Neonatal Business Case v7 - NHS Wales · Wales which includes evidence-based prevention strategies...

Betsi Cadwaladr University Health Board

(Version 6 – March 2012 1 Chris Jones, Neonatal Project Support Manager

CHILDREN & YOUNG PEOPLE’S CLINICAL PROGRAMME GROUP

Neonatal Care services for North Wales

BUSINESS CASE

March 2012

Betsi Cadwaladr University Health Board (BCUHB)



Document control sheet

Document history

Version Date Author Comments

1 14.07.2011 CJ Initial draft

2 05.12.2011 CJ 2nd

draft reviewed with Dr. Michael Cronin

3 15.12.2011 CJ 3rd

draft

4 12.01.2012 CJ 4th

draft

5 02.03.2012 CJ 5th

draft

6 09.03.2012 CJ/MC 6th

draft reviewed with Dr. Michael Cronin

7 23.03.2012 MC Feedback from neonatal working group re. scoring for access and strategic fit criteria

Client Maternity, Gynae & Neonatal workstream (Maternity & Child Health Service review)

Document Title Business Case for Neonatal Services for North Wales

Version 6

Status Draft

Author Chris Jones

Date 09.03.2011

Further copies from [email protected]



CONTENTS

PAGE

1. Brief description of the proposal

2. Defining the need

2.1 Population factors 2.2 Networking 2.3 National standards 2.4 Recruitment & training 2.5 Co-location dependencies 2.6 Activity 2.7 Access 2.8 Facilities & equipment 2.9 Finance and affordability 2.10 Strategic context

3. Outline proposal 3.1 Existing service 3.2 Proposal 3.3 Consultation 3.4 Benefits 3.5 Impact 3.6 Support 3.7 Evaluation

4. Option Appraisal 4.1 Generating options 4.2 Benefit criteria summary 4.3 Option evaluation 4.4 Cost Implications

5. Costs 5.1 Revenue 5.2 Capital 5.3 Transitional 5.4 Expenditure profile

6. Feasibility 6.1 Affordability 6.2 Sustainability

7. Approval

Appendices



1. Brief description of the proposal

This document proposes a viable configuration for neonatal units working within a network for North Wales. The paper compares options which include the status quo, to those of providing a fully functional Neonatal Intensive Care Unit (NICU) from one site within North Wales or alternatively, contracting out specialist-level activity to an English healthcare provider trust. The option appraisal evaluation detailed in section 4.3 of this report ranks the order of preference for the options that were considered. Following evaluation it was concluded that option 2 offers the greatest benefit to both the catchment population and Betsi Cadwaladr Health Board. This model retains 3 neonatal units within North Wales but centralises intensive care at Glan Glwyd Hospital whilst designating units at Gwynedd and Wrexham as Local Neonatal Units. This option allows for the continued provision of short-term intensive care at the two Local Neonatal Units in North Wales but provides specialized services at Glan Clwyd for the very small number of very pre-term babies that require longer-term intensive care The vast majority of families will therefore see little change other than qualitative improvements to their local services.

2. Defining the Need

This document is structured in the BCUHB standard business case format. The following section identifies the criteria against which every option identified during the service review process will be compared. The sub-sections are broadly aligned to the principles described within the Department of Health Toolkit for High Quality Neonatal Services, published in October 2009. Where appropriate a ‘position statement’ briefly summarizes the present state of services within North Wales. At the beginning of each sub-section the benefit criteria will state the measure that will be later used for comparative purposes. The Health Board’s Triple Aim provides a clear principle on which to base a need for change in the way Neonatal services are provided. The approach has been applied in the follow way:

o Improve the heath and wellbeing of the population by: Ensuring the best and highest quality care and support is available to the most vulnerable, giving them the best possible start in life.

o Provide an excellent experience by: Ensuring optimum outcomes; achieving national standards; developing facilities and support and reducing unnecessary transfers keeping care as close to home as possible.

o Reduce the cost of health per capita, thereby helping to deliver within the resources available by:



Designing and implementing innovative, flexible and sustainable workforce solutions to consistently provide high quality services whenever they are needed. There is a strong economic case for investing in the early years of life.

1

The factors which are increasing the pressures on our existing neonatal units are described within this document. These factors are already impacting upon the sustainability of neonatal services for the population of North Wales and for some of North Powys patients who also access services here. The Department of Health Toolkit for High-Quality Neonatal services (2009) describes the case for change in neonatal care and highlights the following examples of why more babies now need neonatal care: • An increase in fertility rates for all age groups, but particularly for women aged over 40

and under 20; • The availability of assisted conception; • A 30% increase in women admitted at 25 weeks of gestation or less whose babies

need specialist care 2 In addition advances in technology and treatment have led to an increase in the number of vulnerable babies who survive after being admitted to neonatal care. The Toolkit is also explicit is stating that approximately 60% of infant deaths occur during the neonatal period and that here is significant evidence to show that maternal age, maternal health, multiple births, ethnicity and deprivation are primary risk factors for neonatal death. The Children and Young People’s Clinical Programme Group (CPG) will ensure that our services are safe and consistently deliver the best possible standards of care which match the needs of our local population. This paper focuses on service standards for the provision of neonatal care at all levels. National standards are the Welsh Government’s accepted indicators of service quality and the tool by which all health boards are monitored. Population health need, geography and human resource factors have together influenced the proposal for, what we think is the best, most cost-effective and sustainable configuration for a North Wales Neonatal Network.

2.1 Population factors

Benefit criteria number 1 Provides the required number of cots and at the appropriate level of acuity to meet projected population need.

1 BCUHB Executive Director of Public Health Annual Report 2011

2 EPICure study. www.epicure.ac.uk



2.1.1 Fertility rate3

There has been a slow rise in the fertility rate in North Wales since 2001. It is considered likely that this has been largely driven by increasing birth rates among older women. This group is generally higher risk and more likely to require access to neonatal services including intensive care. 2.1.2 Impact of Deprivation The Executive Director of Pubic Health’s Annual report 2011 acknowledges that North Wales has areas of local deprivation and, that there is considerable variation in low birth weight across the region which is know to be linked to deprivation. Some areas have a statistically significantly higher % of low birth weight that the Wales average of 5%; up to 8.2% in some parts of Denbighshire. Some of our areas are in the top five most deprived areas in Wales. A local Public Health strategic framework has been developed in North Wales which includes evidence-based prevention strategies which aim to focus on issues such as low birth weight.

2.1.3 Population-based neonatal cot numbers There were approximately 7,300 deliveries in North Wales in 2010. The projected number of annual deliveries is expected to increase to 7,900 following the implementation of local repatriation plans for maternity care.

4

The distribution of this anticipated activity is shown in table 1 and is based on the present configuration of three Obstetric Units within North Wales and also the option of reducing to two Obstetric units with a stand-alone midwifery-led unit at Ysbyty Glan Clwyd. Table 1

Annual deliveries

3 x OUs 2 x OUs plus 1 x MLU

Location

Region

OU OU MLU Ysbyty Gwynedd, Bangor West 2,400 3,000 - Ysbyty Glan Clwyd, Bodelwyddan

Central 2,400 - 500

Ysbyty Maelor, Wrexham East 3,100 4,400 - 7,900 7,400 500

TOTAL 7,900 7,900 OU = Consultant-led Obstetric Units MLU = Stand-alone Midwifery-led unit

Various methods have been suggested by organizations with which to estimate the number of cots required to meet population need. In the absence of any consensus the formula applied for the purposes of this business case was guided by:

o Suggested cots required per 1,000 deliveries (BAPM 2004)

3 Maternity & Child Health Review Case for Change documents July 2011

4 BCUHB Women’s Clinical Programme Group repatriation plan 2011



o Recommendations from the All Wales Neonatal Network Capacity review 2

nd iteration (October 2011 & January 2012)

o Local activity data for the past 3 years.

It was noted that the All Wales Capacity Review proposed its cot configuration based on data derived from units in South Wales, adjusted proportionately to the number of deliveries in the North. This paper proposed a broadly consistent configuration to our local activity data in relation to intensive care and high dependency, but less so for special care. It was recognized that demographic and geographical factors may differentiate between regions and therefore require a degree of local agreement on the ultimate cot configuration for the North Wales region using a combination of data available. (Appendix 1) The configuration below represents cot capacity (as reported the October 2011capacity review): Intensive Care 8 cots High Dependency 8 cots Low dependency (Special Care) 25 cots TOTAL 42 cots

Categories of Care 2011 In 1996 The British Association of Perinatal Medicine (BAPM) defined Categories of Neonatal Care. These definitions were updated in 2001 and again in 2011. The categories describe the activities attributed to each category being intensive care, high dependency, special care and transitional care. BAPM commissioned the Neonatal Data Analysis Unit (NDAU) to investigate the impact of the recent changes and the key finding were:

• The overall impact would be small and the national distribution of Categories of Neonatal Care largely unchanged (under the BAPM 2001 definitions 14% of care days were classified as Intensive Care; under the New Category definitions this was 12%)

An audit of Intensive care and High dependency cot days at YMW and YGC for 2011 was undertaken in January 2012 to establish the local effect of the changes in the categories of care (Appendix 2).

Applying the new categories to the projected activity within the North Wales Neonatal Network would impact upon cot acuity numbers as follows: Intensive Care -16% (-1 cot) High Dependency +14% (+1 cot) Special Care No change



Summary of cot requirement Based on the estimated number of annual deliveries, the capacity review recommendations and the new Categories of Care, the neonatal cot provision required for the catchment population has broadly been agreed as: Intensive Care 7 cots* High Dependency 9 cots Low dependency (Special Care) 23 cots TOTAL 39 cots

• This figure will vary between 7 and 6 cots depending upon the total number of neonatal units in North Wales. This is because 1 stabilization cot must be maintained at each unit that is not providing intensive care. The figure is population-based and therefore includes cots that in certain scenarios would need to be purchased from an English provider.

• It should be noted that this is an estimate based on current predictions and cot acuity will be monitored and adjusted as necessary.

Position statement

POPULATION-BASED COT REQUIREMENT

Re-categorization of critical care** activity means that the present number of intensive care cots (as reported through the capacity review) could be reduced by 1 to provide an appropriate service for the predicted number of annual deliveries. There would be a corresponding increase of 1 high dependency cot. There is likely to be further scope to re-profile special care cots in order to reduce some of the staffing deficiencies required to provide the higher level of care.

** Critical Care is the term used to describe intensive care plus high dependency.

2.2 Networking

Benefit criteria number 2

Ensures effective and viable networking and transportation arrangements

2.2.1 The Department of Health Toolkit for High Quality Neonatal Services



In 2001, the Department of Health recommended that neonatal services be organised into Managed Clinical Networks, with hospitals working in teams to ensure that babies were cared for in appropriate settings. The National Audit Office review in 2007 concluded that the development of networks in England had led to improvements in co-ordination and consistency of services. In 2008 the Public Accounts Committee made recommendations to improve the capability of networks and the Toolkit for high Quality Neonatal Services was designed to support improvements in neonatal services. The North Wales neonatal network consists mainly of the 3 neonatal units which are based at each district general hospitals. The units provide the majority of neonatal care for the North Wales population with the majority of Intensive Care being provided at YGC and YMW. Some intensive care is also purchased from Arrowe Park hospital and Liverpool Women’s hospital for reasons of clinical need. Capacity between the 3 units in North Wales has historically been problematic but recent investment from repatriation should improve the networks ability to deliver more care within North Wales. Funding has been received for a 12hr transport system but this service is at present limited by other constraints within the neonatal service.

Position statement

NORTH WALES NETWORK

Following recent repatriation of activity from England North Wales operates an effective network capable of providing most activity at all levels of care within Wales. Some specialist services in England continue to be utilized for reasons of clinical need rather than capacity. However, the transport system requires further development and staffing levels fall consistently short of national standards. This has been flagged by the All Wales Network as a major clinical governance concern.

Recruitment prospects seriously question the sustainability of the present network and are described in more detail in section 2.4

2.2.2 Organisation of services The national guidance acknowledges that the formation of networks will vary depending upon local considerations. Geography, transport links demographic and workforce are some of the factors that will strongly influence the design of a neonatal network for North Wales. The Department of Health Toolkit for High Quality Neonatal services defines the work of three different types of Neonatal unit which form a network which are endorsed by the most recent update of BAPM standards (2010)



2.2.3 Types of Neonatal Unit

5

In recent months the All Wales Neonatal Network has stated that Health Boards in Wales should adopt the BAPM (2010) terminology for Neonatal Units for the purpose of service planning. These describe Neonatal care taking place in three types of unit:

Special Care Units (SCU): These provide special care for their own local population. They also provide, by agreement with their neonatal network, some high dependency services. Local Neonatal Units (LNU): These provide special care and high dependency care and a restricted volume of intensive care (as agreed locally) and would expect to transfer babies who require complex or longer-term intensive care to a Neonatal Intensive Care Unit. Neonatal Intensive Care Unit (NICU): These are larger intensive care units that provide the whole range of medical (and sometimes surgical) neonatal care for their local population and additional care for babies and their families referred from the neonatal network in which they are based, and also from other networks when necessary to deal with peaks of demand or requests for specialist care not available elsewhere. Many will be sited within perinatal centres that are able to offer similarly complex obstetric care. These units will also require close working arrangements with all of the relevant paediatric sub-specialties. The exact number of each type of unit and the precise definition of their role will vary between networks but each network will have at least one Neonatal Intensive Care Unit. Access to a specialised transport service is also essential for each network. The transport service should facilitate not only the transfer of babies needing urgent specialist support but also enable the timely return of babies to their “home” unit as soon as clinically possible.

Each unit within a network should also have access to 24-hour transfer services to ensure that babies receive care in appropriate settings timed to maximise clinical outcomes. Babies requiring surgical care should receive the same level of care, support, resource and specialist input as a baby receiving care in a medical neonatal unit.

5 BAPM standards (2010)



Position statement

APPLYING BAPM 2010 TERMINOLOGY

Under the definitions described above the present configuration of units within the North Wales Neonatal Network would best be described as: Type of Unit Ysbyty Gwynedd, Bangor adapted LNU* Ysbyty Maelor, Wrexham NICU** Ysbyty Glan Clwyd, Bodelwyddan NICU** The present neonatal transport system operates on an ‘as required’ basis and is not fulfilling the 12 hour requirement due to staffing pressures on maintaining the core service. * This unit provides high dependency care for the local population. ** These units provide all levels of care including long-term intensive care

and do not transfer out on the basis of clinical need other than in exceptional complicated cases. for surgery and cardiology.

2.3 National standards

Many of the issues preventing delivery of the All Wales standards are linked closely to the manpower resources available to deliver them. The benefit criteria used as a means to compare options against this criteria is manpower based.

Benefit criteria number 3 – Workforce standards

Enables progress towards the ultimate achievement of medical, nursing and therapies workforce standards within an agreed timeframe

2.3.1 All Wales Neonatal standards The All Wales Neonatal Standards (2008) reflect the aspirations of the Toolkit for High Quality Neonatal Services.

6 The standards were designed to provide a

basis from which to plan and deliver effective services. They are to be used to benchmark current services and inform the development of future services to meet the specialised health needs of children and young people across Wales

7.

6 Department of Health (2009) Toolkit for High Quality Neonatal Services.

7 All Wales Neonatal Standards (2008)



The All Wales standards comprise of 7 standards, each with it)s own set of key actions, deliverable over a period of between 1 an 10 years. The vast majority of standards require compliance within 3 years. The standards are: Standard 1 Access to Neonatal Care Standard 2 Staffing of Neonatal services Standard 3 Facilities for Neonatal Services including equipment Standard 4 Care of the baby and family / patient experience Standard 5 Transportation Standard 6 Clinical Pathways, Protocols and Guidelines / Clinical Governance Standard 7 Education and Training / Clinical Governance

Position statement

ALL WALES STANDARDS

Our present evaluation against the All Wales Neonatal standards identify the following problem areas

8:

Access: The formal identification of a level III (Intensive care) unit for the Managed Clinical Network in North Wales. This business case will aim to identify a future service strategy as part of a wider review of maternity & Child Health Services (also see section 2.10.2) Staffing: Insufficient medical and nursing staff for its level III (Intensive Care) units. Insufficient establishment for the recommended levels required for level II (high dependency) care. Facilities & Equipment: Availability of support services Lack of a dedicated equipment budget Transportation: Transport service in need of further development and staffing Clinical pathways, protocols & guidelines / clinical governance: IT systems require development to feed into national database Information Governance structure for the designated specialist centre Education & training: Some staff attending home births require training in Newborn Life Support The availability of post registration neonatal education needs to be more readily available.

2.3.2 European Working Time Directive (EWTD)

8 CPC AWNS Compliance reporting December 2011



1 August 2009 saw the full implementation of the European Working Time Directive (EWTD) into UK legislation, including doctors in training. The directive limits doctors in training to a maximum 48-hour week, averaged over a six month period. It lays down minimum requirements in relation to working hours, rest periods and annual leave. The workforce standards which follow in section 2.3.3 stipulate that all staffing rotas are compliant with the EWTD.

Position statement

EWTD COMPLIANCE

With the exception of the junior doctor rota at YGC (which has a separate rota for neonatal) all rotas are shared with general paediatrics. Rotas are presently EWTD compliant and the main risk to this will be the inability to recruit to posts. Alternative ways to staff traditional medical rotas are being considered to ensure future sustainability. Rotas must ensure that direct service provision is adequately balanced with training needs for junior doctors.

2.3.3 Wales Deanery Planned reduction in core trainees Notification has been received from the Deanery that there will be a reduction in Core Trainees from August 2012; however the only definitive planned reductions in posts have been received from the surgical specialties. In January 2012 the Wales Neonatal Steering Group received an update on proposals from the Wales Deanery which included the following key points (it should be noted that these changes have not yet been confirmed or agreed): No planned change to the training rota until 2014 from whence the number of neonatal posts at most levels may be halved. By 2016 ST1-3 may reduce from 22 to 11 By 2017 ST4-5 may reduce from 9 to 4.5 By 2019 ST6-8 (non-Grid) may reduce from 1.5 (3 posts per year) to 1 and GRID (inc. transport) may reduce from 0-7.5 to 0-5 As a limited number of training posts will be available in the future they will be placed in Level 3 units (NICU) able to provide a critical mass of patient activity for training. The standards for training units stipulate that: - Based on guidance within the curriculum each neonatal training unit will

need to have a minimum of 4,800 deliveries (based on an 8 person rota) per year.

- Each rota should have a minimum of 4 specialty trainees



2.3.4 Medical Workforce standards BAPM 2010: Quotes: that traditionally all types of neonatal units have had access to doctors at three levels (Tiers): A junior level containing doctors new to the specialty, a middle level equivalent to “registrar” who was typically competent to manage the usual range of cases presenting in the short term, and the experienced specialist – a consultant. Given the changes that have occurred in medical training, the restriction on doctors’ hours and changes to the organisation of paediatric and neonatal services, this model is no longer entirely feasible. As a result, it is anticipated that some of these traditional medical roles will be taken by nurses and similarly not all three tiers will be maintained in all sites. Therefore the following represents the skill sets and combinations of staff considered appropriate in different settings. The BAPM 2010 standards recommend that the numbers of staff to undertake the ‘traditional medical’ role for each type of Neonatal unit is as follows: i) Special Care Units

• Tier 1: Rotas should be EWTD compliant and have a minimum of 8 staff who may cover paediatrics in addition.

• Tier 2: Shared rota with paediatrics comprising a minimum of 8 staff. • Tier 3: A minimum of 7 consultants on the on call rota with a minimum

of 1 consultant with a designated lead interest in neonatology. It is recognised that in some settings that tiers 1 and 2 may be able to merge especially where appropriate skilled nursing support exists.

ii) Local Neonatal Units.

• Tier 1: Rotas should be EWTD compliant and have a minimum of 8 staff who do not cover general paediatrics in addition. This is expected of a standard model of LNU.

• Tier 2: Shared rota with paediatrics comprising a minimum of 8 staff, but see note 1 blow.

• Tier 3: A minimum of 7 consultants on the on call rota with a minimum of 1 consultant with a designated lead interest in neonatology. All consultants covering the service must demonstrate expertise in neonatal care (based on training, experience, CPD and on-going appraisal).

Note 1 Where local neonatal units regularly provide intensive care, and/or have a very busy paediatric service, and/or have neonatal and paediatric services that are physically a significant distance apart, then the above staffing levels should be enhanced. The threshold should be judged and monitored on clinical governance grounds such as the ability to consistently attend paediatric or neonatal emergencies immediately when summoned.

iii) Neonatal Intensive Care Units

All staffing roles should be limited to neonatal care at all levels, i.e. no cross cover with general paediatrics.



• Tier 1: Separate neonatal rotas with a minimum of 8 staff. • Tier 2: Separate neonatal rota with a minimum of 8 staff. • Tier 3: A minimum of 7 consultants on the on call rota with resident

consultants on the tier 2 rota additional to this number. All tier 3 consultants should be identified neonatal specialists.

Position statement

MEDICAL WORKFORCE

(Appendix 3) With the present configuration of Neonatal Units in North Wales (based on 2.2.3 above) the additional service requirements for medical rotas to meet recommended staffing levels are: Tier 1: 14.00 wte medical (or equivalent) staff Tier 2: on-call rotas require an additional 16.00 wte middle grade staff Tier 3: rotas require an additional 11.00 wte Consultants. The total number of extra doctors needed is therefore 41 wte. The estimated total cost of the wte Tier 1, 2 & 3 rotas deficit is presently estimated to be approximately £3.6 million

2.3.5 Nursing Workforce standards i) Direct Clinical Care The All Wales neonatal Standards (2.7, 2.8, 2.16, 2.17) and The British

Association of Perinatal Medicine Standards (BAPM) (2001 & 2010) recommend the following minimum staffing levels:

Intensive Care A ratio of 1 neonatal nurse Qualified In Specialty (QIS) to 1 baby High Dependency A ratio of 1 neonatal nurse (QIS) to 2 babies. More stable and less dependent babies may be cared for by a registered nurse not QIS. Special Care A ratio of 1 neonatal nurse to 4 babies (registered nurses and non-registered clinical staff under supervision)

The National Leadership and Innovation Agency for Healthcare (NLIAH) workforce tool, May 2010 has been used to calculate that 6 wte neonatal nurses are required for a 1:1 nurse to baby ratio.

ii) Non-direct Clinical Care

Non direct clinical care is an essential element of a nursing establishment. These nurses however are not available to provide daily ongoing care at the cot side i.e.



• senior nurse manager

• community outreach team

• staff dedicated to transport

• practice development facilitator/educators

• research/care pathway coordinators

• nurse in charge with no direct clinical responsibility

Position statement

NURSING WORKFORCE

(Appendix 4) With the present cot configuration in North Wales the service requires an additional 15.76 wte nursing staff to meet the staffing ratios quoted to provide safe standards of direct clinical nursing care. In addition 8.24 wte nurses are required to provide essential non-direct clinical care. Note: This calculation includes an uplift of 24.5% for sickness, annual leave and study leave, but does not include uplift for maternity leave.

The total cost of the 24.00 wte nursing deficit is estimated to be approximately £946,058

2.3.6 Allied Health Professionals Workforce standards BAPM (2010) and All Wales Neonatal standards incorporate standards for the provision of the therapy services specifically for neonatal care. Neonatal units should include appropriate provision for outreach / community therapy services in order to support babies and their families who have ongoing therapy needs post discharge from the neonatal unit. The following assessment summarizes the recent audit undertaken by therapies service in determining compliance against BAPM 2010 standards. No information was included within the report to the All wales Steering group regarding Pharmacy, Psychology and Social services. i) Dietetics BAPM 2010 Standard 6.1, specialist dieticians have a major role in assessing and improving the nutrition of premature infants and data exists that documents the benefit of including a neonatal dietician within a NNU team for nutritional support. The toolkit for high quality neonatal services recommends that all neonatal units have access to a neonatal dietitian or a Paediatric dietitian competent in neonatal nutrition. Dietetic support should also be available after discharge to infants identified as at nutritional risk. In addition there should be access to a



specialist neonatal dietitian whose job plan contains identified capacity for providing advice and support across the network The Paediatric dietitians currently attend the neonatal units in North Wales on a request basis only. They work with SCBU community nurses to ensure that ex-preterm infants with nutritional problems are identified and seen as quickly as possible in the community The service does not presently have sufficiently trained specialist staff to meet BAPM 2010 standards. With investment the service will operate on a pan-North Wales basis.

ii) Occupational Therapy and Physiotherapy Standard 6.2 states that neonatal occupational therapists and neonatal physiotherapists, with the appropriate skills, knowledge base and experience to provide developmental based neurological behavioral assessment and follow-up of high risk infants, are vital in the event of an early diagnosis. This requires an OT with specialist skills and knowledge in order to meet the requirements as there is currently no service provision into Neonatal Units in North Wales. Services are provided within community teams post discharge. There are no specialist neonatal physiotherapists working across North wales but there are paediatric physiotherapists who attend neonatal units if babies are referred. As with all physiotherapy services there is no ring fenced allocation for this service. Historically, nursing staff provide the respiratory care for the babies and referrals are for positioning issues and developmental issues. In the community, care for these babies is provided by appropriately skilled community physiotherapy paediatric teams. With investment the service will operate on a pan-North Wales basis.

iii) Speech and Language Therapy (S&LT) Standard 6.3 identifies that a specialist speech and language therapist is a key member of the multi-disciplinary NNU team with a unique role of the assessment and management of infant feeding and swallowing. Prematurity and poor early feeding are known risks to developing feeding problems in future. It is evident that babies with drug-withdrawal symptoms tend to stay longer in a neonatal unit than pre-term babies. Specialist training is required for Speech and Language Therapists working with neonates. A Specialist SLT will work with pre-term & neonatal infants to: • provide an assessment of sucking & swallowing • possibly reduce the time an infant is tube-fed thereby reducing the impact on

future oral feeding development • recommend appropriate oro-motor strategies, equipment, texture

modification if required (thickening feeds) • establish a relationship with families at the beginning & work with them to

ensure a smooth transition from SCBU to home



• Address communication early as this caseload are a potential for risk of developmental delay.

This service is experiencing increasing perceived demand for service to neonates. This is not historically been an agreed service and there is a current lack of evidence base as to need for S&LT input, equating to current demand. With investment the service will operate on a pan-North Wales basis. Pharmacy No information Psychological Support No information Social Services No information

Position statement

ALLIED HEALTH PROFESSIONALS WORKFORCE

(Appendix 5) The number, location and level of care provided at Neonatal intensive Care units is not expected to affect the level of additional resource required to meet BAPM 2010 standards. This is because specialist support service input is required at all levels of care and that service plans for these are will operate on a pan-North Wales basis. This will ensure staff working either in a neonatal unit or in the community have equitable access to specialist advice and support across the network. These services estimate that approximately £185,000 recurrent investment is required within the therapy service areas to attain BAPM 2010 standards, plus £13,000 non-recurrent training.

2.4 Recruitment & Training

Benefit criteria number 4 – Recruitment & training Enables the recruitment and training of sufficient numbers of medical, nursing and other neonatal staff to ensure future sustainability of services



2.4.1 Recruitment i) Neonatology Medical workforce The 2011 RCPCH workforce report

9 concluded that to deliver a safe and

sustainable service, the current UK consultant workforce in paediatrics needs to expand from 3084 WTE posts to between 4500 and 4900 WTEs. In addition, working practices will also need to change, with increased use of resident consultants, an expansion of the number of advanced nurse practitioners and an increase in the number of GPs trained in paediatrics. It is recommended that the number of specialty trainees be reduced from 3000 to 1720 WTEs.

The supply of senior and junior doctors to work on neonatal units comes from the national paediatric training programmes. There are currently no plans at UK level to decrease the number of doctors in training for paediatrics. However, recommendations from both Deaneries and the Royal College of Paediatrics and Child Health require us to plan to concentrate trainees in fewer hospitals than presently, to improve the quality of their training. We are told that a failure to do this in the near future will result in these doctors (and their funding) being withdrawn. The trainees will then be reallocated to units which can offer better experience. Speculation as to why Wales may have difficulty recruiting doctors to training posts has considered the following possible factors: the relative rurality of Wales, the practical difficulties faced by trainees who rotate between North and South Wales, the lower number of trainees on rotas compared to some areas of the UK, the greater proportion of our junior workforce who are non-training grades, the lack of academic opportunities, the statistic that the number of medical students and Foundation Programme doctors from Wales who seek jobs outside Wales is not matched by those seeking to come in to Wales. In North Wales difficulties in recruiting to two Neonatal Consultant posts have probably been influenced by the perceived absence of a clear commitment to develop neonatal intensive care in the region. In response to the pressures placed upon traditional medical staffing rotas it is important to look carefully at alternative ways to sustain these roles by considering the development of enhanced and advanced nursing roles. Whilst indications are that this is a more costly option, it is potentially a way to respond in part to the predicted shortages and provide high quality, safe and sustainable services in the future. To respond to the predicted deficit for trainee and junior medical staffing grades it is important that we consider alternative ways to traditional medical roles. This can, to some extent be supported by the use of enhanced and advanced nursing roles. This approach does however attract additional cost due the difference is full-time working hours i.e. medical staff work 48 hours per week and nurses work 37.5 hours per week. In addition, payments to nursing staff will attract enhancement for certain unsocial hour shift working. It must

9 Royal College of Paediatrics and Child Health. Facing the Future: A Review of Paediatric

Services. London: RCPCH; 2011



therefore be assumed that for approximately every 2 traditional doctor role we replace we will require approximately 2.5 nurses at higher cost ii) Neonatology Nursing workforce No specific concerns have been raised regarding the future recruitment and training prospects for neonatal nursing staff.

Position statement

RECRUITMENT & TRAINING

North Wales like the rest of Wales and the UK as a whole is anticipating unprecedented pressures in relation to the future availability of its medical workforce. Reducing the number of medical staffing rotas and replacing traditional medical roles with trained staff from alternative disciplines will be required to ensure the future sustainability of neonatal services.

2.6 Activity

Benefit criteria number 5 – Occupancy & closures

Allows for optimum occupancy levels to be achieved and maintained; reduce the likelihood of service closure to admissions and transfer for reasons other than access to a higher level of clinical care.

2.6.1 All North Wales Units Neonatal activity (Appendix 6) In 2011 the number of births* in North Wales hospitals was: Ysbyty Gwynedd 2,233 Ysbyty Glan Clwyd 2,469 Ysbyty Maelor 2,677 All North Wales 7,379 The number of admissions to neonatal units was: Ysbyty Gwynedd 197 (9% of births) Ysbyty Glan Clwyd 332 (13% of births) Ysbyty Maelor 260 (10% of births) All North Wales 789 (10.68% of births)



Following the implementation of plans for repatriation of maternity activity currently taking place in England, and increased activity from North Powys area is estimated that the number of births in North Wales will increase to approximately 7,900. This represents a rise in activity of 7.1% for maternity and neonatal care. This translates to about 56 infants per year who might require admission to a neonatal unit. * Total births for North Wales population including stillbirths. Births at other hospitals, e.g. Arrowe Park, Liverpool Women's, etc., have not been included as repatriation estimates will account for these as increased activity

2.6.2 Length of stay and occupancy levels Average Length of Stay Unnecessarily long lengths of stay are a sign of service inefficiency and separates babies from their families. A recent ‘review of Low Dependency provision and best practice recommendations undertaken by the All Wales Neonatal Network January 2012) makes recommendations for ways in which organizations can actively reduce length of stay for low dependency babies. For certain categories of gestation both Bangor and Wrexham have extended lengths of stay compared to the Welsh average. Occupancy levels BAPM recommends the following occupancy levels for neonatal units: Critical Care cots (IC & HD) 70% Low Dependency Cots 80% The January 2012 iteration of the All Wales Neonatal Capacity Review highlighted the mean occupancy percentage levels in the North community as:

Intensive Care 55.2% Both units providing intensive care have similar occupancy levels at around 54% indicating an adequate provision for population need. High Dependency 45.4% There is considerable variation in occupancy high dependency cots with YGC reporting 98%, YMW 39% and YG 5%. The main variation is attributed to YGC providing most high dependency care for YG. Since this report was produced actions have been implemented to increase high dependency capacity at YG which should reflect a more even distribution of activity. Low Dependency 80.5% The very high occupancy at this level of care is seen elsewhere in Wales however, the higher provision of Special Care cots in North Wales indicates a greater problem than elsewhere.



2.6.3 Neonatal Unit Closure & transfers The basis of operating as a clinical network is founded on the principle of maximizing capacity within a given area during variation of activity levels. The relatively small number of babies requiring neonatal care and the corresponding cot provision will inevitably mean that even a small increase in demand can outweigh capacity at the local neonatal unit. On these occasions closure to admissions will occur and transfer to other units will be required. Service closure does not mean that existing babies on the units will need to be moved; it means that the service cannot safely take new admissions. i) Closures and partial closures April to December 2011 (Appendix 7)

In the 6 months April to September 2011 the Neonatal units in total reported 71 incidences of closure. No closures were reported between October and December 2011. The majority of closure incidents were recorded at the Wrexham unit (70%). Glan Clwyd recorded 24% of the total closures. During April to December 2011 an additional 82 incidences of partial closure were reported. A partial closure is when a unit still has capacity to deal with certain levels of care. i.e. the unit may be open for intensive care or to take retrievals from another unit. Wrexham and Glan Clwyd reported approximately the same number of partial closures accounting for around 94% of the total reported. During this period no neonatal transfers out of North Wales were reported as a direct result of unit closures.

ii) Transfers – January to December 2011

Between January and December 2011 there were a total of 70 transfers recorded. 42 of these transfers (59%) were recorded as ‘elective’ and include booked transfers to and from other units both within the North Wales network and in England (8). There were 29 emergency transfers (41%) during the same 12 month period of which 3 were within Wales and due to capacity reasons. 10 transfers were for Tertiary assessment 12 transfers were from YG to YGC in order to access a higher level of care. 3 transfers were from YGC to YMW as that was the booking hospital and there was 1 emergency transfer in from Aberystwyth to YGC to access a higher level of care.

iii) In-utero transfers (April to December 2011) (Appendix 8) During this 9 month period there were 47 in-utero transfers recorded due to lack of capacity at the local neonatal unit. 32 (68%) of these transfers were to units within North Wales and 15 (32%) were to English units.

2.6.3 Neonates requiring specialist or long-term intensive care (Appendix

9)



The gestation age of 27 weeks or less has been used as a broad indicator of the neonates who would require a more specialist or longer-term period of intensive care. In 2011 there were 7,379 birth recorded at units within North Wales. Of these 789 (10.7%) were admitted to a neonatal unit. The highest admission rate in % terms was at YGC with 13% and YWM at 10%. The number of babies admitted to YGC and YG neonatal units at 27 weeks or less was 27, representing 0.6% of the total combined births*. The number admitted to YMW neonatal unit was 7 which is 0.3% of the births in that area and half of that for central and west regions. On this basis 34 babies (0.46% of total births) would require specialist or long-term intensive care at a Neonatal Intensive Care Unit. Women’s services predict an increase in activity to approximately 7900 births a year, which represents an increase of around 7.1%. It is therefore estimated that the number of neonates who will require access to a specialist Neonatal Unit in future will be in the region of 36 per year. * Note: as YGC provides higher level of acuity than YG the early gestation figures for these 2 units have been combined.

Position statement

ACTIVITY

The present network of units operates quite effectively in that when maximum capacity has been reached neonates can access services at normally the next nearest unit. There are however high levels of variation in occupancy from week to week which is not dissimilar to other health communities in Wales. There does appear to be scope to improve utilization of cots by reducing occupancy and length of stay. It is anticipated that whatever configuration of cots exists within North Wales we will remain reliant upon English units to assist at times of particularly high activity.

2.7 Access

Benefit criteria number 6 - Access

The service is accessible given the extent to which babies and families will need to travel; that this can be done safely and for a sufficient volume to make the service viable



Recent engagement sessions with staff and service user representatives (as part of the maternity & child health review) raised access to services as a major factor to consider in developing proposals for neonatal care. Similarly, in the Health Commission Wales Neonatology Review (2005) access was weighted as the second most important criteria for option appraisal (second to ability to recruit and retain staff). It is essential therefore to consider the travel times and distances between neonatal units when planning future services. It should be noted however that any regional networking arrangements is founded on the assumption that to ensure access to services travel between units will be unavoidable. Arrangements must therefore be in place to ensure that transfers are minimized and when they are required can be undertaken safely and effectively in all cases including emergency situations. 2.7.1 Patient Choice Giving people more choice is a priority of the modern NHS. This is because research in the UK and overseas has shown that treatments are more effective if patients choose, understand and control their care

10.

Patient choices include:

• Rights to choose a GP and, to change to another if you are not happy with the service you receive.

• The right to choose which hospital to go to if your GP refers you to see a specialist.

• The right to be involved in decisions about your healthcare and to be given the information you need to do this.

BCUHB recognise and upholds the rights of patients to choose where they receive their care. It is widely recognised however that, whilst we always aim to keep services as close to home as possible, sometimes, especially for specialist care, patients may be required to travel.

The Royal College Obstetricians and Gynaecologist Expert Advisory Group report

11 recently concluded that:

‘within current resources (financial, workforce, facilities), choice may have to be influenced by the availability of services. Choice needs to be aligned to the level of complexity and risk. Women will be expected to make informed choice based on the best care available: for example, in neonatal networks the family may need to travel further to a level 3 intensive care unit because that is the designated unit with the specialist resource, expertise and facilities.

10

NHS Choices website – Your health your choices 11

High Quality Women’s Heath Care (July 2011)



Position statement

ACCESS

The present configuration of units allows for good access with the maximum number of DGH sites providing neonatal services. Not each unit provides the same level of neonatal care and access may require transportation arrangements.

2.8 Facilities and equipment

Benefit criteria number 7 – Facilities & equipment Ensures that all units have physical space for the required number of cots and can provide the appropriate level of accommodation and facilities for families

All units should provide accommodation for families to stay on, or close to the unit. The need will be greater the further the babies are transferred from home. BAPM 2010: Neonatal Intensive Care Units should have, in addition, highly developed fetal medicine and maternal medicine services in order that women whose babies are likely to require intensive care are managed in centres which can provide appropriate facilities for both mother and baby. These centres should also have facilities for families to be resident, for prolonged periods if necessary.

DOH Toolkit for High Quality Neonatal Services Dedicated facilities should be available for parents and families of babies receiving neonatal care. As a minimum there is: • Overnight accommodation for parents:

- One room per intensive care cot located within 10–15 minutes walking distance (dressing gown distance) of the unit.

- Two rooms within or adjacent to the unit (with gas and air supply points to be available) for ‘rooming in’ prior to discharge.

- All rooms should be free of charge and with bathroom facilities. • Arrangements for secure and readily accessible storage of parents’ personal

items; • Cot-side, non-secure storage for personal items (e.g. baby clothes);



• A parent sitting room; • A kitchen with hot drink and snack-making facilities, including provision of a

microwave; • A toilet and washing area; • A changing area for other young children; • A play area for siblings of infants receiving care; • Access to a telephone and internet connection within the hospital; • A room set aside and furnished appropriately for counselling and to provide

distressed parents with privacy and quiet.

Position statement

FACILITIES & EQUIPMENT

The existing neonatal units are well equipped and can adequately accommodate the present requirement for physical cot space. There are sufficient facilities available in terms of parental accommodation to match the number of intensive care cots at each unit.

2.9 Finances and affordability

Benefit criteria number 8 - Affordability

The service is affordable, promotes the most efficient use of resources and demonstrates best value for money

2.9.1 Betsi Cadwaladr Health Board The annual revenue resource limit for the Health Board is £1.221 billion. As at 31

st January 2012 the Health Board was reporting a month 10 cumulative

in-year adverse variance of £5.843 million against the year to date budget of £998.417 million

12

Although the Health Board has been forecasting breakeven and has a track record of delivery of breakeven targets, the Health Board has been forecasting a risk of £10 million for a number of months and this level of risk remains at this time. The Health Board is aware of the seriousness of the financial position and the necessity of ensuring the Health Board achieves its statutory duty of breakeven by 31

st March 2012.

12

BCUHB Finance report Month 10 2011/12



2.9.2 Children & Young Peoples Clinical Programme Group (CPG) The CPG delegated annual budget for 2011/12 is £42.859 million. As at 31

st January 2012 the CPG was reporting a month 10 cumulative in-year

adverse variance of £1.339 million against the year to date budget of £35.766 million. The CPG forecasted a year-end adverse variance of £1.525 million

13

The CPG’s Cost Reducing Efficiency Scheme (CRES) target for 2011/12 was £ 1, 537million which equates to 4% of the annual budget.

As at month 10 the CPGs year to date planned saving was £1.281 million of which £0.983 million was achieved (77%). The CRES target for 2012/13 is not yet known.

2.9.3 Designated Neonatal funding The basis for historical allocation of neonatal funding for East, Central and Western areas of North Wales has not been subject to the same financial management accounting procedures. It is therefore not possible to state, with accuracy the complete funding allocation for this service as some budgets (e.g. medical staffing) are combined with those of general paediatrics. However, the resource that can be separately identified for neonatal services represents the majority of funding available: 2010/11 Pay £3.622 million (86%) Non-pay £0.956 million (14%) Total £4.578 million At year end the service reported an adverse variance again this budget allocation of £0.201 million 2011/12 The designated Neonatal Budget for 2011/12 is £ 4.2 Pay £ 3.548 million (87%) Non-pay £ 0.519 million (13%) Total £ 4.067 million

2.9.4 Cross border activity

In 2011 BCUHB invested an additional £416,196 in neonatal care on an interim basis to reduce transfers to Arrowe Park hospital due purely to a lack of local capacity (as opposed to clinical need). This money has enabled us to increase the number of high dependency cots promoting a more efficient use of financial resource within North Wales. The funding was not however sufficient to progress compliance with recommended staffing ratios as required by national standards, but will provide a short-term response to local capacity needs. 2.9.5 Funding for Neonatal Units

13

C&YP Month 10 2011/12 Finance report



Plans for the development of neonatal intensive care come under the auspices of Welsh Health Specialist Services Committee (WHSSC) (as a specialist service). This includes arrangements for transportation to that unit. Plans for development of Special and High Dependency Care (where delivered on a site not designated as an Intensive Care Unit) are explicitly excluded from WHSSC’s responsibilities. These latter responsibilities rest with LHBs.

Position statement

FINANCE & AFFORDABILITY

The Health Board has a statutory obligation to operate within the resource limit agreed by Welsh Government. The Health Board plans to achieve a balanced financial position in 2011/12, mindful of patient and staff safety and quality of service. A risk against delivering the breakeven target has been reported for a number of months. The financial pressures on all public sector bodies provide unprecedented financial challenges throughout the UK. Affordability will factor as a major consideration in decision making for any proposed service reconfiguration.

2.10 Strategic Context

Benefit criteria number 9 – Strategic Direction The service is designed to match plans for associated services and other healthcare providers; maintaining adequate flexibility to meet future changes.

2.10.1 National context In the BLISS 30

th birthday Baby report published in 2009 it was reported that

neonatal services in Wales had undergone 12 reviews over the past 30 years conducted by a range of official governmental, parliamentary bodies and professional bodies

14. Each review documented failures in the system and

recommended action to remedy these problems however none has been fully implemented. As such the need to drive forward improvements in services for sick and premature babies remains high on the agenda of the Welsh Government. The All Wales neonatal standards published in 2008 present an ambitious vision for services for special care babies and their families, to be achieved over a ten year period. Welsh Health Boards are responsible for ensuring that

14

BLISS 30th birthday baby report – Neonatal Care in Wales 2009



neonatal services in their area meet the All Wales Neonatal standards. A Welsh Neonatal Network, overseen by a national steering group was established in 2010. This network aims to support health boards in working towards the standards, ensuring that there is a coordinated approach to developing services across Wales which realises the benefits of collaborative working. As the All Wales Neonatal Network develops its information resource its recommendations inform the development of our local improvement strategy and delivery plans.

2.10.2 Local context Neonatal services have inextricable links with obstetric and general paediatric services, which, in turn have interdependent relationships with many other specialties. The most closely dependent links have been identified as: i) Obstetrics

A consultant-led obstetric unit providing care for low and high risk pregnancies requires access to on site high dependency neonatal care. Specialist obstetric units will require an appropriate level of specialist Neonatal service on site. The plans to develop local Fetal Medicine services in North Wales will be limited to assessment level and will not extend to the level whereby all specialist obstetric care will be provided locally. Specialist obstetric and neonatal care will continue to be provided by the Liverpool Women’s hospital, being the closest available specialist centre for Obstetric care.

All sites providing consultant-led obstetric services will provide on site access to adult critical care facilities.

ii) General Paediatrics

General Paediatrics will in some instances support the provision of a neonatal unit where traditional medical staff rotas can be shared. Where there is no requirement for shared rotas at any tier within the medical staffing structure (i.e. NICU) co-location is not essential.

iii) Neonatal Surgery and Cardiology

Neonatal Surgery and Cardiology are provided by Alder Hey Children’s NHS Foundation Trust. Due to the highly specialist nature of this service there will no plans which effect existing arrangements.

BCUHB review of Maternity & Child health services

The proposals described within this document will inform the wider review of maternity & child health services which commenced in July 2010. Links and interdependencies between neonatal, paediatric, maternity and other associated service, some of which may be themselves under review in North Wales will be recognized as part of the presently ongoing reviews.



An interim plan has been developed for neonatal services which consist of building local critical care capacity through repatriation investment. This will ensure that, whilst services remain short in terms of compliance with recommended standards they are being delivered in the more cost effective way pending agreement of a long-term strategy.

Plans for neighboring healthcare providers This business case has taken into account plans which are currently being

developed with providers of healthcare to the population of North Powys. The projected activity growth has factored in any known changes in order that the neonatal service in North Wales can adequately provide for the redefined catchment population.

Any proposals developed within this business case which feature Arrowe park

as a potential provider of long-term neonatal care have been done so on the basis of a business case submitted by the Cheshire and Merseyside Neonatal Network.

Position statement

STRATEGIC DIRECTION

The current configuration of neonatal units facilitates the co-location of services appropriate for the levels of general paediatric and obstetric care currently provided at the District General Hospitals within North Wales. However, the absence of formal strategy for neonatal services raises concerns both locally, with staff working within the service and amongst All Wales Neonatal Network and beyond. There is growing interest the North Wales service on a national level and a real urgency to define the long-term direction for neonatal care. This will ensure plans are in place to manage governance concerns and secure future sustainability of services. BCUHB commenced a process to review maternity and child health services in July 2010. The review acknowledges the need for a clear strategy for neonatal care in North Wales. The review is likely to result in changes for maternity and paediatrics services and the option for neonatal care must match these plans and maintain flexibility to meet any future changes.



3. Outline proposal

3.1 Existing Service 3.1.1 Capacity The present neonatal network for North Wales consists of three neonatal units located within North Wales and neighboring English provider trusts. Overall the total capacity appears sufficient to meet the present local demand. Increased activity is predicted as a result of plans to repatriate some maternity activity from neighboring English hospitals and to provide services for North East Powys. Recently, the Health Board supported some investment at all three neonatal units to reduce the number of costly transfers to Arrowe Park hospital due purely to a lack of local capacity rather than for clinical reasons. At present, not all physical capacity can be used for clinical care due to staffing shortages which can be due to a variety of reasons and change on a day to day basis.

3.2 Proposal Defining the North Wales network

3.3 Consultation

3.4 Benefits

3.5 Impact

3.6 Support

3.7 Evaluation

4.0 OPTION APPRAISAL



4.1 Generating options Note: All options maintain that the majority of neonates will be able to access all levels of care including short-term intensive care within North Wales and as close to home as possible.

The proposed cot configuration for each option is shown in appendix 10 Of the following 7 options, numbers 1 to 4 relate to provision of specialist, long-term neonatal care within a designated NICU in North Wales. Options 5 to 7 consider specialist-level NICU services being out-sourced to Arrowe Park hospital located in Upton, Wirral. The options shortlisted as being appropriate for further consideration during the review of maternity & child health services are as follows:

Option 1 3 x Neonatal Units with 2 x Neonatal Intensive Care Units (NICU at Ysbyty Maelor Wrexham & Ysbyty Glan Clwyd) This option maintains 3 neonatal units within North Wales and represents the ‘Status Quo’ position: Ysbyty Gwynedd. This unit will be best described under the new BAPM 2010 terminology as an ‘adapted Local Neonatal Unit’. This unit will provide all special care and most high dependency care for its local population Intensive Care will not be provided other than for stabilization and some high risk pregnancies and neonates will continue to be transferred out to the nearest specialist centre for access to an appropriate level of care. Ysbyty Glan Clwyd. This unit is defined as a Neonatal Intensive Care Unit (NICU), providing short and long-term intensive care for its local population and for Gwynedd residents. The unit operates on a network basis with YMW for Intensive Care. YGC will continue to provide all High Dependency care for the Central region and some HD care for Gwynedd. All special care for the central population will be provided here. Ysbyty Maelor. This unit is also defined as a Neonatal Intensive Care Unit

and will provide short and long-term intensive care for its local population. The unit will continue to operate on a network basis with YGC for intensive care. YMW will continue to provide all High Dependency Care and Special Care for its local population.

Option 2 3 x Neonatal units with a specialist Neonatal Intensive Care Unit (NICU) at Ysbyty Glan Clwyd



This option maintains 3 neonatal units within North Wales: Ysbyty Gwynedd. In essence there will be little change to the status quo and this unit will operate as an adapted Local Neonatal. The YG Neonatal unit will provide all special care and most high dependency care for its local population. Intensive Care will not be provided other than for stabilization and some high risk pregnancies and neonates will continue to be transferred out to the nearest specialist centre for access to the appropriate level of care. Ysbyty Glan Clwyd. This unit will be the single specialist Neonatal Intensive Care Unit, providing short term intensive care for its local population and long-term intensive care for the population of North Wales. The unit will continue to operate on a network basis with the other 2 units in North Wales. YGC will continue to provide all High Dependency care for the Central region and some HD care for Gwynedd residents. All special care for the central population will be provided here. Ysbyty Maelor. This unit will become a ‘standard Local Neonatal Unit’ and as such will continue to provide the majority of short-term Neonatal Intensive Care requirement for its local population. Longer-term Intensive Care will no longer be provided at this unit and transfer will be required to the Specialist centre at YGC. YMW will continue to provide all High Dependency Care and Special Care for its local population.

Option 3 3 x Neonatal units with a specialist Neonatal Intensive Care Unit (NICU) at Ysbyty Maelor Wrexham This option maintains 3 neonatal units within North Wales: Ysbyty Gwynedd. Again there will be little change to the status quo and this unit will operate as an adapted Local Neonatal. The YG Neonatal unit will provide all special care and most high dependency care for its local population. Intensive Care will not be provided other than for stabilization and some high risk pregnancies and neonates will continue to be transferred out to the nearest specialist centre for access to the appropriate level of care. Ysbyty Glan Clwyd. This unit will become a ‘standard Local Neonatal Unit’ and as such will continue to provide the majority of short-term Neonatal Intensive Care requirement for its local population. Longer-term Intensive Care will no longer be provided at this unit and transfer will be required to the Specialist centre at YMW. YGC will continue to provide all High Dependency Care and Special Care for its local population and also some High dependency Care for Gwynedd residents. Ysbyty Maelor Wrexham. This unit will be the single specialist Neonatal Intensive Care Unit, providing short term intensive care for its local population and long-term intensive care for the population of North Wales. The unit will continue to operate on a network basis with the other 2 units in North Wales. YMW will continue to provide all high dependency and special care for its local population.

Option 4



2 x Neonatal units with a specialist Neonatal Intensive Care Unit (NICU) at Ysbyty Maelor Wrexham Options 4 and 5 reduce the number of neonatal units in North Wales from 3 to 2. The overall number and acuity of cots for the population remains unchanged apart from a reduction of 1 stabilization cot (as there will be no neonatal unit at YGC). This option is considered alongside 3 General Paediatric Inpatient units and 2 Consultant-led Obstetric Units.: Ysbyty Gwynedd. This unit will become a ‘standard Local Neonatal Unit’ providing short-term intensive care / stabilization. The unit will provide all high dependency and special care for a redefined population which includes Gwynedd and a proportion of activity historically provided at YGC. Only babies requiring long-term or specialist intensive care will require transfer to the specialist NICU at YMW, Wrexham. Ysbyty Glan Clwyd. There will be no neonatal unit at YGC as the maternity service on this site will consist of a midwifery-led unit providing care for only low risk pregnancies. High risk pregnancies and low risk which later develop into high risk deliveries will require transfer to an alternative unit with appropriate care provision. Ysbyty Maelor Wrexham. This unit will be the single specialist Neonatal Intensive Care Unit, providing short term intensive care for its local population and long-term intensive care for the population of North Wales. The unit will continue to operate on a network basis with YG. YMW will continue to provide all high dependency and special care for its local population and a proportion of new activity historically provided other units serving an extended catchment population.

Option 5

3 x Neonatal units in North Wales and all specialist, long-term neonatal intensive care provided by Arrowe Park hospital NICU.

This option maintains 3 neonatal units within North Wales: Ysbyty Gwynedd. YG will continue to provide a very similar level of service to that presently available. As an ‘adapted Local Neonatal Unit’ the unit will provide all special care and most high dependency care for its local population Intensive Care will not be provided other than for stabilization and some high risk pregnancies and neonates will continue to be transferred out to the nearest more specialist centre for access to an appropriate level of care. Ysbyty Glan Clwyd. This unit will be defined as an ‘enhanced Local Neonatal Unit’, providing short-term intensive care and high dependency care for its local population and for some Gwynedd residents. The unit will operate on a network basis with YMW for short-term Intensive Care to expand local capacity. All special care for the central population will continue to be provided here.



Ysbyty Maelor. This unit will function as a ‘standard Local Neonatal Unit’ and will provide short-term intensive care / stabilization, all high dependency care and Special Care for its local population. Arrowe Park. This hospital will be the designated specialist Neonatal Intensive Care Unit and will be the provider of all specialist and long-term neonatal intensive care (except for surgery) for the population of North Wales and North East Powys. The majority of neonates requiring intensive care will continue to receive services at a neonatal unit within North Wales. Approximately 60% of our estimated intensive care cot days will be provided by Arrowe Park. This does not represent the total number of babies receiving IC, but the total number of days. The very pre-term babies will require longer periods of intensive care and these are proportionately a small number of overall births. The Cheshire and Merseyside Neonatal Transfer service will provide a retrieval service for the safe transportation of patients to the NICU, located on the Wirral.

Option 6 3 x Neonatal units in North Wales and all specialist, long-term neonatal intensive care provided by Arrowe Park hospital NICU.

This option also maintains 3 neonatal units within North Wales: Ysbyty Gwynedd. YG will continue to provide a very similar level of service to that presently available. As an ‘adapted Local Neonatal Unit’ the unit will provide all special care and most high dependency care for its local population Intensive Care will not be provided other than for stabilization and some high risk pregnancies and neonates will continue to be transferred out to the nearest more specialist centre for access to an appropriate level of care. Ysbyty Glan Clwyd. This unit will become as a ‘standard Local Neonatal Unit’ and will provide short-term intensive care / stabilization, all high dependency care and Special Care for its local population. In addition the unit will work on a network basis to provide some high dependency care for Gwynedd residents. Ysbyty Maelor. This unit will be become an ‘enhanced Local Neonatal Unit’, providing regular short-term intensive care and receiving transfers in from the other two units when additional short-term intensive care capacity is required. All special care for the eastern population will continue to be provided here. Arrowe Park. The unit will be the designated specialist Neonatal Intensive Care Unit as described in option 6 above.

Option 7 2 x Neonatal units in North Wales and all specialist, long-term neonatal intensive care provided by Arrowe Park hospital NICU. As with options 4 and 5 above, this option reduces the number of neonatal units in North Wales from 3 to 2. The overall number and acuity of cots for the



population remains unchanged apart from a reduction of 1 stabilization cot (as there will be no neonatal unit at YGC). This option is considered alongside 3 General Paediatric Inpatient units and 2 Consultant-led Obstetric Units: Ysbyty Gwynedd. This unit will become a ‘standard Local Neonatal Unit’ providing short-term intensive care / stabilization. The unit will provide all high dependency and special care for a redefined population which includes Gwynedd and a proportion of activity historically provided at YGC. Only babies requiring long-term or specialist intensive care will require transfer to the specialist NICU at Arrowe Park. Ysbyty Maelor. This unit will be become an ‘enhanced Local Neonatal Unit’, providing regular short-term intensive care and receiving transfers in from YG units when additional short-term intensive care capacity is required. All special care for the eastern population will continue to be provided here and a proportion of new activity historically provided other units serving an extended catchment population. Arrowe Park. The unit will be the designated specialist Neonatal Intensive Care Unit as described in option 6 above.



4.2 Benefit Criteria Summary

1. Provides the required number of cots at the appropriate level of acuity to

meet projected population need 2. Ensures effective and viable networking and transportation arrangements 3. Enables progress towards ultimate achievement of the medical, nursing

and therapies workforce standards within an agreed timeframe 4. Enables the recruitment and training of sufficient numbers of medical,

nursing and other neonatal staff to ensure future sustainability of services 5. Allows for optimum occupancy levels to be achieved and maintained;

reduce the likelihood of service closure to admissions and transfer for reasons other than access to a higher level of clinical care.

6. The service is accessible given the extent to which babies and families will

need to travel; that this can be done safely and for a sufficient volume to make the service viable

7. Ensures that all units have physical space for the required number of cots

and can provide the appropriate level of accommodation and facilities for families

8. The service is affordable, promotes the most efficient use of resources

and demonstrates best value for money 9. The service is designed to match plans for associated services and other

healthcare providers; maintaining adequate flexibility to meet future changes



4.3 Option evaluation

Option Evaluation

Benefit Criteria OPTIONS ( Score 1-5)

1 2 3 4 5 6 7

i Cot numbers & acuity 4 5 5 5 5 5 5

ii Network & transport 5 4 4 2 3 3 1

iii Workforce standards 4 4 4 4 5 5 5

iv Recruitment & Sustainability 1 2 2 3 4 4 5

v Optimum occupancy & reduced closures 5 5 5 5 5 5 5

vi Access 5 4 3 3 2 2 1

vii Facilities & equipment 5 5 4 2 5 5 3

viii Affordability 1 2 2 3 4 4 5

ix Strategic direction (not scored) 1 5 4 4 3 3 2

TOTAL SCORE 31 36 33 31 36 36 32

Transition* 3 2 1

FINAL SCORE 31 39 33 31 38 37 32

Position: 6 1 4 6 2 3 5

The recommended option based on option appraisal is therefore option:

2

Option 2 consists of:

1 x Adapted LNU 1 x Standard LNU 1 x NICU YG Bangor

YMW Wrexham YGC Bodelwyddan

The estimated recurring cost of this option is approximately £2.47 (compared to the status quo of £4.01m) * three have attained the same maximum score, transitional implications have been used to determine the ultimate preferred option based on the potential local impact in delivering change.

The summary of additional cost is shown in Appendix 11



4.4 Cost implications It is widely recognised that in order to meet the requirements of the All Wales and BAPM 2010 service standards, neonatal services in most Health Boards will require additional investment. It is important to note that the figures included within the cost analysis (appendix 11) should be considered purely as a guide for comparative purposes rather than a conclusive summary of the final cost implications of the preferred option. The latter cannot be worked up in sufficient detail for all options within the scope of this business case due to the complexities of options for staffing traditional medical rotas with different levels of nursing staff. Early calculations however indicate that nurses are likely to be a considerably more expensive alternative as 1.28 nurses are required for each doctor replaced. A separate, more comprehensive cost analysis will be required once the principle strategy for neonatal service has been agreed and accepted by the BCUHB Board The costing does not take into account potential efficiencies that might release resource in future e.g. a potential to reduce low dependency cots. The reasons for this are three-fold: Firstly, conversion of cots to a higher acuity requires higher ratio of nurse staffing and is therefore likely to significantly reduce the potential for cash release. Secondly, to address issues of long lengths of stay and improve occupancy levels investment in community outreach service is likely to be required. Thirdly, all services with the CPG are subject to ongoing Cost Reduction Efficiency Scheme (CRES). Any supplementary cash-releasing efficiency savings would therefore serve as a contribution to the scheme. Alterations to existing funding arrangements for Neonatal Care will need to be clarified with the Welsh Health Specialist Services Committee as commissioners of specialist services.

5.0 COST

5.1 Revenue Costs

5.2 Capital Costs

5.3 Transitional Costs

5.4 Expenditure Profile



6.0 FEASIBILITY 6.1 Affordability

• Re-organising existing services.

• Additional investment required to comply with standards

6.2 Sustainability Assessment of reasonable risks:

• Timescale

• Availability of staff

• Capacity of other affected services

7.0 IMPLICATIONS OF DOING NOTHING

7.1 Risks

8.0 APPROVAL

Chief of Staff Signed: Date: Associate Chief of Staff (Nursing)

Signed: Date:

Clinical Director Signed: Date: Executive Team Signed: Date:

Neonatal Business Case v7 - NHS Wales · Wales which includes evidence-based prevention strategies...

Documents

Transcript of Neonatal Business Case v7 - NHS Wales · Wales which includes evidence-based prevention strategies...