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Examination of Witnesses (Questions 1-19)
NATIONAL HEALTH SERVICES
27 FEBRUARY 2008
Q1 Chairman: Welcome to the Committee of Public Accounts which today is considering the Report of the Comptroller and Auditor General Caring for Vulnerable Babies: the Reorganisation of Neonatal Services in England. We welcome back to the Committee David Nicholson, Chief Executive and Accounting Officer of the National Health Service. Perhaps you would like to introduce your team.
Mr Nicholson: I have with me Professor Christine Beasley, Chief Nursing Officer for England, Dr Sheila Shribman, National Clinical Director for Children, Young People and Maternity Services, and Professor Sir Bruce Keogh, Medical Director for the NHS.
Q2 Chairman: I should like to welcome to our hearing a delegation from Uganda including members of its Committee of Public Accounts and the Auditor General. I think some Members of this Committee will be talking to them after this session. Mr Nicholson, yesterday some of us had a most instructive visit to Homerton Hospital. All of us felt it to be a moving experience and we should like to pay tribute to your staff. The expression: "the most vulnerable members of our society" is perhaps overused but when you look at a 24 week-old baby and see the amount of care provided it is very humbling, and we should all be grateful for what your staff do. But there are some questions I wish to ask you which relate to the pressure placed on staff. It is quite obvious that this is an extremely pressurised job and is often emotionally demanding. Capacity and staffing problems are dealt with beginning on page 24 and it goes on to paragraph 3.15 to which I wish to refer. That tells us that there is a shortfall of nearly 2,300 neonatal nurses. Do you think that is acceptable, and what are you doing to address the problem?
Mr Nicholson: Obviously, staffing levels in neonatal services are extremely important and quite a lot of work has been done in that regard over the past few years. A set of guidelines, the BAPM (British Association of Perinatal Medicine) guidelines, has been published. As a matter of principle the Department of Health does not support or pass out particular guidelines for particular services nor does it endorse them, largely because, first, it believes that is much better done by local decision-making based on clinical need, and, second, in other parts of the world where people have tried to do this in a national way it simply has not worked. Therefore, as a matter of principle we do not do that. I believe the figure of 2,300 comes from using the BAPM guidelines and multiplying them by the number of cots we have. We do not do staffing levels for cots anyway; we do them for babies.
Q3 Chairman: But do you accept there is a real problem? We have just been briefed by BLISS, the premature baby charity. They tell us that there has been a 5% increase in demand and a 2% increase in staffing. We cannot deny that the birth rate is increasing and the number of premature babies increasing and so there is very severe pressure on this part of the NHS. The fact that there is pressure is not your fault, but your responsibility is how responsive your service is to that increasing pressure.
Mr Nicholson: I understand that and I shall ask Christine Beasley to say a little about the detail of nurse staffing in particular which is where the pressure point is. There is no doubt that if you look at the trends of rising birth rate they are significant. Right up until October the Office for National Statistics said that the birth rate looking forward would be relatively flat. It has now revised those figures and said there will be an increase. That is one of the reasons why we have asked all health systems to look in detail at both their maternity staffing—hence the announcement on Monday by the Secretary of State about the potential for 4,000 more midwives—and the operating framework sent out to the NHS before Christmas which asked every health organisation to look at the staffing of neonatal teams and come up with some plans to increase the numbers and explain how they might do it.
Q4 Chairman: Look at figure 9 on the page to which I have just referred. It explains to us that on average the number of vacancies increases as the intensity of care provided by the units increases. Therefore, it appears from this that as the problem gets worse the shortage also gets worse, which is very worrying, is it not?
Professor Christine Beasley: There is no doubt that it is a highly pressurised service. In my experience over many years, recruiting staff to neonatal units has always been a challenge because it is such a pressurised area. I absolutely agree that we always have to work on how to get more staff into these areas. In terms of the chart in the Report to which you refer, it goes back to the BAPM guidelines. Because the 2,300 relates to the BAPM guidelines, which for intensive care are one to one, that is why looking at that as the denominator it appears that the vacancies are higher. When one talks to clinical staff they are very clear that at that high level of intensive care there is variability around babies. Some very sick babies may need two nurses to one baby and others in the same intensive care may need half a nurse, so the ratio is one to two and one will get a different picture if one looks at that. Although we collect data only on paediatric nurses in terms of the increase as a national figure we shall try to collect it for neonatal nurses when we get the electronic staff system. We have had a big increase of paediatric nurses over the past 10 years and each of the regions is doing an awful lot not only to recruit nurses to neonatal care but to provide the sort of training that is often work-based. One of the real problems is being able to release people to go away.
Q5 Chairman: Do you think it is fair or just that adults have the right to one-to-one intensive care and in paediatrics it is the same but with this most vulnerable group, where everybody accepts that what is done in the early days is absolutely vital, the health service does not give babies the right to that level of care?
Professor Christine Beasley: Put in that bald way, it is not just, but the guidelines for adult and paediatric intensive care are just that—guidelines—like the BAPM guidelines.
Q6 Chairman: Which according to our briefing are met in large part but not here?
Professor Christine Beasley: My understanding is that they are met in the same way that the neonatal guidelines are met. It is down to the condition of the patient and what seems to be the best care, and that applies also to adult intensive care.
Q7 Chairman: Let us look now at bed occupancy. If we look at paragraph 3.4 we see that many units find themselves operating at over 70% cot occupancy, some at over 100%, and most close to new admissions on average once a week. We saw one example yesterday of a very ill baby that had been referred from Whipps Cross to Homerton, had been sent to Medway, then to St George's and back to Homerton and could not get back to Whipps Cross. If you were the parent the stress of that would be appalling, would it not?
Mr Nicholson: Absolutely. I do not defend that position at all, but it seems to me that the most important thing is to make sure that the child is in the place best fitted to deal with the particular condition it has, and inevitably in those circumstances it will be necessary sometimes to move a child. Increasingly, we try to move the mother rather than the child to make sure the birth is in the right place, but some kinds of movements are inevitable. The key issue for me is the way in which the network operates. We have had some significant progress in terms of treating individual babies within networks, but sometimes—the case you cite is an example—it does not work. In all those cases it is incumbent on the NHS to do an absolutely root cause analysis as to what happened in the individual case and feed that back to the network to ensure action is taken to avoid it in future. We have increased the number of cots over the past three years by about 167 and developed tools such as the cot locator scheme and capacity planning tools to help people identify the number of cots they need to provide services for patients, and we continue to take that seriously.
Q8 Chairman: You talked about networks which are dealt with briefly in paragraph 1.17. Your department declared that the introduction of neonatal networks would help reduce variations in infant mortality rates within different social groups and save 200 to 300 lives a year. Has it achieved a reduction in variation between social groups in terms of mortality? Has it saved up to 300 lives a year?
Mr Nicholson: I shall ask Sir Bruce to talk a little about different social groups, but the general point I make here is that the figure of between 200 and 300 was based on an analysis of information from California on the one hand and Sheffield and the rest of the UK on the other. That was how the figure came about. The work we have done in identifying the expected level shows that in the three years up to the end of 2006 we have saved 310 lives.
Q9 Phil Wilson: Having read the Report, since 2003 things have improved in some areas. Parents seem to be content with the kind of services their babies get in these care units. We all know the stress and strain for parents and nurses as well, but I understand there are some problems concerned with staffing, financial management and even transport. As far as concerns the recruitment of neonatal staff and nurses in particular, what mechanisms do you have in place to recruit more staff to this particular field?
Professor Christine Beasley: There are some very good examples of networks. Three networks cover the West Midlands and together they have increased funding and are putting over £ half a million into the employment of about five very advanced neonatal practitioners working almost always in level 3 units. They have also put in more resources this year to appoint another 29 or 30 nurses to neonatal services, so in every area they are putting money into it. At the same time, although money and resources are an issue, there is the question of people having training and still staffing the unit. In the West Midlands there are other examples. They are doing competency-based training on the job and, critically, putting in some work for nurses at preregistration level. They get experience in neonatal services and so it is an area to which they want to return, because nurses are often frightened of going into that area if they have never had any experience of it. There are examples across the country where people have a package of measures to improve staffing.
Q10 Phil Wilson: Are there any difficulties concerned with on-the-job training of nurses, for want of a better expression, to keep up to date with techniques? Is there any shortfall in that? How do you train them and basically re-educate them in new techniques?
Professor Christine Beasley: Clearly, it is a range of areas in which people are trained. For on-the-job training there is a link between the local university and the hospital itself and there will be competency-based training on all the things one would do. For advanced neonatal practitioners right at the very top end that is commonly a year's course, some of it spent in the academic world and some in practical courses. Both clinicians and practitioners teach as well as people who have academic underpinning.
Q11 Phil Wilson: In paragraph 10 on page 9 it is said that: "each network had closed to new admissions an average of 52 times during 2006-07 due mainly to either lack of cots or shortages of nursing staff". To me, that is a pretty significant figure. I also understand that of the neonatal nurses who work in that area 30% come up for retirement in the next few years. Does that not exacerbate your problem?
Professor Christine Beasley: The whole of the nursing workforce is aging—I sit before you as one example—and we are doing all we can to increase the appeal of nursing across the piece, including neonatal nursing, not just for young people but older people. There is a whole range of mechanisms. There are nurses who want to retire when they are 55 but will often come back to do one day a week. Perhaps they do not want to do a whole week. We are trying to address a whole range of things to make sure we keep very skilled people particularly in the area of neonatal nursing.
Mr Nicholson: It is true that in the past we have not necessarily put a national overlay onto this to ensure it happens. Essentially, we have left it to local organisations to take it forward. This year we have changed that. In the operating framework we have said that every strategic health authority should come together to set out exactly how it will deal with the very issues you have described in a concerted way across the whole of the health system.
Q12 Phil Wilson: To turn to transport, why do only 50% of networks offer specialist transport 24/7?
Mr Nicholson: Networks have been working quite hard over the past three years to get the transport system properly set up because in the past that was certainly identified as a serious difficulty. All units are capable of stabilising a baby and looking after it in the initial period, so you can be reassured that that is the case in all units. As far as concerns transport, currently 12 of the networks have a 24/7 service and three have access to such a service. For example, parts of the east of England use the London one out of hours. Five of the networks plan to introduce 24/7 this year[1] which leaves us with three. We shall pursue each of those three to make sure that next year we can get 24/7 transport across the whole country.
Q13 Phil Wilson: The national cot locator also did not get a very good write up in the Report. What is the point of it when 20 out of 23 networks do not use it?
Dr Shribman: We introduced the cot locator to enable people by one phone call to move a baby if they had to move from their existing unit. What we know from the NAO Report is that we are maintaining babies within networks a large proportion of the time and we have certainly decreased the number of transfers across the country. The cot locator is a help to people and we encourage them to use it. They can contact people more easily to find a cot. Therefore, it was designed to assist with that, but we plan to review progress with it this year and see how well it is doing.
Q14 Phil Wilson: If 20 out of 23 are not using it perhaps you should be looking at what they are doing and build on that. Is that what you intend to do?
Dr Shribman: Indeed we do. It was certainly something that people wanted, which was why we developed it. People welcomed it and it was launched with enthusiasm, but as with everything we do we need to review whether it is really doing the job. When people work closely together in networks sometimes it is the phone call to the department which they know is the speedy way to get the baby to the right place at the right time, but this was designed to back up the system so that people would have access to advice and not have to make quite so many phone calls as they had to do previously to get the baby to the right place at the right time.
Q15 Phil Wilson: The northern region which is an area very close to my heart—I represent one of its constituencies—does not have a network which apparently clinicians would like. Is there any particular reason why that is so?
Dr Shribman: My understanding is that before we established formal networks clinicians in the northern region were already working very closely together in a networked way, so at first perhaps they did not feel the need for a formal management structure with a network manager, clinical lead and so on. There is no reason why a network should not be developed and I am sure that is something we can look at as part of the way forward because it is the ideal way to go.
Mr Nicholson: The northern region will have one.
Q16 Phil Wilson: I have a couple of questions on finance. I refer to the £72 million additional money that was not ring-fenced. According to the Report it is not known where £25 million of that sum is, or it has been spent on something else. There are indications that it has been siphoned off into other areas of the NHS to do whatever. Is that the case? Has £72 million of additional money been put into neonatal services or is it £25 million less than that?
Mr Nicholson: You are absolutely right that the money was not ring-fenced. We identified it nationally and it went out to the NHS. £20 million of that was a recurring sum every year and the rest was pump priming. I know that the NAO did a sterling job to find out where it had been spent and on what. There is no doubt that this is slightly exacerbated by the fact that during the period we went through one of our regular processes of reorganisation in the NHS whereby we moved round all our organisations. It has been quite difficult to pin down some of it because most of the organisations holding it have disappeared. What we can say is that when we looked at our programme budgeting information we calculated that about £150 million extra had been spent on neonatal care, so we do not believe that in overall terms there has been a siphoning off of the money, although we cannot pin down all of that in the way the NAO tried and you have described.
Q17 Phil Wilson: I want to ask about revenue income and expenditure. Some of the income from the units exceeds the cost and yet they do not seem to get the money to spend on those units; it goes somewhere else. Is there a reason for that? Is that normal practice within the NHS? Is this not money that could be reinvested in neonatal services?
Mr Nicholson: What is true is that we are on a journey in terms of financial management of the NHS and understanding what our costs are and controlling and organising them properly. We are significantly better than we were two or three years ago. Nevertheless there are areas where we could do better. If you look at the total amount of income that a particular hospital receives, for some specialties the income against expenditure shows surpluses and for some there will be deficits. Our view at the moment is that it is up to the hospital to organise itself appropriately so it can make sure it uses that money to best effect. There are occasions when one specialty subsidises another, but it seems to me that that is perfectly okay when regard is had to the hospital as a whole. We need to be much better both at the way we collect information and the way we apportion cost. Our experience is that once you start to design the tariff, which is exactly what we are trying to do for neonatal services at the moment, the discipline becomes much better and more transparent.
Q18 Angela Browning: Mr Nicholson, why is it that neonatal units are not formally inspected by the Healthcare Commission?
Mr Nicholson: All healthcare organisations are inspected by the Healthcare Commission. I do not know why the Commission has not at this particular moment chosen to specialise in neonatal services. I think you will have to talk to the Commission.
Q19 Angela Browning: We are told in the NAO Report that they are not. I have just been involved in the committee stage of the Health and Social Care Bill. I was rather astonished to read this because the point certainly was not raised in committee on the Bill, which is rather relevant to that. As the NAO has picked this up in its Report I wondered if there was a reason for it. It read as an exemption.
Mr Nicholson: It is certainly not an exemption.
Professor Sir Bruce Keogh: As a former Commissioner of the Healthcare Commission, its philosophy is to reduce the burden of inspection and ensure that inspections are focused. It has tried to base its inspections on intelligent information that comes in which indicates an inspection may be required and, where appropriate, that is coupled with random inspections. I do not know why it has not focused specifically on the neonatal units.
1 Note by witness: This year, or next year. Back
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