of beds throughout the day and week, patient/nurse and patient/doctor ratios, severity of illness and the operative rather than the planned mean level of care of the ICU [14].

The overall number of critical care beds for Europe was 11.5/100,000 head of population. This is in marked contrast to the number for the USA, which Carr found to be 28/100,000 in 2010 [15]. The heterogeneity of the data between European countries is consistent with the findings reported by other groups. Wunsch and colleagues [9] presented similar data although only on a very limited number (six) of European countries in addition to a number of other non-European countries. The provision of intensive care beds that they found within the European region was very similar to the numbers presented in this study, despite their collection of data being from 2005, 5 years earlier.

An interesting question that arises from examination of this data is how the different countries cope with the widely differing levels of critical care capacity. Presumably, in a grossly homogeneous geographical and developed region such as Europe, one would expect that comparable numbers of patients would develop acute critical illness in the different countries. One would hence expect that the different levels of provision should have a major impact on practice and hence presumably outcomes [6, 16–19]. Again comparing Portugal and Germany, it is impossible that Portugal is able to admit the same amount of patients to critical care as in Germany. The implication must therefore be that either patients in Portugal with need for critical care are unable to get it or that Germany overprovides intensive care for its population. Only further analysis of data that describe provision and practice of critical care in detail across countries will enable us to answer these questions. As a start, comparison of data from European countries with established national registries of intensive care could give more insight into such details. At present such registries are operative in England, Scotland, Norway, Finland and Sweden, The Netherlands, and Austria. With the exception of Austria, these are all countries with a relatively low number of ICU beds per population unit, as can be seen in Fig. 1.

We have been able to demonstrate that there are still major differences within Europe regarding provision of critical care services. These differences are too large to be explained purely by differences in the characteristics of the populations and are inadequately explained by the economic strength of the country. In that respect, the three wealthiest countries in Europe [measured in GDP ($)/inhabitant]: Luxembourg (107,358), Norway (83,936), and Switzerland (67,110) have respectively 21, 8, and 11 ICU beds/100,000 population. It seems likely that the healthcare models present in each country have a major impact on the development and prioritization of this resource. This is likely to reflect a variety of factors that range from specialty status, bed and patient models and bed utilization (admission and discharge criteria) protocols. In addition, the staffing of other hospital wards may also play a major role. We restricted this study to the provision of beds through the public healthcare systems, excluding private providers. There may, therefore, be an underestimation of numbers in some countries due to the missing private sector.

More research is urgently needed to understand how the differing numbers of critical care beds impact on practice and ultimately on patient outcomes. If the need for these beds continues to grow, then the most effective and cost-efficient use of this level of care must be developed in order for most countries to be able to afford this level of provision of healthcare.