Neonatal Care

– in the House of Commons at 6:00 pm on 12th October 2006.

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Motion made, and Question proposed, That this House do now adjourn. —[Liz Blackman.]

Photo of Sadiq Khan Sadiq Khan Labour, Tooting 6:01 pm, 12th October 2006

I am grateful for the opportunity to highlight the important issues surrounding neonatal care. There may not be as many speakers in this debate as there were in the preceding one, and it may not go on as long, but I hope the response from the Minister on the Treasury Bench will be as positive as that given to the preceding debate.

BLISS, which is funded almost entirely through donations and grants, is the leading national charity focusing on neonatal care and has been established for more than 25 years. I appreciate the support that the charity has provided to me in making me aware of the amazing work that goes on in neonatal care, as well as some of the challenges. I understand that my hon. Friend the Minister will be presenting an award at the inaugural BLISS ceremony on 24 October, which confirms the Government's respect for BLISS.

One in eight babies born in the UK require neonatal care, which represents 80,000 children, 17,000 of whom will require intensive care. About 11,000 babies in London each year need the extra care provided in neonatal units. The majority of the babies in neonatal units are there because they were born prematurely. However, there is a diverse range of other causes. For example, a child born with an infection might require antibiotics, some children need help to breathe via a ventilator, and other children with a serious case of jaundice may need to kept under observation in a neonatal unit.

The strides taken forward in the past two decades are there for us all to see. In the mid-1980s only one in five babies weighing less than 1 kg at birth could survive. That proportion has increased rapidly and stands at four in five babies. The fact that four in five babies now survive, compared with one in five in the 1980s, is testament not only to the technological advances achieved in this period, but to the tireless efforts of doctors and nurses who, as I am sure hon. Members on both sides of the House will agree, can never receive too much praise.

The number of babies born prematurely has also increased significantly in recent years. A number of social factors have contributed to the escalating numbers of premature births. The increased prevalence of fertility treatment has resulted in a corresponding rise in multiple births, which are more likely to result in premature labour. When women have children later in life there is an increased prospect of obstetric complications, particularly if mothers are over 40 years of age at the time of giving birth. Babies born as a result of teenage pregnancy are also at high risk of being born premature and/or at a low birth-weight. Unfortunately, the UK still has the highest rate of teenage pregnancies in western Europe. Mothers from ethnic minority backgrounds are more likely to give birth to a baby with a low birth weight.

The need for effective neonatal care is becoming ever more apparent and growing. However, the capacity of neonatal services is not sufficient to cope with the current demand, let alone future needs. I welcomed the Government's additional targeted funding of £72 million between 2003 and 2006, which among other benefits helped to establish five neonatal networks across London, a neonatal transfer service to transport babies to an alternative hospital when necessary, and an increase in capacity.

The Greater London authority report, "Counting the Cots", which was published in May this year, also highlighted the point that the number of neonatal cots in London has increased by 12 per cent. in the past four years. London has 77 more neonatal cots in 2006 than it had in 2002. The report concluded that

"neonatal care services are generally working well", for which the Government deserve huge praise.

Notwithstanding that encouraging progress, I hope that my hon. Friend the Minister recognises the urgent need to go even further. In July this year, I visited the neonatal unit at St. George's hospital in my constituency for the second time in recent months. The visit provided me with the opportunity to meet the parents of premature babies and the staff, who make an invaluable contribution. Visiting a neonatal unit is a reminder of how our NHS does a fantastic job giving hope and joy to the parents of those tiny miracles. Premature babies are some of the most vulnerable patients, and they are looked after by skilled, specialist caring staff, who also provide tremendous support to understandably distressed parents.

St. George's hospital plays an integral role in the provision of neonatal care in south-west London. The Department of Health review, which was published in April 2003, recommended that neonatal care should be reconstructed into clinical networks with units divided into three levels depending on the level of care that the hospital can provide. First, there are intensive care units, where one nurse looks after one baby. Those units are necessary for babies with particularly complicated medical needs. Secondly, there are high-dependency units, where a nurse should be responsible for no more than two babies. Those units are necessary for babies weighing less than 1 kg who do not need intensive care, but who still require treatment, such as intravenous feeding. Finally, there are special care units, where a nurse should not have responsibility for more than four babies. Those units are necessary for babies who require regular monitoring.

The system ensures that each region has at least one hospital that can offer so-called level 3 intensive care support for the mothers of premature or ill babies. I am pleased that the hospital in my constituency where my two daughters were born not so long ago—I was also born there slightly longer ago—offers the most advanced neonatal care in south-west London. The Government recommend that 95 per cent. of premature babies should be cared for within their local network, but too many mothers still have to travel hundreds of miles to obtain the appropriate level of neonatal care.

More than 90 per cent. of units were compelled to transfer patients last year because of lack of capacity. The neonatal units at St. George's hospital accepted transfer cases from areas such as Brighton, Farnborough, Southampton and Wrexham Park, which is near Slough. While I accept that a system of networks is the most effective method of supporting parents, we cannot escape the fact that there needs to be an increase in the number of specialist nurses, cots and dedicated transport services to alleviate those concerns. In that regard, many hon. Members hope that the Minister's excellent relationship with the Treasury, as a result of his previous ministerial experience, will enable him successfully to lobby the Treasury in the 2007 spending review for an even greater prioritisation of funding to health services for sick and premature babies.

The British Association of Perinatal Medicine believes that the average occupancy of neonatal units should be 70 per cent. to ensure that capacity is available in unforeseen circumstances. Recent research undertaken by BLISS highlighted that 78 per cent. of units nationwide have been forced to close to new admissions as a result of insufficient capacity. Furthermore, St. George's hospital has an average occupancy rate of 91 per cent. of its cots. In 2005, it had to turn away 518 babies because of the lack of staffed cots. In fact, the unit had to be closed to new admissions as recently as 3 October, which is one of 71 days in the past six months in which that situation arose. More alarmingly, I have been advised that St. George's is currently 27 nurses short of the standard set by the BAPM, if it is to achieve the level 3 target of one nurse caring for no more than one child.

I realise that resources in the NHS are finite, but it is clear that the lack of national nursing standards and of a national focus mean that local trusts and PCTs are not giving neonatal units the funding that they require. When difficult choices about the allocation of resources need to be made, neonatal units suffer. Research from BLISS found that only 3 per cent. of units in the UK can provide one-to-one nursing for premature babies in intensive care. It estimates the nursing shortfall to be about 2,700, including 540 in London alone. Moreover, a third of the most highly qualified neonatal nurses currently employed in hospitals will retire within the next three years.

Health professionals and specialists were keen to stress to me that the recruitment and retention of doctors in neonatal units has markedly improved under this Government. However, there is a problem with regard to suitably qualified and experienced neonatal nurses. One of the main reasons for that is the uncertainty generated by the lack of national guidance and primary care trusts not funding staff at the appropriate levels. I hope that my hon. Friend is in a position to reassure the House that the Government are listening to those concerns and will urgently investigate them.

Many of the health professionals to whom I spoke welcome the Government's proposed reforms in neonatal health care. Nevertheless, they have stressed the need for improved delivery mechanisms within neonatal care. There is a particular problem with a commissioning system that appears disjointed. Neonatal intensive care is deemed to be a "specialist service" and is therefore commissioned by a number of PCTs sharing the investment and associated risk of commissioning funding to this important area. In contrast, level 1 neonatal care is commissioned by the relevant PCTs individually.

Another problem that the specialists identified is that of insufficient inducements provided by the Department of Health for PCTs to ring-fence the necessary funding for neonatal care, which is compounded by the lack of national standards that I mentioned. I ask my hon. Friend for his help in persuading PCTs of the fundamental importance of neonatal care and dissuading them from reducing the level of service provision in this area. At the same time, I ask him urgently to look into improving the commissioning of neonatal care and the allocation of future funding. One of the things that we have been very good at is starting to involve patient representation and parental involvement within neonatal care. There are now several user involvement projects that recruit, train, and then support parents who wish to become board members for neonatal networks as user representatives. Parents need to be more involved with the commissioning of local community services. I am sure that any support that the Department of Health can provide in this area will reap benefits for all users.

As hon. Members will know, the Healthcare Commission has a statutory duty to evaluate the performance of healthcare organisations. Unfortunately, it still has not conducted an investigation into neonatal care. Maternity and paediatric services have been thoroughly investigated by the commission, and improvements made as a consequence, but that is not the case with neonatal care. I understand that an audit of neonatal services has just been commissioned and is currently being undertaken by the Royal College of Paediatrics and Child Health. However, an audit that merely monitors such variables as transfers and occupancy rates is insufficient and does not compensate for the lack of an investigation. I hope that my hon. Friend will provide the House with a commitment that he will look into the Healthcare Commission's embarking on an examination into neonatal care in the near future.

The national health service has made significant progress since 1997, with waiting lists and waiting times down significantly. Record numbers of patients are being treated, with record numbers of lives being saved. Neonatal care has also made huge strides, but there is concern among parents, staff and professionals that more can and must be done in this vital area. I am therefore pleased that I have had the opportunity to highlight these issues in the House. I am grateful for the attention of my hon. Friend the Minister and very much look forward to his response.

Photo of Ivan Lewis Ivan Lewis Parliamentary Under-Secretary (Department of Health) (Care Services) 6:13 pm, 12th October 2006

I congratulate my hon. Friend Mr. Khan on securing the debate. He spoke passionately and eloquently about a subject that is massively important to many people, although that is not reflected by the turnout in the Chamber. I am delighted to see Mike Penning in his place, and I will give him the opportunity to intervene in a few moments.

I echo my hon. Friend's comments about the contribution of BLISS, and I look forward to presenting the award that he mentioned. The organisation has made a tremendous difference and we should pay tribute to its exceptional work.

Neonatal services provide high quality care for some of the most vulnerable babies in our society. It is a credit to the skill and dedication of all those working in neonatal care and other services for babies that perinatal, neonatal and infant mortality rates for England and Wales are the lowest recorded.

The Government want most care for pregnant and newly delivered mothers and their babies to be provided as close to their homes as possible and, when possible, in a setting of their and their partners' choice.

Photo of Mike Penning Mike Penning Conservative, Hemel Hempstead

I thank the Minister for his generosity. I, too, pay tribute to the work of BLISS, which is a fantastic organisation. Mr. Khan has done well to mention its work in the House this evening.

If care is contracted to specialist units, it moves increasingly further from where the mums and dads live. Many parents travel a long distance to see their babies in special care units. I would have expected parents from my constituency to have to travel to London to the excellent units there, but some have ended up in Yarmouth or Nottingham. That causes parents grave concern, at a time when anxiety is already high. Is there any way that we can reconsider the configurations so that parents do not have to travel so far?

Photo of Ivan Lewis Ivan Lewis Parliamentary Under-Secretary (Department of Health) (Care Services)

The hon. Gentleman makes an important, valid point. We must be sensitive. Anyone who knows people who have been through trauma and concern at such a stage in a baby's life realises how horrendously stressful it is for parents and the wider family. The difficulty is the concept of determining local configuration nationally. It becomes a contradictory position in the context of independence for operational decisions in the health service, which is the Conservative party's new policy. However, I do not want to bring politics into the discussion.

A genuine problem is that at some times in the system, there are pressures on beds that do not occur throughout the year. In some periods there are many empty beds, which means that there is no problem with people getting the sort of care that they need closer to home. Unfortunately, at other times beds are full, and that presents major problems for the system and the affected families.

Photo of Ivan Lewis Ivan Lewis Parliamentary Under-Secretary (Department of Health) (Care Services)

Indeed. However, we must be sensitive and I urge all those who make the decisions to be aware that such a situation is difficult for any family, and to take account of that when they decide about the location, quality and nature of the health care available.

There will be occasions when transfer to a more specialist unit may offer better outcomes. Sometimes the sort of medical and other expertise available means that it would be better, in terms of reassurance and saving lives, for the babies and the parents to go further away from home than would normally be desirable. However, transferring a mother or baby must be done in a planned, informed way and for the best clinical reasons.

Several challenges need to be addressed. My hon. Friend the Member for Tooting referred to some of them. Happily, the increased capability of technology and the development of health care expertise has led to more very premature or very low birth weight babies being born alive and surviving. Such babies require prolonged periods of intensive supportive care, often over several weeks. It is important that there is enough capacity in the national health service to meet that demand.

The Department established an expert review group on neonatal intensive care to provide advice on the most effective ways of caring for very sick or very premature newborn babies. It considered the views of professionals and parents whose babies had received care from the service. The review group published its findings in 2003. It suggested a more structured, collaborative approach to caring for newborn babies, and proposed that hospitals work closely together in formal, managed networks to provide the safest and most effective service for mothers and babies. That would include the designation of some hospitals specially equipped to care for the sickest and smallest babies, with other hospitals providing high dependency care and shorter periods of intensive care as close to home as possible. Subsequent to that report, we have been supporting the specialised services commissioners for neonatal intensive care as they work with the NHS locally to facilitate the development of neonatal managed clinical networks. Such networks are incredibly important.

It is also important to say—this is linked to a point that I made to the hon. Member for Hemel Hempstead—that it was not central Government that dictated the nature of these local networks, their structures or which localities they ought to cover. We have said that the system needs to create the networks, but that it is for people at local level to determine the most appropriate configurations and partnership arrangements. As a consequence of that, 24 networks have now been established across England. It is fair to say that some have developed faster than others. That is to be expected, as it takes time to develop them and to ensure that the right structures are in place.

We have put additional funding into the system. More than £70 million has been made available to support the implementation of the report since 2003. That was divided into £20 million for capital expenditure and £12 million for running costs in 2003-04, with the additional money for running costs increasing to £19 million in 2004-05 and to £20 million in 2005-06. That is now in primary care trusts' baseline budgets. That funding is in addition to the general increase in NHS funding, from which neonatal services can of course also benefit.

We recognise the importance of ensuring that capacity in neonatal intensive care is available at all times, and that there is still sufficient flexibility in the service to meet unforeseen demand. Weekly situation reports indicate a national average neonatal intensive care cot occupancy of about 75 per cent. That reinforces the point that at any one time, 25 per cent. of the national capacity is not being used. However, that does not always reflect what is happening in individual localities. In that respect, noting the finding of BLISS that over 90 per cent. of units had to transfer patients last year, it is important to recognise that there are genuine issues that we have to address. There are also various reasons why a unit might close to new admissions for a time—a sudden outbreak of an infection, or a sudden problem with staff availability. That can lead to the temporary closure of units, and can cause babies to have to go further away from home than we would want.

The development of the networks has made a difference. The match between supply and demand is getting better, and there is the full range of special care, high dependency and intensive care in most localities. The networks are only beginning to get to grips with case load and case mix, and with securing the right level of care in that context. Their objective is to provide over 90 per cent. of neonatal care locally. However, in some situations that might not be possible or desirable.

The Department has also funded the development of the neonatal intensive care unit capacity planning tool to assist in making decisions about the configuration of neonatal intensive care units within a region. Those decisions include the location of neonatal intensive care units, the number of cots, staffing levels, and the levels of intensive care each unit provides. The tool also allows consideration of different hospitals operating together in networks, thus sharing the workloads between hospitals.

Photo of Sadiq Khan Sadiq Khan Labour, Tooting

Can my hon. Friend explain the inconsistency between a tool giving guidance on staff numbers and the fact that the BAPM guideline on, for example, one nurse per high dependency cot is not met if PCTs do not fund the staff?

Photo of Ivan Lewis Ivan Lewis Parliamentary Under-Secretary (Department of Health) (Care Services)

My hon. Friend makes a reasonable point, but it is difficult to say, "We issue guidance and we identify priorities," but then add, "We instruct PCTs to deliver in every area in a particular way." That would take away the capacity to make flexible innovative local decisions.

One of the difficulties in this respect is that the definition of one-to-one support is not always clear. There can be ambiguity about what that might mean in any given set of circumstances. Does it mean support 24 hours a day? Does it mean having one named person who is clearly responsible for care and is available all the time, but who may not be physically present all the time?

So there are different definitions, but we also have to be honest and point out that PCTs are constantly making choices about priorities in the light of finite resources. In some areas that will be reflected in staffing levels that BLISS would regard as acceptable and desirable, but in others, although I believe that staffing levels always meet minimum safety standards, they do not necessarily meet the high standards that appear in the guidance. So on these occasions, it is important that we be frank about the consequences of finite resources and local management decisions, because we cannot avoid them. At the same time, it is also right that we constantly try to stretch the system to do better, and to ensure that such families are properly supported, not just through health interventions but from an emotional point of view as well. We all accept that that is very important.

It is worth focusing for a moment on a linked issue—the availability of nurses. As at September 2005, 19,178 paediatric nurses were employed in the NHS in total. That figure includes neonatal nurses and other nurses involved in the care of children, and represents an increase of 25 per cent. since 1997—to pick a random date. The annual number of students entering training to be children's nurses increased by 59 per cent. between 1996-97 and 2004-05. The national vacancy rate for paediatric nurses has fallen from 4.4 per cent. in 2000 to 1.7 per cent. in 2005. Interestingly, that compares with a vacancy rate of 1.9 per cent. for all qualified nurses. So the message is that there has been a lot of progress, and a lot of positive developments and steps forward, but there is still a long way to go. We should be honest about that, and be clear about the challenges ahead.

Another challenge, to which my hon. Friend referred, is commissioning. Specialised services—defined as services with a planning population of more than 1 million—are those with low patient numbers, which need a critical mass of patients to make treatment centres clinically safe and cost-effective. Under this definition, level 2 and level 3 care are defined as specialised services. Level 1 care is not a specialised service and is generally provided as part of each maternity service. At the moment there are no plans to redefine level 1 as a specialised service—an issue to which my hon. Friend referred.

There are currently no tariffs for neonatal intensive care. Critical care is outside the scope of payment by results, and funding for the service continues to be locally negotiated between commissioners and providers. Health care resource groups, which are the underlying currency for tariffs, are being developed for neonatal critical care by the NHS information centre.

Given the sensitivity of this issue, it is very important that in developing services we also consider how we relate to parents as user representatives; it is important that they have a strong voice in such development. A review group has recommended that in future, each network should have a supervisory structure that includes key stakeholders in the provision of care. Those stakeholders should include representatives of parents, providers and commissioners. So we do envisage governance arrangements that will ensure that the voice of users is extremely strong as we re-engineer and reshape services.

For maternity services more generally, a comprehensive service review is scheduled to take place next year, partly as a result of four recent investigation reports. My hon. Friend is correct to say that the Healthcare Commission has recently contracted the Royal College of Paediatrics and Child Health to run a general clinical audit of neonatal care. I congratulate my hon. Friend again on raising these important issues in the House today.

Photo of Sadiq Khan Sadiq Khan Labour, Tooting

Before my hon. Friend finishes speaking, may I point out that the one question that he has not dealt with is his special relationship with the Treasury, and how much more money he will be able to lever into this important area?

Photo of Ivan Lewis Ivan Lewis Parliamentary Under-Secretary (Department of Health) (Care Services)

If I want to continue to enjoy a special relationship with the Chancellor and the Treasury, I should not refer to any financial decisions. I shall simply say that this is a matter for the comprehensive spending review. That is a very boring answer, but it is very wise one from a career point of view.

We have made a great deal of progress, and parents can feel reassured. However, there are many challenges ahead, and we need to work with organisations such as BLISS and the representatives of other stakeholders to ensure that we get our interventions right. In the way in which we treat parents and babies in those incredibly challenging circumstances, there is nothing more important than that.

Question put and agreed to.

Adjourned accordingly at half-past Six o'clock.