Memorandum submitted by BLISS
"WHY ARE OUR MOST VULNERABLE BABIES NOT BEING GIVEN THE ONE TO ONE NURSING CARE THAT CLINICIANS SAY THEY NEED?"
EXECUTIVE SUMMARY
— The National Audit Office Report shows that the demand for neonatal care is outstripping supply and there is a lack of strategic planning in place to meet this increasing demand.
— The national shortage of specialist neonatal nurses means that the clinical standards are not being met.
— Units are often unable to provide the level of care that babies need and are forced to turn babies away.
The care that our most vulnerable babies receive in their first days and weeks may affect their health for the rest of their lives. It is unacceptable that babies do not receive the equivalent level of critical nursing care that children and adults do. If we do not ensure the best start for these babies, we are failing them, their families and the professionals who treat them both in terms of health outcomes and the associated cost to the NHS.
BACKGROUND
In 2003, the Department of Health (DH) published a strategy for the improvement of neonatal care. It recommended that hospitals coordinate the care of the sickest babies in a series of clinically managed networks. The Government made an extra £72 million available to neonatal services over three years to implement the recommendations. The NAO Report has found a shortfall of £25 million in terms of how this money was spent.
NURSING
The BLISS report Too little, too late?[7] found that from 2005 to 2006, nursing numbers increased by 2%. It also found that the number of days of care they provided increased by over 5%. The NAO Report confirmed this figure. Demand is outstripping supply. Neonatal units have told BLISS that their ability to meet minimum nursing levels has got worse. Our data shows that the shortfall of specialist neonatal nurses in England currently stands at about 2,200.
What's more, the scale of the problem is masked because nurses and doctors work beyond agreed capacity. Professionals faced with too many babies and too few staff often prefer to cope with the situation as best they can rather than highlight the shortage and refuse to take on more work. This has knock-on effects on the level of care they are able to provide and the amount of time they can spend with parents. It also has an impact on their ability to keep their skills and knowledge up to date in this rapidly evolving field of medicine.
STANDARDS
In 2001 the British Association of Perinatal Medicine produced a set of clinical standards on the operating practices that neonatal units should follow to ensure that babies receive the best level of care.
One key point was that neonatal intensive care should be provided on a one baby to one nurse basis "as a minimum standard". The RAND survey, The provision of neonatal services which was conducted to inform the NAO Report, cites examples of where this one to one nursing recommendation is also in place in other countries. These standards were endorsed by the Department of Health External Working Group in their report on Neonatal Intensive Care and are included in the Children's and Maternity National Services Framework. In 2007, only 10 units across England told BLISS that they comply with this minimum standard.
A study published in 2007 found that increasing the number of specialist neonatal nurses to the recommended one to one ratio was associated with a decrease in the risk-adjusted mortality of the smallest babies of 48%.
CAPACITY
The RAND survey also found that 78% of neonatal units in the UK had to turn babies away in 2006—this is 8% higher than in 2005. A BLISS survey in 2007 found that units were forced to close their doors to new admissions for an average total of two weeks in six months.
When this happens, it is usually either due to a shortage of staffed cots or the lack of specialist transport teams. This can leave parents facing an agonising wait while staff phone round different hospitals trying to find somewhere that can provide the care their baby so urgently needs.
NETWORKS
The organisation of neonatal care into networks, as recommended by the 2003 review, has achieved notable improvements. These include better transport of babies; improvements in the way parents are involved in the care of their babies; and in general better coordination to ensure that our sickest babies receive the right level of care at the right time.
Networks are still a long way from achieving their full potential, however, and they now have to compete for funding alongside PCTs' other priorities. Some networks have managed to secure further funds. Others have not and this naturally contributes to instability, particularly over the funding of staff posts.
PAYMENT BY RESULTS
The Payment by Results (PbR) system of funding, if carefully implemented, may help to improve the funding of neonatal care. The DH consultation document on PbR points out that it can be used to encourage a particular standard or norm. If the payment "tariffs" are set according to the standards set by the British Association of Perinatal Medicine, PbR would provide a financial incentive for healthcare providers to focus on the care of sick and premature babies. However, if the standards are not taken into account, PbR will only serve to compound the historic under-funding of neonatal care in England.
The NAO Report points out that under the existing arrangements, 27% of units examined would have to operate above the recommended 70% occupancy to cover their costs—while 9% of units would have to operate at 100%. The tariff is therefore not viable and needs changing.
14 February 2008
7 Information provided, not printed. Back
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