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NIHR Signal Reconfiguring neonatal services balances survival chances against increased travel for families

Published on 5 February 2019

doi: 10.3310/signal-000723

Centralising services so that all babies are delivered in high-volume neonatal units could more than halve the number of units from 161 to 72, meaning that more parents would need to travel above 30 minutes. However, ensuring that all very preterm and low birthweight babies are cared for in high-volume neonatal intensive care units would reduce mortality.

NHS reconfiguration plans for neonatal services include closing smaller neonatal units to concentrate care where there are resources and specialised staff experienced in caring for higher risk babies. However, there is some tension between providing safe, high-quality care and ease of access for local communities.

This multi-method NIHR-funded study analysed the key issues related to reconfiguration.  Using modelling techniques and qualitative research, it developed a range of scenarios and identified trade-offs and values for parents, clinicians and commissioners.  It shows that changing the location of some neonatal intensive care units could widen their catchment areas.  

Though longer travel increases family expenses including transport, childcare, parking and lost wages, receiving the best care for mother and baby remains the priority for parents.

  •   Commissioning, Health management, Neonates and neonatal care, Acute and general medicine
Reconfiguring neonatal services balances survival chances against increased travel for families

Why was this study needed?

NHS England reports that 60,000 to 70,000 newborns (1 in 10) require neonatal care each year. Increased requirements are attributed to improved fertility (including from assisted conception) and increased admissions of mothers before their third trimester. The Office for National Statistics shows that in 2016, over 2,000 infants in England and Wales were born before 27 weeks of pregnancy.

Optimal care for the sickest newborns is provided at third tier neonatal intensive care units (NICUs). Local neonatal units (LNUs) are second tier services, and special care units (SCUs) the lowest tier.

There is evidence that very preterm and very low birthweight newborns have better survival if cared for in high volume NICUs. Reconfiguration plans for neonatal services, therefore, include centralising care to larger units with specialist resources and expertise. This may increase parental travel time. 

This national, multi-method project aimed to create a framework to address key factors associated with service reconfiguration.

What did this study do?

The study involved three main components: location analysis and modelling; economic analysis; and qualitative interviews. This kind of operational research can be very useful to support difficult system decisions, like configuration and location of services.

The study considered geographic areas with approximately equal population size (average 1,500 people). The Office for National Statistics was used for demographic and mortality data; a geographic information system for travel times; Hospital Episode Statistics for birth data; and the National Neonatal Research Database for neonatal care data. A simulation model was used to evaluate scenarios, such as admissions over time, transfers and unit capacities. The economic model explored the impact of service reconfiguration on clinical outcomes and costs including length of stay and family expenses. Parent preferences were assessed through semi-structured interviews with ten mothers/parents, five workshops and a survey of 1,347 parents.

Missing data may lead to inaccurate estimations for length of stay, travel time and family costs. Estimates cannot assess the impact of resource availability and transitional costs of service reconfiguration.

What did it find?

  • There are currently 161 maternity units, (including NICUs, LNUs and SCUs) in England. Average parent travel time is 15 minutes and maximum 82 minutes, with 93% living within a 30-minute drive. Only 20% of births occur in high volume units with ≥6,000 births a year. To achieve 100% would need a reduction to 72 units. Roughly halving the number of units increases average travel time to 21 minutes and maximum to 99 minutes, with 84% living within a 30-minute drive.
  • There are 45 existing NICUs with maximum travel time 142 minutes. Increasing the number up to 60 units in all possible locations would only reduce the maximum travel time by 5 minutes. However, increasing the number of units decreases the number of admissions to each one. Changing the location of some of the 45 existing units could reduce maximum travel to 86 minutes. 
  • In order for 100% of very low birthweight infants to be cared for in a high volume NICU which admits ≥100 such newborns per year, either some of the 45 existing NICUs would need to be relocated, which would also reduce parental travel time, or nine of them would need to be closed, increasing travel time. 
  • Based on 12,687 births, the birth of very preterm infants (born <32 weeks) in high volume units reduced mortality by up to 5%. Total length of stay following birth in a high volume unit is nine days longer and costs £5,715 more than birth in another neonatal unit. The main determinants of parental costs, as collected by the UK charity BLISS, were food and travel, use of child care, car parking, unpaid leave, average income, and the support of the partner’s employer.
  • The interviewed families had very different maternity/neonatal experiences. Common themes discussed related to the hospital environment, how staff communicated with them, understanding risks, family disruption, and impact of travel (some families reported having to rely on public transport or spend ≥3 hours daily travelling). However, the priority of parents was the health of their baby, and they were willing to do what was necessary to make this happen.

What does current guidance say on this issue?

The NHS England Service Specifications for Neonatal Critical Care advised that there is evidence that care for high-risk babies should be concentrated in a few centres to:

  • Ensure expert staff who treat sufficient numbers to maintain safe, high-quality care
  • Maximise use of scarce, expensive resources
  • Organise retrieval services across large enough areas to be effective and economic
  • Ensure services provide family-centred care

The British Association of Perinatal Medicine recommends all NICUs should admit ≥100 very low birthweight infants each year. Neonatal Networks should consider combining small units. Recommendations are given for increasing senior cover if the number of annual intensive care day admissions exceeds set thresholds. All NICUs should provide free accommodation and car parking for parents.

The Royal College of Obstetrics and Gynaecology recommends that obstetric-led units should deliver ≥6,000 births a year to ensure 24/7 consultant cover.

What are the implications?

These complex findings highlight various issues for service reconfiguration. The effective geographical positioning of units seems essential, taking into consideration population density, and the size and level of unit required.

The main priority of parents and providers is the health of mother and baby. But those restructuring services need to consider the quality of life effects. The experience of families will be greatly influenced by travel times and their family and financial circumstances. Of note, travel times were based on driving and did not take public transport into account. The support that units provide to families including free accommodation and parking is vital.

The model is inherently limited by various factors, such as inability to assess morbidity, the influence of maternity care, or the effect of transfers.  However, this robust study used a range of modelling, simulation and scenario approaches which included input from parents and provides important new evidence to support system decisions in this area.

Citation and Funding

Villeneuve E, Landa P, Allen M et al. A framework to address key issues of neonatal service configuration in England: the NeoNet multimethods study. Health Serv Deliv Res. 2018;6(35).

This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 14/19/08). 

Bibliography

BAPM. Service standards for hospitals providing neonatal care, 3rd edition. London: British Association of Perinatal Medicine; 2010.

BAPM. Optimal arrangements for neonatal intensive care units in the UK including guidance on their medical staffing: a framework for practice. London: British Association of Perinatal Medicine; 2014.

NQB. Safe, sustainable and productive staffing: An improvement resource for neonatal care. London: National Quality Board; 2018.

NHS website. Your pregnancy and baby guide: Special care: ill or premature babies. London: Department of Health; updated 2018.

NHS England. E08. Neonatal critical care. London: NHS England; 2015.

NICE.  Neonatal specialist care. QS4. London: National Institute for Health and Care Excellence; 2010.

RCOG. Reconfiguration of women’s services in the UK. Good Practice No. 15. London: Royal College of Obstetricians and Gynaecologists; 2013.

The King’s Fund. The reconfiguration of clinical services: what is the evidence? London: The King’s Fund; 2014.

Expert commentary

This insightful report examines the structure of neonatal services and contains invaluable information for the practising neonatologist. It has much to say on staffing and costs, but the real interest lies in the analysis of location, travel distances, and the effect this has on parents.

If you have ever wondered whether we could site and manage our intensive care networks better, the evidence is here.

Professor David Edwards, Chair in Paediatrics and Neonatal Medicine, King’s College London

The commentator declares no conflicting interests