Neonatal care levels criteria: framework for practice

1. Background/Context

Well-organised and effective neonatal care can make a lifelong difference to families and their babies. The NHS has a responsibility at all levels to ensure that neonatal care is of high quality, effective and well-integrated with maternity, paediatric and family services. To optimise outcome, modern neonatal services should be provided in variety of clinical environments, selected according to the interventions and level of care required for the baby, supported by a dedicated national Neonatal Transport Service which transfers babies between neonatal units as their care demands.

Neonatal care is highly technical and has rapidly evolved over the last three decades with advances that have improved outcomes for both sick and very premature infants. National and international evidence has identified that the delivery of care for those premature babies born before 27 weeks of gestation, and care for infants in other higher-risk categories (e.g. more mature babies requiring prolonged intensive care), should be concentrated in a smaller number of tertiary care centres in order to:

• Optimise clinical outcomes.
• Ensure that expert and experienced staff treat a sufficient number of cases to maintain skills to allow the delivery of high-quality clinical care.
• Maximise the utilisation of specialist staff, associated equipment and facilities.

The importance of care pathways that facilitate the birth of extremely premature infants in tertiary units has been further consolidated by recent data from the UK, which have demonstrated a clear relationship between birth in a non-tertiary unit, either with or without early postnatal transfer, and an increased risk of death before discharge and/or severe brain injury. This aligns with recommendations in the updated British Association of Perinatal Medicine (BAPM) Framework on the Perinatal Management of Extreme Premature Infants Before 27 Weeks of Gestation. Such births should be managed whenever possible within a maternity unit co-located with a Neonatal Intensive Care Unit (NICU), and in-utero transfer to a NICU is the optimal pathway of care for threatened preterm births prior to this gestational age.

Across NHS England, the Department of Health centralised specialist neonatal care provision in 2003. This service redesign has resulted in an increased proportion of babies born under 27 weeks delivering in a NICU in 2015-16 compared to 2006 (73%vs. 56%, NNRD data) and its success has been validated by a variety of publications including the Neonatal Critical Care Specifications NHS England 2013. Their definitions of levels of care are utilised by Neonatal Operational Delivery Networks (ODNs) throughout NHS England and are unchanged in the context of NHS England’s on-going Neonatal Transformation programme “Better Newborn Care”. Whilst commissioning processes are not directly transferrable to NHS Scotland, the criteria and definitions utilised to define models of neonatal care in NHS England align with the clinical recommendations which underpin “Best Start”. These include aligning nomenclature of units with BAPM definitions to facilitate benchmarking and redesigning Neonatal Services within NHS Scotland to ensure that the smallest and sickest babies are treated in a smaller number of intensive care units with full support services, experienced staff and a critical mass of activity, returning near to home as soon as clinically appropriate for on-going care.

Criteria to assist in determining the most appropriate care location for babies requiring on-going and/or complex intensive care have been implemented across NHS England and have been utilised in this framework to align the proposed care pathways for NHS Scotland with those utilised by Neonatal ODNs across NHS England. On-going care will be provided in Local Neonatal Units (LNUs), or in a Special Care Unit (SCUs) as and when clinically appropriate.