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

Risks And Issues

Tayside babies

56. Based on historical patient numbers, of the three recommended future NICUs, the unit in Aberdeen is currently admitting the fewest babies with birth weights <1500g. Despite proposed redesign, Aberdeen is very unlikely to reach the benchmark of 100 VLBW babies per annum associated with improved outcomes. However, having a third Unit in the North would support accessible services for local populations, taking into account the geography of Scotland. This would negate the need for families in the North to potentially have to travel extensively to receive care.

57. The Perinatal Sub Group discussed the destination for Tayside babies that fall within the criteria for transfer under the new model. Tayside have expressed concerns about transferring babies to Aberdeen, as whilst it will increase the number of VLBW babies being cared for by Aberdeen clinicians and therefore bring them nearer to the 100 VLBW babies, they will still not make the expert recommendation defined as care for a minimum of 100 VLBW babies a year. For some Tayside families, such as those in Angus, Aberdeen is geographically closer and therefore they may choose this option. Perthshire, North Fife and Dundee families are equidistant from Edinburgh or Glasgow.

58. As Aberdeen is unlikely to meet the 100 VLBW babies a year expert recommendation, the Perinatal Sub Group proposes close monitoring of implementation and enhanced support for staff in the Unit in Aberdeen. It will be important to ensure accurate patient information is available to support informed parental choice.

Maternity Engagement and Capacity

59. The Early Implementers highlighted the need to engage with maternity services at an early stage in planning and modelling for the change. Women who are suspected of being in pre-term labour (or likely to be at high risk of pre-term labour) need to be identified by maternity services. Best Start recommends that women in pre-term labour are transferred in utero so that their babies can be born in maternity units with Neonatal Intensive Care Units on site. This will have an impact on the receiving maternity services, and the predicted capacity increase will need to be modelled and resourced. In addition staff in transferring units will need to understand the new model, the anticipated benefits and ensure pathways are in place and families informed and supported. The Perinatal Network has work underway to improve the efficiency and accurate prediction of the need for in-utero transfer.

Skills maintenance

60. Clinicians in the early implementer units identified skills depletion as a key concern for those units no longer categorised as a NICU. This is based on the expectation that small and sick babies will continue to be delivered unexpectedly outwith NICUs and that some babies in local neonatal units and special care units will require stabilisation and transfer for additional care in NICUs. However, LNUs will continue to deliver intensive care and care for babies from 27+0 weeks that need stabilisation and treatment, so both nursing staff and medical staff will continue to have experience in delivering these aspects of intensive care.

61. Skills maintenance should be considered on a tiered basis:

(i) emphasising ongoing local Health Board responsibilities

(ii) building and strengthening clinical interactions between units (NICUs and LNUs/SCUs) to support decision making

(iii) developments specifically to assist in skill maintenance.

Current Position and Opportunities

62. Actions for Health Boards:

• Health Boards have a responsibility to ensure all relevant staff have mandatory neonatal resuscitation training.
• Simulation (SIM) training is recommended for medical staff as a local Board responsibility and increasingly multidisciplinary teams are recommended to undertake SIM training together as a perinatal team (BAPM and Periprem etc).
• Simulation programmes both within neonatal units and across Perinatal teams should be recommended in all units.
• Boards should ensure clinical teams utilise all opportunities for shared educational opportunities at both national and local level, including attendance at morbidity and mortality meetings, repatriation calls and grand rounds - both in person and virtually.

63. Actions for the Scottish Perinatal Network

• Opportunities should be identified for a regular clinical update item within network events and specifically within the Consultant forum as a quarterly agenda item, these would be updating on evidence rather than practical skills training.
• Ensuring sharing of new and updated clinical guidelines across the network highlighting any changes to clinical practice this entails.
• Emphasis should be on building on existing interactions as teams and reinforcing working as one team across Scotland.
• Explore opportunities for Consultants within LNUs and SCUs to attend NICU ward rounds.

64. Actions for NHS Education for Scotland (NES)

• NES could support/coordinate a perinatal approach to development and participation in SIM training programmes. Consideration should be given to a NES role specifically in enabling all teams to have the skills, training and leadership to deliver SIM training as this is often the barrier to successful implementation of SIM programmes.
• Recommend that the QIS working group look at the importance of post QIS training and competencies that should be developed within a post QIS Framework.
• NES are best placed to offer specific skill training where this is requested (recognising there is already a joint NES ScotSTAR Stabilisation course developed and run for CMU staff). Developing an aligned course for LNUs/SCUs should be further discussed with NES.

Planning and modelling

65. Through the experience of the early implementers it is clear that Boards need sufficient time to plan and prepare for implementing the changes, and that this needs to involve the whole multidisciplinary team (maternity and neonatal).

Funding and Timescales

66. There will be costs associated with resourcing implementation of the new model of care, and with the redistribution of neonatal workload. While the Scottish Government can seek to identify short term transformational funding, a long-term sustainable model for recurrent funding will be required to meet those costs and a funding mechanism agreed through Directors of Health Finance and with Boards. Detailed clinical modelling work undertaken in early 2023 will inform the financial modelling.

67. 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 £1m and we expect the same level of funding in 2023/2024.