Maternity Services Action Group (MSAG) Neonatal Services Sub Group. Review of Neonatal Services in Scotland

Transcription

1 Maternity Services Action Group (MSAG) Neonatal Services Sub Group Review of Neonatal Services in Scotland November

2 Table of Contents Executive Summary... 3 Introduction Neonatal Services Review Aim Remit Process... 8 Background Establishing the Maternity Services Action Group The Policy Context Neonatal Services in Scotland Why Change is Needed Now Published Evidence on Neonatal Services Standards for Neonatal Services Literature Review Epidemiology Births and Neonatal Admissions in Scotland Future Needs for Neonatal Services Findings of Review Process Results from the Neonatal Unit Questionnaire Professional views Nursing and Midwifery Workload and Workforce Planning Project Education and Training Neonatal transport Parental perspectives Conclusions and recommendations Clinical standards Service networks Staffing levels and cot numbers Pathways of care and transfers Parent care and involvement Data Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Membership of the Neonatal Sub-group Neonatal Unit Questionnaire Literature Review BAPM Standards Epidemiology Responses from Neonatal Units 2

3 Executive Summary Introduction The Scottish Government Maternity Services Action Group (MSAG) established a Neonatal Services Review Sub-group in December 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. 3

4 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 cover 1 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. 4

5 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 5

6 To support the early repatriation of babies admitted to geographically distant units, the subgroup 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 subgroup: 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 6

7 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 7

8 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 . The report was presented to MSAG in September 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) 8

9 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. 9

10 Background 2.1 Establishing the Maternity Services Action Group In February 2001 the Scottish Executive published A Framework for Maternity Services in Scotland 2. 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 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 Health 5 - 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 Subgroup 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 A Framework for Maternity Services in Scotland 3 Scottish Executive Health Department Expert Group on Acute Maternity Services: Implementing a Framework for Maternity Services in Scotland 4 Scottish Executive Health Department Building a Health Service Fit for the Future, May Scottish Executive Health Department Delivering for Health, November

11 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 11

12 The Better Health, Better Care: Action Plan 6 restates a commitment to provide familycentred 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 Today 7 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 million 8 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 Better Health, Better Care: Action Plan 7 Scottish Government Health Directorates Better Health, Better Care: Planning Tomorrow s Workforce Today 8 General Register Office for Scotland (GROS). 12

13 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 13

14 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. 14

15 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 Dedicated Level of Care 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 15

16 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 16

17 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 (2 nd 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 17

18 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 Medicine 9 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 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 Scotland 10 ) Proposals to develop managed clinical networks to provide services 9 BAPM Designing a Neonatal Unit. Report for the British Association of Paediatric Medicine. May Scottish Executive Health Department A Framework for Maternity Services in Scotland 18

19 Recognition of the need for workforce and resource planning to provide services The need for more robust data to inform service provision and planning 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 paper 11 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 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 units 12. 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 Indirect vs. direct hospital quality indicators for very low-birth-weight infants. Journal of the American Medical Association (JAMA) 14; 291(2): 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

20 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 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;

21 Epidemiology 4.1 Births and Neonatal Admissions in Scotland There were 52,721 live births in Scotland in 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, 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 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 , 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 ISD Scotland National Statistics. Source: SMR11 & SBR for 2002/2003. SBR for IR ISD Scotland National Statistics (2005), 'All births by term and birth weight'. Table 7 17 General Register Office for Scotland 21

22 In the past 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. 22

23 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: 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 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 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 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%. 23

24 5.1.5 Support Services There was no clear pattern between level of care and on site access to diagnostic facilities Other Facilities Five of the 16 units stated that they have dedicated transitional care cots and five had a dedicated bereavement counsellor 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 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 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 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 Designing a Neonatal Unit. Report for the British Association of Paediatric Medicine. May

25 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

26 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 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 The interim data has now been collated and was returned to each NHS Board in March Discussions will be held in NHS Health Boards and consideration will be given to staffing requirements for the individual areas. 26

27 5.4 Education and Training 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 subspecialise 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 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

28 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 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 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 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

29 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 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 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

30 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) 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 A further two started in February 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 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

31 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 hours 1 Air West East North Total (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 ; 19 BLISS Small babies, short changed? Are we ensuring the best start for babies born too soon in Scotland? 31

32 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. 20, 21 Subsequent reports 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 Arch Dis Child, Fetal & Neonatal Ed. 92: F Gill et al Perinatal transport: problems in neonatal intensive care capacity. Arch Dis Child Fetal &Neonatal Ed 2004; 89: F