Neonatal care in the UK is organised into fifteen managed clinical networks; hospitals within a region work collectively to provide high quality neonatal care for all babies within their catchment. Services covered by neonatology include support for newborn babies requiring resuscitation at delivery and during the early postnatal period, and critical care services for sick preterm and term neonates and their families. Critical care services include intensive care (IC), high dependency (HD) care, and special care (SC). Intensive and high dependency care take place within neonatal units, whereas special care can take place within neonatal units or, increasingly, in other settings where a mother or the whole family can be resident with their baby, eg transitional care. The importance of parents and families as partners in their baby‘s care is increasingly recognised and neonatal units are encouraged to increase family involvement in care through quality improvement programs such as UNICEF Baby Friendly Initiative1 and the Bliss Baby Charter2.
Hospitals provide three different types of neonatal service for their local population34. Local Neonatal Units (LNUs) provide short term IC and HD/SC/TC services for their local populations; Special Care Units (SCUs) provide short term IC/HD, and SC/TC for their local population. The different types of neonatal services have varying medical and nurse staffing requirements, and standards for these are set by British Association of Perinatal Medicine (BAPM)567.
Shortages in neonatal medical and nurse staffing have been highlighted in previous national reports including the NHS England (NHSE) and Department of Health and Social Care (DHSC) (2019) report, Implementing the Recommendations of the Neonatal Critical Care Transformation Review8 and the National Neonatal Audit Programme (NNAP) annual report (2019)9. These reports recommended neonatal networks and services should produce a gap analysis of medical and nurse staffing and that workforce transformation was needed, working closely with Health Education England (HEE) and the RCPCH. The Getting It Right First Time (GIRFT) programme is supporting the implementation of the Neonatal Critical Care Transformation Review (NCCR) and worked in conjunction with the RCPCH to develop this snapshot survey to provide an 'on the ground' picture of shortages and day-to-day realities for people working in neonatology.
The current study was conducted on a weekday and weekend day in September 2019. One hundred and ninety-one neonatal services (58 NICUs, 87 LNUs and 46 SCUs) in the UK were contacted, requesting staffing and activity information at a departmental level. In addition, we requested that all individuals working on Tier 1, 2 and 3 medical rosters on the days of the snapshot complete information about their shift. This included workload and responsibilities and their opinions on safety, governance, staff support and wellbeing during the shift. Results from this snapshot were reported back to neonatal services in January 2020 through individual benchmarking reports produced by the GIRFT team. This report summarises the findings at a national level.
Rota and staffing levels:
- Overall, 10% neonatal units had gaps in medical staffing with 5% of these shifts covered by locums. Gaps were highest for Tier 1 and Tier 2 staff on the weekday (14%) and weekend day (7%) with few gaps at night (1-2%).
- 15% of neonatal units had gaps in nurse staffing.
- There were twice as many gaps in medical and nursing rotas in NICUs compared with LNUs and SCUs and wide regional variation in medical and nurse staffing gaps.
- There is poor compliance with BAPM medical standards across all neonatal units. Standards are more likely to be met in NICUs; highest compliance for all units was on weekday daytime shifts.
- 79% of nursing shifts met the numerical BAPM staffing standard, being lowest in NICUs (60%) and highest in SCUs (94%). 88% of shifts met the QIS standard, and this was similar across all designations.
- There is wide variation in the numbers of junior doctors available relative to occupied intensive care/high dependency cots.
- Neonatal units provide a predominantly non-elective service and bed day activity is unchanged at weekends. However, there are fewer admissions, deliveries, and other planning and supporting activities occurring at weekends.
- Weekend medical staffing levels are around two thirds of weekday levels for all NICU medical Tiers. For LNUs, this was the case for Tier 1 and 2, and for SCUs this was the case for Tier 1 staff. BAPM compliance was lower at weekends (60% NICUs, 40% LNUs)
- Lower numbers of medical staff felt there was sufficient medical and nursing staff to manage safely at the weekend compared with the weekday, particularly in LNUs and SCUs.
- Medical staff in LNUs and SCUs reported lower levels of enjoyment and higher levels of stress, anxiety and feeling overloaded at work at the weekend compared with the weekday.
- There was less administrative support available at weekend and only 52% of staff felt there was sufficient administrative staff to manage the service safely at the weekend.
Multidisciplinary team and medical staff activity:
- Allied Health Professionals (AHPs) and other support services were available in less than half of neonatal units during the week and were almost completely absent at weekends.
- Only one-fifth of NICUs and a tenth of LNUs/SCUs had a psychologist available to support families during the weekday, and no services were available at weekends.
- Only 35% of units reported that midwives had performed all or most of the Newborn Infant Physical Examination (NIPE) checks on well term babies during the survey period. NIPE checks were more likely to be done by midwives in NICUs.
- Medical staff reported more blood tests performed by non-medical personnel in NICUs than LNUs and SCUs.
- Neonatal staff attended 43% of all deliveries as a first responder for resuscitation.
- Only 49% of Tier 1 and Tier 2 staff had a break of 30 minutes or more. Breaks were more common in NICUs.
This snapshot, undertaken prior to the COVID-19 pandemic, highlights ongoing problems with staffing within both the medical, nursing and Allied health Professional workforce in neonatology. Medical staffing demonstrates low levels of compliance with BAPM staffing standards as well as a 10% gap in rotas, with half of these gaps filled by locums. Medical rota gaps occurred predominately in daytime shifts. Although this could be a chance finding, it is consistent across both days of the snapshot and suggests that staffing on night-time rotas (which is significantly lower than daytime rotas) is prioritised to support safe care, which may come at the expense of weekday medical training opportunities. Neonatal nurse staffing a 15% gap in rotas and low compliance with BAPM nursing standards, which was most severe in NICUs.
A number of concerns were identified around weekend working including safe medical, nursing and administrative staffing levels, higher stress and overworking in LNUs and SCUs and non-availability of the wider multidisciplinary team. Medical staffing levels and compliance with BAPM staffing standards is much lower at weekends, particularly in LNUs; this should be a priority. In addition, a review of current junior doctor activities both during the week and at weekends is warranted given current variations in practise. This should include NIPE checks (which for normal infants should be performed by the woman’s midwife10, routine blood tests, attendance at deliveries and timing and frequency of breaks. The development of the wider multidisciplinary team, including the Allied Health Professionals, pharmacy, and psychology services and other support roles, such as phlebotomy, Physician Associates, is required to ensure a holistic, safe and high quality neonatal service for the future.
Nursing and medical rotas
- All units should strive to achieve BAPM nursing standards as there is good evidence of improved outcomes with higher nurse to patient staffing ratios.
- All units should strive to achieve BAPM medical standards with particular focus on improving weekend daytime medical cover in LNUs.
- Units should review medical workload and activities particularly at weekends in light of concerns regarding higher stress, anxiety and feelings of overload at weekends.
- Neonatal Networks should review medical and nursing staff requirements against current activity and any reconfiguration planned in the context of the NCCR. A regional workforce strategy should be developed by Neonatal Networks in conjunction with relevant local Health Education boards, Local Maternity Systems, and national bodies including RCPCH and the Royal College of Nursing (RCN).
- Neonatal units should review medical and nurse staffing requirements using the snapshot, local and national benchmarking data, eg National Neonatal Audit Project, GIRFT datapacks. Plans should align with neonatal network requirements for the service.
Multidisciplinary team and medical staff activity
- All units should review the roles and responsibilities of the whole multidisciplinary team, including role of AHPs, pharmacy, psychology and other support roles such as phlebotomy and Physician Associates; workforce transformation is required to provide a good quality service for the future.
- All units should review the role and availability of administrative and clerical support in neonatal services including weekend working requirements.
- Tier 1 doctors should perform NIPE checks for unwell infants in the neonatal unit and review babies in the postnatal wards when problems are detected. NIPE checks for well term babies should be performed by the midwife and should not be a routine part of the Tier 1 medical role.
- Blood tests and other routine procedures on neonatal units should be minimised to reduce painful experiences for infants. These procedures should be shared amongst the multidisciplinary team in order to time procedures to suit the needs of the baby where possible.
- All units should have agreed guidelines for which deliveries require neonatal attendance and practise should be regularly audited to prevent unnecessary attendance.
- Units need to work harder to create a culture where medical staff are expected to take breaks in line with the BMA junior doctor contract and RCPCH trainee charter. Organisation of workload, communication with staff groups and mini audits with feedback to all colleagues can be helpful to try to reinforce this habit. This has become even more important since the arrival of COVID-19.
- 1. UNICEF (2016). Baby Friendly neonatal standards. www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/neonatal-guide-to-the-standards/
- 2. Bliss (2015). Bliss Baby Charter. shop.bliss.org.uk/shop/files/BlissBabyCharterbookletforprintLR.pdf
- 3. Department of Health (2009). Toolkit for High Quality Neonatal Services www.londonneonatalnetwork.org.uk/wp-content/uploads/2015/09/Toolkit-2009.pdf
- 4. NHS Commissioning (2015). NICU Service Specification: Neonatal Critical Care www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e08/
- 5. BAPM (2014). Optimal Arrangements for Neonatal Intensive Care Units in the UK. www.bapm.org/resources/31-optimal-arrangements-for-neonatal-intensive-care-units-in-the-uk-2014
- 6. BAPM (2010). Service Standards for Hospitals Providing Neonatal Care. www.bapm.org/resources/32-service-standards-for-hospitals-providing-neonatal-care-3rd-edition-2010
- 7. BAPM (2018) Optimal arrangements for local neonatal units and special care units in the UK. www.bapm.org/resources/2-optimal-arrangements-for-local-neonatal-units-and-special-care-units-in-the-uk-2018
- 8. NHSE and DHSC (2019). Implementing the Recommendations of the Neonatal Transformation Review. www.england.nhs.uk/publication/implementing-the-recommendations-of-the-neonatal-critical-care-transformation-review/
- 9. RCPCH (2019) National Neonatal Audit Programme annual report 2019. www.rcpch.ac.uk/resources/national-neonatal-audit-programme-annual-report-2019
- 10. NHSE (2016). Better births: Improving outcomes of maternity services in England. www.england.nhs.uk/publication/better-births-improving-outcomes-of-maternity-services-in-england-a-five-year-forward-view-for-maternity-care/