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Neonatal Care

Volume 558: debated on Wednesday 6 February 2013

It is a pleasure to serve under your chairmanship once again, Mr Streeter. I thank my hon. Friend the Minister, who could have been, but was not, slightly late, which is ironic in a way because the debate is about babies who turn up very early. He was due to be in the Chamber as we speak, but kindly rearranged a whole host of things to be here this afternoon to answer the debate. I thank him very much indeed. He and I have often spoken about neonatal care, and indeed stillbirth, so I know that he will do all he can to answer the debate with deeds as well as words.

Neonatal care is an absolutely vital service that no parent or prospective parent ever wants to have to rely on, but lots do. One in every nine babies in the UK is born either premature or sick—more than 80,000 every year. We therefore need a service that is fit for purpose and provides the best possible care to all premature or sick babies and their families in facilities that can give the best care—sometimes very specialised care—at a harrowing time for the parents concerned.

One of my constituents, a fantastic mum called Catherine Allcott, alas, had to rely on neonatal care a few years ago. Catherine’s twins, Luke and Grace, were born unexpectedly at 26-weeks gestation. At six weeks old, they were separated and sent to neonatal units 40 miles apart due to Luke’s critical condition. Catherine and her husband, Nigel, spent the next three months visiting two hospitals every day until Luke sadly died and Grace was discharged. Grace is now a delightful, happy, healthy six-year-old and Catherine’s experiences during that time have shaped her fundraising and campaigning work for Bliss—a fantastic charity that campaigns for continual improvements to neonatal care and is a strong advocate of care for babies.

When the results of the 2010 general election were announced, Catherine was one of the first people to find my advice centre. Before I knew it, I was being whisked around the Gosset neonatal ward of Northampton general hospital, looking at their facilities and talking to staff and parents. Since then, I have had the pleasure of visiting many other maternity and neonatal wards across the midlands and the south-east.

Catherine is concerned, as Bliss is, about the national shortage of neonatal nurses, particularly those qualified in that specialty. Half of all units do not have enough nurses to meet national standards and one in 10 units is so busy or understaffed that they cannot release nurses for specialist training. According to Bliss’s report on saving our specialist nurses—by specialist, I mean nurses who have a recognised qualification in specialist neonatal care—that figure is pretty solid.

As was shown by a Bliss report in 2010, that boils down to the need for 1,150 extra qualified specialist neonatal nurses—the figure has changed since that date, but that is the latest I have—if we are adequately to provide the service that this country so desperately needs and that babies and their families deserve. Not all nurses working in neonatal care have the specialist qualification, but the “Toolkit for high quality neonatal services” states that 70% of a unit’s nursing work force should hold one.

According to an Oxford university study, an increase in the ratio of qualified and specialist nurses to babies in intensive and high-dependency care might reduce infant mortality rates by 48%, something that is surely worth every penny and for which it is definitely worth fighting. I am told that that works out at about £1,400 of additional investment per baby, which, as the Government have themselves highlighted, would benefit society in the longer term to the tune of approximately £1.4 billion.

As I have said, I have seen my local neonatal care unit in action and know the pressures that Gosset ward is under. The staff at Northampton general hospital do an excellent job, but they face significant pressures, even after an increase in staff equivalent to 4.3 full-time nurses. Despite that increase, the unit has had to close its doors to new admissions more than 20 times in the past year for non-medical reasons, a statistic that is surely not good enough. We should not and cannot restrict access to health care to some of the most vulnerable and innocent in our society—the next generation—on the basis of those lax numbers. Frankly, we must do better and we must do more.

The shortfall nationally shows the extent of the issues that we face. More than half of all units do not have enough specialist nurses to meet the national standard—that 70% of the nursing work force should hold a specialist neonatal care qualification—and the importance of such specialist care is so clearly shown in an area where such tiny and fragile babies can have such complex and often multiple conditions. It is not a hole that can just be plugged in the short term to meet a budget, but something that needs long-term planning and investment in a skilled work force.

If we are to achieve such a national standard and address the recruitment of specialist nurses that neonatal units require, continued investment in education is of paramount importance. I therefore welcome the national changes to the commissioning of specialised services. They promise to ensure that we do not face a postcode lottery, thus improving the consistency of services across the country and spreading best practice.

Locally, my constituents in Daventry and I have other concerns and opportunities. The Minister will know of the “Healthier Together” programme in the south-east midlands, which is looking at the services provided at the five main hospitals in Bedford, Kettering, Luton and Dunstable, Milton Keynes and Northampton. There are options or plans to reduce the number of maternity units that are consultant-led from five to three, an action that would have a clear impact on neonatal services, because it is most likely to result in the closure of neonatal units at the hospitals that have midwife-led units.

I congratulate my hon. Friend on securing this important debate. I have a very successful midwife-led maternity unit at Hexham general hospital. Does he agree that such units can provide a fantastic ongoing service, but that it is very important that parent and larger hospitals in the region provide them with neonatal transfers and ongoing support?

I am happy to agree with my hon. Friend, and I will speak about that in more detail later.

I am not particularly against the mooted changes in the south-east midlands if they provide a higher quality of specialist care at nearby centres of excellence. However, the changes raise several important questions that I hope the Minister will answer either now or later by letter. Will he ensure that the “Healthier Together” proposals and similar ones up and down the country are driven by a genuine programme to improve outcomes and quality, and not just to save costs or money?

As my hon. Friend the Member for Hexham (Guy Opperman) said, it is absolutely vital that the needs of families of premature and sick babies are factored into any changes and are not inadvertently overlooked when mainstream maternity and children’s services are redesigned. Will the Minister say something about transport to neonatal centres, both now and in the future? Many parents find themselves quickly transported from knowing what is happening and where they expect a birth to take place, to not knowing what is going on and intense worry.

When parents have to travel further afield to centres of excellence, they have plenty of increased costs in the travel, parking charges and time considerations that come from such changes. Those responsible for planning services must take that into account. I hope that the Minister will respond on that point, and assure me that those planning services take costs into account so that not only do babies receive the highest quality care, but services and support are in place to meet families’ needs.

The parent is intrinsic to the care of the child, which I believe sets neonatal care apart from almost every other branch of medicine. We must therefore consider the needs of the parent alongside those of the child. It makes good economic sense: babies whose parents are included in their care grow faster, have less illness, go home sooner and do not come back; and their parents have less stress and fewer mental problems later. There is a huge benefit from getting neonatal care right, and if we can get it right at an early stage of planning service changes, that is all to the good.

Has the Minister heard of the children’s air ambulance service that is currently being set up by the East Midlands air ambulance, which will help to cut transfer times? It will go operational on 13 March, but has already done the odd transfer here and there. On Monday 10 December, a baby who was a few days old was flown from Glenfield hospital to Sheffield children’s hospital for potentially life-saving treatment. The total transfer time was only 34 minutes, but it would have taken one hour and 23 minutes for the team to have gone by road, which is a huge time saving for a baby suffering from a serious illness. Obviously, being operated by the air ambulance service, such transfers are at little, if any, cost to the taxpayer.

As I said, when I visited neonatal wards—especially at my local hospital, Northampton general, and the John Radcliffe in Oxford—I was really taken by the kind and understanding manner with which the staff dealt with parents. From stories related to me from across the country, I am absolutely sure that best practice can be better spread. I hope that the Minister might comment on how he will continue to ensure that the needs of such families are taken into account and that best practice is spread.

In any Westminster Hall debate on health, we get to talk about money. Although cost should not act as a disincentive to provide quality and specialised care, it is obviously a factor that cannot be overlooked. Payment by results, which has been introduced in this area, works for many other areas of policy where there is a national currency but a local tariff. However, payment by results takes into account only the current levels of service provision, rather than the services required to meet national standards; currently, those standards are not quite being met. Thus, the current shortfalls that I have outlined will only be reinforced, rather than addressed, by the payment system. A set national price would ensure that commissioners can focus on quality and outcomes of service. However, neonatal care faces a local tariff, where price invariably is a larger factor, and that equates to variable outcomes across the country.

In other types of care, significant service levels remain available under the system, but the statistics show that the disparity between one unit and another is growing in neonatal care, which suggests that the system is not working in this particular case. What steps is the Department taking to ensure that the current shortfalls are addressed and how can we ensure that this Government’s legacy sets a precedent for future neonatal care?

On a day when a disaster in Staffordshire will dominate the news on the national health service, I want to acknowledge that, all across the country, there are some amazingly wonderful NHS staff delivering the best care that they can and helping mums, such as my constituent, Catherine, and their premature babies get through some of the toughest times any of us can possibly imagine. However, with the help and advice of charities such as Bliss, the spreading of best practice and the sensible allocation of resources, I believe that neonatal care—this fantastic service that we already offer—could, and should, be delivered in a better and more consistent way.

I am most grateful to you, Mr Streeter, and to my hon. Friend the Member for Daventry (Chris Heaton-Harris) for letting me speak for literally 90 seconds at the end of his impressive speech.

I endorse everything that my hon. Friend says, and I want to add my endorsement of the amazing work done by the NHS staff in my area of Northumberland, specifically at Hexham general hospital. It is an outstanding hospital that the Minister will, with a bit of luck, visit when he comes to Northumberland in April. It fits well between the trusts developing in Northumberland and Cumbria and is effectively the heart of the wheel with the spokes being the various other health services around it. It is a general hospital, but it has an outstanding midwife-led maternity unit. I have visited it and met staff and patients, and it is fantastically popular and successful.

I want the Minister, who has great expertise in this field—let us not say that we do not have specialists in this Government—to endorse the fact that midwife-led units have a role to play in the ongoing provision of health services, particularly in rural areas such as mine. I hope that he agrees that the standard and quality of the care provided and the outcomes are just as good in midwife-led units as in consultant-led specialist hospitals. They are different, but they are just as good. It is to this Government’s great credit that we continue to support midwife-led units and provide such services.

Specifically on neonatal care and transfer, I am interested in the importance of neonatal transfer in the isolated cases where things do not pan out in the right way. Changes are afoot, and my hope is that the Minister agrees that it is incumbent upon the lead hospitals in the region to ensure that the quality of training throughout the region is high, so that where there is neonatal transfer, it goes off without a hitch.

I have taken up enough time. I thank you for your indulgence, Mr Streeter.

It is a great pleasure to serve under your chairmanship, Mr Streeter. I congratulate my hon. Friend the Member for Daventry (Chris Heaton-Harris) on securing this important debate on neonatal services. He strongly advocates the needs of his constituents, but also raises an important issue that we are already focusing on and improving, to give every child the very best start in life.

It is also a pleasure to hear from my hon. Friend the Member for Hexham (Guy Opperman), and I am looking forward to visiting his constituency in the near future. An April visit is in the diary at the moment, and I look forward to visiting and seeing for myself some of the excellent care delivered locally. He is right to highlight that midwifery-led units play an absolutely vital part in delivering high-quality care for women and their families. The Birthplace study absolutely supports his points and suggests that midwifery-led units may well play an even more vital role in the future provision of maternity services. I am sure that we will discuss such matters in future debates.

Before we get on to the specifics of neonatal care, I want to discuss some of the more general points made by my hon. Friend the Member for Daventry. He mentioned air ambulance services, and he is quite right to say that if we want a co-ordinated and integrated emergency response, particularly in more rural and sparsely populated areas, air ambulances must play an important part. The land and air-based responses need to be co-ordinated effectively, particularly for road traffic accidents. He makes a good point and I am sure that the local commissioners in Daventry and elsewhere will take note of our discussions today.

My hon. Friend was quite right to say that the payment- by-results system has been problematic in many areas of medicine. My right hon. Friend the Leader of the House, when he was Secretary of State for Health, made strides towards changing the tariff system in many areas of care, particularly the year-of-care tariff for people with longer-term and more chronic conditions. We also have changes being implemented to the maternity tariff to encourage a normalisation of birth. We want to view birth as a normal, everyday, natural process and to move away from births that need hospitalisation, by supporting people better in the round through antenatal care and more holistically throughout pregnancy, childbirth and the post-natal period.

My hon. Friend mentioned the unacceptable variations in care that exist across the country, which was highlighted poignantly today in the debate on the NHS in mid-Staffordshire. He has also previously advocated the reduction of stillbirths and supports the excellent work that Bliss does to raise the importance of high-quality neonatal care. More work is necessary, but I want to describe some of our achievements and the progress that the Government have made over the past couple of years, which shows that we are taking such issues seriously. As my hon. Friend quite rightly outlines, there is more that we can do and we intend to do more over the months and years ahead.

As has been said throughout the debate, we cannot divorce childbirth and midwifery care from neonatal care; the two are linked in terms of service provision and the care that is provided for premature babies. We want to provide more care and support for women during pregnancy, and the latest work force figures show that midwife numbers increased by 1,117 between May 2010 and October 2012. Training places in midwifery are at a record high, and we are ensuring that commissions for future training places will remain at a record high, so that we can continue to provide personalised, one-to-one midwifery care for women. The birth rate is increasing, and that is why we are employing more midwives and keeping training commissions high.

On neonatal care, 1,376 neonatal intensive care cots were available in December 2012, of which 951 were occupied. In December 2011, only 1,295 such cots were available. So in a period of 12 months—between 2011 and 2012—we have seen an increase in the number of neonatal intensive care cots available nationally, and I am sure that my hon. Friend will agree that that is a good thing.

The number of paediatric consultants has also increased, from 1,507 in 2001 to 2,646 in 2011, and the number of paediatric registrars—or middle-grade junior doctors—has also increased by almost fourfold in the same period, with some of those registrars specialising in neonatal medicine. Consequently, I believe that we must give some credit to the previous Government for some of the work that they did in this area, but this Government have taken their work forward with renewed vigour to make this a priority.

The number of full-time paediatric nurses has also risen, from 13,300 at the beginning of the century to 15,629 in 2011. So, in general, we are seeing good progress being made in putting more resources into children’s health care, giving every child the very best start in life.

Specifically on neonatal services, my hon. Friend is right to highlight the fact that we need to do more to ensure that there is no variability in the system. We made a commitment very clearly as a Government to high-quality, safe neonatal services, founded on evidence-based good practice and good outcomes for women and their babies. Improving outcomes, rather than focusing on process measures, is what we are all interested in. We want to ensure that babies who need neonatal care are given the very best care and have the very best outcomes in terms of their future life and, indeed, the care that they receive on neonatal wards.

In our mandate to the new NHS Commissioning Board, we will be holding it accountable for all health outcomes. We want to see the NHS in England leading the way in Europe on health care outcomes. The Secretary of State for Health has made it clear that mid-table mediocrity must be a thing of the past in all areas of medicine, and I will make sure that I work closely with Bliss and other organisations and, indeed, with my hon. Friend to make sure that we hold the NHS Commissioning Board to account for delivering high-quality health outcomes everywhere, particularly in this important area of neonatal care.

It is worth highlighting, and I think that I have time to do so, the different types of neonatal facilities that are available; the different types of special care baby units, or the level 1, level 2 and level 3 units. Special care units, traditionally known as level 1 units, provide care effectively just for the local population in the local area. They provide neonatal services, in general, for singleton babies born after 31 weeks and six days gestation, provided the birth weight is above 1,000 grams. For slightly more complicated births or slightly more premature births, there are level 2 units, which provide neonatal care for their own local population and for some sicker, or more premature, babies from elsewhere. They provide neonatal services, in general, for singleton babies born after 26 weeks and six days gestation, and for multiple-birth babies born after 27 weeks and six days gestation, provided the birth weight is above 800 grams. Then we have level 3 units as they are traditionally known, which are neonatal intensive care units, and they are sited alongside highly specialist obstetric and fetomaternal medical services. For example, there is a level 3 unit across the river from here, at St Thomas’ hospital. Such units take very premature babies.

That description highlights the fact that neonatal care must be considered alongside the provision of high-quality maternal care; the two go very much hand in hand. The point that my hon. Friend made—my hon. Friend the Member for Hexham made it as well—is that when services are being redesigned or reconfigured the most important thing is to provide high-quality patient care. Reconfiguration is about delivering those high-quality patient outcomes and that high-quality care.

The best example of where service reconfiguration has really benefited patients that I can think of was in Manchester, which I visited towards the end of last year. A redesign of the maternity and neonatal provision in Manchester in a very planned, systemic way resulted in about 30 babies’ lives being saved every year. When the case for reconfiguration is made in terms of patient care and not in terms of cost, as my hon. Friend the Member for Daventry outlined, that is the right reason to reconfigure and redesign services. What we cannot have, and what has been expressly ruled out under the criteria for reconfiguration, is redesigning services purely on the basis of cost. If we are going to redesign the way that we deliver care, it must be done in the way that it was done in Manchester, where—as Mike Farrar, who is now the chief executive of the NHS Confederation, said—it is about saving babies’ lives. That service reconfiguration in Manchester was right, because it is saving 30 babies’ lives every year. That is the right reason for reconfiguration.

My hon. Friend was absolutely right to highlight that in some cases, when we look at these issues in areas where there are long distances to travel and considerable rurality, all these factors need to be taken into account when redesigning services. However, the end result must always be for the benefit of patients. It may be the case that sometimes people have to travel a little bit further to get that high-quality care, but these decisions must be considered in the round and on the basis of achieving high-quality outcomes and doing the best things for mothers and their babies.

In conclusion, it might be worth highlighting a few other specific things about neonatal care that the Government are committed to doing. We now have a toolkit for neonatal care, and we are looking to ensure that it is properly implemented across the NHS. Some parts of the country are doing very well in ensuring that the majority of their staff working as nurses in neonatal units have specialist training, but that is not the case everywhere. We have established that toolkit; that was a direct challenge that the Government have picked up and taken forward, to ensure that we drive up the standard of neonatal care everywhere.

Does the Minister accept that, as the health care reforms kick in, it is incumbent upon GPs to make the point when they first advise expectant mothers that they can give birth at various places and that midwife-led units provide the full spectrum of care from well before the birth to well after it?

My hon. Friend is absolutely right. It is vital that whenever there is a discussion with any patient—in this case, it is a discussion with an expectant woman about where she should give birth—that an informed choice is made. That should not just happen initially, but that choice should be reviewed consistently, according to what the risk factors might be throughout the pregnancy, and women should be helped and supported into choosing the most appropriate birth setting for them. And all factors, such as the woman’s safety or what care might be required immediately after the birth, are vital ingredients in that decision-making process.

What we want to promote, and what we all believe in, is patient choice in the NHS. One thing that is facilitating patient choice in maternity care is having a national set of maternity notes now, so that all women effectively have a transferrable set of notes that they can take from one unit to another. That is something that is being driven across maternity care, and I think that it will make a real difference if the location of care needs to change in the future.

I will also say something specifically about how we will ensure that we better implement the toolkit, which we agree is a good thing in driving up the quality of training available to neonatal nurses. Very shortly, I will be devising and helping to set up the Health Education England mandate, which will be responsible for training health care professionals in England; not just doctors but all health care professionals. A mandate will be established for how that body will operate and what it will prioritise as areas of training. I am very happy to give a commitment, just as we did on the mandate for the NHS Commissioning Board, to ensure that giving every mum the right support in pregnancy and every baby the very best start in life is something that we will look to incorporate in that mandate, to make sure that high-quality training is available for health care professionals involved in all aspects of pregnancy, birth and beyond, and of course neonatal care is an important part of that.

That is something that I will take away from this debate, to ensure that it is clearly an important part of the Health Education England mandate that we look very seriously at neonatal services, to help to iron out the unacceptable variability in training that we have identified. I hope that that is reassuring to my hon. Friend the Member for Daventry. I thank him for securing this debate, and I thank you, Mr Streeter, for chairing it.

Question put and agreed to.

Sitting adjourned.