Neonatal intensive care unit services - demand and capacity modelling: final report
This report outlines this modelling approach, inputs, and interpretation of the outputs to support the future of neonatal intensive care unit (NICU) services.
6. Implementation
6.1 Lessons learnt from other areas
To inform considerations for implementation, learning has been gleaned from similar models of care that have been implemented in other areas. Experience from England suggests that 85-90% of births should happen in the correct setting and any increase in maternity transfers can be mitigated by using a firm guideline to ensure that risk stratification is optimised to underpin this. Furthermore, women giving birth at extremely low gestations have themselves increased health needs due to the conditions necessitating early delivery[6]. Implementation must therefore be monitored carefully to ensure that guidance is followed, and that care occurs in the appropriate setting. The development of firm monitoring criteria is necessary with regular review and exception reporting in situations where the patient pathway is not followed. These should be monitored by teams in each of the NICU-associated networks and reported centrally.
The flow of babies is not simply one way and, given current high survival rates and likely pressure on beds from the stochastic nature of neonatal admissions, it is also imperative within this model to ensure that staff are in place to optimise back transfer without delays, capacity is present in receiving units and that transfer policy and delays to this are minimised and monitored. Again, the experience of transformation in England has highlighted the important of Family Care Coordinators in supporting families though this difficult transition and minimising differences in family care practices at the constituent Network units.
Care and attention will be needed to support communication and liaison where exceptions to practice may occur. Intensive care activity (and expertise) will still be required in non-NICU sites and consideration given to Network wide skills and training to support this. Outreach by NICU teams to optimise these areas will be important. Regular publication of national outcomes (through NHS Scotland and the National Neonatal Audit Project to benchmark performance within the Scottish Network) is essential.
6.2 Implementation considerations
As a part of the engagement with operational and strategic stakeholders throughout the modelling process, a range of feedback has been provided, that will need to be considered during the implementation of the future national model of care. This has been captured and summarised into four key themes: Workforce; Capacity and occupancy; NICU flows and repatriation; and Implementation enablers. Each of these themes and implementation considerations has been shared and refined during the final set of workshops with stakeholders. The final set of implementation considerations have been summarised in tables below and will be for consideration of Scottish Government and the Regional Planning teams to take forward.
The primary area which will need to be considered prior to implementation is workforce, with this thematic area significantly interlinking with capacity and NICU flows.
6.2.1 Workforce
| What we have heard | What does this mean for implementation |
|---|---|
| Workforce has been identified as fundamental to the successful implementation of the future national model of care, with the recruitment of neonatal nurses / midwives recognised as an ongoing challenge | In order to ensure the there is sufficient staff to meet the capacity requirements projected within the capacity modelling, there will need to be consideration of a workforce model for each region. This should align with the BAPM guidance on safe staffing. Workforce planning will also need to consider the recruitment of any additional workforce, alongside supporting the retention of current staff in-post. |
| There is a nominal threshold of medical staffing that is required to be met (including ANNPs). Reducing the number of cot days at the future LNUs may not correlate to a reduction in medical workforce required in these units. | BAPM guidance relating to the medical workforce should be reviewed when considering regional workforce planning to meet the demand. |
| Where there have been transfers out of a baby’s normal pathway of care within the baseline period for a lack of capacity in the nearest suitable centre, a lack of neonatal nurses is seen as one of the main reasons. As well as overall capacity, there is also a high sickness absence in this workforce. | Levels of sickness absence will need to be considered within initial workforce planning (in terms of WTE staff required). In the medium-term, a review of sickness absence (to determine whether any additional supports can be provided) should be undertaken. |
| The role of wider supporting care roles (outside of medical and nursing/midwifery) should be explored as part of the future model, to ensure optimal outcomes for babies. There should also be consideration of the required non-clinical roles and the footprint of these roles (e.g. educators and clinical co-ordinators etc). | As a part of the regional workforce planning, consideration will need to be made for wider clinical roles (e.g AHPs, Pharmacists, Psychological support services etc.) and non-clinical roles based on BAPM guidance. |
| There will also need to be consideration for the educational requirements (e.g Neonatal QIS for nursing / midwifery workforce) and over what time horizon this will need to be achieved, to ensure skills maintenance across units. | During implementation planning, there will need to be consideration of any changes in the numbers of nurses / midwives required to staff the future model of care and how this will impact education requirements. For example: taking into account BAPM guidance for the proportion Neonatal QIS staff required (70%), a forward plan to support units to meet these requirements is recommended. |
6.2.2 Capacity
| What we have heard | What does this mean for implementation |
|---|---|
| Maternity capacity has been raised as a frequent and increasingly more common barrier to IUT in situations where there is neonatal capacity but a lack of capacity to accept women in labour. Maternity length of stay can be lengthy (pre delivery as well as following delivery) as many of these women will be high risk and require significant complex care. Units very much rely on capacity for maternity admissions. | While the modelling has outlined the additional bed days necessary to support increased in-utero transfers in the maternity services, the capacity and policy of local maternity units on-site at each of the three designated NICU sites should be reviewed. This review will need to address how maternal care is delivered within maternity services alongside each NICU site and to understand where pressure points for each site may occur |
| Staff capacity is seen as the most common reason for lack of capacity (rather than cots), and operationally the staffing of these cots is the limiting factor rather than the number of physical cots. | In order for the future model of care to be implemented, staff capacity will need to be sufficient for the capacity requirements projected within the modelling (see workforce theme above for more details). |
| Due to the model scope, there still needs to be consideration of the work which has historically been transferred to LNUs (which was outside of the scope for this modelling) | Individual units should review where capacity transferred have been required to units who were outside the scope of this modelling. This information should be considered alongside these modelling outputs. |
6.2.3 NICU flows and repatriation
| What we have heard | What does this mean for implementation |
|---|---|
| Across each of the eight units, there have been both in- and ex-utero transfers as a result of capacity. Patient flows outside these normal pathways (although reduced) may still occur in the future model due to the stochastic nature of NICU admissions. This will need to be appropriately managed. | During implementation planning, good practice co-ordination approaches should be considered. Examples of this include:
|
| Sufficient staffed capacity will be required at LNU sites to allow for timely repatriation. | During workforce planning (see workforce theme above), considerations will also need to be given to the staffing of wider LNU units (to prevent unnecessary transfers to NICU sites, and to enable the flow for timely repatriation so that these sites have the capacity to take babies back). Safe staffing guidance from BAPM and the principles from the National Neonatal Discharge Planning and Follow-up Framework (2019) should be considered. |
| There are a number of areas suggesting a lack of community and transitional care infrastructure, which has an impact on the length of stay for babies in those areas. Improving community and transitional care will improve flows and free up capacity in LNU and thus NICUs. | Within regional implementation planning, forward planning around how community and transitional care can be improved to reduce cot days and send babies home (where appropriate). |
6.2.4 Implementation enablers
| What we have heard | What does this mean for implementation |
|---|---|
| Data for the current modelling exercise had to be manually collated. As a result, data collection is not standardised across units. There is an ongoing challenge around the collation of data at a regional / national level for the purposes of service planning. | The establishment of a standardised monitoring dashboard (incorporating in key activity, capacity and flows etc.) across all units would ensure consistency in the national model of care and support in the evidence-based identification of pressure points. |
| Wider support services (e.g temporary accommodation for parents) have been mentioned throughout engagement with stakeholders. | During implementation planning, a review of the current wider supporting services would identify any key supporting enablers across each region, alongside areas which may need further support (to further enhance the national model). |
| A range of stakeholders have queried how the future model of care will be financed, citing a range of operational challenges which could be influenced by the future funding model. | It is critical that an agreement on the financial arrangements for the future model of care is made, prior to its implementation. This should form part of the initial next steps following this modelling exercise. The focus of the financial model will need to promote safe, high-quality care for Scottish babies. |
| There is an acknowledgement that there will be a significant level of change for operational staff as the future model of change is embedded. | Comprehensive communication plans should be developed as part of the implementation considerations, to ensure transparency and that all staff are informed throughout implementation. |
Contact
Email: thebeststart@gov.scot
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