Developments in hospital medicine combined with social and demographic changes are likely to increase the need for intensive care services at a time when cost containment and cost-efficacy are the main items on the political agenda. This will exaggerate the supply-demand outcome mismatch unless the problem is approached in a constructive manner by clinicians, managers and politicians. More resources will be required for intensive care, but these must be better targeted and more efficiently employed. Opportunities for prevention should be explored, with intensive care being given a pro-active rather than a re-active role. Intensive care clinicians should understand that this expanded role cannot be achieved if they are willing only to accept responsibility for patient care after the patient has been admitted to the ICU. Clinicians and managers should develop methods for linking the various disciplines which contribute to emergency care, to form an acute care framework within the hospital. Research into the factors which determine risk of critical illness should be combined with enhanced medical and nursing training in intensive care, accompanied by an expansion in resources for intermediate and high dependency care in countries like the UK where there is clear evidence of rationing.