Maternity Services Action Group (MSAG)

Neonatal Services Sub Group

Review of Neonatal Services in Scotland

November 2008

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Table of Contents Executive Summary ................................................................................................................ 3 Introduction ............................................................................................................................. 8

1.1 Neonatal Services Review ...................................................................................... 8 1.2 Aim .......................................................................................................................... 8 1.3 Remit ....................................................................................................................... 8 1.4 Process ................................................................................................................... 8

Background........................................................................................................................... 10 2.1 Establishing the Maternity Services Action Group ................................................ 10 2.2 The Policy Context ................................................................................................ 10 2.3 Neonatal Services in Scotland .............................................................................. 12 2.4 Why Change is Needed Now ................................................................................ 16

Published Evidence on Neonatal Services ........................................................................... 17 3.1 Standards for Neonatal Services........................................................................... 17 3.2 Literature Review .................................................................................................. 18

Epidemiology ........................................................................................................................ 21 4.1 Births and Neonatal Admissions in Scotland......................................................... 21 4.2 Future Needs for Neonatal Services ..................................................................... 21

Findings of Review Process.................................................................................................. 23 5.1 Results from the Neonatal Unit Questionnaire ...................................................... 23 5.2 Professional views................................................................................................. 25 5.3 Nursing and Midwifery Workload and Workforce Planning Project ....................... 26 5.4 Education and Training ......................................................................................... 27 5.5 Neonatal transport................................................................................................. 30 5.7 Parental perspectives............................................................................................ 34

Conclusions and recommendations...................................................................................... 36 6.1 Clinical standards .................................................................................................. 36 6.2 Service networks ................................................................................................... 37 6.3 Staffing levels and cot numbers ............................................................................ 37 6.4 Pathways of care and transfers............................................................................. 38 6.5 Parent care and involvement................................................................................. 39 6.6 Data....................................................................................................................... 39

Appendix A Membership of the Neonatal Sub-group

Appendix B Neonatal Unit Questionnaire

Appendix C Literature Review

Appendix D BAPM Standards

Appendix E Epidemiology

Appendix F Responses from Neonatal Units

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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.

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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.

1 The issue of whether consultants should resident on call and this issue was not considered by the

Neonatal- Sub-Group as it was not within their remit. The recommendations in this review does not

imply that any dedicated consultant rota should be resident.

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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

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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

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• 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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Introduction 1.1 Neonatal Services Review The Scottish Government receives advice on the provision of maternity services in Scotland

from the Maternity Services Action Group [formerly known as the Ministerial Action Group on

Maternity Services].

One of the priority areas recognised by the Maternity Services Action Group is the provision

of neonatal services. To consider this issue the Maternity Services Action Group established

a Neonatal Services Sub-group which was tasked to undertake a review. This report

comprises the conclusions of that review and the recommendations the sub-group is making

to the Maternity Services Action Group.

1.2 Aim The aim of the sub-group was to review the provision of neonatal services in Scotland.

1.3 Remit In undertaking the review, the Neonatal Services Sub-group sought to:

• Describe current neonatal services

• Identify how to best meet the needs of the people of Scotland

• Identify any requirements for changes to services

• Make recommendations to the Maternity Services Action Group to provide a

framework to ensure a sustainable, safe and high quality, Scottish neonatal service

1.4 Process The multi-disciplinary sub-group met on six occasions from December 2006 to November

2007, and then corresponded by email. The report was presented to MSAG in September

2008. The sub-group’s membership can be found in Appendix A.

To review the provision of neonatal services in Scotland the sub-group undertook a number

of approaches:

• Routinely collected data were reviewed

• A bespoke questionnaire was devised and used to collect information on facilities,

admissions and staffing, from all 16 neonatal units in Scotland (Appendix B)

• A literature review was commissioned (Appendix C)

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• A series of visits to neonatal units was undertaken by the sub-group’s Chairman to

inform staff of the review and to gather their views as to the future of neonatal

services

• Members of the sub-group from the three regions convened local meetings with

representative unit staff to consider the main issues and challenges to service

provision

• Data from the Scottish Neonatal Transport Service (2005), and the NHS Quality

Improvement Scotland funded prospective study of ‘in-utero transfers’, the Perinatal

Collaborative Transport Study (CoTS) 2008, were presented to the sub group

• Information was sought on arrangements for training neonatal nurses in Scotland and

on educational courses for neonatal nurses and other disciplines

The issue of workforce planning in terms of birth numbers and skill mix was seen as critical

to the provision of neonatal services. To collect baseline data the sub-group included

questions in the questionnaire sent to all units. In parallel, a workload and workforce review

of neonatal services staffing was being conducted as part of the Nursing and Midwifery

Workload and Workforce Planning Programme (NMWWPP). This workstream was taken

into account by this review.

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Background 2.1 Establishing the Maternity Services Action Group In February 2001 the Scottish Executive published A Framework for Maternity Services in

Scotland2. The document presented a set of principles by which maternity services should

be governed. It described the type of service that women should expect to receive, and

highlighted the importance of information, communication, risk assessment, service

organisation and provision.

After the Framework was published, further work was undertaken to examine how the

principles should be applied to the acute maternity setting. This was published as the report

of the Expert Group on Acute Maternity Services (EGAMS) in December 20023. EGAMS set

out recommendations for actions to develop services.

Building a Health Service Fit for the Future(2005)4 reported on progress, and recommended

further action to strengthen commitments in the Framework and EGAMS. The Scottish

Executive response to this report - Delivering for Health5 - made a commitment to continue

delivering the Framework and EGAMS and recommended the establishment of a national

maternity services group to oversee implementation.

This group was established as the Maternity Services Action Group [formerly the Ministerial

Action Group on Maternity Services]. One of the early priority areas agreed by the group

was to review neonatal services. To undertake this the Neonatal Services Review Sub-

group was convened.

2.2 The Policy Context A Framework for Maternity Services in Scotland, defined a model of Neonatal Levels of Care

for NHS Scotland:

2 Scottish Executive Health Department. 2001. A Framework for Maternity Services in Scotland 3 Scottish Executive Health Department. 2003. Expert Group on Acute Maternity Services: Implementing a Framework for

Maternity Services in Scotland 4 Scottish Executive Health Department. 2005. Building a Health Service Fit for the Future, May 2005 5Scottish Executive Health Department. 2005. Delivering for Health, November 2005

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Table 1: Neonatal Levels of Care [Extract from A Framework for Maternity Services, 2001]

Designation of neonatal

unit

BAPM category of

care

Location Lead carer Support carer

Care

Normal Care

Home, GP/Midwife Unit, Maternity Unit I-III

Mother + wider family

Midwife, Neonatal Nurse, Paediatrician

Advice and supervision, birth examination, vitamin K administration, discharge examination, screening programme, parental support and education

Level 1 Special Care

Maternity Unit I-III, Postnatal Ward, Transitional Ward, Special Care Baby Unit

Midwife, Specialist neonatal nurse, Mother

Paediatrician, Midwife, Specialist Neonatal Nurse

Care and treatment exceeding normal care

Level 2 High Dependency Care and short term Intensive Care

Maternity Unit II-III, Special Care Baby Unit, Neonatal Intensive Care

Paediatrician/ Neonatologist

Specialist Neonatal Nurse

Continuous skilled supervision but not as intensive as Level 3, parenteral nutrition, short term respiratory support, intra arterial monitoring, includes Special care

Level 3 Maximal Intensive Care

Maternity Unit II-III, Neonatal Intensive Care

Neonatologist Specialist Neonatal Nurse, ANNP, other consultant specialities

Continuous highly skilled supervision, assisted ventilation, circulatory support, peritoneal dialysis, post-op care, intensive parental support, Includes Special and High Dependency Care

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The Better Health, Better Care: Action Plan6 restates a commitment to provide family-

centred care offered as locally as possible by clinically competent professionals, defining

services at a national, regional and local level.

Additionally Better Health, Better Care: Planning Tomorrow’s Workforce Today7 sets out the

direction of travel for workforce planning, emphasising the importance of investment in

education and training, both for the existing workforce and for new staff. This may require

the workforce to operate in different ways, utilising different evidence-based models of care

and skill mix to deliver services that meet the needs of children and families with multiple or

complex needs, to give every child the opportunity that they deserve.

2.3 Neonatal Services in Scotland Scotland has a population of approximately 5.1 million8 with 14 territorial NHS Health Boards

within three regional networks: the West of Scotland, the South East and Tayside (SEAT)

and the North of Scotland.

Maternity Units

Currently there are 18 consultant led maternity units and 22 community maternity units. The

West of Scotland Region has seven consultant led maternity units, the South East and

Tayside Region six and there are five based in the North of Scotland Region.

6 Scottish Government Health Directorates. 2007. Better Health, Better Care: Action Plan 7 Scottish Government Health Directorates. 2007. Better Health, Better Care: Planning Tomorrow’s Workforce Today 8 General Register Office for Scotland (GROS). http://www.gro-scotland.gov.uk/files/ar05.pdf

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The Scottish population is unevenly distributed across the country with some 80% living in

20% of the land area. Reflecting this, and the geography of Scotland, there are wide

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variations in women’s ease of access to a maternity unit. In Greater Glasgow and Clyde,

virtually every woman lives within one hour’s travelling of a tertiary centre; in contrast, in

Highland, almost a quarter are more than an hour from any form of consultant-led unit.

Neonatal Units

There are 16 neonatal units in Scotland, all co-located with a consultant led maternity unit.

The West of Scotland Region has seven neonatal units, the South East and Tayside Region

six and there are three based in the North of Scotland Region.

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The Units are distributed throughout the 3 Regions and offer levels of care from intensive

care, and high dependency to special care for lower levels of need.

As noted above in table 1, the Framework for Maternity Services states that Level 3 units

should provide a Neonatologist as the lead carer, and that care should be delivered with

‘continuous highly skilled supervision’. The Framework also equates Level 3 care with the

British Association of Perinatal Medicine (BAPM) guidelines for ‘intensive care’. The BAPM

guidelines are considered in section 3.1, and detailed in Appendix D. They include the

recommendation that units providing intensive care should be staffed by consultants whose

primary duty is to the neonatal intensive care unit. However, not all of the Level 3 units

provide a separate neonatal unit consultant rota.

Table 2: Neonatal Units in Scotland and their self-designated Level of Care

Level of Care

Dedicated neonatal unit

Consultant Rota

West of Scotland

Paisley Royal, Glasgow Level 3 Yes

Southern General, Glasgow Level 3 Yes

Queen Mothers, Glasgow Level 3 Yes

Princess Royal, Glasgow Level 3 Yes

Wishaw General, Lanarkshire Level 3 Yes

Crosshouse Hospital, Ayrshire Level 3 No

Cresswell Hospital, Dumfries and Galloway Level 2 No

South East and Tayside

Ninewells Hospital, Tayside Level 3 Yes

Forth Park, Kirkcaldy Level 3 No

Simpson Centre for Reproductive Health Level 3 Yes

St Johns, Livingston Level 1 No

Stirling, Forth Valley Level 3 No

Borders General, Borders Level 2 No

North of Scotland

Aberdeen Maternity, Grampian Level 3 Yes

Raigmore Hospital, Inverness Level 3 No

Dr Grays, Elgin Level 1 No

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2.4 Why Change is Needed Now Within this service and policy context there are number of issues relevant to the provision of

neonatal services that need to be considered:

• The most seriously ill babies with complex clinical conditions are relatively small in

number and they need highly specialised care

• The need to design services and develop staffing models that will meet the

requirements of the European Working Time Directive and the impact of Modernising

Medical Careers

• Concerns about the recruitment and retention of trained neonatal nurses

• Reports of units exceeding their recommended occupancy levels

• Concerns about the number of mothers and babies that are transferred between units

for intensive or high dependency care as a consequence of local capacity issues

• The lack of data on the service provision and clinical outcomes

• The desire to support local service provision

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Published Evidence on Neonatal Services 3.1 Standards for Neonatal Services Within the UK, the British Association of Perinatal Medicine (BAPM) is the largest

professional body in the field of perinatal medicine. They published Standards for Hospitals

Providing Neonatal Intensive and High Dependency Care (2nd edition), in 2001 [shown in

detail Appendix D].

The BAPM standards recommend that units should provide care to a designated level:

Level 1 Special Care

Level 2 High Dependency Care and short term Intensive Care

Level 3 Maximal Intensive Care

They also include recommendations on:

• Services that should be provided by units at each level of care

• Staffing levels and skill mix

• Resources including equipment, access to other specialists and diagnostics, and

transport

• Service quality improvement including the use of guidelines and protocols, quality

assurance, audit and training

These standards are widely recognised by experts in neonatal care both in the UK and

internationally. The literature review commissioned for this service review sought, but did

not identify, any alternative standards or guidelines.

The most important elements of the BAPM standards centre around staffing levels and skill

mix. They recommend that, in line with children’s and adult intensive care, nursing ratios for

intensive care should be 1 nurse: 1 baby. For high dependency they recommended a ratio

of 1 nurse: 2 babies, and 1 nurse: 4 babies for special care. The BAPM standards include

clinical criteria as to which babies should be considered ‘intensive care’ and which ‘high

dependency’ (see Appendix D). These criteria include expert judgement, i.e. intensive care

includes any other very unstable baby considered by the nurse-in-charge to need 1:1

nursing.

For medical staffing, BAPM recommends that neonatal intensive care units should be staffed

by consultants whose principle duties are to the intensive care unit. That all new

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appointments should hold a Certificate of Completion of Training sub-specialist training in

neonatal medicine, and that emergency consultant cover should be provided through a

dedicated rota that does not also cover any other service.

BAPM recommends that to achieve these standards, services should be organised as

regional networks, including Managed Clinical Networks. The standards note that the role of

units within each network will vary, but that at least one unit should provide the full range of

medical neonatal intensive care. Regional networks should be served by a dedicated

transport service. Services should be planned for average occupancy of 70%.

With regard to cot provision, the British Association of Perinatal Medicine9 recommend that

the average population requires 0.75 cots per 1000 birth population for intensive care, 0.7

cots per 1000 for high dependency care and 4.4 cots per 1000 for special care.

3.2 Literature Review A literature review was undertaken for the Neonatal Services Sub-group and can be found in

full in Appendix C. This literature review examines the published evidence on the provision

and organisation of neonatal services, and the association between service organisation and

outcomes for neonates.

The literature search identified policy based services reviews from other countries, including

England and Northern Ireland, as well as secondary and primary research papers which

examine the association between service configuration, staffing and outcomes.

3.2.1 Service policy in other countries Policy reviews of neonatal services in England, Northern Ireland, New Zealand and Australia

identified some common themes:

• A recognised tension between centralisation of services, which provides higher

volumes and the ability to provide dedicated neonatologists 24 hours a day,

against the impact on families of travelling further

• Recommendations to designate units’ levels of care (current policy in Scotland10)

• Proposals to develop managed clinical networks to provide services

9BAPM. 2004. Designing a Neonatal Unit. Report for the British Association of Paediatric Medicine. May 2004 10 Scottish Executive Health Department. 2001. A Framework for Maternity Services in Scotland

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• Recognition of the need for workforce and resource planning to provide services

• The need for more robust data to inform service provision and planning

3.2.2 Association between volume and outcome The review identified six papers which had analysed the association between low birth

weight and outcomes for nearly 200,000 neonates using statistical techniques (logistical

regression analyses).

The findings of these papers are strikingly similar: there is a strong positive association

between outcome and unit volume.

In other words, in these analyses, babies were more likely to survive to go home if they were

treated in units that had large numbers of patients. This association was particularly strong

for neonates delivered at <29 weeks.

One paper11 also found that survival improved as units grew larger, up to an average volume

of about 50 very low birth weight (<1,500g) admissions per year.

3.2.3 Impact of staffing on outcomes The UK Neonatal Staffing Study analysed outcomes for a prospective cohort of about 13,500

neonates (all birth weights) admitted from March 1998 to April 1999 to 12 UK neonatal

units12.

The study found, following risk-adjustment, that outcomes by clinical or nursing staffing

levels were not significantly different in different types of units. The findings suggested that

there may be an association between unit occupancy levels and outcomes, however this

finding had wide (statistical) uncertainty. A statistically significant association was found

between higher levels of consultant, or nursing provision, and lower levels of hospital

acquired infections. Further analysis of a subset of the UK Staffing Study data showed that

11 Rogowski JA et al. 2004 ‘Indirect vs. direct hospital quality indicators for very low-birth-weight infants’. Journal of the

American Medical Association (JAMA) 14; 291(2):202-9. 12 UK Neonatal Staffing Study. A prospective evaluation of risk-adjusted outcomes of neonatal intensive care in relation to

volume, staffing, and workload in UK neonatal intensive care units. NHS executive Mother and Child Health Initiative.

November 2000.

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increasing the ratio of nurses with specialist neonatal qualifications to intensive care and

high dependency infants to 1:1 was associated with a decrease in risk-adjusted mortality13.

3.3 Conclusions from the published evidence There is strong evidence from primary research that treatment in units with larger volumes is

associated with improved survival:

• Neonates <29 weeks, or <1,500g, should be treated in specialist intensive care

units, especially between 12 hours and 72 hours of life

• Specialist units (providing intensive care) should have a reasonable expectation

of >50 annual admission of neonates <1,500g

With the exception of the analyses between volume and outcome, evidence is based on

policy and expert opinions, and supports:

• Adoption of national standards for service provision

• The implementation of designated levels of care for each neonatal unit

• Development of networked services, at a regional level

• The need for robust routine data collection

• The optimum staffing for babies requiring full intensive care is one baby:one

nurse ratio; there should be a dedicated neonatal consultant rota

13 Hamilton, K.E. StC, Renshaw, M.E. and Tarnow-Mordi, W. Nurse staffing in relation to risk-adjusted mortality in neonatal

care. Arch. Dis. Child. Fetal Neontal Ed. 2007;92; 99-103.

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Epidemiology 4.1 Births and Neonatal Admissions in Scotland There were 52,721 live births in Scotland in 200514. Births in Scotland have been steadily

rising over recent years from 50,599 in 2002; this is a reversal of the downward trend seen in

the late 1990’s and in contrast to previous population predictions [Appendix E]. Around

6,00015 babies, 11% of all live births, are admitted for neonatal care in Scotland each year.

The main groups of newborns that are admitted to neonatal units are those that are born

prematurely or with low birth weight. Scotland has seen an increase in the proportion of

births that are preterm (babies born before 37 weeks gestation) from 7.3% of total live births

in 1995 to 7.9% of total live births in 200516. There are some marked variations between

NHS Boards, these are shown in Appendix E.

Low birth weight is defined as a weight of <2,500g, very low birth weight is <1,500g. Low

birth weight may result from preterm delivery and/or from poor intrauterine growth. The rate

of low birth weight in Scotland has fluctuated around 6% of total births in the last 10 years.

As with preterm births there are marked variations in the proportion of births that are of low

birth weight among NHS Boards.

4.2 Future Needs for Neonatal Services At present Scotland has a rising birth rate and a rising preterm birth rate, thus the numbers

of admissions to neonatal units are likely to rise in the medium term.

General Register Office for Scotland (GRO) projects a continuing rise in births to 57,600

births in 201017, these 2006 projections from GRO are about 12% higher than the 2004

projections. However from 2015 onwards births are projected to fall, leading to a long term

trend projection of a decline in births.

14 ISD Scotland National Statistics. 2006. http://www.isdscotland.org/isd/1022.html 15 ISD Scotland National Statistics. Source: SMR11 & SBR for 2002/2003. SBR for 2004-2006. IR 2007-2692 16 ISD Scotland National Statistics (2005), 'All births by term and birth weight'. Table 7 17 General Register Office for Scotland

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In the past 20-30 years technological and pharmacological advances in neonatal care have

improved outcomes for babies born at very low gestations. This increases workloads as

babies who would not have survived previously are now doing so, and require more

intensive care and care for longer periods of time. At the same time some babies born at a

higher gestation (35+ weeks) that were previously admitted to neonatal services may not

routinely require admission and may now be cared for in transitional care facilities or on the

post natal ward.

Over the last ten years Scotland has seen a marked rise in the proportion of births that are to

older women [Appendix E]. Older maternal age may be associated with pre-existing ill

health, multiple births, complications of pregnancy, and an increased risk of adverse

outcomes, which as stated earlier can increase the demand for neonatal care.

The changing demographic make up of the population of Scotland also impacts on workload

in a variety of ways to meet the differing needs of our multi-cultural society.

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Findings of Review Process 5.1 Results from the Neonatal Unit Questionnaire The Neonatal Sub-group undertook a bespoke questionnaire review of all the neonatal units

in Scotland. Data on facilities, workload and staffing in 2005 were collected. Thanks to the

cooperation and hard work of all the neonatal unit staff a 100% return rate was achieved. A

copy of the questionnaire can be found at Appendix B, and the detailed results are shown in

Appendix F. The main findings from the questionnaire were:

5.1.1 Levels of care

♦ There were a number of differences between level of care provision in each unit

according to British Association of Perinatal Medicine (BAPM) standards and that self

reported. Several units did not self designate a level; where units did, there was a

tendency to report a higher level than the application of BAPM standards would suggest.

5.1.2 Number of Cots

♦ There were 347 physical cot spaces in the 16 units in 2005; unit size ranged from 44 to 4

cots. Most units stated that physical cot numbers were determined by

hereditary/historical factors.

♦ 306 of the 347 cots were staffed in 2005, approximately 12% less than the potential

physical space available. However one unit stated they staffed to 70% occupancy and

another to 80% occupancy, thus in practical terms their staffed complement is lower.

5.1.3 Admissions

♦ The units reported 7,846 admissions, this contrasts with the 5,853 babies in centrally

recorded data; a difference of about 2,000 admissions. It is not possible to conclude

which data source is more accurate.

5.1.4 Occupancy

♦ ISD provided routine data on occupancy levels showing average occupancy at about

67%. The units reported slightly lower numbers of staffed cots, thus the analysis was

recalculated and estimated average occupancy was about 71%. BAPM recommends

that services should be planned for average occupancy of 70%.

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5.1.5 Support Services

♦ There was no clear pattern between level of care and on site access to diagnostic

facilities.

5.1.6 Other Facilities

♦ Five of the 16 units stated that they have dedicated transitional care cots and five had a

dedicated bereavement counsellor.

5.1.7 Workforce

♦ There were 84 whole time equivalents (WTEs) provided by consultants who work on

neonatal units reported, however, only 31 of these WTEs were provided by consultants

dedicated to neonatology alone.

♦ Eight units reported a separate neonatal consultant rota, nine a separate neonatal

‘middle grade’ rota and ten a separate junior doctor/ANNP rota. These rotas will be

markedly affected by the European Working Time Directive and Modernising Medical

Careers.

♦ Throughout the 16 units there were 26.4 WTEs of advanced neonatal nurse practitioners

(ANNPs), and 671.4 WTEs of neonatal nurses/midwives. Work needs to continue to

balance staffing with capacity and activity and the results of the Nursing and Midwifery

Workload and Workforce Planning Programme (NMWWPP) when available, should help

inform this work.

5.1.8 Population estimated need for cots

♦ BAPM standards state that there should be 0.75 intensive care cots per 1,000 births, 0.7

high dependency cots per 1000 and 4.4 special care cots per 100018.

♦ Comparison of this recommendation to current staffed cot provision in Scotland suggests

that in Scotland we provide a higher number of intensive care/high dependency cots than

this benchmark (by an estimated 19 intensive care and high dependency cots), but are

under resourced for special care by about 42 cots.

18 BAPM. 2004. Designing a Neonatal Unit. Report for the British Association of Paediatric Medicine. May 2004

24

5.2 Professional views The views from the three regional meetings were fed back to the sub-group, in conjunction

with the individual meetings conducted by the sub-group Chair. These views are

summarised here.

There was widespread agreement that neonatal units in Scotland should use BAPM 2001

definitions, when discussing cots in intensive care, high dependency and special care. It was

noted that many units do not differentiate between intensive care and high dependency care

cots; this is also evident in the data returns from the unit questionnaires.

There was no unified view regarding the best model for delivery of neonatal care and there

were variations of views within each regional meeting and in the key stakeholder meetings.

However, there was broad agreement that:

• The sickest babies should be looked after by a team led by dedicated neonatologists,

who are on a separate rota from general paediatricians (as per BAPM Standards)

• The majority seemed to agree that a gestational cut off should be used to determine

the services provided by different levels of neonatal unit. There was no consensus

reached of what that gestational cut off should be

• It was recognised that roles and skill mix within units will need to change and that

planning needs to take place now to ensure adequate numbers of suitable trained

staff will be available

• The neonatal workload and workforce planning tool developed as part of the Nursing

and Midwifery Workload and Workforce Planning Programme (NMWWPP) was

raised at all the meetings and it was felt that full consideration should be taken of its

results when planning future workforce needs.

• If a network approach was to be adopted, strict criteria regarding patient pathways

would need to be agreed nationally. There should also be discussion about the

necessary support structures and mechanisms in place including accommodation

and transport

25

5.3 Nursing and Midwifery Workload and Workforce Planning Project The Nursing and Midwifery Workload and Workforce Planning Programme (NMWWPP) was

developing a neonatal tool at the same time as this neonatal review was being undertaken.

One of the objectives of that project was to develop workload measurement tools for all

specialties. In addition a professional judgement tool was also used to provide a comparison

measure. The programme was advised by representatives from the Scottish Neonatal

Nurses Group (SNNG).

The tool was based on the BAPM 2001 recommendations for the categorisation of care.

The workload tool was first tested in April 2006, in NHS Tayside, NHS Grampian, NHS

Lothian, NHS Lanarkshire, NHS Ayrshire & Arran and NHS Greater Glasgow & Clyde and a

full test including observation studies was carried out in September 2006. Evaluation of the

tools was carried out after each test and a validation exercise against other sources of

information was conducted.

The neonatal nursing workload tool and the professional judgement tool were implemented

in November 2007 in all neonatal units with the exception of NHS Greater Glasgow & Clyde

who implemented in January 2008.

The interim data has now been collated and was returned to each NHS Board in March

2008. Discussions will be held in NHS Health Boards and consideration will be given to

staffing requirements for the individual areas.

26

5.4 Education and Training 5.4.1 Medical Education and Training Medical trainees in paediatrics are introduced to neonatology during ‘basic training’ (years

one to three) and then undergo more intensive training with added responsibility during

years four to five. After year five, trainees can elect to enter a subspecialty for the last two to

three years of Specialist Training, or to continue as a general paediatrician. If they sub-

specialise in neonatology, the trainee will receive a Certificate of Completion of Training

(CCT) in Paediatrics (Subspecialty - Neonatology).

As Level 3 units should care for the extremely preterm infants and complex cases, it has

been recommended that new consultant appointees to these units should have sub

specialist neonatal training in addition to a CCT in Paediatrics.

To determine how many consultants should be trained as (a) purely neonatologists and (b)

paediatricians with an interest in neonatology, the Royal College of Paediatrics and Child

Health (RCPCH) conduct workforce planning exercises with the Departments of Health and

Deaneries. Informed by this, the National Training Number (NTN) Grid scheme is used to

appoint trainees. The NTN scheme is a joint college/deanery initiative, supported by the

Postgraduate Medical Education and Training Board (PMETB), which provides equity of

access to, and ensures the quality of, sub specialist training programmes. The Scottish

teaching hospitals are all training centres and neonatal units are accredited as training

centres.

The number of trainees accepted on to the Grid in any one year is determined by the future

perceived need for neonatal consultants throughout the UK. There is strong competition for

neonatal posts with less than 25% of applicants accepted for subspecialist neonatal training.

5.4.2 Modernising Medical Careers Recent changes to the structure and organisation of medical training have been introduced

through Modernising Medical Careers (MMC). The first step is a two year foundation

programme that provides a broad based education; this is followed by Specialist Training

Programmes with trainees now known as Specialty Registrars. In paediatrics, this phase of

training is likely to take eight years to complete. Foundation training was introduced in

August 2005 and specialty training programmes in August 2007.

27

Prior to the introduction of MMC there were 254 Senior House Officer (SHO) posts in

paediatrics in Scotland but only 91 Specialist Registrar (SpR) training posts. This was a

ratio of 2.8 SHOs for every SpR. All 16 neonatal units had paediatric, and neonatal rotas,

with ten units having a separate junior doctor rota, and nine having a separate middle grade

neonatal rota.

In 2005/06, 92 (37%) of the SHO posts were removed from the paediatric training scheme

and redistributed between the Foundation Programme and GP Training. Workforce planning

has indicated that 19-21 trainees need to gain their CCT every year in order to provide the

necessary number of consultants for the paediatric and neonatal service in Scotland.

The phased introduction of MMC will allow some units to continue to man current numbers of

junior doctor rotas in the short term. However, there will be a marked decrease after 2011.

This decrease in numbers, in conjunction with the effect of the European Working Time

Directive in August 2009, will lead to Scottish neonatal units having insufficient trainee

medical staff to sustain current arrangements for first on-call neonatal and paediatric rotas.

5.4.3 Nurse Education and Training Neonatal nurses may have a background as a Registered General Nurse / Registered Nurse

(Adult), a Registered Nurse (Child Health) or a Registered Midwife. At this time, the majority

of neonatal nurses in Scotland are midwives, although this profile is changing due to Nursing

and Midwifery Council regulations. Registered Nurses (Adult) and Registered Nurses (Child

Health) will gradually become the majority.

Neonatal nurses work in the community or are hospital based. The training and ongoing

education that they require may be dependent on the level of care they provide to their

patients.

None of the current pre-registration education programmes prepare for neonatal nursing

practice, therefore following basic orientation programmes in neonatal units, new recruits are

expected to undertake Qualified in Specialty training. Currently this is provided at Scottish

Credit and Qualification Framework (SCQF) level 9 (degree level).

Despite this level of education being available for some time, there is still a national shortage

of neonatal nurses trained to Qualified in Specialty level in the UK and in Scotland

particularly. There may be delays in neonatal nurses accessing such training given that it is

only provided by two higher education institutions in Scotland. Funding and release is often

28

reported to be problematic as there tend to be no funds to resource backfill to their post

whilst they are undertaking training. Funding of fees is also problematic.

There are limited educational opportunities specifically for neonatal nurses who are Qualified

in Specialty although the Neonatal Nurse Education project [see below] may help redress

this.

Some neonatal nurses have undergone further specialised training to become Advanced

Neonatal Nurse Practitioners (ANNPs). In Scotland this education is available at SCQF

level 11 (Masters level). In addition, it is expected that neonatal nurses and medical staff in

intensive care and high dependency units are trained in advanced neonatal resuscitation by

completing the Newborn Life Support (NLS) course, or the Neonatal Resuscitation Program

(NRP). Not all neonatal nurses have achieved this level of resuscitation training.

When planning services NHS Boards should take into account the need to release staff for

training, this includes the need for backfill.

5.4.4 Scottish Multiprofessional Maternity Development Programme (SMMDP) The SMMDP is hosted by NHS Education Scotland and has developed a number of obstetric

and neonatal courses that are aimed at a multidisciplinary group of clinicians.

The Scottish Neonatal Resuscitation Course was developed in 2003. This course focuses

particularly on the initial assessment and airway management required in resuscitation and

was designed to meet the needs of maternity care professionals who do not require the

more advanced skills provided by NLS and NRP. Since 2004, 833 candidates have

undertaken this training programme of which 723 are midwifery/nursing, 70 are medical and

40 are from Scottish Ambulance service.

Following the success of the Scottish Neonatal Resuscitation Course, the Scottish Neonatal

Pre-transport Care Course was developed by the Scottish Neonatal Transport Service

(SNTS) in collaboration with the SMMDP. The course provides training for healthcare

professionals working in community maternity care settings, including midwives, GPs,

ambulance personnel, and A&E staff. It prepares participants to offer safe and effective care

of babies in the pre-transport period. The course has been run at nine venues: 135

candidates have attended this training of which 105 were midwives/nurses, 19 were doctors

(ranging from GPs to Consultant anaesthetists) and one was a paramedic.

29

The Scottish Neonatal Transport Course run by the SNTS which teaches advanced

resuscitation, stabilisation and transport, is mainly aimed at SNTS staff, but is also available

to neonatal nurses and doctors. Currently this course is credited at Scottish Credit and

Qualification Framework (SCQF) level 10 (honours level).

5.4.5 Neonatal Nurse Education Project Despite Qualified in Specialty and Advanced Neonatal Nurse Practitioner education being

available in Scotland, it was recognised that there were few opportunities for specific

neonatal nurse education at an intermediate level. Funding was identified in early 2007 by

NHS Education for Scotland (NES) and, following a successful bid, a consortium was

commissioned to develop modules at this intermediate level.

The consortium involves Napier, Glasgow Caledonian and Robert Gordon Universities and

NHS Lothian, Greater Glasgow and Clyde and Grampian. Two seconded part time lecturers

and a consultant senior lecturer have been appointed and a suite of three modules at

(SCQF) level 10 were developed. Twenty two candidates were entered for the first module

that commenced in October 2007. A further two started in February 2008.

It is hoped that the introduction of these modules will complement the existing neonatal

nurse education provision and significantly help with retaining neonatal nurses in Scotland.

5.5 Neonatal transport Neonatal units in Scotland are supported by a dedicated National Neonatal Transport

Service which was established in 2002. It transfers neonatal patients to an appropriate level

of care, but is not a neonatal ‘Flying Squad’. The service is provided on a regional basis:

Table 3: West North East Base: Glasgow Bases:

Aberdeen and Dundee Base: Edinburgh

• NHS Ayrshire and Arran • NHS Dumfries and Galloway • NHS Forth Valley • NHS Greater Glasgow & Clyde • NHS Lanarkshire • NHS Western Isles

• NHS Grampian • NHS Highland • NHS Orkney • NHS Shetland • NHS Tayside

• NHS Borders • NHS Fife • NHS Lothian

At any one time there are three teams on-call for neonatal transfers across Scotland, one for

each geographical region. In certain circumstances the transport teams may be required to

30

transfer infants beyond Scotland’s geographic boundaries. Each regional team will cover

another geographical area if the local team has already been called out.

The National Director and three Regional Directors are consultant neonatologists. Each

regional team is also supported by an experienced Advanced Neonatal Nurse Practitioner in

their role as Regional Transport Co-ordinators. The service would not be able to operate if it

were not for the medical staff (consultant staff and junior doctors), the neonatal nurses and

the ambulance staff that support the service.

In 2005/06, 1,317 neonatal transports occurred. Of these, 387 (29.5%) were classed as

emergencies, and 693 (52.5%) took place 'out of hours'. Air transport was used on 84

occasions (6.5%). 60 of the transfers involved babies being transferred to, or collected from

other hospitals in England, Wales, Northern Ireland and Ireland.

Table 4: Number Emergency Out of hours1 Air

West 679 197 381 50

East 343 106 157 2

North 295 84 155 32

Total 1317 387 (29.5%) 693 (52.5%) 84 (6.5%) 1 Out of Hours = Outwith 9am-5pm Monday to Friday

The Scottish Neonatal Transport Service is “lauded throughout the UK and has been the

template for the development of English services”19;

19BLISS. 2007. Small babies, short changed? Are we ensuring the best start for babies born too soon in Scotland?

31

5.6 In-utero transport In-utero transport is the transport of the pregnant mother before delivery. It is undertaken to

ensure that she, or her baby, is in the correct facility at the time of delivery, given their

clinical situation. It may reflect a normal planned system of maternity provision with an

escalation of maternal or fetal dependency level. However it may also occur between two

specialist (tertiary) units, taking a woman out of a unit that normally provides an appropriate

level of care for her clinical case but is unable to do so because demand in the unit is higher

than the unit can accommodate.

A long held belief is that it is safer to transfer a baby in-utero to a neonatal unit to receive the

necessary level of care than to transfer once the baby is born. This is true if the transfer is

planned well in advance of the delivery. However, in-utero transfers may also occur as

emergencies at a time when the mother or fetus is in a vulnerable clinical situation. Transfers

may involve a lengthy ambulance or plane journey, during which time clinical monitoring is

not optimal.

The Clinical Standards Advisory Group (CSAG) (1993 and 1995) examined access to and

availability of neonatal intensive care; it stated that: “It is accepted that non-referral units

should have easy access to intensive care beds in a regional or sub-regional centre and that

sub-regional centres should not normally need to transfer their own in born babies...”and

used the term “inappropriate transfer” to describe transfers when these criteria were not met.

Subsequent reports20, 21 have consistently cited the following criteria:

♦ Pregnant women should not travel beyond their nearest referral centre.

♦ Tertiary centres should not transfer out mothers or babies who are booked for

care with them.

The second edition of guidance published by the British Association of Perinatal Medicine

(BAPM, 2001) reiterated a recommendation from the second CSAG report in 1995 which

stated: “That, as a quality measure, events when a baby (or mother) is transferred

20 Cusack et al. Impact of service changes on neonatal transfer patterns over 10 years. 2007. Arch Dis Child, Fetal &

Neonatal Ed. 92: F181-184 21 Gill et al. 2004. Perinatal transport: problems in neonatal intensive care capacity. Arch Dis Child Fetal &Neonatal Ed 2004;

89: F220-223

32

inappropriately, are recorded and a goal of reducing such journeys to 10% of all transfers is

set”.

Recent publications have highlighted the fact that these criteria are not being met by many

areas throughout the UK . In a Yorkshire study it was reported that 37% of in-utero transfers

occurred because the neonatal unit/labour ward was full or cots were not staffed, of these

17.3% were transferred outside normal commissioning boundaries21.

During an external review of the Scottish Neonatal Transport Service in 2005, Dr Andrew

Berry, State Medical Director of the Neonatal Emergency Transport Service of New South

Wales, recommended that a perinatal advisory system be established in Scotland.

Further investigation by the Neonatal Transport Service revealed that there were no data

available to evaluate in-utero transfers in Scotland.

5.6.1 Perinatal Collaborative Transport Study (CoTS) In 2006 NHS QIS funded a ‘Perinatal Collaborative Transport Study’ (CoTS)22. The study

aimed to collate clinical data on all in-utero transfers over a 6 month period, to determine the

timing and outcomes of such transfers, and to assess the number of transfers that breached

the CSAG guidelines.

Data were collected from all the Scottish maternity units over a 6 month period in 2006/07.

There were 599 in-utero transfers; 72.5% (434) were from community maternity units

(CMUs), 5.7% (34) women were transferred past their nearest referral centre and 19.8 %

(86) were transferred out of a tertiary unit.

The study collated data on the occupancy levels of units during the study period. It found

that there was wide variation in the number of days units were ‘shut’ to new admissions, and

in the occupancy levels when units reported that they were ‘shut’. It recommended that more

work be undertaken to understand why staffed neonatal cots were unavailable when

occupancy was less than 70% including a review of staffing levels.

22 Perinatal Collaborative Transport Study (CoTS). A report on behalf of the CoTs Steering Group and the Scottish Neonatal

Transport Service. NHS Quality Improvement Scotland (Project Reference Number P06/01). July 2008

33

The CoTS Study also considered a wide range of other issues related to the need for and

organisation of in-utero transfers. It made a number of recommendations including the need

for further accurate tests to predict and diagnose labour, the need for guidelines on the use

of tocolytics (drugs used to delay labour), the potential benefit of a centralised system to

identify available beds.

5.7 Parental perspectives The birth of a baby is a cause for celebration. However, if a baby is born either premature or

sick, the expectations of parents are not realised and their experience can be frightening and

bewildering. In 2005 the premature baby charity, BLISS, commissioned the National

Perinatal Epidemiology Unit in Oxford to undertake an independent research review of

neonatal care in the UK23 .

Among its findings to support parents and families it recommended that “More attention

needs to be focussed on the individual needs of the baby. Parents, irrespective of their race,

religion, culture or social class need continuing support whilst their baby is in the unit and at

home”.

Some aspects of the survey were very encouraging: the majority of parents felt their child’s

problems were always discussed with them, and that equipment and procedures were

explained to them. However, the birth of most preterm infants is sudden and unexpected.

The view was expressed that an improvement in the identification of ‘at risk’ mothers would

enable parents to be better informed about neonatal care earlier in pregnancy. There was a

perceived lack of ‘care pathways’ should the pregnancy not go to plan and/or complications

develop.

A further study in 200724 found that half of the parents felt they were not given enough time

to ask questions about the care of their baby. They also felt insufficient time was given to

them with regard to feeding and the basics of care for a preterm or sick newborn baby.

These problems were perceived to be due to a shortage of neonatal nurses and parents felt

that nurses needed more time to address these issues.

23 BLISS. 2005. ’Special Care for sick babies-choice or chance?’ BLISS Baby Report July 2005 24 BLISS. 2007. Small babies, short changed? Are we ensuring the best start for babies born too soon in Scotland?

34

A majority of neonatal units provided access to a private room in which mothers could

breastfeed or express breast milk; 75% of units had specific accommodation for parents and

tea and coffee making facilities. Few had play areas for siblings. Other problems identified

were a lack of adequate, cheap/free car parking and the provision of counselling support.

There was limited provision of language support for parents for whom English was not the

first language.

Bliss made the following recommendations:

• Provision of clear, written information on possible transfer/care pathways to

prospective mothers, at the time of booking, should there be complications in the

pregnancy for mother and/or baby

• If babies are initially cared for outside the proposed unit of delivery, to ensure their

repatriation as soon as clinically possible

• To establish breastfeeding facilities and support at every unit

• To establish a minimum standard of parent and sibling accommodation, and facilities

• To provide counselling and language support services

• To provide financial support for families that have to travel long distances to visit their

babies

• Units to consistently promote and work alongside family support systems and the

voluntary sector, such as BLISS

BLISS also conducted an on-line parent survey in 2007 regarding the financial implications

of having a sick or preterm baby25. The most significant reported costs were:

• Cost of travel to and from hospital (all parents spent money on travelling to see their

baby and the average weekly cost was £62)

• Paying for food away from home (90% of parents found themselves paying extra for

food and the average weekly cost was £24)

• Lost earnings through having to take time off work (44% of parents lost money this

way, with the average total loss being £2,457)

25 BLISS 2007 The findings were drawn from a survey of parents that was live on BLISS’s website from mid-August to mid-

November. http://www.bliss.org.uk/pagebuild.php?texttype=press281107

35

This financial burden had a marked impact on the poorest families who often lived in remote

and rural areas, and received little or no financial support.

Conclusions and recommendations Throughout the review process the dedication and hard work of all staff involved in providing

neonatal services was evident. The review itself would not have been possible without this

dedication, and the 100% return rate from the unit questionnaire is remarkable.

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 . 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.

Against this background a number of key issues emerged from the review:

♦ Clinical standards

♦ Service networks

♦ Pathways of care and transfers

♦ Staffing levels and cot numbers

♦ Patient care and involvement

♦ Data

6.1 Clinical standards 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.

The only clinical standards identified by the review were the BAPM 2001 standards. 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

36

• Intensive care should have a dedicated, 24 hour, consultant neonatologist rota and

junior doctor rota26

• 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

• The provision of specified levels of equipment, facilities and support services

6.2 Service networks 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 a dedicated 24 hour consultant neonatologist rota26

To provide evidence based care in practice this means that:

♦ Networks should agree the capacity required to serve their populations and provide

staff and facilities to meet that predicted demand

♦ The number of intensive care, high dependency and special care units in each

network must be determined

6.3 Staffing levels and cot numbers 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.

26 The BAPM recommendations do not comment on the issue of whether consultants should resident

on call and this issue was not considered by the Neonatal- Sub-Group as it was not within their remit.

The recommendations in this review does not imply that any dedicated consultant rota should be

resident.

37

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 review has also found that data suggests that there may be a need for more special

care and transitional care facilities and recommendations to address this are made in the

context of transfers below.

6.4 Pathways of care and transfers 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

38

• 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

6.5 Parent care and involvement 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 language support services 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

6.6 Data 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.

39

40

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 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

Appendix A Membership of Neonatal Services Review Sub Group

Chair: Dr Phil Booth Chair Neonatal Sub Group and Consultant Paediatrician,

Aberdeen Maternity Hospital

Members: Elizabeth Callander Neonatal Manager/ Lead Midwife, Princess Royal Maternity,

Glasgow

Robert Colburn General Manager for Highland and the Western Isles,

Scottish Ambulance Service

Andy Cole Chief Executive, Bliss

Fiona Collins Neonatal Services Co-ordinator, NHS Lanarkshire,

representing West of Scotland Regional Planning Group

Dr Jonathan Coutts Clinical Director of Neonatology, NHS Greater Glasgow &

Clyde

Fiona Dagge-Bell Professional Practice Development Officer, Women,

Children & Learning Disability Services, NHS Quality

Improvement Scotland

Dr David Evans Consultant Obstetrician, Dr Gray’s Hospital, Elgin

Professor David Godden Director, Centre for Rural Health, University of Aberdeen

Dr Claire Greig Senior Lecturer in neonatal nursing/midwifery, Napier

University

Dr Barbara Holland Consultant Neonatologist, Queen Mother’s Hospital, Glasgow

Anne Hoyle Senior Midwife/ Neonatal Manager, Ayrshire Maternity Unit,

Crosshouse Hospital, Kilmarnock

Dr Annie Ingram Director of Regional Planning & Workforce Development,

representing North of Scotland Regional Planning Group

Caroline Inwood Director of Nursing, NHS Fife representing South East and

Tayside Regional Planning Group

Margaret Kerr Neonatal Manager/ Newborn Screening Co-ordinator, NHS

Dumfries & Galloway

Dr Sheena Kinmond Consultant Neonatologist, Ayrshire Maternity Unit, Crosshouse

Hospital, Kilmarnock

Dr Ian Laing Consultant Neonatologist, Royal Infirmary, Edinburgh

Dr Ian McDonald Consultant Paediatrician, Raigmore Hospital, Inverness

1

2

Dr Lesley McDonald Consultant Community Paediatrician, NHS Greater Glasgow &

Clyde

Tom McEwan Neonatal Midwife, Royal Alexandra Hospital, Paisley

Monica Thompson Programme Director NHS Education Scotland (Midwifery

and Women’s Health

Dr Rennie Urquhart Consultant Obstetrician, Forth Park Hospital, Kirkcaldy

Dr Andrew Watt Consultant Paediatric Radiologist, Clinical Lead, Yorkhill

Hospital, Glasgow

Shona Wilkins Lay Member / involvement with Bliss Shared Experience

Register

Alison Wright Senior Nurse, Neonatal Services, NHS Tayside, Ninewells

Hospital, Dundee

Secretariat, Scottish Government Health Directorates Dr Ian Bashford Senior Medical Officer, Women and Children (to March 2007)

John Froggatt Deputy Director, Child and Maternal Health Division

Lyn Hutchison Senior Project Manager, Maternity Services Action Group (to

March 2008)

Nim Kumar Policy Manager, Child and Maternal Health Division (to

January 2008)

Katrina McDonald Policy Officer, Child and Maternal Health Division (from August

2007)

Dr Mags McGuire Interim Deputy Chief Nursing Officer and Nursing Officer,

Women & Children

Dr Louise Smith Senior Medical Officer, Women and Children (from September

2007)

Mike Watson Head of Maternal and Infant Health Branch (from June 2007)

Contribution to Report Jean Bain Neonatal transport co-ordinator for the North and part of the

development team for the neonatal workforce planning tool

Irene Barkby Programme Manager, Nursing and Midwifery Workload and

Workforce Planning Project

Emma McCallum Health Analytical Services

Appendix B Neonatal Unit Questionnaire

Neonatal Services in Scotland

Name of Neonatal unit

Address and Unit telephone number

Name and designation of person completing this form and contact e-mail

Highest Level of ongoing care provided by unit Cot establishment Total Cot

Spaces = Total Staffed Cots =

Special Care

High Dependency Care

Cot establishment broken down according to level of care (if these figures are available)

Intensive Care

How has total number of established cots been calculated? (e.g. BAPM/Local health board calculation/hereditary)

Do you have onsite access to the following services Yes No Radiology X-Rays Radiologist opinion/report within 24 hrs on above Barium Studies (ba meal, contrast enema etc)

Ultrasound Scan cranial (by Paed/sono/Rad)

Ultrasound other (e.g. renal/abdo by Paed/Sono/Rad)

MRI Scanning

CT Scanning

Laboratories Full service

Other EEG

Please give any additional comments and elaborate on types of services available i.e. echocardiography, dietetics, speech and language.

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Services for Families Yes No

Accommodation (short term)

Accommodation (longer term)

Community liaison service

Breastfeeding Advisor

Family room

Bereavement room

Counselling room

Counsellor (i.e. bereavement or psychology)

Social work input

Please give any additional comments/details such as more specific details of what social work/counselling services are available.

Section 1 – Unit Statistics for 2005

Admissions 1st Jan 2005-31st Dec 2005 Total

Patient Days Intensive Care (Excluding short term stabilisation prior to transfer)

E T Number ventilated (Patient Days)

CPAP

Special care

High Dependency Care Admission breakdown by days

Intensive Care

Yes No

Do you provide Neonatal Surgical Services

Do you have Transitional care facilities

If Yes please state how many cots

Please give any further comment.

<24 weeks 24- 28 weeks

Breakdown by gestation* *(Completed weeks, i.e. 24+6 weeks = 24)

29-32 weeks

2

33-36 weeks 37 weeks and above

≥2500g 1500 - 2499g 1000 -1499g

Breakdown by birth weight

≤999g Section 2 – Workforce issues

Medical

Number of WTE Consultants on Unit *please complete table 6

Number of WTE who deal purely with Neonatal services

Number of WTE Junior Staff and Grade

Yes No

Do you have a separate neonatal consultant on-call rota

Is there a dedicated neonatal middle grade staff rota

Is there a dedicated neonatal junior staff rota

Please give any further comment

ANNPs

Number of WTE ANNPs

From which budget are ANNP’s paid?

Does the unit have ANNPs in training (if yes how many and WTE)

From which budget are the student ANNP’s salary paid?

Please give any further comment.

Nursing/Midwifery/Clerical

Number of WTE Nursing/Midwifery staff *please complete tables 1-5 which follow

What are the criteria for neonatal nursing staff to attend in theatre/labour suite? Please list or attach copy of the unit policy/guidelines re attendance

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Does the unit have a Community liaison service? If yes, how many staff (Number and WTE) and of what grade/band are involved?

Are the community liaison service staff paid from the nursing budget? If not from which budget are they paid?

Does the unit employ a ward clerkess/es and/or a receptionist/s? If yes how many (Number and WTE) are employed?

Are the ward clerkesses/receptionists paid from the nursing budget? If not from which budget are they paid?

Regarding recruitment and retention and staffing of the unit please detail any issues/difficulties such as impact of Agenda for Change. Could you also give details of issues regarding staff training, such as lack of places, ability to grant study leave etc.

Please complete tables 1 – 5 in relation to staffing Table 1 – new recruits

Recruited to which grade/ Band

Professional Registration/s

Number of nurses/

midwives with no neonatal qualification

Number of nurses/

Midwives qualified in Specialty

i.e. neonatal course

Other neonatal qualifications

e.g. ANNP

Vacancies

Total number

Total WTE

RN (adult)

RN (child)

RM

At which grade A/B C D E F G Other And/or at which band 2/3 4 5 6 7

New staff/ recruits from January 2006 to December 2006

Other

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Table 2 - current staff

Grade/ Band

Professional Registration/s

Number of nurses/

midwives with no

neonatal qualification

Number of nurses/

Midwives with Qualified in Specialty status i.e. neonatal course

Other neonatal

qualification e.g. ANNP

Vacant posts

Total number

Total WTE

RN (adult)

RN (child)

RM

At which grade A/B C D E F G Other And/or at which band 2/3 4 5 6 7

Current staff as at 31st December 2006

Other The age of staff currently in post is important to this scoping exercise. Please estimate the number and/or WTE of staff in each of the following age ranges.

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Table 3 – age range Age range Total number of staff Total WTE of staff

<20 years old 20-29 years old 30-39 years old 40-49 years old 50-59 years old >60 years old Table 4 – maternity leave and sick leave

Grade/ Band

Professional Registration/s

Number of nurses/

midwives with no neonatal qualification

Number of nurses/

Midwives Qualified in Specialty status i.e. neonatal course

Other neonatal qualifications

e.g. ANNP

Total number

Total WTE

RN (adult)

RN (child)

RM

At which grade A/B C D E F G Other And/or at which band 2/3 4 5 6 7

Staff on maternity leave or long term (>one month) sick leave (Jan – Dec 2006)

Other

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Table 5 - exits

Grade/ Band

Professional Registration/s

Number of nurses/

midwives with no

neonatal qualification

Number of nurses/

Midwives qualified in

Specialty i.e. neonatal course

Other neonatal qualifications

e.g. ANNP

Length of service

Total number

Total WTE

RN (adult)

RN (child)

RM

At which grade A/B C D E F G Other And/or at which band 2/3 4 5 6 7

Exits Jan – Dec 2006

Other Please list the reasons staff gave for leaving, linking to specific staff as listed in table 5. The age of staff currently in post is important to this scoping exercise. Please estimate the number of Consultants/Staff grades in each of the following age ranges.

Table 6 Age range of Consultants/Staff grades

Age range Total number of staff 25–30 years old 30-39 years old 40-49 years old 50-59 years old >60 years old

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Appendix C Literature Review: Published Evidence on Neonatal Services Provision

1. Introduction This literature review was undertaken on behalf of the Maternity Services Action Group Neonatal Services Review sub-group. It examines the published evidence on neonatal unit provision and the resultant health outcomes for babies. 2. Neonatal Services in Scotland Scotland’s maternity and neonatal services are provided in line with the 2001 Framework for Maternity Services. This policy document defines four levels of care for neonates: normal care, special care, high dependency and intensive care. Similarly the British Association of Perinatal Medicine (BAPM) defines the levels of care as:

1 Special Care 2 High Dependency Care 3 Intensive Care

3. Evidence searches A database search for published literature was conducted using the following key words:

Neonatal service* Maternity service* Provision

Papers that presented evidence on the provision and organisation of neonatal services and the association between service organisation and outcomes for neonates were reviewed. Papers over ten years old were excluded. A wide range of types of evidence was sought: services reviews and policies from other countries with similar health services, guidelines and standards for services, secondary reviews such as literature reviews and meta-analyses and primary research analysis papers. 4. Database search The following databases/sources were searched:

• Idox • ASSIA • ERIC • Social Services Abstracts • Social Abstracts • OVID databases • INGENTA • EMERALD • Applied Social Sciences Index and Abstracts (ASSIA) • Social Services Abstracts • Sociological Abstracts • Criminal Justice Abstracts

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In addition, a search for secondary research, guidelines and standards was undertaken using the following search engines:

• TRIP • Guidelines Clearing House • NHS Scotland e-library • Google Scholar

Given the resources and time available this review is a literature review rather than a fully comprehensive systematic review. However, efforts were made to ensure completeness of relevant evidence both through examination of references in identified articles and through consultation with the experts on the Neonatal Services Sub-Group. 5. Results from literature search The review identified four service reviews, from England, Northern Ireland, Australia, and New Zealand. Very little secondary research was identified: an editorial review of service provision in the UK from 2000 (Turrell 2000), and a literature review that examined the published evidence on indicators measure of outcome in health service provision (DoH 2003). The British Association of Perinatal Medicine (BAPM) guidelines and standards for service provision were identified: Standards for Hospitals Providing Neonatal Intensive Care and High Dependency Care (2001) and Designing a Neonatal Unit (2004) but no other similar guidelines were identified. To assess the association between neonatal outcomes and volume, a total of six papers were identified (see Section 6.5). All of these papers used similar methods: statistical regression analyses using routine data with the main outcome measure being survival to discharge from hospital. Finally, a large study that examined the association between staffing and outcomes was identified: the UK Neonatal Staffing Study. 6. Results 6.1 Reviews of neonatal services in other countries There have been recent reviews of neonatal services in England, Northern Ireland, New Zealand and Victoria, Australia. Common themes included:

• A recognised tension between centralisation of services, which provides higher volumes with the ability to provide dedicated neonatologists 24 hours a day, against the impact on families of travelling further

• Recommendations to designate units’ levels of care e.g. BAPM standards (this is already policy in Scotland in the Framework for Maternity Services (2001))

• Proposals to develop managed clinical networks to provide services • Recognition of the need for workforce and resource planning to provide services • The need for more robust data to inform service provision and planning

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Table 1: Summary of reviews from other countries

Country Objectives Process Conclusions & recommendations

England (DoH, 2003)

DoH stakeholder review of neonatal services. Options considered: 1. Regional provision of services (centralisation) 2. Develop regional networks

The expert working group considered: • Views of professionals • Views of parents. • Routine data • Occasional published

evidence

• Develop regional managed clinical networks to deliver neonatal intensive care

• Define the categories of care (proposed adopting BAPM 2001)

• Designate each unit’s level of care

• Resource each unit to its designated level of care

Northern Ireland (Neonatal Service Working Group 2006)

To provide a baseline position for specialist neonatal services activity, to inform future service planning, provision and development.

A project group established to: • Describe current

specialist neonatal service profile, including staffing.

• Describe and analyse existing sources of information

• Compare services to similar countries

• Compile a report on specialist neonatal services in Northern Ireland

• More robust data required • Babies born before 28 weeks

and <1,000g should receive their initial care in a regional unit with 24 hours neonatal cover (BAPM standard)

• Plan services to operate at an average 70% occupancy

• Increase capacity for training nurses

• Develop a managed clinical network

• Develop a regional transport system

Victoria, Australia (Dept Human Services 1998)

To assess the ability of the existing structures and resources to meet current and future demand for neonatal care of an appropriate standard and make recommendations for system improvements.

Stakeholder review including site visits, staff interviews, analysis of routine data and

• Admissions to intensive care, and transfer to local special care units have increased

• A major concern was medical and nursing workforce planning

• Services should be provided as a unified or linked system (network)

• The importance of public health measures to address risk factors for prematurity

• A need for capital funding and funding distribution to reflect case mix

• Consider setting up women and baby units for drug dependency

New Zealand (Ministry of Health 2004)

Ministry of Health review of services provision

Analysis of routine data • The numbers of neonatal cots at each level of care may not reflect need (too few intensive care, too many high dependency)

• To review staffing levels, prioritise training, and reduce turnover

• Need better routine data

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In the England Department of Health (DoH) 2003 review of Neonatal Intensive Care Services major centralisation was rejected for the following reasons:

• Neonatal intensive care is often needed for some weeks • Major centralisation would impose considerable travel and other burdens on

families, and • Capacity and staffing factors.

This DoH report recommended that it is important that babies are cared for as close to home as possible and that only the sickest babies would require care in the more specialist centres. 6.2 Editorials, guidelines and standards The literature search identified one editorial (Turrill 2000) that reviewed the evidence base (to about 1998). It identified the need for better routine data, national definitions to standardise services and recommended regional provision of services. Table 2

Paper Country Methodology Findings Turrill 2000

UK Examines the historical and political basis for current models of service, and makes recommendations to achieve a standardised, provision of services.

Recommends • a regional provision of NICU • the introduction of national and regional

data collection and analysis • national definitions standardising

service criteria

Turrill recommends a centralised regional provision of NIC for a number of reasons:

• Better nurse to babies ratio • Better academic standing and educational provision of doctors and nurses (often

links to university teaching hospitals) • Staff with more experience of high-risk deliveries and neonatal babies • Specialist staff will automatically migrate to ‘centres of excellence’. It is these

staff which are more likely to evaluate an use new technology and treatments • Less recruitment difficulties

The search for evidence also sought guidelines and standards for service provision. The search identified the BAPM Standards for Hospitals Providing Neonatal Intensive Care and High Dependency Care (2001) and Designing a Neonatal Unit (2004). These documents had already been identified and considered in detail by the Neonatal Services Review Subgroup. Thus these documents are not critiqued in this literature review but are considered as part of the services review for which this literature review was conducted. 6.3 Secondary research: literature review One literature review, which sought to characterise and compare the health service systems in USA, Australia, Canada and the UK, was identified.

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Table 3: Summary of secondary research and editorials Paper Country Methodology Findings Critique Thompson 2002

US, Australia, Canada and UK

Systematic literature review 1993 - 2000

Comparison of selected indicators of reproductive care and mortality. The United States has significantly greater neonatal intensive care resources per capita, compared with 3 other developed countries, without having consistently better birth weight-specific mortality.

The study highlights the differences in outcomes between the USA system of health service provision and services such as the universal approach of the NHS which include provision preconception and antenatal care to maximise health outcomes.

6.4 Published research evidence: primary research The primary research on services organisation identified by this literature review comprised:

• Large scale statistical analyses that use routine data to examine the association between service organisation and outcome

• Examination of the association between staffing (numbers and skills) and outcomes

6.5 Association between structure of neonatal services and outcomes for babies This group of six papers, which are detailed below in table 4, all conducted sophisticated statistical analyses of the association between low birth weight and outcomes for neonates. The logistical regression analyses allow the researchers to take other potential risk factors, for example multiple births, into account in the analyses. Collectively these papers represent analysis of nearly 200,000 infants. The findings of these papers are strikingly similar: there is a strong positive association between outcome and unit volume. In other words, in these analyses, babies were more likely to survive to go home if they were treated in units that had large numbers of patients. Thus this provides quite a weight of evidence which argues that centralised regional provision of Neonatal Intensive Care (NIC) results in better outcomes (measured as number of deaths) than a local or district level of provision. Bartels (2006) lends further weight to the evidence in favour of creating larger perinatal centres finding that the increase in mortality rate in small NICUs had the largest impact on survival for infants of < 29 weeks. In Rogowski (2004) the data analysis suggested that survival improved as units grew larger up to an average volume of about 50 very low birth weight admissions per year. This finding may provide a useful bench mark for the review of Scottish neonatal services. In addition a positive association was found between outcome (survival to discharge) and level of care provided by the unit; this second finding was dependent on volume). In other words babies had better survival in units that provided higher levels of care regardless of their volume.

5

It is important to note that these studies are all retrospective analyses of routine data. They cannot account for selection bias, for example that deliveries in larger neonatal units may have better outcomes as a result of having a healthier population, or a better obstetric service. Only one study provides a comparison group and this is between countries which may have many differences other than the nature of their neonatal services. Tucker (2002) suggests that the reduced mortality seen in Australia is due to more than centralisation: and is also due to the highly different volume and specialisation effect together with national recommendations for high levels of clinical and nursing staffing and degree of specialisation and training. However, and these studies are striking in both the numbers of cases that were analysed and in the consistency of their findings.

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Table 4: Summary of primary research Paper Country Study Population Research

methodology Findings

Phibbs 2007

California, USA

48,237 low-birth-weight infants 1991 - 2000 Based on an urban population, does not account for longer distances travel (>2 hours.)

Retrospective, logistic regression analysis of routine data.

Mortality among very-low-birth-weight infants was halved in hospitals with NICUs that had both a high level of care and a high volume of patients. These results suggest a positive relationship between volumes and outcomes and a positive relationship between unit level of care and outcome.

Bartels 2006

Germany Perinatal data for very low birth weight infants born in 1991 to 1999 (n = 7,745) Analyses restricted to infants born at 24 - 30 weeks (n = 4,379).

Retrospective, logistic regression analysis of routine data.

A positive association between the volume of the NICU and 28-day mortality for infants of < 29 weeks.

Rogowski 2004

332 hospitals Vermont USA

Retrospective study of 94,110 very low birth weights (501 – 1,500g), 1995 - 2000.

Retrospective, logistic regression analysis of routine data.

The annual volume of admissions explained <10% of the variation in mortality,

Cifuentes 2002

California 16,732 singletons <2000 g 1992 – 1993.

Logistic regression analysis. Controlled for demographic risks, diagnoses, transfer, and NICU level.

Birth at a hospital with a regional NICU is associated with a lower risk-adjusted mortality than birth at a hospital with no NICU, intermediate NICU of any size, or small community NICU.

Hellera 2002

Germany 582,655 births 1990 – 1999 Outcomes were death within the first 7 days of life (early-neonatal death).

Mortality rates and corresponding 95% CI were calculated according to hospital volume measured by births per year and birth weight categories.

Birth weight-specific mortality rates were lowest in large delivery units and highest in smaller delivery units.

International Neonatal Network, 2000

Scotland Australia

2,621 infants of < 1,500 g or < 31 weeks' gestation admitted to a sample of 8/17 Scottish NICUs and 6/12 tertiary NICUs in New South Wales and Queensland in 1993-1994 5,986 infants of 500 < 1,500g registered as live born in Scotland and Australia (1993-1994).

Risk adjusted cohort study. Population based cohort study (1993-1996)

Risk adjusted mortality was significantly lower in Australian NICUs. Australian units much higher volume. Neonatal mortality rates for very low birth weight or very preterm infants were 20-30% higher in the UK than in Australia.

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6.6 Association between staffing (numbers and skills) and outcomes The UK neonatal staffing study (2002) was a two phase project which sought to assess whether risk-adjusted outcomes of UK neonates are related to:

• Differences in primary organisational characteristics of volumes, staffing levels and workload

• Adherence to national standards of service provision • Measures of staff wellbeing

To address these research questions the study analysed outcomes for a prospective cohort of ~13,515 neonates (all birth weights) admitted from March 1998 to April 1999 to 12, representative, neonatal units in the UK. The study found, following risk-adjustment, that outcomes by patient volume and by clinical or nursing staffing levels were not significantly different in different types of units. The study suggested that there may be an association between units occupancy levels and outcomes however this finding had wide (statistical) uncertainty. The study found that for every 10% increase in occupancy the risk of mortality increased by 9% (confidence interval: 5% to 18%). Infants admitted when the NICU was 50% occupied had about 50% lower odds of dying (confidence interval 5 – 90%). The study found a statistically significant association between higher levels of consultant or nursing provision and lower levels of hospital acquired infections. Later analysis of a subset of the UK Staffing Study data analysis showed that increasing the ratio of nurses with specialist neonatal qualifications to intensive care and high dependency infants to 1:1 was associated with a decrease in risk-adjusted mortality (Hamilton 2007) 6.7 Parents and users experiences Clearly the experience of having a baby in a neonatal unit has a major impact for parents. Bliss, the voluntary agency that supports and campaigns on behalf of parents with premature babies published a survey of their users in 2007. They found that about 64% of parents first knew their baby would need admission to a neonatal unit during labour or after birth. Parents reported reasonable satisfaction and experiences with neonatal services, for example about 64% felt always involved in their babies care, but there was room for improvement in involving parents. Parents reported spending an average £11.23 per day travelling to see their baby, with average lengths of stay in this cohort of 66 days, this accumulated to an average spend per family of about £700. Particular distress was reported when multiples (twins or triplets) were divided between different units. Hawthorne (2006) used qualitative interview based approaches to explore how practitioners and parents share information and care of the babies in 4 units in England. The key points were:

• Parents in neonatal units are distressed when their baby is transferred to another hospital

• Parents in neonatal units can also be upset when their baby is moved within the unit or the hospital

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• Careful preparation needs to be made for the transfer, sharing information with the parents about their baby

• Neonatal units need to design a transfer plan incorporating the parents’ and babies’ emotional needs

Hawthorne (2006) suggests that neonatal networks draw up a care plan with contributions from parents and staff about the parents’ and babies’ psychological as well as medical needs around transfer to another unit. 6.8 Other issues related to service configuration This literature review examined evidence on the association between service organisation and outcomes for neonates. When considering evidence on the configuration of services a number of issues are highly relevant. These include:

• The relationship between low birth weight and socio-economic inequalities • Transfers and transport • Staff training and retention

6.9 Relationship between low birth weight and inequality A ten year study from 1994 to 2003 (Smith 2007) of 55,000 births per year in the former Trent Health region found:

• Substantial socioeconomic inequalities in the incidence of very preterm birth: women from very deprived areas are at twice the risk of very preterm birth as those living in the least deprived areas

• Rises in the number of very preterm births for all groups over the last ten years • That the number of very preterm births could be reduced by 30-40% if the rate of

very preterm births among the least deprived decile was experienced by all women. Consequently rates of perinatal mortality and morbidity would also be considerably reduced

• No evidence of a reduction in inequalities over time 6.10 Transfers and transport The arrangements for transfer of both pregnant women who are at risk of premature delivery, and of neonatal transfers are critical for the provision of neonatal services. Cifuentes (2002) results support the recommendation that hospitals with no, or intermediate, NIC units transfer high-risk mothers with estimated fetal weight of <2000 g to a regional NICU. They advise that babies should be transferred in-utero where possible. Parmanum (2000) and Bennett (2002) report on transfers out of major units. In the main, a neonatal intensive care cot could not be accessed either because the unit was full, or there was staff shortage. Whilst transfer to access higher levels of care (from less specialist local units) is accepted, transfers between specialist units are not regarded as appropriate care. Bennett (2002) examines maternal morbidity and pregnancy outcome from these ‘inappropriate’ emergency transfers in the UK and finds a number of poor outcomes including, inappropriate birth surroundings and a maternal death. It is not possible to determine whether these poor outcomes relate to initial selection of very high risk group of patients or whether clinical outcomes are exacerbated by the transfer. However it seems highly unlikely that the need to transfer patients between specialist units is beneficial.

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Phibbs (1993) found that high-risk women are prepared to travel further to give birth where this will provide better care for their baby:

“While patients tend to prefer hospitals close to home, research has found that high-risk women are willing to travel farther to give birth in a tertiary centre”

Bliss (2007) also raise the issue that long-distance travel should be minimised as the costs on families may impose a financial strain. None of the literature identified provided evidence on the best ways to provide transport systems for either pregnant women or neonates. 6.11 Staff training and retention Kane (2007) describes a rotational staffing programme which aims to provide a continued clinical development pathway for neonatal nursing staff. This initiative was set up in response to the development of service network which led to some units designated to provide high dependency care and not intensive care. There was concern that staff would be attracted to move from the high dependency unit to more specialist units. The rotational working arrangements led to benefits for both high dependency and intensive care units including:

• Enhanced skills • Improved recruitment and retention of staff • Better communication between the units as staff know one another • More open and honest culture because of the on-going movement of staff

between units and their willingness to share knowledge and expertise. • Families benefit as staff familiar to them when they are transferred between units

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References Bartels DB, Wypij D, Wenzlaff P, Dammann O, Poets CF. (2006) ‘Hospital volume and neonatal mortality among very low birth weight infants’. Pediatrics. 117(6):2206-14. Bennett CC, Lal MK, Field DJ, Wilkinson AR. (2002) ‘Maternal morbidity and pregnancy outcome in a cohort of mothers transferred out of perinatal centres during a national census’, British Journal of Obstetrics and Gynaecology ;109 :663-6 BLISS (2007) Handle with care: a review of Scottish neonatal services. British Association of Perinatal Medicine (December 2001). Standards For Hospitals Providing Neonatal Intensive And High Dependency Care and Categories of Babies requiring Neonatal Care (Second Edition) British Association of Perinatal Medicine (2004): Designing a Neonatal Unit Cifuentes, J, Bronstein J, Phibbs, C.S. Phibbs, R.H. Schmitt, S.K., Waldemar, A. C. (2002) Mortality in Low Birth Weight Infants According to Level of Neonatal Care at Hospital of Birth. Pediatrics; 109: 745-751 Department of Health (2003) Neonatal intensive care services - report of the Department of Health Expert Working Group and Review Background Papers Department of Human Services, Victoria Australia. (Dec 1998) Neonatal Services Review. Field D, Hodges, S, Mason, E, Burton P (1990) Survival and place of treatment after premature delivery. Arch Dis Child Fetal Neonatal Ed 66: 408-11 Hamilton, K, Redshaw, M E Tarnow-Mordi, W (2007) ‘Nurse staffing in relation to risk-adjusted mortality in neonatal care’ Archives of Disease in Childhood - Fetal and Neonatal Edition 92:F99-F103 Hawthorne, J., Killen M. (2006) ‘Transferring babies between units: Issues for Parents’ Infant 2006; 2(2): 16-18 Hellera, G, Richardson D.K, Schnellc, R, Misselwitzd, B, Künzele, W, Schmidtf, S. (2002) ‘Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990–1999’ International Journal of Epidemiology ;31:1061-1068 International Neonatal Network, Scottish Neonatal Consultants, Nurses Collaborative Study Group (2000) ‘Risk adjusted and population based studies of the outcome for high risk infants in Scotland and Australia’ Arch Dis Child Fetal Neonatal Ed; 82:F118-F123 (March) Kane, T (2007) ‘Cross-boundary rotational working for neonatal nurses’. Paediatric Nursing. May ;19 (4):36-8 17542321 Ministry of Health (Feb 2004) A review of neonatal intensive care provision in New Zealand Neonatal Services Working Group / Northern Ireland Neonatal Network. (May 2006) Position paper on Specialist neonatal services in Northern Ireland Parmanum J, Field D, Rennie J, Steer P, on behalf of BAPM. (2000) ‘National census of availability of neonatal intensive care’ British Medical Journal (BMJ); 321: 727-9

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Phibbs CS, Mark DH, Luft HS, et al. (1993) ‘Choice of hospital for delivery: a comparison of high-risk and low-risk women’. Health Serv Res. 28:201-222. Phibbs, C. S. Baker, L. C. Caughey A. B. Danielsen, B, Schmitt, S.K. Phibbs, R.H. (2007) Level and Volume of Neonatal Intensive Care and Mortality in Very –Low-Birth-Weight Infants. New England Journal of Medicine 356;2165-2175. Rogowski JA, Horbar JD, Staiger DO, Kenny M, Carpenter J, Geppert J. (2004) ‘Indirect vs direct hospital quality indicators for very low-birth-weight infants’. Journal of the American Medical Association (JAMA) 14; 291(2):202-9. Smith, L K, Draper, E S Manktelow, B N Dorling, J S and Field D J (2007) ‘Socioeconomic inequalities in very preterm birth rates’ Archives of Disease in Childhood - Fetal and Neonatal Edition; 92:F11-F14 Thompson, L.A, Goodman, D.C, Little, G.A. (2002). Is More Neontal Intensive Care Always Better? Insights from a cross-national comparison of reproductive care. Pediatrics 109(6); 1036 - 43 UK Neonatal staffing study group / Tucker et al (2002) ‘Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation’. The Lancet, Volume 359, Issue 9301, Pages 99-107 Turrill BSC, RGN, RM (2000) ‘Is access to a standardized neonatal intensive care possible?’ Journal of Nursing Management 8 (1), 49–56.

Appendix D Extract from: Standards for Hospitals Providing Neonatal Intensive and High Dependency Care (second edition) and Categories of Babies Requiring Neonatal Care. British Association of Perinatal Medicine. December 2001. http://www.bapm.org/documents/publications/hosp_standards.pdf Intensive Care High Dependency Care Special Care These babies have the most complex problems. • Receiving any respiratory support

via a tracheal tube and in the first 24 hours after its withdrawal

• Receiving NCPAP for any part of the day and less than five days old

• Below 1000g current weight and receiving NCPAP for any part of the day and for 24 hours after withdrawal

• Less than 29 weeks gestational age and less than 48 hours old

• Requiring major emergency surgery, for the pre-operative period and post-operatively for 24 hours

• Requiring complex clinical procedures:

• Full exchange transfusion • Peritoneal dialysis • Infusion of an inotrope, pulmonary

vasodilator or prostaglandin and for 24 hours afterwards

• Any other very unstable baby considered by the nurse-in-charge to need 1:1 nursing: for audit, a register should be kept of the clinical details of babies recorded in this category

• A baby on the day of death.

• Receiving NCPAP for any part

of the day and not fulfilling any of the criteria for intensive care

• Below 1000g current weight and not fulfilling any of the criteria for intensive care

• Receiving parenteral nutrition • Having convulsions • Receiving oxygen therapy and

below 1500g current weight • Requiring treatment for

neonatal abstinence syndrome • Requiring specified procedures

that do not fulfil any criteria for intensive care:

• Care of an intra-arterial catheter or chest drain

• Partial exchange transfusion • Tracheostomy care until

supervised by a parent • Requiring frequent stimulation

for severe apnoea.

Special care is provided for all other babies who could not reasonably be expected to be looked after at home by their mother.

Neonatal Nursing Staff The BAPM standards state that all units undertaking neonatal intensive and high-dependency care should be able to demonstrate the required number of appropriately trained and qualified nurses. The current nursing staffing levels BAPM regard as a minimum standard are:

i) Intensive Care: Because of the complexities of care needed for a baby receiving intensive care, there should be 1:1 nursing. Occasionally when a baby is particularly unstable, two nurses will be required. ii) High Dependency Care: A nurse should not have responsibility for the care of more than two babies. iii) Special Care: A nurse should not have responsibility for more than four babies who are receiving Special Care.

Nurses caring for babies receiving any intensive or high dependency care should have post-basic training and hold one of the nationally recognised qualifications.

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2

Regarding medical staffing (it is recognised that this will usually be doctors but appropriately trained skilled advanced neonatal nurse practitioners will increasingly be able to take over some of these roles) the following BAPM standards apply: Medical Consultants

Where a maternity hospital is not intending to provide intensive or high dependency care (Level 1 Unit), there should be a designated consultant paediatrician responsible for the clinical standards of care of newborn babies. Where only high dependency and short-term intensive care is to be provided (Level 2 Unit), the Unit should have one consultant who is responsible for the direction and management of the Unit. There should be 24 hour availability of a consultant or non-consultant career grade doctor with neonatal training. In future those appointed to posts providing cover for the neonatal unit should have had at least one year of specialist training in a post or posts approved for neonatal training. They should maintain their professional development in the care of newborn babies. This should include regular revalidation in Newborn Life Support. Where continuing neonatal intensive care is provided (Level 3 Unit), the unit should be staffed by consultants whose principal duties are to the NICU. All new appointees to such posts should have CCST in paediatrics (neonatal medicine).

Resident medical staff Where only high dependency and short-term intensive care is provided (Level 2 Unit), a resident doctor holding MRCPCH or equivalent, who has completed General Professional Training, must be available. If a paediatric service and a neonatal high dependency service co-exist, staffing arrangements should ensure the immediate availability to the neonatal unit of a professional competent to manage a neonatal emergency when the paediatric service is busy. Where continuing neonatal intensive care is provided (Level 3 Unit), there must be 24-hour resident cover by a doctor who has completed General Professional Training and in addition has experience equivalent to at least one year of ‘core’ Higher Specialist Training in paediatrics, including four months of neonatology. This doctor should be available for the Intensive Care Unit at all times and not be required to cover any other Service. Units undertaking intensive and high dependency care (Level 2 and 3 Units), must have 24-hour cover by an SHO or ANNP whose only responsibilities are to the neonatal and maternity services. In large Neonatal Units, it will be necessary to have more than one SHO or ANNP on duty at all times. Pre-registration House Officers should not provide resident medical cover for neonatal intensive or high dependency care.

The standards conclude that each unit providing neonatal intensive and high dependency care should comply fully with clinical guidelines and undertake:

• Quality assurance • Follow up of high risk survivors • Monitoring of service provision and access • Training and continuing education

Appendix E 1. Epidemiology 1.1 Births in Scotland Statistics from Information Services Division (ISD), show that there were 52,721 live births in

Scotland in 20051, of these approximately 47% were in the West of Scotland, 33% in South

East and Tayside (SEAT) and just over 15% in the North of Scotland.

Live births in Scotland have been steadily rising over recent years from 50,599 in 2002 to

52,721 in 2005. This is a reversal of the downward trend seen in the late 1990’s and in contrast

to previous population predictions.

It should be noted that the General Register Office for Scotland (GROS) recorded 53,849 live

births in Scotland in 20052. The shortfall is approximately 2%. ISD data are derived from

SMR02 (maternity hospital records) and are based on date of discharge from hospital. Unlike

civil registrations, there is no legal requirement to complete the maternity return, and data

collection may under-record. However for the purposes of this report ISD data is used to

ensure consistency with other statistics provided from maternity hospital records. Where other

data are used the alternative source will be highlighted.

1.2 Admissions to neonatal units Around 6,0003 babies, 11% of all live births, are admitted for neonatal care in Scotland each

year4. There is a suggestion from the data that numbers of admissions to neonatal units have

stayed steady, thus there has been a small drop in the proportion of births that are admitted.

Table 1: Babies cared for within intensive and special care units1,2

20023 20033, 2004 2005 Live Births 50,599 50,764 52,335 52,721 Total Number Babies admitted to Neonatal Units 6,150 5,809 5,818 5,853 % of all Births 12.1 11.4 11.1 11.1

1 - Includes special care baby units, high dependency units and intensive care units. There is known to be variation in admission criteria and recording practice. 2 - It is not possible to distinguish between intensive and special care units. 3 - There may be some inaccuracy in the results as two data sets were used. Source: SMR11 & SBR for 2002/2003. SBR for 2004-2006. IR2007-2692

1 ISD Scotland National Statistics. 2006. http://www.isdscotland.org/isd/1022.html 2 General Register Office for Scotland. http://www.gro-scotland.gov.uk/statistics/publications-and-data/vital-events/vital-events-reference-tables-2005/section-3-births.html 3 ISD Scotland National Statistics. Source: SMR11 & SBR for 2002/2003. SBR for 2004-2006. IR2007-2692 4 ISD Scotland National Statistics. http://www.isdscotland.org/isd/1022.html

1

1.3 Preterm births The main groups of newborns that are admitted to neonatal units are those that are born

prematurely (before 37 completed weeks) and those with low birth weights. Scotland has seen

an increase in the proportion of births that are preterm (babies born before 37 weeks gestation)

from 7.3% of total live births in 1995 to 7.9% of total live births in 20055.

Table 2: Trends in Preterm Birth 1995 2000 2002 2003 2004 2005 Total Live Births 60,261 53,872 50,599 50,764 52,335 52,721 Total Preterm Births 4,395 4082 3,867 3,976 4,334 4,174 % of total live births 7.3 7.6 7.6 7.8 8.2 7.9

Source: SMR02, ISD Scotland 2005.

Several factors have contributed to the rise in preterm birth including increasing rates of multiple

births, and more obstetric intervention6. About one in four preterm births occur in multiple

pregnancies and about one in five preterm infants are delivered because of maternal or fetal

complications of pregnancy. In addition, preterm delivery is associated with poor

socioeconomic status of the mother7. There are some marked variations between NHS Boards

ranging from 5.9% to 9.1%. Note that these data are proportions of the total number of

deliveries and are not standardised for maternal age or deprivation.

Table 3: Preterm births by NHS Board, year ending 31 March 2005¹,²,³

NHS Board Area Total Births

Total Preterm Births (before 37 weeks gestation)

% of all births

Argyll and Clyde 3,757 317 8.4 Ayrshire and Arran 3,675 337 9.1 Borders 1,032 61 5.9 Dumfries and Galloway 1,382 104 7.5 Fife 3,772 239 6.3 Forth Valley 3,145 217 6.8 Grampian 5,339 437 8.1 Greater Glasgow 9,637 822 8.5 Highland 2,122 160 7.5 Lanarkshire 6,175 454 7.3 Lothian 8,311 666 8.0 Orkney 182 16 8.7 Shetland 232 17 7.3 Tayside 3,789 285 7.5 Western Isles 221 19 8.5

1 - Excludes home births and births at non-NHS hospitals. 2 - Where four or more babies are involved in a pregnancy, birth details are recorded only for the first three babies delivered. 3 - Data for Argyll and Clyde NHS Board are incomplete affecting mainly Inverclyde residents. Source: SMR02, ISD Scotland

5 ISD Scotland National Statistics (2005), 'All births by term and birthweight'. Table 7 6 BMJ Editorial. 2006. ‘Why should preterm births be rising?’ BMJ 2006: 332; p924-5 7 K Moser et al. 2003 ‘Social inequalities in low birthweight in England and Wales: trends and implications for future population health.’. J Epidemiol Community Health

2

1.4 Low Birth Weight In addition to preterm delivery, the other major reason for admission to a neonatal unit is low

birth weight. Low birth weight is defined as a weight of <2,500g, very low birth weight is

<1,500g. Low birth weight may result from preterm delivery, from poor intrauterine growth or,

often both. Factors associated with low birth weight include maternal smoking, maternal age

(older and younger mothers are more likely to have a low birth weight baby), deprivation, low

pre-pregnancy maternal weight, drug/alcohol use, hypertension and multiple births.

These show trends in opposing directions: the increase in the proportion of babies born to older

mothers would tend to produce an increase in proportion of low birth weight babies. However,

the decrease in maternal smoking, and in the proportion of babies born to younger mothers

(under 25 years) would tend to produce a decrease in the proportion of low birth weight babies8.

The rate of low birth weight (<2,500g) in Scotland has fluctuated around 6% of total births in the

last 10 years. As with preterm births there are significant variations in the proportion of births

that are of low birth weight rates among NHS Boards9.

Table 4: All Births by NHS Board, term and birth weight, year ending 31 March 2005

NHS Board Area

Total Births

Total Preterm Births (before 37 weeks gestation)

% of preterm Very Low Birth weight (under 1500g)

% of preterm Low Birth Weight

(1500 - 2499g)

Argyll and Clyde 3,757 317 19.2 45.4 Ayrshire and Arran 3,675 337 16.6 46.9 Borders 1,032 61 13.1 47.5 Dumfries and Galloway 1,382 104 8.7 48.1 Fife 3,772 239 20.9 46.4 Forth Valley 3,145 217 19.8 47.0 Grampian 5,339 437 15.1 41.2 Greater Glasgow 9,637 822 15.5 46.5 Highland 2,122 160 15.0 43.8 Lanarkshire 6,175 454 13.9 46.3 Lothian 8,311 666 18.8 48.6 Orkney 182 16 12.5 37.5 Shetland 232 17 11.8 52.9 Tayside 3,789 285 13.0 48.1 Western Isles 221 19 5.3 47.4

8 ISD Scotland National Statistics Births and babies. Birthweight and Gestation http://www.isdscotland.org/isd/information-and-statistics.jsp?pContentID=1461&p_applic=CCC&p_service=Content.show& 9 ISD Scotland National Statistics (2005), 'All births by term and birth weight'. Table 7

3

NHS Board Area

Total Births

Total Full term Births (37 weeks gestation or above)

% of full term Very Low Birth weight (under 1500g)

% of full term Low Birth Weight

(1500 - 2499g)

Argyll and Clyde 3,757 3,440 0.1 2.8 Ayrshire and Arran 3,675 3,338 - 2.3

Borders 1,032

971 - 3.5 Dumfries and Galloway 1,382 1,278 - 1.9 Fife 3,772 3,533 - 3.4 Forth Valley 3,145 2,928 - 2.8 Grampian 5,339 4,902 0.0 2.0 Greater Glasgow 9,637 8,815 0.1 3.3 Highland 2,122 1,962 0.1 2.7 Lanarkshire 6,175 5,721 0.0 2.8 Lothian 8,311 7,645 - 2.4 Orkney 182 166 - 1.2 Shetland 232 215 - 0.9 Tayside 3,789 3,504 0.0 2.3 Western Isles 221 202 - 3.0

1 - Excludes home births and births at non-NHS hospitals. 2 - Where four or more babies are involved in a pregnancy, birth details are recorded only for the first three babies delivered. 3 - Data for Argyll and Clyde NHS Board are incomplete affecting mainly Inverclyde residents. p – Provisional Source: SMR02 2. Future Needs for Neonatal Services

2.1 Projected births At present Scotland has a rising birth rate and a rising preterm birth rate, thus the numbers of

admissions are likely to rise in the medium term. GRO projects a continuing rise in births to

57,600 births in 201010, from 2015 onwards births are projected to start to fall.

The 2006 projections from GRO are about 12% higher than the 2004 projections, although the

long term trend is still of long-term decline.

Table 5: Projected births (GRO 2006-based), Scotland 2010-11 2015-16 2020-21 2025-26 2030-31 2006 based 57,600 56,000 54,500 52,200 50,300 2004 based 51,500 51,400 50,800 48,700 46,200

* Rounded to nearest 100

These Scotland wide data show some interesting variations when examined at Health Board

level. For example, Orkney is projected to remain stable at around 190 births per annum for the

next decade. The previous 2004 based projections estimated a decline from 150 to 130 over

the same period. In other words, births in 10 years time will be 50% higher than previously

10 General Register Office for Scotland. http://www.gro-scotland.gov.uk/statistics/publications-and-data/vital-events/vital-events-reference-tables-2005/section-3-births.html

4

5

modelled. Long term to 2030, Edinburgh, Argyle and Clyde and the Borders seem to be the

only areas where the 2006-based projections have made downwards revisions.

2.2 Changing clinical need In the past 20-30 years technological and pharmacological advances in neonatal care have

improved outcomes for babies born at very low gestations. This increases workloads as babies

who would not have survived previously are now doing so and require more intensive care and

care for longer periods of time. It should also be noted though, that some babies born at a

higher gestation (35+ weeks) that were previously admitted to neonatal services may not

routinely require admission and may now be cared for in transitional care facilities or on the post

natal ward.

2.3 Changing maternal age Over the last ten years Scotland has seen a marked rise in the proportion of births that are to

older women demonstrated in table 6 below.

Table 6: All live births by age of mother Total live births % <35 years % 35+ years

1996 59,344 89 11 1997 58,323 88 12 1998 58,389 87 13 1999 56,589 86 14 2000 54,114 85 15 2001 52,595 84 16 2002 50,858 83 17 2003 51,010 82 18 2004 52,657 81 19

2005 p 52,974 80 20 1 - Excludes home births and births at non-NHS hospitals. 2 - Birth details are recorded only for the first three babies delivered. 3 - Includes births where age of mother is unknown. p - Provisional. Source: SMR02, ISD Scotland

Older maternal age may be associated with pre-existing ill health, infertility interventions,

multiple births, complications of pregnancy, and an increased risk of adverse outcomes, which

as stated earlier can increase the demand for neonatal care.

The changing demographic make up of the population of Scotland also impacts on workload in

a variety of ways to meet the differing needs of our multi-cultural society.

Appendix F Findings of Review Process 1. Neonatal unit questionnaire The Neonatal sub-group undertook a bespoke questionnaire review of all the neonatal units in

Scotland. Data on physical numbers of cots, workload, staffing and access to other facilities in

2005 were collected. Thanks to the cooperation and hard work of all the neonatal unit staff a

100% return rate was achieved, a copy of the questionnaire can be found at Appendix B.

2. Levels of Care Units were asked which level of care they provided. These self reported levels were compared

to the level of care that would be assigned to each unit on the basis of British Association of

Perinatal Medicine (BAPM) standards (based on professional judgement following visits to

units). The BAPM guidelines are described in Appendix D. Amongst their recommendations

they state that a unit providing intensive care should be staffed with a 1:1 ratio of nurse to

intensive care neonate, and that the unit should have 24 hour cover by consultants whose

primary duty is to the neonatal unit.

There were differences between level of care provision in each unit according to BAPM

standards and that self reported. Several units did not self designate a level, where units did

there was a tendency to report a higher level that BAPM standards would suggest.

Table 1: Unit designation of level of care

By BAPM Self Reported West of Scotland Royal Alexandra Hospital, Glasgow Level 2 Level 1 Southern General, Glasgow Level 2 Level 3 The Queen Mother’s, Glasgow Level 3 Level 4* Princess Royal, Glasgow Level 3 Level 3 Wishaw General Level 3 Level 3 Ayrshire Maternity Hospital Level 2 Level 3 Dumfries and Galloway Royal Infirmary Level 1 Level 2 South East and Tayside Ninewells Hospital, Dundee Level 3 Level 3 Forth Park, Kirkcaldy Level 2 Level 3 Simpson Centre for Reproductive Health Level 3 St John’s, Livingston, Level 1 Stirling Royal Infirmary Level 2 Borders General Level 1 Level 2 North of Scotland Aberdeen Maternity, Level 3 Level 3 Raigmore Hospital, Inverness Level 2 Dr Gray’s, Elgin Level 1

* Includes neonatal surgery

1

3. Physical Cot Space Units were asked about their physical establishment. In other words the physical capacity for

cots their unit had, broken down by level of care (Special Care (SC); High Dependency Care

(HDC) and Intensive Care (IC)) and then the number of theses cots that they could staff, again

broken down into levels of care.

There were 347 physical cot spaces in the 16 units in 2005; unit size ranged from 44 to 4 cots.

The units self reported 67 intensive care cots, 22 high dependency care cots and 214 special

care cots. One unit could not distinguish between SC, HDC and IC cots.

Of those units that specified cots based level of care, most stated that physical cot numbers

were determined by hereditary/historical factors, some stated that it was calculated using BAPM

standards or local calculations.

Table 2: Physical Cot Spaces Special

Care High

Dependency Care

Intensive Care

Total

Aberdeen Maternity Hospital 21 7 10 38 Ninewells Hospital, Dundee 14 3 4 21 Simpson Centre for Reproductive Health

44

St John's Hospital, Livingston 14 0 0 14 Borders General 8 2 0 10 Stirling Royal Infirmary 15 2 5 22 Raigmore Hospital 8 1 2 11 Royal Alexandra Hospital 16 0 4 20 The Queen Mother's Hospital 18 0 10 28 Princess Royal , Glasgow 23 0 10 33 Wishaw General Hospital 22 0 8 30 Dumfries & Galloway Royal Infirmary 9 0 2 11 Ayrshire Maternity Hospital 11 4 5 20 Dr Gray's, Elgin 4 0 0 4 Southern General, Glasgow 17 1 3 21 Forth Park, Kirkcaldy 14 2 4 20 Scotland 214 22 67 347

Staffed Cots From data supplied, 306 of the 347 cots were staffed, approximately 12% less than the potential

physical space available.

Four units were unable to breakdown staffed cots by level of care, furthermore, several stated

the numbers provided were approximations and that the numbers in each level vary depending

2

on the current workload. One unit stated they staffed to 70% occupancy and another said to

80% occupancy.

Table 3: Staffed cot spaces

Special Care

High Dependency

Care

Intensive Care

Total

Aberdeen Maternity Hospital 16 7 10 33 Ninewells Hospital, Dundee 14 3 4 21 Simpson Centre for Reproductive Health 24 8 7 39 St John's Hospital, Livingston 10 0 0 10 Borders General 8 2 0 10 Stirling Royal Infirmary 22 Raigmore Hospital 11 Royal Alexandra Hospital 16 0 4 20 The Queen Mother's Hospital 12 7 19 Princess Royal , Glasgow 7 0 16 23 Wishaw General Hospital 14 0 8 22 Dumfries & Galloway Royal Infirmary 9 0 2 11 Ayrshire Maternity Hospital 20 Dr Gray's, Elgin 4 - - 4 Southern General, Glasgow 17 1 3 21 Forth Park, Kirkcaldy 14 2 4 20 Scotland 165 23 65 306

4. Population estimated need for cots BAPM standards state that there should be 0.75 intensive care cots per 1,000 birth population,

0.7 cots high dependency care per 1,000 and 4.4 special care cots per 1,0001. This benchmark

was used to compare current cot provision in Scotland (using the questionnaire reported staffed

cot numbers) to the number of cots that would be expected to meet BAPM recommendations.

This analysis suggests that in Scotland we provide more that the recommended number of

intensive care/high dependency cots (by an estimated 19 cots) but are under the recommended

number of special care level cots (by an estimated 42 cots). This should be examined at a

regional level in the context of networks of care.

1 BAPM. 2004. Designing a Neonatal Unit. Report for the British Association of Paediatric Medicine. May 2004

3

Table 4: Recommended Configuration on Neonatal Cots

Board Population (2005)

Births (2005)

Recommended Cot numbers [ BAPM

Standards]

Current Physical

Cot Spaces

Current Staffed Cot Provision

Ayrshire & Arran 367,950 3,576 2.7 IC

2.5 HDC 15.8 SC

5 IC 4 HDC 11 SC

5 IC 4 HDC 11 SC

Borders 109,270 1,013 0.8 IC

0.7 HDC 4.4 SC

0 IC 2 HDC 8 SC

0 IC 2 HDC 8 SC

Dumfries & Galloway 147,930 1,410

1.1 IC 1.0 HDC 6.2 SC

2 IC 0 HDC 9 SC

2 IC 0 HDC 9 SC

Fife 354,519 3,335 2.5 IC 2.3 HC 14.5 SC

4 IC 2 HDC 14 SC

4 IC 2 HDC 14 SC

Forth Valley 281,764 3,221 2.4 IC 2.2 HC 14.1 SC

5 IC 2 HDC 15 SC

5 IC 2 HDC 15 SC

Grampian 524,000 5,466 4.1 IC

3.9 HDC 24.2 SC

10 IC 7 HDC 21 SC

10 IC 7 HDC 16 SC

Greater Glasgow & Clyde 867,083 15,198

11.4 IC 10.6 HDC 66.9 SC

27 IC 1 HDC * 74 SC

21 IC 1 HDC

61.7 SC

Highland 301,340 2,327 1.7 IC

1.6 HDC 10.1 SC

2 IC 1 HDC 12 SC

2 IC 1 HDC 12 SC

Lanarkshire 556,114 4,959 3.8 IC

3.5 HDC 22 SC

8 IC 0 HDC 22 SC

8 IC 0 HDC 14 SC

Lothian 787,504 9,054 6.8 IC

6.4 HDC 40 SC

**58 Cot spaces in

total

7 IC 8 HDC 24 SC

Tayside 387,908 4,354 3.3 IC

3.1 HDC 19.4 SC

4 IC 3 HDU 14 SC

4 IC 3 HDU 14 SC

Orkney 19,500 182 0.2 IC

0.1 HDC 0.9 SC

0 0

Shetland 21,940 218 0.2 IC

0.1 HDC 0.9 SC

0 0

Western Isles 26,260 222 0.2 IC

0.1 HDC 0.9 SC

0 0

All Scotland 4,753,082 54,535 41.2 IC

38.1 HDC 240.3 SC

~77 ** IC ~32** HDC 230+* SC

68 IC 30 HDC 198 SC

*Some units do not differentiate between IC and HDC provision ** Lothian did not provide a breakdown of Cot allocation by level. For this analysis 10 Cots were assigned to intensive care, 10 to high dependency and 230 to special care.

4

5. Admissions In response to the questionnaire the units reported 7,846 admissions. This contrasts with the

5,853 babies in centrally recorded admissions in ISD’s data; a difference of about 2000

admissions. The higher number of admission episodes may be partly due to ‘double counting’

of babies are transferred between units, or readmitted after discharge home. In addition data in

the questionnaire relate to the calendar year 2005, whereas the ISD data is for the year ending

31 March 2006.

It is not possible to conclude which data source is more accurate: there are acknowledged

issues over the completeness of the SMR returns used by ISD, and around the quality of self

reported data provided.

The questionnaire returns reported admissions of 422 babies of <28 weeks gestation and 800

infants with a birth weight <1500g. SBR data recorded 290, and 685 admissions respectively.

The self reported data from the questionnaires on clinical activity (gestations, birth weight,

ventilation days etc) was examined but due to discrepancies in data and the inability of some

units to provide detailed figures no further meaningful analysis was possible. This level of data

is also not held centrally at present.

6. Occupancy ISD provided routine data on average occupied cots. This data was used to calculate average

occupancy percentages using two different denominators: the analysis was performed firstly

using ISD data on total number of cots, and again using self reported data on staffed cots.

These analyses suggest that ISD data slightly overestimates that number of cots available, and

so slightly underestimates occupancy.

The average occupancy in Scotland, based on units estimates of number of staffed cots, is

estimated to be about 71%. BAPM recommendations that services should be planned for

average occupancy of 70%.

5

Table 5: Estimated Average Occupancy Levels

ISD Average occupied

cots

ISD Number of cots

Unit reported staffed

cots

Average occupancy

/ ISD number cots (%)

Average occupancy / Unit reported

number staffed cots (%)

Ayrshire & Arran 16 25 20 64 80 Borders 3 8 10 37 30 Dumfries & Galloway

7 12 11 58 64

Fife 9 18 20 50 45 Forth Valley1 3 15 22 20 14 Grampian 24 38 37 63 65 Greater Glasgow & Clyde

69 97 83 71 83

Highland 10 12 11 83 91 Lanarkshire 19 22 22 86 86 Lothian 40 58 49 68 82 Tayside2 16 21 21 76 76 Scotland 216 326 306 66 71

1. - Data for NHS Forth Valley is under recorded centrally. Local information sources indicate an additional 15 special care cots are available for neonatal care but the occupancy of these cots is not identifiable from the central return 2. - Data for NHS Tayside is under recorded on the central return for aggregate hospital statistics (ISD(S) 1). An occupancy rate for 2005, 2006 and 2007 has been taken from the NHS Tayside return for the Scottish Health Service Costs publication. The data for this publication is sourced from local hospital systems so should align closely with the data expected on the central ISD(S) 1 return Neonatal special care usually, but not always, takes place in a neonatal unit. Neonatal cots providing special care and which are located outwith a neonatal unit cannot be explicitly identified from the national dataset and so are excluded from the occupancy figures shown in the table

To achieve a Scotland average of 70% occupancy, rough estimation of needing ten more cots

(to give total of 316) however this headline figure needs fuller examination to explore the level of

cots required and their location.

7. Support Services BAPM recommend that Level 3 units should have defined lines of communication and access to

a number of specialist services and diagnostic facilities, although this does not necessarily need

to be provided onsite. It should also be noted that Level 1 units would not be expected to have

all of these facilities.

The questionnaire sought data on ‘on-site’ access to a number of diagnostic services. It can be

seen that there is no clear pattern between level of care and on site access to diagnostic

facilities. It is likely that units will have access to these services elsewhere, although there may

not necessarily be formal lines of communication established.

6

Table 6: Level 3 units onsite support services

X-R

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St

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Ultr

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CT

scan

Full

lab

serv

ices

EEG

Aberdeen Maternity, Grampian

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Ninewells Hospital, Dundee

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Simpson Centre for Reproductive Health*

Yes Yes No Yes Yes No No Yes Yes

The Queen Mother's Hospital*

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Princess Royal, Glasgow

Yes Yes No Yes Yes No No Yes No

Wishaw General Hospital

Yes Yes No Yes Yes Yes Yes Yes No

*Provide neonatal surgery (in Edinburgh surgery is undertaken in the RHSC which is located in a different part of the city) Table 7: Level 2 units onsite support services

X-R

ays

Rad

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gist

Bar

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St

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Ultr

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nd

cran

ial

Ultr

asou

nd

othe

r

MR

I sca

n

CT

scan

Full

lab

serv

ices

EEG

Stirling Royal Infirmary

Yes Yes Yes Yes Yes No Yes Yes No

Raigmore Hospital, Inverness

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Royal Alexandra Hospital

Yes Yes Yes Yes Yes No No Yes No

Ayrshire Maternity Hospital

Yes Yes No Yes Yes Yes Yes Yes Yes

Southern General Yes No No Yes No No No No Yes Forth Park Yes Yes No Yes Yes Yes Yes Yes Yes

Table 8: Level 1 units onsite support services

X-R

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Rad

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t

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St

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ial

Ultr

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nd

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n

CT

scan

Full

lab

serv

ices

EEG

St John's Hospital, Livingston

Yes Yes No Yes Yes No No Yes No

Borders General Yes Yes Yes Yes Yes Yes Yes Yes No Dumfries & Galloway Royal Infirmary

Yes Yes No Yes Yes No Yes Yes No

Dr Gray's, Elgin Yes Yes Yes Yes Yes No Yes Yes No

7

8. Other Facilities Fifteen units stated that they can provide short term accommodation, of these nine can provide

long term accommodation for parents. Only five of the units stated that they have dedicated

transitional care cots within their establishment. Fourteen had a family room available and

13 had a bereavement room. All units had a dedicated room to allow mothers to breast feed or

express breast milk, and 15 had a breastfeeding advisor. Eleven units provided a community

liaison service and 14 have social work input. Twelve units had a counselling room, but only

five of the units reported that they have a dedicated counsellor.

Table 8: Other facilities Number of units % Accommodation - short term 15/16 94 Accommodation - long term 9/16 56 Breastfeeding advisor 15/16 94 Family room 14/16 88 Social work input 14/16 81 Bereavement room 13/16 81 Counselling room 12/16 75 Community liaison service 11/16 69 Counsellor 5/16 31 Transitional care facilities 5/16 31

9. Workforce There were 72.8 whole time equivalents (WTEs) provided by consultants who work on neonatal

units reported. However, only 37.6 WTEs were provided by consultants dedicated to

neonatology alone. Only 8/16 units reported dedicated neonatal consultants.

Eight units report a separate neonatal consultant rota, ten a separate neonatal ‘middle grade’

rota and ten a separate junior doctor/ANNP rota. These rotas will be markedly affected by the

European Working Time Directive and Modernising Medical Careers.

8

Table 9: Medical Staffing

WTE Consultants

WTE Consultants dedicated to

Neonatal Services

WTE Trainee Medical

Staff

Separate neonatal

Consultant on-call rota

Dedicated neonatal middle grade rota

Dedicated neonatal

junior rota

Aberdeen Maternity Hospital

6 6 16.86 Yes Yes Yes

Ninewells Hospital, Dundee

6 3.7 10 Yes Yes Yes

Simpson Centre for Reproductive Health

6.5 6.5 17 Yes Yes Yes

St John's Hospital, Livingston

5 12 No No No

Borders General

5 0 6 No No No

Stirling Royal Infirmary

5 16.6 No No No

Raigmore Hospital

5.5 0 11.5 No No No

Royal Alexandra Hospital

8.6 19 Yes Yes Yes

The Queen Mother's Hospital

4.8 3.8 11 Yes Yes Yes

Princess Royal, Glasgow

4.4 4.4 14 Yes Yes Yes

Wishaw General Hospital

4.2 4.2 13 Yes Yes Yes

Dumfries & Galloway Royal Infirmary

5 0 No No No

Ayrshire Maternity Hospital

6 0 No Yes Yes

Dr Gray's, Elgin

4 1 4 No No No

Southern General

2.8 0 Yes Yes Yes

Forth Park, Kirkcaldy

2 0.5 No Yes Yes

Total 72.8 37.6 151.4 8 10 10 47% 59% 59%

Table 10: Age range of medical consultants/staff grades

Age Range Total Number of Staff

30-39 years 32 40-49 years 39.2 50-59 years 23.2 >60 years 8

9

Throughout the 16 units there were 26.43 WTEs of advanced neonatal nurse practitioners

(ANNPs), and 323.33 WTEs of neonatal nurses/midwives.

Work needs to continue to balance staffing with capacity and activity and the results of the

Nursing and Midwifery Workload and Workforce Planning Programme (NMWWPP) when they

are available.

Table 11: Nursing and midwifery staffing

WTE

AN

NPs

From

whi

ch

budg

et?

WTE

AN

NPs

in

trai

ning

From

whi

ch

budg

et ?

Num

ber o

f W

TE N

ursi

ng/

Mid

wife

ry s

taff

Com

mun

ity

liais

on

serv

ice?

WTE

war

d ad

min

istr

ativ

e su

ppor

t

Aberdeen Maternity Hospital 2.91 Special

Nursing 0 Nursing 64.33 1

Ninewells Hospital, Dundee 1 ANNP

budget 2.8 51.8 Yes 1

Simpson Centre for Reproductive Health 0 0 98.7 3 WTE 2.36

St John's Hospital, Livingston 2 0 Nursing 19.43 No 0

Borders 0 0

Stirling Royal Infirmary 1.54 Nursing 43.97 No 0.6

Raigmore Hospital 3 Nursing 1 26.18 2 WTE 0.4

Royal Alexandra Hospital 4.72 0.76 Nursing 36 2 WTE 1

The Queen Mother's Hospital 2 Midwifery 62.98 1 WTE 1.3

Princess Royal Maternity 2

Designated medical budget

0 66.58 1 1

Wishaw General Hospital 1 Nursing 1.4 Nursing 60.7 Yes 2.72

Dumfries & Galloway Royal Infirmary 3 Nursing 0 17.6 Yes 0

Ayrshire Maternity Hospital 5.8 Nursing/

midwifery 0 Nursing/ midwifery 54.28 1 WTE 1

Dr Gray's, Elgin 0 No 0

Southern General 0 39.36 0.66

Forth Park 1 Nursing 2 Nursing 29.5 No 0

Total 26.43 11.5 671.41

10

Table 12: Nursing Staff Grade, Registration and Qualifications

Gra

de:

Num

ber

WTE

Prof

essi

onal

R

egis

trat

ion

RN

(adu

lt)

RN

(chi

ld)

RM

Num

ber w

ith

no n

eona

tal

qual

ifica

tion

Num

ber

Qua

lifie

d in

Sp

ecia

lty

Oth

er

neon

atal

qu

alifi

cat-

ions

e.g

. A

NN

P

Vaca

ncie

s

A/B 36 27.9 0 0 0 4 0 0 0.45 C 14 10.15 0 0 0 3 0 0 1.16 D 44 38.67 6 14 2 27 12 0 3.6 E 136 108.38 39.64 23.6 58.3 34.64 105.6 0 3.07 F 165 137.89 75 7 97.08 17.08 137.64 7 2.37 G 47 44.08 29 5.8 33 0 45.8 5 0.23 Other 31 25.53 17 0 30 7 18 1 0 GRADE TOTAL 473 392.6 166.64 50.4 220.38 92.72 319.04 13 10.88 And/or Band 2/3 48 32.6 0 0 0 0 0 0 3 4 23 24.32 0 0 0 8.6 0 0 0 5 72 52.1 35 40.35 9.24 31.35 28.24 0 0 6 306 243.42 135.45 24.87 234.46 69.54 218.64 6 8.1 7 54 48.91 26 7 46.2 0 50.2 11 0.8 Other 8 9.8 7 1 9 0 9.8 5.8 0 BAND TOTAL 511 411.15 203.45 73.22 298.9 109.49 306.88 22.8 11.9

Table 13: Age range of nursing and midwifery staff

Age Range Total Number Total WTE

<20 years 0 1 20-29 years 135 79.53 30-39 years 187 105.16 40-49 years 363 208.78 50-59 years 139 84.51 >60 years 29 12.77

11