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Executive Summary

Introduction

The Scottish Government Maternity Services Action Group ( MSAG) established a Neonatal Services Review Sub-group in December 2006. Its aims were to describe the current provision of neonatal services in Scotland, identify any requirements for change and make recommendations to MSAG to ensure a sustainable, safe and high quality Scottish neonatal service. Information was gathered from a number of sources. A literature review was commissioned. Data was obtained from central sources and from local units by means of a specifically designed questionnaire. There was liaison with other interested organisations and experts visited a number of neonatal units and convened regional meetings. This report describes the Sub-group's findings, conclusions and recommendations to the Maternity Services Action Group.

Current neonatal service provision

There are 16 neonatal units in Scotland. These units range in the level of care they provide, from special care for babies who need a little extra support, through high-dependency, to intensive care for the sickest babies, as defined in A Framework for Maternity Services in Scotland (2001).

There are a number of concerns that act as drivers for change: the most seriously ill babies need highly specialised care; staffing levels need to meet the requirements of the European Working Time Directive and Modernising Medical Careers; there are concerns about the recruitment and retention of neonatal nurses, and concerns about the number of mothers and babies that are transferred between units for care as a consequence of local capacity issues.

Conclusions and recommendations

Along with many other NHS services, neonatal services in Scotland have developed on an 'ad hoc' basis. Epidemiology, and clinical trends, suggest that the need for neonatal services is likely to increase, due to a projected rise in birth rates and changing clinical need. Changing clinical technologies, and underlying case mix mean that care is becoming more intensive and complex: extremely preterm infants and babies with complex problems require intensive care facilities provided by highly skilled medical and nursing teams whose sole responsibility is to the neonatal unit.

There is a strong view from clinicians that the adoption and implementation of appropriate clinical standards for the provision of neonatal services is central to quality improvement. Thus the sub-group recommends that:

• The 2001 British Association of Perinatal Medicine ( BAPM) Standards and levels of care be adopted and fully implemented across NHS Scotland

The adoption and implementation of these standards will have a number of implications including:

• The level of care provided by each neonatal unit should be clearly designated and used to inform the clinical services that are offered by the unit
• Intensive care should have a dedicated, 24 hour, consultant neonatologist rota and junior doctor rota
• Staffing levels should meet recommended ratio of nurses to babies (a minimum of 1:1 for intensive care, 1:2 for high dependency, 1:4 for special care). For this a clear number of cots provided by each unit must be agreed

In line with the BAPM guidelines the sub-group recommends:

• That neonatal services are planned and provided as Regional Networks
• As part of the regional service networks, regional Managed Clinical Networks should be established to agree pathways of care and protocols with maternity and neonatal surgical services
• The most ill and complex babies (especially <28 weeks gestation) should normally initially be cared for in a level 3 intensive care unit with 24 hour consultant neonatologist cover¹

Central to the provision of neonatal services are the availability of physical cots and staff to provide care. The review found a discrepancy between the number of physical cots and the number of staffed cots. Clinicians are concerned that staffed cot numbers are insufficient, leading to high occupancy rates and units closing to new admissions because they are full. In turn this has an impact on the number of transfers that take place.

Analyses of the quantitative data on staffing levels and occupancy are frustrated by the poor levels of data available. It is anticipated that the results from the Nursing and Midwifery Workload and Workforce Planning Programme ( NMWWPP), when available, will allow more definitive conclusions to be reached about nursing staffing levels.

There are deep concerns amongst clinical staff about future staffing levels. Particularly concerns that the continued 'roll-out' of MMC, and the 2009 milestone for the implementation of the European Working Time Directive, will mean a reduction in available junior doctors on which middle grade medical rotas are dependent. Furthermore there are concerns over the recruitment and retention of trained neonatal nurses in Scotland.

The sub-group recommends that:

• Workforce planning takes into account the findings of the Nursing and Midwifery Workload and Workforce Planning Project ( NMWWPP), and implements plans to accommodate anticipated changes in medical staffing availability
• Staffing levels in Level 3 units should be adequate to minimise the number of in-utero transfers required as a consequence of local capacity issues
• When planning services, NHS Boards should take into account the need to release staff for training, this includes the need for back-fill

The sub-group endorses the principle that care should be provided by local services wherever possible, and that efforts should be made to minimise the number of neonatal and 'in utero' transfers. The sub-group recommends that:

• The national neonatal transport service be sustained and supported
• This national neonatal transport service should provide both emergency transfers and the repatriation of babies to their local unit (back transfers)

Furthermore the sub-group recommends that:

• An adequate and safe transport service must be provided for 'in utero' transfers
• There should be national guidelines for decision making regarding transfers and arrangements for identifying available cots
• If babies are cared for away from the proposed local unit of delivery, their care should be actively planned to ensure that they are repatriated as soon as it is clinically appropriate to do so

To support the early repatriation of babies admitted to geographically distant units, the sub-group recommends that:

• Regional planning, and regional network (once established) assess their local needs for special care cots and transitional care facilities, and implement their conclusions
• Regional managed clinical networks (once established) develop protocols for discharge planning and repatriation

Throughout the review the impact of having a baby admitted to a neonatal unit on parents and families was clear. The unit questionnaire suggests that most units do have facilities to support parents in place, however a number of further actions are recommended by the sub-group:

• At booking, prospective parents should be given information about arrangements should mother or baby develop complications and require to be transferred from their planned local maternity unit
• All units should provide counselling services and a language support service for parents whose first language is not English
• There is a need for units to provide more long-term accommodation for parents, and other practical support (including financial and car parking), especially if they are a long distance away from their local maternity unit

The review process was frustrated by the difficulties in obtaining informative valid data. Centrally collected routine data currently contains very little clinical information, and the activity data that is available is not recognised by units providing care.

In addition to the collection of routine data on clinical activity to inform service planning, there is a need for more detailed clinical data to inform and drive service audit and quality improvement. The establishment of clinical data collection at unit level is necessary to allow data analysis on a national, regional and local basis. This is prerequisite to allow audit and research programmes into all aspects of neonatal care to be developed.

The sub-group recommends that:

• The collection of routine data on neonatal unit activity should be reviewed by ISD, and service providers, to assure the collection of valid activity data
• To facilitate clinical data collection, an electronically based neonatal database, along with appropriate administrative support, should be established in each unit
• This investment in IT should be undertaken in a co-ordinated manner between regions

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