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

Options Appraisal Process Stage 3: Post Covid Review

35. The advent of the COVID pandemic paused progress with the new model of neonatal care. However the Early Implementer Boards continued to operate the new model of care, as outlined in data in the previous chapter.

36. Ahead of receiving advice on the outcome of the options appraisal process and feasibility testing, Scottish Ministers asked the Perinatal Sub Group to:

• Review current data to understand whether the profile of babies in neonatal care has changed significantly during the pandemic;
• Review readiness in light of COVID and include advice on planning for capacity management and implementation and develop a phased plan for the transition and;
• Consider communication.

37. The Perinatal Sub Group were therefore remobilised following the pause brought about by Covid and reviewed current Public Health Scotland (PHS) data on the number of extreme pre-term babies being born in Scotland. The Group also agreed a planned programme of engagement including:

• Discussions with the Neonatal Early Implementers on operation of the model
• Discussion with the final three neonatal ICUs on readiness to restart, including capacity, phasing of implementation (where required), pathways and protocols, training requirements, ScotSTAR pathways, information for parents and local communication.

Neonatal Early Implementers – Summary of Discussions and Key Points

Successes:

38. The Model, including pathways and repatriation is operating well, with only a very small number of out of pathway transfers.

39. Lothian reflected upon the successful work on ‘Keeping mums and babies together’ including delivery of more neonatal care in the community through a well-established seven-day neonatal community service, with criteria led discharge, as well as development of transitional care and home phototherapy.

40. Lothian, Fife, GG&C and Ayrshire and Arran teams all reported improved and good quality communication and collaboration. This included regular meetings between clinical teams to discuss operation of the new model, which encouraged collaborative working, sharing of expertise and ideas as well as providing an opportunity to reflect upon and improve processes. Repatriation protocols were also reported as working well.

Issues to address:

41. Staffing remains an ongoing challenge. The advent of Covid saw staffing challenges impacting capacity across all Units in Scotland. Capacity in RIE and QEUH neonatal Units meant they were closed to admissions on occasion, simultaneously at one point which led to a small number of out-of-pathway transfers. Maternity capacity remains a challenge.

42. NHS Fife noted that they did not think there was any anticipated saving on QIS staff required because of an increased acuity of care, and because, whilst some intensive care is no longer provided in Fife in their function as a LNU, they still accept babies from others Units that do require some level of intensive care.

43. NHS Fife also expressed concerns about decreased confidence and de-skilling amongst nursing and medical staff in situations where they may have to provide the initial care for an extreme pre-term baby, prior to transfer to a neonatal intensive care unit.

Discussions with Three NICU Boards

44. In addition to understanding operation of the early implementers, preliminary discussions were held with senior leads in all three NICU Boards to alert them to the remobilisation of the work and discuss readiness to proceed. Key points from all those discussions:

• Lothian, Grampian and GG&C are all content to move forward. GG&C is already doing some planning work.
• GG&C highlighted building accommodation limitations in RHC/QEUH Neonatal Units which restrict expansion of physical capacity.
• Grampian highlighted considerations in relation to work on Dr Grays and opening of the new Baird Family Hospital, which will have single bay neonatal accommodation and a family hotel (scheduled to open early 2024).
• All Boards highlighted essential modelling (maternity and neonatal) required to inform capacity planning, and staffing (in particular the importance of including maternity capacity planning, and NHS Lothian are doing some work on this).
• Accommodation for parents: Both Lothian and GG&C reported challenges with parental accommodation capacity, which would increase with numbers of very sick babies transferred in.
• A sustainable staffing model for the three neonatal intensive care units and recurrent funding of any uplift were highlighted as key requirements.

Consideration of timescales, governance and funding to support implementation

Governance

45. The Perinatal Sub Group propose that:

a. Regional Planning leads (Chief Execs NHS GG&C, Lothian & Grampian) should drive forward implementation within and between Boards.

b. The Best Start Programme Board’s Terms of Reference should be amended to include oversight of implementation.

c. Progress on implementation will be reported into the Best Start Programme Board on a quarterly basis.

d. The Boards where the final three neonatal intensive units will be located should be asked to submit an implementation plan to the NHS Chief Operating Officer and Scottish Ministers by September 2023.

e. Should issues or delays arise in relation to implementation, the NHS Chief Operating Officer will work with those Boards to further understand any identified issues and identify possible solutions.

Timescales

46. It is evident through discussions with the neonatal community that capacity and staff planning and modelling work is required to further inform implementation, including potential phasing, of moving to three neonatal intensive care units.

47. Through discussions with the Boards where the final three intensive care units will be located, it is clear that there is limited capacity within those Boards to undertake the Scotland-wide detailed cross-Board planning and modelling for the change, so the Perinatal Sub-Group proposes that this could be carried out by a third party. This will also add a level of external assurance to the planning process.

48. This further underlines the requirement for a decision on the location of the final three units to be publicly known, as detailed discussions around capacity, staff planning and modelling cannot commence with all Boards affected by the change, until this is known.

49. Modelling should be completed by Summer 2023, giving Boards a year to fully implement the new model, keeping within timescales set out for the implementation of Best Start. The phased roll out of the new model of Neonatal Intensive Care should then commence across Scotland, based on the new criteria set for the transfer of the smallest babies. An initial outline of timescales is set out below:

• Early 2023 – Public announcement on location of final three Units. Initiate procurement process to identify expertise to undertake modelling work required.
• Feb 2023 – Best Start Programme Board meeting to agree revised terms of reference to oversee implementation.
• Summer 2023 – Outputs from detailed modelling received. Regional planning leads to establish delivery groups in each of the regions.
• Autumn 2023 - submission of implementation plan, including phasing to Scottish Ministers.
• September 2023 – March 2025 – phased implementation of new model.

Funding

50. Since 2018/2019, the Scottish Government has invested £2.4 million to support the Early Implementer Boards to plan for the changes and to support NHS Lothian and NHS GG&C in capacity building in preparation for full implementation of the changes.

51. The Neonatal Expenses Fund (NEF) was established on 1 April 2018 and supports parents with babies in neonatal care with the cost of meal and travel expenses. The scope of this fund has since been widened to include all families with a child under the age of 18 in hospital and includes reimbursement of reasonable accommodation costs, allowing more equity of access for parents and is now called the Young Patients’ Family Fund.

52. NHS Directors of Finance should be commissioned to develop a cross boundary model for recurrent funding that sees a transfer of resource whereby the funding follows the mothers and babies.

53. Best Start transformational change funding will continue to be provided to bridge any gap in funding to support capacity building in the final three Units, until a sustainable funding model is in place. In 2022/2023 this amounts to £1.1m and we expect the same level of funding in 2023/2024.

54. The Best Start Programme Board should drive development of this sustainable funding model.

Evaluation

55. All units should be monitored in respect of the numbers of very low birth weight babies treated, capacity, patient flow and pathways and parental feedback as part of an ongoing annual evaluation of services against the new model of care which will be overseen by the Best Start Programme Board reporting to Scottish Government. In addition the quality of care provided in all three Units will continue to be monitored through the NMPA, MBRRACE and NNAP national audits.