Children and Young People Committee
CYP(4)-05-12 Paper 2

Neonatal Services in Wales

Evidence from Bliss

Introduction

Bliss is the UK charity dedicated to ensuring that all babies born too soon, too small or too sick survive and go on to have the best possible quality of life. We provide practical and emotional support to families during an extremely difficult time so they can give the best care to their babies. Our specialist study days and training supports doctors and nurses to develop their skills and we fund research to improve care for premature and sick babies. We also raise awareness of the issues affecting these vulnerable babies and their families, and campaign for essential change within government and the NHS.

Bliss welcomes the Children and Young People Committee’s decision to review the provision of services for premature and sick babies and their families and, in particular, the degree to which progress has been made implementing the recommendations of the previous Health, Wellbeing and Local Government Committee inquiry into neonatal care in 2010. 

Around 4000 babies are admitted to neonatal services in Wales each year. This is equal to approximately one in nine babies born in Wales. This briefing sets out some of the key challenges facing neonatal services in Wales, and how these issues have progressed since the previous National Assembly for Wales’ committee inquiry in 2010.

Nurse staffing problems

As Bliss outlined in our evidence to the Health, Wellbeing and Local Government Committee inquiry into neonatal care in 2010, the shortage of nurses available to care for babies born premature and sick has long been the central challenge faced by services in Wales. This still continues to be the case today. 

A review of the neonatal nursing workforce conducted by the nursing and therapies subgroup of the Wales Neonatal Network Steering Group (referred in this paper as the ‘network’) identified a shortfall in the number of nurses available to provide direct clinical care across units in Wales equivalent to 82.64 whole time equivalent (wte) nurses.

This shortfall in nurses affects every Health Board and every unit, and as such the All Wales Neonatal Standards on nurse to baby staffing ratios are far from being met. This critical nursing shortfall is putting babies’ lives at risk, significantly reducing the ability of staff to provide family centred care, and leading to inappropriate and unnecessary long distance transfers of babies, which in turn is putting additional strain on families at an already very difficult time.

As well as the overall shortage of nurses, the network nursing and therapies sub group report also identified that neonatal services across Wales are heavily reliant on nurses graded Band 5 and below. The report points out that many nurses working at this level will not have received the training required for the care of critically sick babies, which can at times lead to an inappropriate skill mix in the available nursing workforce, putting babies’ at risk.

The same report identified that nurse shortages are resulting in difficulties in the ability of units to release nurses for initial training as well as ongoing development and updating, perpetuating this problem further still.

The nursing and therapies subgroup workforce report and recent network capacity review points to this shortfall in nurses being due a lack of funded posts, rather than a problem in recruiting nurses into the speciality. Bliss urges the committee to find out what action is being taken by Health Boards to address this very serious staffing crisis.

Medical staffing

The two capacity reviews conducted by the network since it was established have clearly identified that the most serious issues in relation to access to consultant and middle grade doctors in Wales lie within the three neonatal units in Betsi Cadwaladr University Health Board (UHB).  It is of serious concern to Bliss that, despite the provision of ongoing intensive care to babies in Ysbyty Glan Clwyd and Wrexham Maelor Hospital, neither of these units are even approaching compliance with the All Wales Neonatal Standards on medical staffing of a unit providing this level of care. While a review of maternity, neonatal and paediatric services in north Wales is currently underway, which seeks to address this issue amongst others, it has already been subject to a number of delays.

We believe that despite the best efforts of staff currently involved in the care of babies in north Wales, there are serious safety implications that the Health Board must address without delay regarding the sickest and most vulnerable babies being cared for without sufficient access to dedicated expert neonatal consultants and middle grade doctors with sole responsibility to the neonatal unit. The safety of these babies is paramount. However any changes to the way neonatal services are organised could also have a significant impact on families, and the review must fully address any additional support they may require as a result of changes.

Aside from the particular issues facing services in north Wales, the network has also received reports regarding problems with the recruitment of junior doctors, and a drastic reduction in the number of trainee slots that is expected from 2014. These issues are expected to have significant implications on the ability of services to run as they are currently configured. Bliss believes that Health Boards must work together with neighbouring Boards to undertake detailed workforce planning to address what impact these issues may have on services in coming years. We believe that any changes that may need to take place to ensure services are safe and of high quality must be very carefully planned, and also address the needs of the wider family.

Therapy services

In addition to the problems highlighted above in relation to nursing and medical staffing, Bliss is highly concerned that services for premature and sick babies are falling well short of national standards on access to allied health professionals.

The 2008 All Wales Neonatal Standards (standard 3.5) outlined that support services including dietetics, physiotherapy and speech and language therapy should be readily available within a timescale of one to three years, and provided by therapists with appropriate knowledge and competencies in this highly specialist area of care. The BAPM 2010 standards build on these standards and set out in more detail the level of allied health professional input required as part of the neonatal service.

However an audit of therapy provision by the neonatal nursing and therapies subgroup presented to the network in July 2011, revealed that only three out of the 12 neonatal units were fully compliant with the All Wales Standards in just one aspect of therapy provision: namely physiotherapy. In relation to access to other therapies, the audit revealed at best only partial compliance. Where some provision did exist, the audit found that no assurance could be given that it was being provided by staff with required competencies and knowledge base in this specialist area of care, and that it was largely reliant on the good will of paediatric therapy services.

Further action is required to ensure that all babies who have been admitted to neonatal care have access to the therapy support they need, and which is so vital to their long term outcomes.

Cot capacity issues

The recent network capacity review identifies a significant mismatch between demand and available capacity within neonatal services. It identifies some units with occupancy levels that are either very high for the safe provision of care (a maximum 70 per cent in high dependency and intensive care, and maximum of 80 per cent in special care cots) or very low for the most effective use of resources.

Overall the network has identified that a different distribution of neonatal capacity may be required between units, and that a fairly modest amount of additional capacity is needed.

However, the review has not taken into account the additional capacity that will be required if the increase in birth rates seen in recent years continues. Therefore further staffed cots are likely to be required if the birth rate continues to increase up until the end of this decade, as currently projected. 

Support for families

The original Health, Wellbeing and Local Government Committee inquiry into neonatal care recommended that the Welsh Government should ensure that health Boards review their current arrangements for supporting parents of special care babies. Bliss welcomes the commitment that has been shown by the network to work with Bliss to review the support available to families and to ensure services are provided in a family centred way, using the recently published Bliss Baby Charter Audit Tool (January 2012).

The Bliss Baby Charter Audit Tool helps organisations focus on and improve their neonatal service against a range of issues of importance to families ranging from access to emotional/psychological support, through to the provision of overnight accommodation for parents whose babies are receiving neonatal intensive care. Bliss looks forward to working with the network, individual units and Health Boards to roll out this audit.

Delivery of the network, transport service and data system

A number of the recommendations of the Health, Wellbeing and Local Government Committee inquiry into neonatal services related to the delivery of the network, dedicated 12 hour transport service and data system funded for by the recurrent £2m per annum, first announced by the former Health Minister in 2008. The last 18 months has seen the effective establishment of the network, however as outlined below, it does not itself have the authority implied by some of the previous committee inquiry’s recommendations as it has been set up as more of an advisory body to the Health Boards.

The 12 hour dedicated neonatal transport services is now also running effectively, has introduced some extra capacity into the system, and has helped ensure more babies receive the right care in the right place.

Finally, the data system has been introduced, however we understand some issues have been encountered related to the ability of network to access the data centrally for planning purposes due to Health Board business confidentiality issues. It would therefore appear that some work remains to be done to ensure this is operating as effectively as possible. 

Accountability for implementation of All Wales Standards

The terms of reference of the network steering group set out its role in providing advice to Health Minister and Health Boards through the Welsh Health Specialised Services Committee (WHSSC). 

As set out above, the network has now conducted two detailed reviews of capacity across neonatal services in Wales, in addition to a number of separate audits and reviews addressing issues such as improving efficiency in low dependency care and access to therapy services for premature and sick babies. With each review the network has presented clear recommendations to Health Boards, via WHSSC, about what action is required to address the identified service shortfalls and inefficiencies. 

The Welsh Assembly Government’s response to the Health, Wellbeing and Local Government 2010 inquiry recommendations set out that responsibility for compliance with the All Wales Neonatal Standards and decisions such as resourcing of neonatal care ultimately lay with Health Boards. However, Bliss is concerned that implementation of the All Wales Neonatal Standards remains a low priority for Health Boards.

We therefore recommend that the Children and Young People Committee invites each Health Board to outline:

· what plans they have in place to address the critical staffing and occupancy issues highlighted in the network’s capacity reviews

· what plans they have for investing into neonatal services in order for all services in their areas to be fully compliant with the 2008 All Wales Neonatal Standards

· and what action, if any, they have taken with regard to the resourcing of neonatal services since the Health, Wellbeing and Local Government inquiry recommendations were published in 2010.

Summary of recommendations

· Bliss urges the committee to find out what action is being taken by Health Boards to address the serious neonatal nurse staffing shortages.

· Bliss believes that Health Boards should work with neighbouring Boards to undertake detailed workforce planning to address what impact changes to junior doctor recruitment and the number of training places in the future will have on services in coming years. Health Boards must carefully plan for any changes that need to take place to ensure services are safe and of high quality, and also ensure that the needs of the wider family are taken into consideration in any such changes.

· Betsi Cadwaladr UHB must address without delay the serious safety implications regarding the sickest and most vulnerable babies being cared for without sufficient access to dedicated expert neonatal consultants and middle grade doctors with sole responsibility to the neonatal unit. The review of maternity, neonatal and paediatric services being conducted by Betsi Cadwaladr UHB also fully addresses any additional support families may require as a result of any changes to services.

· Further action is required to ensure that all babies who have been admitted to neonatal care have access to the therapy support they need.

· Further work remains to be done to ensure that the data system is operating as effectively as possible, which the network should lead on. 

· We recommend that the Children and Young People Committee invites each Health Board to outline:

o what plans they have in place to address the critical staffing and occupancy issues highlighted in the network’s capacity reviews

o what plans they have for investing into neonatal services in order for all services in their areas to be fully compliant with the 2008 All Wales Neonatal Standards

o and what action, if any, they have taken with regard to the resourcing of neonatal services since the Health, Wellbeing and Local Government inquiry recommendations were published in 2010.