Maternity and neonatal services - neonatal intensive care plan: options appraisal

Background and Evidence

2. The Best Start, published in January 2017, outlined a new model of neonatal service provision which suggests care for the smallest and sickest babies is consolidated to deliver the best possible outcomes; emphasises parents as key partners in caring for their baby and; aims to keep mothers and babies together as much as possible, with services designed around them.

3. The recommendations for the new neonatal model of care are underpinned by strong evidence that population outcomes for the most premature and sickest babies are improved by delivery and care in units looking after a “critical mass” of these babies. They include:

• That access to on site paediatric, surgical, laboratory and radiology services is beneficial for the most preterm babies;
• That parents are partners in care, involved in decision making and care delivery;
• That mothers and babies should not be separated unless essential for care of one or other;
• That early discharge and ongoing care is in the interest of families;
• That parents should receive clear information;
• That kangaroo mother care and breastfeeding are essential to high quality care;
• That a skilled workforce is essential in units of all designation.

4. The wider package of recommendations include:

• Providing accommodation for parents to stay on or near the unit and facilities within the unit to encourage kangaroo skin to skin care and early support for breastfeeding;
• Development of Transitional Care.

5. In Scotland there were approximately 48,000 births in the year to 31 March 2020.^[1] Numbers fluctuate, but of these, around 5200 babies a year are admitted to neonatal care. Approximately 1,100 of these require a significant level of care which is described as intensive care. A very small proportion of these babies will be affected by the change in model of care.

6. The vast majority of babies (around 3000) admitted to a neonatal unit need care described as “Special Care”. Some of these babies may alternatively receive additional support alongside their mothers, on postnatal wards or in Transitional Care units. A further 1,100 need High Dependency care, and around 1,100 are admitted to a Neonatal Intensive Care. A very small proportion of these babies (around 50 – 60 per annum) will be affected by the change in model of care. All fifteen ^[2]Neonatal Units provide special care, some neonatal units also provide high dependency care and eight of those Units provide intensive care.

7. At the time of publication, The Best Start recommended that Scotland should move from the current model of eight Neonatal Intensive Care Units (NICU) to a model of three to five units in the short term, progressing to three units within five years supported by the continuation of current NICUs redesignated as Local Neonatal Units (LNU). These Local Neonatal Units will continue to provide a level of neonatal intensive care, but the most preterm and sickest babies will receive specialist complex care in fewer Neonatal Intensive Care Units, while returning babies to their local area as soon as clinically appropriate. To support service redesign, formal pathways between these units were recommended, to ensure smooth transfer and repatriation processes.

8. This is part of a larger package of measures outlined above to redesign neonatal services described in Best Start, aiming to minimise separation of families (through the development of Transitional Care and community support to facilitate early discharge), to provide care appropriate to need, and to improve outcomes for the most preterm and sickest babies. In addition, the Young Patient's Family Fund, formerly the Neonatal Expenses Fund, supports families with the additional cost associated with having to travel to be with their baby in hospital. Transformation of neonatal care in Scotland is underway and further detail on progress relating to redesign of neonatal services is available at Annex B.

Evidence to Support the Change in Model of Care

9. This recommendation is aimed at the most premature and sickest of babies and is based on a review of evidence (carried out by Dr Anna Gavine, Dr Steve MacGillivray and Prof Mary Renfrew of the University of Dundee and published alongside The Best Start). The evidence showed that outcomes for very low birth weight babies (VLBW) are better when they are delivered and treated in NICUs with full support services, experienced staff and a critical mass of activity (expert recommendation defines this as care for a minimum of 100 VLBW babies a year).

10. [Note: This evidence has since strengthened with the publication in 2021 of the British Association for Perinatal Medicine (BAPM) Framework for Practice, which sets out optimal arrangements for neonatal intensive care]