Exclusive: Neonatal care review may lead to ‘reconfiguration’ of intensive care units

Transformation review makes recommendations for future of neonatal critical care

Transformation review makes recommendations for future of neonatal critical care

Picture: iStock

Neonatal critical care is one of the medical success stories of the NHS. Over the past quarter of a century, the prospects for severely ill babies have improved greatly.

Services have changed and adapted as medicine has advanced. But they are now at a crossroads.

Staff shortages, rising demand as more severely ill babies survive and variations in outcomes have created major challenges in England.

As these have emerged, the system has been rocked by failures of care leading to maternal and baby deaths at Morecambe Bay, which were highlighted in a report in 2015, and at Shrewsbury and Telford Hospital NHS Trust, where an independent review is ongoing.


babies are admitted to neonatal units each year

Source: Neonatal Critical Care Transformation Review 2018

In 2016, the government called for a review of services, called the Neonatal Critical Care Transformation Review. This was undertaken by the Neonatal Critical Care Clinical Reference Group, led by professor of neonatal medicine at University College London Neil Marlow.

After over a year of work, the review group’s draft findings have been unveiled.

The report, Better Newborn Care, sets out what it says is an ‘ambitious programme of transformation’. It outlines steps for NHS leaders, regional networks and education providers in England. Addressing these will take years, the review says.

Staff shortages

In describing nurse staffing as the ‘single most important risk’ to neonatal care, the report draws on research in 2017 that found the system was more than 2,260 neonatal nurses below the number needed.

This shortfall of about one third explains why hospitals are struggling to be compliant with official staffing guidance.

According to NHS England’s National Peer Review Report last year, just 24% of services have enough nurses.

To tackle this problem, Better Newborn Care calls for robust monitoring, better access to training and education, and new roles for non-registered staff.

It suggests, for example, that non-registered staff could take on more responsibility in transitional care and special care.

Chronic underfunding

RCN children and young people acute care forum member Doreen Crawford, who was part of the review team, says more money is needed to ensure this vision is realised.

There has been a ‘chronic underfunding and lack of clear direction for too long’, she says, adding: ‘The service has been let down by successive governments of all political hue.’

She believes there is an opportunity for ‘innovation and creation’, but only if there is proper funding.

Otherwise, there will just be ‘small patchworks’ of good practice springing up.

Neonatal Nurses Association chair Claire O’Mara hopes there will be new investment given that maternity and neonatal care are expected to be priorities in the ten-year plan being compiled by NHS England chief executive Simon Stevens.

‘This is a really important moment. The actions present a clear vision for the future. It brings everything together and is something we have needed for some time.’


neonatal units in England

Source: Neonatal Critical Care Transformation Review 2018

She also hopes Better Newborn Care will have a ‘positive impact’ on recruitment and retention. ‘There’s a considerable deficit in neonatal nurses. Nurses are not getting access to essential training.’

Call for action

In the meantime, Ms O’Mara wants nurses to take note of the report’s call for action to keep parents and babies together, and to help families get more involved in care.

She says the role of families should be ‘celebrated’ and ‘resonate’ with nurses.

She says she is also delighted to see the input of the wider allied health professional workforce highlighted, adding that dieticians, occupational therapists, physiotherapists, psychotherapists and pharmacists have the skill and expertise to ‘improve and optimise’ outcomes if they are fully involved.

But alongside the need for investment, the review makes clear some significant structural changes must be made.

Some of these, such as devising a new tariff structure, are technical, but others concern organisation of services. For example, the review suggests some intensive care units are too small and should be reconfigured.

Evidence shows that neonatal intensive care units with fewer than 2,000 respiratory care days a year tend to have worse outcomes and cannot ensure that staff see enough patients to keep their skills up.

By this definition, one third of England’s 44 units are too small.

Difficult decisions


fewer neonatal nurses than needed

Source: Neonatal Critical Care Transformation Review 2018

Royal College of Nursing professional lead for children and young people Fiona Smith says ‘some difficult decisions’ about how services are organised are likely to be made.

‘The transformation is going to require collaboration, potential changes to the way staff work and the development of new roles,’ she says.

While changes like these can be challenging, she adds, it is important to keep the babies and families who need neonatal care ‘at the forefront of our thinking.’


The Neonatal Critical Care Transformation Review

In 2016, the National Maternity Review report, Better Births, highlighted safety concerns about neonatal critical care.

NHS England asked the Neonatal Critical Care Clinical Reference Group to carry out a review.

It has been undertaken in two parts. The first involved an analysis of data that were fed into the maternity transformation programme last year. This led to immediate recommendations, including:

  • Women likely to deliver before 27 weeks should give birth in a maternity unit with an on-site neonatal intensive care unit
  • All neonatal deaths to be formally investigated using the standardised perinatal mortality review tool

The second part focused on the development of recommendations for issues identified in neonatal services. A draft of these recommendations has been produced and presented at four workshops held in October.

The clinical reference group will produce a final set of recommendations to NHS England by the end of the year. Once agreed, these will be put forward for implementation.

The review recommends that an implementation group is established to introduce the plans over a five-year period.


Better Newborn Care’s main recommendations

  • A new national tariff for neonatal services
  • National reporting of regional neonatal outcomes
  • Clear regional strategies for transition of babies
  • Initiatives to allow parents to stay with babies and to develop families as primary care givers through promotion of the Bliss Baby Charter
  • Ensuring parents have access to psychological support
  • Development of escalation plans to tackle staff shortages
  • Monitoring and reporting of staff levels and vacancy rates
  • Protection of clinical educator roles to help with training students, developing a non-registered workforce and qualified in specialty (QIS) training
  • Promotion of pharmacy and allied health professionals within neonatal teams
  • Training for physician assistants and advanced neonatal nurse practitioners to support medical staff
  • Adult and children’s field of practice training to include an elective in neonatal nursing
  • QIS training should be a priority and each service should have 70% of its nurses QIS trained
  • Development of core competency standards for enhanced and advanced clinical practice


This article is for subscribers only