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Examination of Witnesses (Questions 40-59)
NATIONAL HEALTH SERVICES
27 FEBRUARY 2008
Q40 Mr Mitchell: How about Yorkshire?
Professor Christine Beasley: It already has a network.
Q41 Mr Mitchell: It must be the case—Grimsby is not affected by this because I understand it is plugged into north Nottinghamshire, which seems a bit haphazard given the fact that we are part of Yorkshire for strategic purposes—that the formation of a network gives an impetus to the whole system, must it not? If the North does not have a network it loses out to some extent?
Dr Shribman: You are absolutely right that networks are extremely important. That was why in the 2003 review we were particularly keen to see the establishment of networks and the NAO Report indicates that we have them fairly well established, but there is more to do. You are right that there are a lot of benefits of networks, and certainly they are seen by parents, parent organisations, clinical professionals, managers and others within the system as having led to significant steps forward in the sharing of common guidelines and working together on audit and the patterns of care for babies. Therefore, not to have a network is a bad idea.
Q42 Mr Mitchell: I turn to paragraph 3.13. It seems to me absolutely appalling that only half of the units met the standard for high dependency care and 24% met the standard for intensive care. This is very low. I understand from BLISS that only 12 units in the UK operate at the minimum recommended staffing levels.
Mr Nicholson: The department does not issue recommended staffing levels or guidance on staffing levels.
Q43 Mr Mitchell: Should you?
Mr Nicholson: No. We believe that it is better for local decision based on clinical need. When you look around the world at those places that try to do it because services are so different in the way they operate most have had to move away from it in a relatively straightforward way.
Q44 Mr Mitchell: These services are not all that different; they are all doing the same thing.
Mr Nicholson: But our expectation is that where clinically a child requires one-to-one nursing it should have it; and certainly our experience is that that is the case. As I said before, we do not staff cots but babies.
Q45 Mr Mitchell: I wonder about that because earlier we dealt with the provision of £72 million in funding of which £25 million went walk about and you said that the organisations holding the money disappeared. Did the money disappear with them? This is fairly extraordinary, is it not? We allocate this sum of money and £25 million does not get there.
Mr Nicholson: What I said was that based on the programme budgeting information we identified that an increase in funding for neonatal services of £150 million happened during that period. There was a particular bit of money, £72 million, given to strategic health authorities and the NAO did a sterling job to try to find exactly what happened to every penny of that sum. It could not do so. I am sure that part of the explanation is that the records and the organisations that administered the resource have disappeared.
Q46 Mr Mitchell: Therefore, you do not think it went to the intended purpose; it just disappeared?
Mr Nicholson: I think the vast majority of it went to the intended purpose. I happen to know because of my own experience in being in one of those strategic health authorities that some of the money did go to other places, but that is part of the tension, if you like, around not ring-fencing money.
Q47 Mr Mitchell: That is the next question. In view of the importance of this service, its understaffing and the costs of training should you not have designated ring-fenced funding for it to indicate the importance you attach to it and improve it?
Mr Nicholson: Our records show that we spent double the amount, £150 million and not £70 million, on improving neonatal services across the service in that period.
Q48 Mr Mitchell: We hear horror stories of staff shortages and too much pressure on nurses so they cannot talk to parents in the way they need to and carry them along which should not be happening in such a crucial area.
Mr Nicholson: We did what we said we would do. We said that we would save between 200 and 300 lives and we did; we said we would set up networks and we did; we said we would set up transport services and we did. We said we would increase the number of cots and we increased them by 167. We have increased the number of staff. If you are asking me whether that is enough quite patently it is not. We know that with the rising birth rate and technical changes that are going on in our ability to look after very small babies there is pressure on the system and that is why we have asked each part of the country at the moment to look at the staffing of their neonatal teams to make sure we have plans going forward to address the very important issues you have described.
Q49 Mr Mitchell: But you have a situation where closure is happening all the time; the service just closes down and is not available to people coming in for maternity services. That is extraordinary. It must cause an enormous amount of waste of time with people ringing round to find cots for kids in other areas.
Mr Nicholson: The other thing we want to do is make sure we can look after all of our children within the networks, and we have got to the position where 95% are looked after within network. I believe that is a significant step forward. You are absolutely right. Occasionally things happen and we need to find ways to avoid them, but the services do not close down. A particular unit may not be able to admit a particular patient but we have always found another unit somewhere else and appropriate transport for that patient.
Q50 Mr Mitchell: It is a continuous process of improvisation?
Mr Nicholson: The vast majority of children are treated exactly where their mothers give birth or in the most appropriate clinical area. Perhaps I may make one point on the question of health inequalities. I have not given up on the target of delivery. I know that it is very difficult and there are very few places in the world that have managed to tackle the issue of health inequalities and narrow that particular gap. That was why at the end of December we published new guidance to add impetus to it and the secretary of state announced a review of the health inequalities strategy to make sure we do not give up on this particular issue—I do not think we should—but redouble our efforts to make it happen.
Q51 Dr Pugh: Perhaps I may pick up where Mr Mitchell started which is figure 6 on page 18. I think my question is directed largely to Sir Bruce. It quite clearly shows a wide variation in neonatal deaths. You have said that socio-economic factors are an element in that and we would expect highly urbanised areas possibly to have a worse profile than leafy rural and suburban areas, but presumably you can factor that into the analysis. Although it would appear that Midlands South is the worst and Surrey & Sussex are the best if you factored in socio-economic factors—clearly you can—you would have a different profile or list, would you not?
Professor Sir Bruce Keogh: Yes, you would.
Q52 Dr Pugh: You would have a list of those networks that performed better and those that performed worse?
Professor Sir Bruce Keogh: Yes. The graph to which you have alluded takes no account of the nature of the babies that appear at the front door of the neonatal intensive care unit. There is a variety of factors that influence how those babies are likely to do. One would be the socio-economic group which for a variety of reasons will be relatively powerful and the others would be things like the size, weight and gestational state of the baby and so on.
Q53 Dr Pugh: There are many factors, but it is possible for you to have a private list in a sense of those networks that perform really well given the circumstances and those that do not perform at all well. Looking at this list of networks, are there any that give you cause for concern; in other words, allowing for all socio-economic factors, they are not doing at all well?
Professor Sir Bruce Keogh: We have not made that analysis.
Q54 Dr Pugh: You do not know which networks should give cause for alarm?
Professor Sir Bruce Keogh: We have not done that level of analysis. This is all very superficial.
Mr Nicholson: Progress here has been fraught by a lack of national data with which we can work. One matter that will help significantly is the Healthcare Commission's national audit which will give us much better comparative data. At the moment it may be possible to say by network what is the expected death rate in neonatal, but we are reluctant to do that because of real worries about some of the data. When we have that data we shall be in a much better position to do exactly what you describe.
Q55 Dr Pugh: In terms of accountability, I am looking at Cheshire & Merseyside which is my area. Apparently they are one of the four worst in terms of neonatal deaths. Allowing for all sociological factors, they may be performing relatively well; on the other hand, they may not. I simply cannot tell.
Mr Nicholson: The figures map remarkably well on infant mortality generally. We know from infant mortality generally that socio-economic factors are very critical in that. In none of the networks is it going in the opposite direction.
Q56 Dr Pugh: All networks are progressing, however good they might be?
Mr Nicholson: It is the same pattern, but if we are to identify a league table in the way you describe of what is expected we need to be cautious until we have some really good data to make sure we can take it forward.
Q57 Dr Pugh: Are there any networks currently on that list that give you cause for concern?
Mr Nicholson: On the basis of the data we have, no.
Q58 Dr Pugh: It says in paragraph 1.9 on page 13 that the concept of a network is a fairly fluid one. We have had discussions so far about formal and informal networks. I understand that it is a very unpredictable field and you cannot plan for births turning out wrong because you simply do not know where and when that will happen. Obviously, there are trends but they are very rough and in broad terms. What is important is that you have a clinical path where the right people can deal with the problems in the right place and within a reasonable range to assure an equal outcome. What is the difference between a formal and informal network? What features does a formal network have that an informal network lacks? You said that the North had an informal network.
Dr Shribman: The key difference is in structure. A formal network will have a designated lead clinician and a funded manager and it will have more structure around it. As to an informal network, one can say that at one end it is just a loose group of clinical staff who get together from time to time to share information and discuss best ways forward. If you formalise it you develop a much clearer structure of sharing to develop guidelines and clear protocols and policies about transfer and so on.
Q59 Dr Pugh: Let us look at the map on page 14 where the networks are laid out. I have the misfortune in a sense of having a constituency that is right on the peak of network 6 which is the Cheshire & Merseyside network. When I looked at it further I thought it was not a very coherent network in many respects. It goes along old health authority lines, but if you are devising a network you will know that most people in Cheshire will look to Manchester rather than parts of Merseyside. The river is a barrier right through that network. In a sense ought not networks be designed on the lines on which people travel rather than existing health authority structures?
Dr Shribman: My understanding is that when the networks were first developed they were based on care pathways and referral patterns. There could be tension between administrative boundaries and patient flows, but we also expect the networks to liaise and work together.
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