NHS England: More centralisation needed to cut neonatal deaths

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Some mothers likely to give birth before 27 weeks give birth outside of NICUs
London missed target for improvement in 2018
Bigger units mean “better staffing”, says NHSE, which commissions the services
“Small number” of units likely to need to merge or close

NHS England has indicated there will be avoidable deaths of young babies without further centralisation of neonatal intensive care units, which it funds and oversees, so they can have ”better staffing”.

A new NHSE specialised commissioning report suggests more trusts and delivery network groups should combine intensive care activity on single sites, with exceptions for particularly remote locations.

The authors recommend providers assess their existing neonatal intensive care units against minimum activity criteria. When they identify gaps, they should either work with regional specialised commissioning teams on five-year improvement plans, or combine activity on single sites.

Providers can redesignate former NICUs as “local neonatal units” or special care units.

The NHSE report states that increasing NICU throughput to at least 2,000 intensive care days per year “would lead to improvements in survival, and to significant economies of scale that permit better staffing and less marked fluctuations in daily admissions”.

“Although this may increase either the need for transfers or lead to increased travel times for parents in some settings, the trade-off for improved survival and economy of scale must be seriously considered as part of the local implementation plan,” it said.

In addition to redesigning neonatal services around set criteria, the implementation report noted providers must identify and work out how to fill significant gaps in the nursing, medical and allied health workforce. It also recommended shoring up neonatal transport services to meet increasing demand.

Recommended criteria for neonatal units:

Neonatal intensive care units should care for at least 100 babies weighing less than 1.5kg, and usually perform more than 2,000 intensive care days per year;
Local neonatal units should, as a minimum, perform at least 500 days of combined intensive and high dependency care per year. They should work towards 1,000 days; and
Smaller services would be designated as special care services.

At present, according to the report, there are:

44 NICUs (18 of which also support a colocated neonatal surgical service).
77 LNUs
35 SCUs

The report, published on NHSE’s website late last week, was drawn up to help providers implement the recommendations of a previous review of neonatal critical care; it is unclear whether this last review was made public and, if so, when. NHSE took over specialised commissioning responsibilities in 2013.

The review found that not enough women expected to give birth early were doing so in maternity units with on-site neonatal intensive care units, which is linked to survival of their babies.

In 2017, only one region saw 80 per cent of women likely to give birth before 27 weeks at an appropriate site. This improved to three out of four regions in 2018, with only London missing the new target.

The review said more than a third of regional variation in neonatal mortality was linked to population or socioeconomic factors such as deprivation, employment and smoking.

However, it said: “One fifth of the variance was explained by the type of neonatal service (NICU, local neonatal unit or special care unit) and the number of staff available.”

It said: “Half of the variation was unexplained and current work is analysing the reasons behind this, including resource availability factors and underlying health issues of babies.”

British Association of Perinatal Medicine honorary secretary Stephen Wardle told HSJ: “There is good evidence that survival rates for the smallest babies are better when they are cared for in NICUs and that larger units with higher levels of activity have improved outcomes. As a result, the review recommends that all NICUs should carry out a minimum number of intensive care days (2000 days pa).

“Most units that are currently designated as NICUs will be able to continue to provide care for the smallest and sickest babies but there are a small number who fall below this level. Several of these are in close proximity to each other and in these cases there may need to be a change but this may occur through merger or reconfiguration of services.”

Services have been centralised to an extent since neonatal networks were introduced in 2003. There have been 11 neonatal operational delivery networks in England since 2013, with each network typically containing between one and three NICUs. Each network has a transfer system to transport babies between intensive care and other units.

Dr Wardle added: “Huge strides have been made in reducing mortality rates in recent years in stillbirths, neonatal and infant deaths and rates continue to decline. Survival rates for the most immature babies have improved considerably and also continue to improve.

“There are variations in mortality rates across England and it is hoped that this transformation programme will improve outcomes and reduce variation.”