Adding to the trauma of premature birth, mothers and their babies are often transported long distances in order to find an available intensive care cot. In April 2003 a government review of neonatal care put forward a strategy for change. BLISS looks at whether the new strategy will be effective.
If implemented, a proposed Department of Health strategy to reorganise neonatal care in England could put an end to haphazard ambulance transfers, which in extreme cases has seen babies born in motorway service stations. Doctors, nurses, professional groups and organisations like premature baby charity BLISS have been stressing to government the need for change for nearly 10 years. During this time, hundreds of mothers and babies have been put at risk, often traveling hundreds of miles because baby units have either been full or short of specialist nurses.
The result was the neonatal intensive care services review. The remit was to assess the challenges facing neonatal care and its ability to expand and develop to meet the increasing demand. The review was widely welcomed, and since its recommendations were published in April last year, changes are now starting to be implemented across England. However, many organisations believe the funds allocated to get the service running efficiently are not enough and they are very concerned that this opportunity will be squandered.
The main problems facing neonatal care were identified as a major shortage of neonatal nurses and a lack of cots. Experiences like those shown in Born too soon have happened to a rising number of mothers and babies.
The increasing capability of technology and the development of health care expertise has led to greater numbers of very small babies being born alive and surviving. In the past, many such babies died before or just after birth. Now, very premature or very low birth weight babies require prolonged periods of intensive supportive care, often over several weeks.
Over the past 25 years, neonatal intensive care has developed from an innovative and highly technical specialism into an established service. As its effectiveness has become apparent, demand has grown because of:
The review calls for a more structured, joint approach to caring for newborn babies, with hospitals working more closely together in managed clinical networks.
It also recommended that the service worked according to BAPM (British Association of Perinatal Medicine) standards which set out medical and nursing ratios and the different levels of care within the profession. Level 3 is the most intensive level of care for the smallest and sickest babies, level 2 is high dependency care and provides shorter periods of intensive care and finally level 1, which provides special care as close to home as possible.
At present, neonatal units are understaffed, with nurses often sharing their time between a dangerous number of babies. Just as significant is the introduction of the new European working hours for junior doctors which will reduce the numbers of hours these doctors can work and further reduce medical staffing levels.
The report states that the staffing of units with enough nurses with the right skills is fundamental to service improvement. More nurses will be needed to improve outcomes, support career development and promote recruitment and retention. This last point is particularly pertinent for BLISS. Not only is there a desperate shortage of neonatal nurses, but there is also a shortage of university places for those wanting to take the children’s nursing course.
An extra 75 intensive care cots (incubators) were also recommended to help meet demand. These changes are hoped to save an extra 200-300 babies each year in England.
The purpose of each network is to make sure that mothers and babies receive care within their local network, in a level of unit that is appropriate for the care their baby needs, as near to home as possible. Each network will contain hospitals with differing types of neonatal units. This would include hospitals equipped and staffed to care for the sickest and smallest babies, enabling longer and more complex care to be concentrated in one location.
Babies needing intensive care would be transferred to the appropriate level 3 unit in their network. Such transfers will be managed and controlled, and mothers and babies will not be travelling huge distances in a haphazard fashion as has been happening in the past.
All organisations gave general support to the review, in particular the recommendation that all neonatal care should be provided within managed clinical networks.
BLISS is generally supportive of the proposals for change to the provision of neonatal care. However, it does have serious concerns as to the level of funding allocated to achieve this reorganisation. It also strongly supports the recommendation that high priority should be given to the needs of the family whose baby is receiving neonatal care and in particular, intensive care. It is disappointing that there were no standards or targets set for this area, as facilities and provision for parents can all too easily be seen as a lesser priority.
The neonatal nurses association (NNA) gave a cautious welcome, with a strong message to the government that official guidelines and positive changes must be implemented quickly to avoid further declines in the service. They also welcomed the public acknowledgement that there are a high level of inappropriate transfers of mothers and babies across units due to the limited capacity.
Katrina Denton, chair of the Royal College of Nurses Paediatric and Neonatal Intensive Care Nurses Forum said: 'Although we welcome this review, the delay in publishing has meant that much needed reforms have been held up for well over a year. Everyone agrees the challenges facing neonatal services in England are huge. There is massive understaffing and a serious lack of training places for nurses wanting to become neonatal nurses. The report rightly points out that most neonatal cot closures and inappropriate hospital transfers of newborn babies are due to lack of nursing staff … This has to be put right as a matter of urgency.'
BAPM was also supportive of the move to provide a stronger structure around neonatal care in England. On an individual note though, it regretted the loss of skills and training opportunities in the centres such as its own not routinely providing intensive care.
However, the document was criticised for lacking standards and targets. Without these to aim for, many feel that obtaining the additional funds from local budgets may prove impossible.
What all agree on is the need to steer the strategy so that babies needing the highest level of neonatal intensive care get the best treatment in the best place.