Too much variation and too little progress found in neonatal units

More needs to be done to drive up basic standards in neonatal units, according to the latest audit of services

More needs to be done to drive up basic standards in neonatal units, according to the latest audit of services.

neonatal care unit
Too little progress has been made in neonatal care units since 2014 review. 
Picture: iStock

The National Neonatal Audit Programme (NNAP) – funded by NHS England and the Welsh and Scottish governments – has found there is too much variation and too little progress made since the last review in 2014.


babies are born each year in England, Scotland and Wales

It came to this conclusion after assessing 95,000 admissions across 179 units in 2015, including, for the first time, hospitals in Scotland.

The team behind the audit said sharing best practice and getting units to work together would be key to driving up standards. To help, they have launched a new interactive tool that helps units compare data and practices.

The audit found
  • Hypothermia remained a common problem with only half of babies born before the 29-week mark having a temperature within the recommended range – almost exactly the same as the 2014 performance.
  • The rate varied between 11% and 91% across the health service.
  • 85% of mothers who gave birth to babies at 24 to 34 weeks gestation received antenatal steroids before birth, which reduces the chance of breathing problems.
  • More than one in 20 babies did not receive eye screening at the recommended time.
  • Some 58% of babies delivered at less than 33 weeks gestation were being fed with the mother’s milk at the time of discharge – a figure that has remained constant since 2012.
  • More than one in ten parents did not have a recorded consultation with a senior member of staff within 24 hours of their baby’s admission. The rate was close to half in some units.
  • Some 60% of babies born at 30 weeks gestation had their 2-year follow-up appointment compared to 54% last time it was measured.


Audit clinical lead Sam Oddie says: ‘Some units are doing remarkably well when it comes to meeting the standards, however there are others which are simply not delivering on these yet. These units need to be looking at improving this.’

He adds that adhering to the standards should not be too difficult citing the way some hospitals ensure the temperature of babies does not drop too low. ‘Solutions can be remarkably simple,’ he says.

‘For example, many units use the combination of plastic bags, radiant warmers, hats and warm delivery rooms to maintain a newborn baby’s temperature and do it very well.’

Practice sharing

He says the key to improvements is sharing good practice – and the report makes the point further by highlighting examples of where hospitals and networks are making progress.

But the lack of progress also raises questions about staffing levels and, in particular, to what extent further improvement is possible given the shortages in staff that have been reported.

1 in 8

babies admitted to a neonatal unit

Last year a survey by the charity Bliss found there was a ‘severe shortage’ of neonatal staff in England which had left services ‘over stretched and under incredible pressure’.

The research found that two thirds of units did not have enough nurses with the problems worst in intensive care units. The charity said nationally this suggested there was a shortage of more than 2,000 nurses to care for premature and sick babies – nearly double the number in 2010 when the charity last carried out the survey.

Neonatal Nurses Association executive member Julia Petty believes this may be the crucial factor in explaining why units have not been able to improve performance.

She says: ‘Many of the issues being highlighted are things we have known about for a long time. They are part of nurse education programmes and are being promoted by the networks which, on the whole, are active in sharing good practice.


units took part in the NNAP audit

‘That suggests there is something else at the core of this. If you don't have enough staff they are difficult to achieve.’

RCN professional lead for children and young people’s nursing Fiona Smith agrees staffing is an issue – but says it is not just about what is happening in neonatal services.

‘We must remember some of this is also about maternity services. For example, ensuring mothers going into premature labour are given steroids.’

But she still believes that, even with the current level of resources, improvements can be made. ‘There are things neonatal nurses can influence, such as raising whether retinopathy screening has been undertaken or whether the baby is being fed with the mother’s milk.

‘By working in partnership and across networks there is much we can do to improve standards. Leadership is crucial in making sure we get the improvements we all want to see.’

How one hospital improved breastfeeding rates

The 2015 audit acted as a wake-up call for the Oliver Fisher Neonatal Intensive Care Unit at Kent’s Medway Maritime Hospital. It showed the unit had seen a worsening in its breastfeeding-on-discharge rates. Just 34% of babies born at less than 33 weeks were being breastfed compared with a national average of 60%.

The hospital was notified that it was an outlier, prompting a review of the way it supported mothers.

Medway NHS foundation trust responded by investing in the infant feeding team. New equipment, including breastfeeding pumps and reclining chairs, was bought.

Doctors and nurses working in and supporting the neonatal unit also underwent training. For nurses this included breastfeeding awareness and help in how to use breast pumps. Latest figures suggest two thirds of babies are now breast fed, which is above the national average.

But the unit does not want to stop there. It is now looking at how parents can be allowed to stay during wards rounds so breastfeeding is not interrupted as well as looking to develop breastfeeding support and advice that can be viewed on smartphones and tablets.

Neonatal nurse educator Karina Vandertak says the unit’s experience shows how ‘simple but focused interventions’ can have a real impact.


Working together to improve care

Yorkshire and Humber Neonatal Operational Delivery Network is a good illustration of why the spirit of cooperation, transparency and benchmarking is important.

The network runs a system of multi-professional peer reviews, which sees nurses, doctors and managers – along with regional Bliss workers – visit units to assess where improvements can be made.

All units in the region take part in the process, which combines on-site visits and data analysis to see where improvements can be made. Information collected by the neonatal audit has been heavily used for the latter. Network lead Chris Day says it has encouraged ‘healthy competition’.

Recently it has seen units helped to improve their performance on temperature on admission and 2-year follow-ups.

Find out more

NNAP annual reports

NNAP online interactive tool for the National Neonatal Audit Programme

Nick Evans is a health writer

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