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The reorganisation of neonatal services in England has helped improve care for premature and low birth weight babies with fewer babies travelling long distances for suitable treatment. But, according to the National Audit Office, further improvements to the service are being limited by shortages in nursing staff, a lack of cots in the right place at the right level of care and a lack of widespread specialist 24 hour transport.

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Every year around 10 per cent, or 60,000, newborn babies require some form of specialized neonatal care. And these numbers are increasing, up 5 per cent between 2005 and 2006, due to an increase in the proportion of women with high risk factors such as high or low maternal age, obesity, ethnic origin, deprivation and assisted conception such as IVF. In 2006-07, some £420 million was spent on running the 180 neonatal units in England, which are organized into 23 managed clinical networks.

Today’s report identified a number of improvements since the Department announced the reorganization of neonatal services into networks in 2003. There has been a reduction in long distance transfers of mothers and babies, with only 3.4 per cent of babies across England admitted to units outside of their network. Overall, 17 networks are meeting the target to treat babies within their network and the consistency, communication and co-ordination of care within and between the networks has improved. The number of cots has also increased from 3,243 to 3,521. Neonatal units have made strides in considering the needs of parents and involving them in their babies care. Parents are mostly very happy with the specialist care and expertise their babies receive.

In 2005, England’s neonatal mortality rate was 3.5 deaths per 1,000 live births, similar to other developed countries. But the report found that this figure masks wide variations across the country. The South West Midlands had the highest mortality rate of 4.8 deaths per 1,000 live births, compared to Surrey and Sussex with 1.8 deaths per live 1,000 births. More work is required to determine the contribution that different socio-economic, ethnic, demographic, cultural and service factors are making to these variations in mortality rates.

The report also highlighted shortages in the numbers of neonatal nurses. On average, each unit had nearly three nursing vacancies for nurses qualified in neonatal care. Only half of units met the British Association of Perinatal Medicine (BAPM) professionally developed standard for high dependency care of one nurse to two babies, and only 24 per cent met the standard for intensive care of one nurse to one baby. The vast majority of level three (intensive care) units, which require a 1:1 ratio of nurses to babies for the whole unit, did not meet the standards for intensive care.

Cots for the right level of care are not always available, resulting in units having to close and babies being cared for in the wrong places on occasions. On average, each unit had to close to new admissions once a week, the most common reasons being a lack of cots or skilled nursing staff. Nearly a third of units had to care for a baby who should have been transferred to a higher level of care and just over half looked after an improving baby who was ready to be transferred but could not because a receiving cot was not available. In 2006-07, nearly a third of neonatal units operated above the BAPM recommended occupancy rate of 70 per cent and three units operated above 100 per cent. High occupancy rates could have consequences for patient safety, for example due to increased risk of infection or inadequate levels of care.

Neonatal transport is an essential element of networked neonatal care, with all bar one providing some form of specialist transport during day time working hours, but only half of networks providing specialist transport services 24 hours a day seven days a week. Few transport services have separate staffing arrangements from the clinical inpatient services meaning that staff have to leave the unit to accompany a baby on a transfer. Three quarters of units experienced delays in moving babies and 44 per cent believed that care was compromised as a result.

The report concludes that the cost of neonatal services as a whole are not fully understood and there is a mismatch between costs and charges. Also charges per day for an intensive care cot varied from £173 to £2,384. The reorganization of care into neonatal networks has improved the co-ordination and consistency of services pointing to increased effectiveness, however there is still capacity and staffing problems and a lack of clear data on outcomes. In addition, the variable financial management information makes it difficult to judge the economy and efficiency of the service.

The NAO recommends that NHS and Foundation Trusts need to improve their financial management information. Commissioners, in conjunction with networks and Strategic Health Authorities, should commission all neonatal care services together and in particular examine the relative cost-effectiveness of the different transport options currently in place. In addition, NHS and Foundation Trusts should develop a targeted action plan to address neonatal staffing shortages.

“Neonatal services are a challenging and necessarily innovative area of medicine, caring for some of the National Health Service’s most vulnerable patients who must receive the best care possible. Efforts made by the Department to improve the service to date are encouraging, but there is still more to do. Top of the list must be addressing the staffing and capacity problems. And it is impossible to say whether the introduction of networks have improved the overall value for money of the service because of the lack of data on outcomes and the variable state, and use of, financial management information.”

Sir John Bourn, head of the National Audit Office

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