NWNODN Neonatal Activity, Demand, and Capacity Report 2020-21 SMT Version Page 1 of 73 Neonatal Activity, Demand & Capacity Report 1st April 2020 to 31st March 2021 NORTH WEST NEONATAL OPERATIONAL DELIVERY NETWORK Working together to provide the highest standard of care for babies and families
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NWNODN Neonatal Activity, Demand, and Capacity Report 2020-21 SMT Version Page 1 of 73
Neonatal Activity, Demand & Capacity Report
1st April 2020 to 31st March 2021
NORTH WEST NEONATAL OPERATIONAL DELIVERY NETWORK
Working together to provide the highest standard of care for babies and families
NWNODN Neonatal Activity, Demand, and Capacity Report 2020-21 SMT Version Page 2 of 73
Table of Contents 1. Introduction ............................................................................................................................................. 5
2.1 Births by Locality & Unit ....................................................................................................................10
2.2 Neonatal Unit First Admissions ..........................................................................................................11
2.2.1 NNU first admissions across the network by locality ...................................................................11
2.2.2 NNU first admissions against the number of live births across the ODN ......................................12
2.2.3 First admissions across the NWNODN by gestation .....................................................................13
2.3 First Admissions and Birth data .........................................................................................................13
2.3.1 First Admissions and Live Births by Locality .................................................................................13
2.3.2 First Admissions and Live Births as a Percentage by Unit.............................................................13
2.4 Total admissions across the NWNODN including out of area postnatal transfers ...............................14
2.5 Term & Late Preterm Admissions ......................................................................................................15
2.5.1 Term Admissions (≥ 37 Weeks) ...................................................................................................15
2.5.2 Late Preterm Admissions (≥ 34 and <37 Weeks)..........................................................................16
2.5.3 Term Admissions (≥37 weeks) by Length of Stay .........................................................................17
2.6 Babies delivered at less than 27 Weeks’ Gestation ............................................................................18
2.6.1 <27 Week Deliveries by Locality ..................................................................................................18
2.6.2 <27 Week Deliveries by Unit .......................................................................................................19
3. Activity and workload .............................................................................................................................21
3.1 NWNODN Activity by Level of Care ....................................................................................................21
3.2 NWNODN NICU Activity by Level of Care ...........................................................................................21
3.3 NWNODN Activity and Workload ......................................................................................................22
3.3.1 NWNODN NICU Activity ..............................................................................................................22
3.3.2 NWNODN LNU Unit Activity ........................................................................................................22
3.3.3 NWNODN SCU Unit Activity ........................................................................................................24
3.3.4 NWNODN NICU Average Length of Stay by Gestations................................................................25
3.3.5 NWNODN LNU & SCU Average Length of Stay by Gestation ........................................................26
8.5 Lancashire & South Cumbria – Summary ...........................................................................................65
Appendix 1: Out of Area Activity Base .........................................................................................................66
Appendix 2: Medical Staffing Review in LNUs and SCUs ..............................................................................67
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1. Introduction
The purpose of this report is to provide an overview of the demand, activity and capacity of the neonatal
units across the North West Neonatal Operational Delivery Network for the period April 2020 to March 2021,
inclusive.
In order to ensure clarity and consistency for the purpose of this report, capacity in neonatal services is
defined by the physical, equipped cots available and the nurse staff available to provide this care. Demand
is defined as the anticipated need for admissions in relation to the number of live births and potential case
mix, with particular regard to the number of extremely preterm births due to the high levels of neonatal care
needed with increasing prematurity.
This report is derived from the data entered by providers in to the Badgernet data system. Where
appropriate, narrative is provided to assist understanding of the data and any changes from previous years.
The impact of the COVID 19 pandemic, whilst not impacting directly on Neonatal services to the same extent
as Adult and Paediatric services, should be considered when reviewing this report. The true impact of the
pandemic on activity and demand is unclear and therefore any fluctuations this year must be carefully
considered prior to any planning assumptions being made on 20/21 data.
The tables and charts presented in this report exclude data from postnatal wards or transitional care, unless
otherwise stated. The definitions of care are:
• XA01Z Intensive Care
• XA02Z High Dependency Care
• XA03Z Special Care, Carer not resident alongside baby
• XA04Z Special Care, Carer Resident at cot side and caring for baby
• XA05Z Normal Care
Where the data in this report suggests that the capacity in any unit is not aligned to demand or activity the Provider, NWNODN and NHS England Specialised Commissioning will follow the NWNODN Cot Base Guideline to review capacity and make any changes based on system wide considerations.
The Cot Base Guideline can be viewed at https://www.neonatalnetwork.co.uk/nwnodn/wp-
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1.1 Overview Summary
Key Findings:
Activity across the region down by 3%
Intensive care days down by 6.8% compared to only a 0.4% decrease in 19/20
High Dependency care days down by only 0.3% compared to a 4 % decrease in 19/20
Special care and Normal care days down by a further 3.1% compared to a 7.6% decrease in 19/20
Birth rate down by 4.8%
Reduction of Postnatal transfers into NWNODN to 72 infants, compared to 101 in 19/20
Reduction of Antenatal transfers into NWNODN to 182 infants, compared to 247 in 19/20
Term admissions (<37 weeks) down by 0.2% bringing the average down to only 5.1% across the region
Late pre-term admissions (>34 and <37 week) have increased slightly to 44%
88% of intensive care activity delivered in NICUs compared to 92% in 19/20 and 88% in 18/19
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1.2 Key Recommendations
Within each locality section the Network Clinical Leads have provided comments, observations and
recommendations for development (sections 6, 7 & 8) in each locality. These recommendations will
be discussed at locality steering groups and where appropriate be incorporated into the NWNODN
work plan.
The key recommendations for relevant for all localities within the North West ODN :
Neonatal Critical Care Review
• Use data to support ODN-led NCCR, commissioned by Specialist Commissioners
< 27week GA deliveries in non-NICU maternity units
• To revisit and agree the process of reviewing all <27week deliveries in non-NICU units (in conjunction with LMS).
• Appropriate place of birth to be monitored as part of the MatNeo Safety Improvement Programme focusing on the optimisation of the pre-term infant
Term/late pre-term admissions
• Use NWNODN Quarterly dashboard to monitor. Separation measure included on dashboard
from April 2021.
• Where >6%, work with NNU with input from the NWNODN Care Co-ordinator to understand
where QI can be made & encourage system working with Maternity
• Work with the ODN Care Co-ordinator and LMS to embed a comprehensive TC offer across
all units
Nursing and Medical Staffing
• All units to work towards being consistently BAPM Compliant for medical staffing
• NNU nurse leads to work with NWNODN Workforce & Education Lead to improve position
against national standards & develop “Quality Roles Tool” to support comprehensive
description/quantification of quality nursing workforce
• Repeat medical workforce survey annually and extend to NICUs
Data Completeness & Triangulation of data
• All units to check data completeness for admissions, discharges and LOS on a regular basis
• All units to check data completeness and accuracy for Respiratory care days, particularly
ventilation days at EPR units
• To consider reviewing the number of respiratory care days & length of stay by gestation to
understand variation between NICUs. LOS Data to be triangulated against clinical factors
from the dashboard such as incidence of chronic lung disease and infection rates alongside
duration of ventilation.
• To consider how discharge pathways may also influence variation in length of stay between
similar units.
NWNODN Neonatal Activity, Demand, and Capacity Report 2019-20 Draft v0.2
1.3 Data Collection and Verification Process
Diagram 1
Approvals and Review Process: July 2021 Greater Manchester / Cheshire & Merseyside / Lancashire & S Cumbria Neonatal
Steering Groups for agreement of locality sections August 2021 Neonatal Senior Management Team for agreement of full report September 2021 NWNODN Board for ratification October 2021 NHSE Specialised Commissioning review November 2021 Commissioner review Commissioner intentions to providers
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1.4 Capacity Reference Tables
Tables 1.3.1 – 1.3.3 show an overview of NWNODN units by designation level and cot capacity for each level of care.
Unit Level colour coded:
Table 1.3.1 *SMH is also a surgical unit as well as a NICU
Cheshire & Merseyside Abbrev.
Unit
Level IC cots HD cots SC cots Total
Arrowe Park Hospital APH NICU 6 8 10 24
Countess of Chester Hospital COC LNU 1 2 10 13
Macclesfield Hospital* ECH SCU 0 1 7 8
Liverpool Neonatal Partnership LNP
• Alder Hey Hospital LNP - AHCH Surgical 0 9 0 9
• Liverpool Women’s LNP - LWH NICU 12 12 20 44
Leighton Hospital MCTH LNU 3 4 8 15
Ormskirk Hospital ODGH LNU 1 1 8 10
Whiston Hospital STHK LNU 0 2 13 15
Warrington Hospital WWH LNU 3 3 12 18
Total 26 42 88 156 Table 1.3.2
* Countess of Chester currently only accepts deliveries of 32 weeks gestation and above Macclesfield unit has been closed throughout the 2020/21 report period
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2.6 Babies delivered at less than 27 Weeks’ Gestation
2.6.1 <27 Week Deliveries by Locality
Tables 2.6.1 shows the number of deliveries of less than 27 weeks or multiple births less than 28
weeks, by locality, unit and appropriate place of birth (i.e. NICU), as reported to NHSE. A multiple birth
counts as one delivery.
NWNODN
2018-19
2019-20
2020-21
Total <27/40 born in NICU 219 192 162
Total <27/40 born in LNU 33 25 24
Total <27/40 born in all categories 252 217 186
% <27/40 born in NICU 87% 88% 87%
Greater Manchester
Total <27/40 born in NICU 106 96 80
Total <27/40 born in LNU 6 11 11
Total <27/40 born in all categories 112 107 91
% <27/40 born in NICU 95% 90% 88%
Cheshire & Merseyside
Total <27/40 born in NICU 59 47 49
Total <27/40 born in LNU 17 10 10
Total <27/40 born in all categories 76 57 59
% <27/40 born in NICU 78% 82% 83%
Lancashire & South Cumbria
Total <27/40 born in NICU 54 49 33
Total <27/40 born in LNU 10 4 3
Total <27/40 born in all categories 65 53 36
% <27/40 born in NICU 84% 92% 92% Table 2.6.1
Note – The table above includes multiple deliveries between 27 to 27+6 weeks gestation and home
births, which are attributed to the neonatal unit where the 1st episode of care was delivered.
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2.6.2 <27 Week Deliveries by Unit
Tables 2.6.2 – 2.6.4 show the number of deliveries of less than 27 weeks, or multiple births less than
28 weeks, by locality and unit. A multiple birth counts as one delivery & home births are attributed to
the 1st episode of care.
Greater Manchester Unit
category 2018-19 2019-20 2020-21
Total <27/40 born in NICU 106 96 80
MFT - SMH NICU 53 37 33
RBH* NICU 25 31 16
ROH NICU 28 28 31
Total <27/40 born in LNU or SCBU 6 11 11
MFT - NMGH LNU 3 3 2
MFT - WYTH LNU 1 3 5
SSH LNU 0 3 2
TGH LNU 1 0 1
WWL LNU 1 2 1
Total <27/40 born in all unit categories 112 107 91
% <27/40 born in NICU 95% 90% 88%
Table 2.6.2
*Includes 1 twin delivery at 27-27+6 weeks gestation 20/21
Cheshire & Merseyside Unit
category 2018-19 2019-20 2020-21
Total <27/40 born in NICU 59 47 49
APH NICU 29 19 12
LNP – LWH* NICU 30 28 37
Total <27/40 born in LNU or SCBU 17 10 10
COC LNU 2 1 1
ECH LNU 0 0 0
MCTH LNU 6 5 1
ODGH** LNU 0 0 4
STHK LNU 6 3 4
WWH LNU 3 1 0
Total <27/40 born in all unit categories 76 57 59
% <27/40 born in NICU 78% 82% 83% Table 2.6.3
* Includes 1 triplet delivery at 27-27+6 weeks gestation 20/21.
** Includes 1 Home birth where first episode of care was carried out in an LNU 20/21.
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Lancashire & South Cumbria Unit
category 2018-19 2019-20 2020-21
Total <27/40 born in NICU 54 49 33
ELHT* NICU 34 26 18
LTHTR** NICU 20 23 15
Total <27/40 born in LNU or SCBU 10 4 3
BTH LNU 9 2 1
MBHT - FGH SCBU 0 1 2
MBHT - RLI LNU 1 1 0
Total <27/40 born in all unit categories 64 53 36
% <27/40 born in NICU 84% 92% 92% Table 2.6.4
*Includes 2 twin deliveries at 27-27+6 weeks gestation 20/21.
** Includes 1 in unknown birth location where first episode of care was carried out in a NICU 20/21.
For 2020/21 the NWNODN exception reporting process showed that that there was a potential missed
opportunity for an antenatal transfer for 4 of the deliveries outside of a centre with a NICU and no
babies remained in LNUs for more than 24 hours.
The NWNODN benchmarks well nationally in relation to birth in the right place. Up-date for 20/21
The following chart is an extract from the NNAP Audit Programme 2020 Annual Report, showing that in 2019 the NWNODN was one of the best performing ODNs for babies less than 27 weeks’ gestational age being born at a centre with a NICU. The full NNAP Annual Report can be accessed at https://www.rcpch.ac.uk/resources/national-neonatal-audit-programme-annual-report-2020-2019-data
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3.3 NWNODN Activity and Workload
3.3.1 NWNODN NICU Activity
In-line with the recommendations included as part of the Neonatal Critical Care Transformation Review (2019) all NICUs should, as a minimum, look after at
least 100 very low birth weight (VLBW) infants per year and be delivering >2000 intensive care days (Health Resource Group definition, 2016 & BAPM Optimal
Arrangements for Neonatal Intensive Care Units in the UK, 2021).
Table 3.3.1 shows all NICU activity, regardless of episode number, and includes surgical care at St. Mary’s Hospital.
Table 3.3.1
3.3.2 NWNODN LNU Unit Activity
In-line with the recommendations included as part of the Neonatal Critical Care Transformation Review (2019) all LNUs should aim to undertake a minimum
of 500 days of combined intensive and high dependency care (Health Resource Group definition, 2016), which is considered the minimum requirement to
maintain expertise. LNUs providing ongoing HD should be working towards delivering 1000 combined ITU/HD days per year, in the longer term (i.e. 5 years
** ECH Neonatal Unit has been closed throughout 2020/21
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3.3.4 NWNODN NICU Average Length of Stay by Gestations
Length of stay for babies discharged in 2020/21, attributed to first episode of care location. Only includes babies discharged Home or to Foster Care. Babies
who died during their neonatal admission or who transferred to a non-neonatal ward have been excluded.
Chart 3.3.4
0102030405060708090
100110120130
APH LNP - LWH MFT - SMH RBH ROH ELHT LTHTR
Cheshire & Merseyside Greater Manchester Lancashire and South Cumbria
Ave
rage
LO
S in
Day
s
Babies with first admission - NICU total average LOS in days
24-25wks 26-27wks 28-29wks 30-31wks 32-33wks
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3.3.5 NWNODN LNU & SCU Average Length of Stay by Gestation
Length of stay for babies discharged in 2020/21, attributed to first episode of care location. Only includes babies discharged Home or to Foster Care. Babies
who died during their neonatal admission or who transferred to a non-neonatal ward have been excluded.
Chart 3.3.5
0102030405060708090
100110
COC MCTH ODGH STHK WWH MFT -NMGH
MFT -WYTH
SHH TGH WWL BTH MBHT -RLI
MBHT -FGH
Cheshire & Merseyside Greater Manchester Lancashire and South Cumbria
Ave
rage
LO
S in
Day
s
Babies with first admission - LNU/SCU total average LOS in days
27wks 28-29wks 30-31wks 32-33wks
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3.4 Cot Activity
Table 3.4 shows the demand (D) for cots based upon activity within each of the localities against actual (A) cots. Care Levels are based upon HRG 2016 codes
but are referred to as IC, HD & SC cots as these are the commissioned cots in each category. An element of surgical care is included in the figures as it is not
possible to separate out surgical activity within the data.
Calculation method which include 80% capacity: Cot Demand = (Number of care days/365)/0.8
Grand Total 63% 64% 52% 68% 60% 61% 53% 50% 53% 56% 65% 57% 58%
NICU = pink, LNU = blue, SCU = green and surgical unit = purple. Occupancy at <80% is shown with a green background, >80% is shown in red. Table 3.5.1 As Macclesfield have been closed throughout 20/21 they have been removed from all occupancy tables
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3.5.2 Average Monthly IC (XA01Z) Occupancy for NICUs only by Locality
XA01Z (IC) Occupancy APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Mean
Grand Total 76% 64% 56% 61% 70% 66% 78% 61% 60% 61% 71% 79% 67% Table 3.5.3
If unit has no HD cots their HD activity has been included in the locality and network totals. Instead of a % actual count of HD days are shown in the table.
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3.5.4 Average Combined XA01Z & XA02Z (IC & HD) Occupancy by Locality and Units
XA01Z & XA02Z IC & HD Occupancy
APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Mean
Table 4.1.1 shows the Inappropriate Postnatal Transfers out of each locality and out of NWNODN. Inappropriate is any support, treatment or surgery that
is available within the NWNODN pathway which took place outside of the NWNODN.
PN Inappropriate Transfers Out
Out of Locality within NWNODN
18/19
Out of Locality within NWNODN
19/20
Out of Locality within NWNODN
20/21
Out of NWNODN
18/19
Out of NWNODN
19/20
Out of NWNODN
20/21
Greater Manchester 9 18 4 2 1 0
Cheshire & Merseyside 19 16 1 0 0 0
Lancashire & South Cumbria 3 5 3 0 1 0
Total 31 39 8 2 2 0 Table 4.1.1
Transfers for specialist treatment or surgery, to another unit within the NWNODN but across locality, is deemed as appropriate. Transfers both out of localities and outside of the region have decreased considerably over the past year. It is unclear if this is due to COVID or that units now adhere to the appropriate pathways. Table 4.1.2 shows appropriate Postnatal Transfers out of NWNODN. These are transfers out of the NWNODN where care is not provided within the region, for example in 2020/21 there were transfers to Leeds & Great Ormond Street for specialist treatment.
PN Appropriate Transfers Out of NWNODN
18/19 19/20 20/21
Cheshire & Merseyside 0 5 1
Greater Manchester 7 3 3
Lancashire & South Cumbria 0 1 1
Total 7 9 5 Table 4.1.2
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4.2 Network and Locality out of area activity.
The following tables show NWNODN activity for babies who are registered with a GP Practice assigned to either a Welsh Local Health Board (HLB) or a CCG
within Yorkshire & Humber, North & West Midlands or Isle of Man (IOM). It is noted that there is a decrease in the numbers transferred in both antenatally
and postnatally which is positive outcome as it means babies are being cared for in their own localities, remaining closer to home.
Table 4.2.1 Babies transferred antenatally into NWNODN units by locality.
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4.3 Out of Area Activity by CCG
Table 4.3 shows a breakdown by region of number of babies admitted in year and the total care days in year
for all babies, whose mothers are registered with a GP whose CCG code is outside of the NWNODN.
Care Days
2020-21 Out of Area CCG into Locality No. of Babies
XA01Z (IC)
XA02Z (HD)
XA03Z & XA04Z (SC)
XA05Z (NC)
Greater Manchester 72 398 318 519 85
NHS England London 7 25 90 50 5
NHS England Midlands & East (Central Midlands) 1 0 0 10 1
NHS England Midlands and East (East) 3 7 6 9 2
NHS England Midlands and East (North Midlands) 35 140 90 308 58
NHS England Midlands and East (West Midlands) 3 29 46 20 2
NHS England North (Cumbria and North East) 3 18 31 46 0
NHS England North (Yorkshire and Humber) 10 145 16 49 14
NHS England South East (Hampshire, Isle of Wight
& Thames Valley) 1 0 0 3 0
NHS England South East (Kent, Surrey and Sussex) 2 0 1 3 2
NHS England South West (South West North) 1 0 0 0 1
WALES 6 34 38 21 0
Cheshire & Merseyside 169 894 1,198 1,331 107
Isle of Man 7 16 92 98 2
NHS England London 2 11 0 0 0
NHS England Midlands and East (North Midlands) 69 91 473 805 59
NHS England Midlands and East (West Midlands) 2 129 4 0 0
NHS England North (Cumbria and North East) 1 4 4 2 0
NHS England North (Yorkshire and Humber) 2 1 1 8 7
NHS England South East (Hampshire, Isle of Wight
and Thames Valley) 2 0 4 5 0
NHS England South East (Kent, Surrey and Sussex) *0 0 0 1 0
NHS England South West (South West North) *0 42 17 2 0
WALES 84 600 603 410 39
Lancashire and South Cumbria 13 78 15 38 16
NHS England Midlands and East (North Midlands) 2 0 0 7 10
NHS England North (Cumbria and North East) 3 0 1 4 2
NHS England North (Yorkshire and Humber) 7 78 14 17 2
NHS England South East (Kent, Surrey and Sussex) 1 0 0 10 2
Grand Total 254 1,370 1,531 1,888 208 Table 4.3
*Babies admitted in previous year.
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4.4 Wales Activity within the NWNODN
Table 4.4.1 shows a summary of all care days across the network for patients registered to GP Practices within Welsh LHBs.
The table only includes units where Welsh activity took place over the period Apr 2020 – Mar 2021. The table also shows the Welsh care days as a percentage
of the total care days on NNU ward within the NWNODN by level of care. Commissioning within Wales continues to be based upon BAP2011.
Activity for Patients registered to GP Practices within Welsh LHBs
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4.7 Isle of Man Activity in NWNODN
Table 4.7.1 shows a summary of all care days across the network for patients registered to GP Practices within Isle of Man. The table only includes units where
Isle of Man activity took place over the period Apr 2020 – Mar 2021. The table also shows the Isle of Man care days as a percentage of the total care days on
NNU ward within the NWNODN by level of care.
Activity for Patients registered to GP Practices within Isle of Man
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5. Nursing & Medical Workforce
Nurse staffing calculations in previous ACD reports have been based the Clinical Reference Group (CRG) 2013/14
nursing workforce calculator (NWC), previously known as the Dinning Tool. Following a review by the national Lead
Nurse group a new calculator, which includes a more accurate calculate for uplifts, has been introduced. Therefore
for the 2020/21 report the new Neonatal Nursing Workforce Tool (2020) has been used. An additional summary of
medical staffing in NW units has also been added.
5.1 Nurse Staffing across the NWNODN
Table 5.1 shows the WTE agreed establishment (as budgeted), vacancies and additional requirements against the Neonatal Nursing Workforce Tool (2020). The 2020/21 staffing information was collected from each NNU and depicts the staffing numbers as of the 31st March 2021.
Chart 5.1 shows that there are currently 108 WTE vacancies across the NWNODN with a further 19 WTE nurses required to achieve BAPM compliance, as recommended by the CRG Nursing Workforce Tool.
119311311103
1023
12221150
0
200
400
600
800
1000
1200
1400
NWNODN 2019/20 NWNODN 2020/21
Summary of Nurse Staffing ODN Requirements
WTE Agreed Establishment(Budget). WTE In Post WTE Neonatal Nursing WF Tool(2020)
Chart 5.1
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The agreed establishment (budgeted WTE nurses) across the NWNODN is 62.3 WTE less than in 19/20. This is possibly a result of on-going work to reduce variance in data submissions. Further standardisation will continue when the new Network Workforce and Education Lead comes into post. The Neonatal Nursing Workforce Tool shows the number of nurses required to be BAPM compliant, based upon the activity for 2020/21 is 72 less than the previous year; however there were more vacancies at the end of March 2021, compared to the previous year.
5.2 Nurse Staffing by Locality
5.3 Nurse Staffing by Unit
551
356
223
1131
488
323212
1023
576
343230
1150
0
200
400
600
800
1000
1200
1400
Greater Manchester Cheshire & Merseyside Lancashire & SouthCumbria
NWNODN
Summary of Nurse Staffing ODN/Locality Requirements WTE Agreed Establishment(Budget). WTE In Post
WTE Neonatal Nursing WF Tool(2020)
28
209
47
97 94
27 25 2432
186
33
85 84
24 20 2339
227
41
91 97
30 22 28
0
50
100
150
200
250
MFT -NMGH
MFT - SMH MFT -WYTH
RBH ROH SHH TGH WWL
Summary of Nurse Staffing ODN RequirementsGreater Manchester
WTE Agreed Establishment(Budget). WTE In Post. WTE Neonatal Nursing WF Tool(2020)
Chart 5.2
Chart 5.3.1
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*Note - LNP - AHCH nurse staffing is for the Neonatal surgical unit only as in table 7.1a
Charts 5.1 to 5.3 highlight there is a shortfall in the number of nurses required to meet the BAPM2011 requirements. It is important to note that the number of WTE in agreed establishment in this report is for those providing direct patient / cot side care only. Therefore nurses in non-direct care roles, including Ward Managers, Clinical Educators and other quality/link roles described in DOH Toolkit (2010) are not included here. It should also be recognised that this is a snap shot in time and recruitment or attrition rates will cause fluctuations in these figures.
52
29 26
141
2719
30 3245
29 26
128
2520 24 26
51
19
32
129
3221
31 27
0
20
40
60
80
100
120
140
160
APH COC LNP - AHCH LNP - LWH MCTH ODGH STHK WWH
Summary of Nurse Staffing ODN RequirementsCheshire & Merseyside
WTE Agreed Establishment(Budget). WTE In Post. WTE Neonatal Nursing WF Tool(2020)
30
8171
14
2729
7771
1323
35
93
68
1221
0
20
40
60
80
100
BTH ELHT LTHTR MBHT - FGH MBHT - RLI
Summary of Nurse Staffing ODN RequirementsLancashire and South Cumbria
WTE Agreed Establishment(Budget). WTE In Post. WTE Neonatal Nursing WF Tool(2020)
Chart 5.3.2
Chart 5.3.3
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5.4 Additional Nurse Requirements
Chart 5.4.1 shows the number and percentage of additional nurses required to be BAPM compliant as calculated using the Neonatal Nursing Workforce Tool (2020), against the agreed establishment (budgeted nurses).
Chart 5.4.2 shows the number and percentage of additional nurses required to be BAPM compliant, as calculated using the Neonatal Nursing Workforce Tool (2020), plus current vacancies against the agreed establishment (budgeted nurses). Therefore across the region an additional 126 WTE nurses would need to be in post to meet the BAPM recommendation for Nurse Staffing.
25
-12
6
19
4.5
-3.5
2.9 1.7
-15
-10
-5
0
5
10
15
20
25
30
Greater Manchester Cheshire &Merseyside
Lancashire & SouthCumbria
NWNODN
Act
ual
No
. & %
of
Nu
rses
Summary of Nurse Staffing ODN Requirements
Neonatal Nursing WF Tool(2020) WTE against Agreed Establishment(Budget).
% of Agreed Establishment(Budget) to reach WTE Neonatal Nursing WF Tool(2020)
88
21 18
126
18.06.4 8.3 12.3
0
20
40
60
80
100
120
140
Greater Manchester Cheshire &Merseyside
Lancashire & SouthCumbria
NWNODN
Act
ual
No
. & %
of
Nu
rses
Summary of Nurse Staffing ODN Requirements
Overall Shortfall 2021.
% of In Post to reach WTE Neonatal Nursing WF Tool(2020)
Chart 5.4.1
Chart 5.4.2
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5.5 Medical staffing across the NWNODN
In March 2021 a self-reporting survey was carried out across all the LNUs and SCUs within the NW region. The
purpose of the survey was to re-assess compliance against BAPM standards across all NWNODN LNUs and SCUs.
Table 5.5 shows compliance against the Tier 1, Tier 2 and Tier 3 recommendations, as outlined in the BAPM Guidance:
Optimal arrangements for Local Neonatal Units and Special Care Units in the UK (2016), for all the LNUs and SCUs
within the NWNODN. It is recognised that the lack of compliance at Tier 1 and Tier 2 is a problem across the country
and the ODNs will be working with units as part of the NCCR to support improvements in the provision of medical
staffing.
Unit Designation Tier 1
compliant? Tier 2
compliant? Tier 3
compliant?
CM
Chester LNU No No Yes
Leighton LNU No No Yes
Macclesfield* LNU N/A N/A N/A
Ormskirk LNU No No Yes
Warrington LNU No No Yes
Whiston LNU No Yes Yes
LSC
Blackpool LNU No No Yes
Lancaster LNU No No Yes
Furness SCU Yes No Yes
GM
North Manchester
LNU Yes Yes Yes
Stockport LNU No No Partial
Tameside LNU No No Yes
Wigan LNU No Yes Yes
Wythenshawe LNU Yes No Partial Table 5.5.1
*Macclesfield was not open throughout this period (2020/21)
A summary of the findings, including the standards for each Tier, is presented in a report (See Appendix 2).
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6. Greater Manchester Activity
6.1 GM Activity by Level of Care
Table 6.1 shows the total care level days by unit and across the GM locality. XA04Z care if delivered in TC is not included.
HRG 2016 XA01Z XA02Z XA03Z + XA04z + XA05Z Total
Unit Name 18/19 19/20 20/21 18/19 19/20 20/21 18/19 19/20 20/21 18/19 19/20 20/21
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6.3 GM Surgical Activity
Table 6.3 shows the surgical activity in St Mary’s Hospital for the period 2020/21 and trend data from previous
years. Surgical care days are included in the activity tables 6.1 for Greater Manchester. The data for table 6.3 is collected locally. For the purpose of this report a surgical cot day is defined as ‘any patient
with a surgical diagnosis which requires input from the surgical team and for whom a Consultants Surgeon is
named alongside the neonatologist’.
The surgical cots shown in the table are cot demand based on the total surgical days using the following
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6.5 GM Cot Activity
Table 6.5 shows the demand (D) for cots based upon activity within each of the providers against actual (A) cots. Care Levels are based upon HRG 2016
codes but are referred to as IC, HD & SC cots as these are the commissioned cots in each category. Surgical care included in the figures as it is not possible
to identify surgical activity within the data.
Calculation method which include 80% capacity: Cot Demand = (Number of care days/365)/0.8
Total 34 36 32 45 52 52 51 50 128 121 118 131 214 209 201 226 Key: Short by 1 or more cot = Red, over by 1 or more cot = Yellow Table 6.5
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6.6 Greater Manchester Summary
Dr Ajit Mahaveer, Clinical Lead for GM & Karen Mainwaring, Lead Nurse for GM
Summary:
• Admission rates have steadily decreased for the last 4 years mirroring our other two localities in the region. This is a combination of reduction in term admissions and late preterm admissions around 200 babies. There has also been in declining birth rate in the region.
• Term admission remains still high within the locality and above 6%.
• There has been left shift to the LOS in many hospitals with ROH decreasing LOS from 22 to 11%
• There is sustained work around delivering preterm babies at the right place and remains around 90% in GM
• All 3 NICU currently meet national standards of NICU activity. It is also noted there has been a decrease in intensive care (HRGXA01Z) activity at Royal Oldham hospital and Royal Bolton Hospital with a downward trend of VLBW admissions.
• St Mary’s Hospital continues to provide neonatal surgical care for GM and the cot numbers has decreased.
• There has been a marked decrease in postnatal inappropriate transfers within GM from 18 to 4
• Medical workforce survey has shown a significant variation and workforce gap within the locality and does not meet BAPM workforce standards.
• The Nurse staffing budgeted establishments in Greater Manchester neonatal units did not meet BAPM Standards for activity with the gap increasing with 63 WTE vacancies noted at the time of reporting
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7. Cheshire & Merseyside
7.1 CM Activity by level of care
Table 7.1 shows the total care level days by unit and across the CM locality. XA04Z care if delivered in TC is not included.
HRG 2016 XA01Z XA02Z XA03Z + XA04Z + XA05Z Total
Unit Name 18/19 19/20 20/21 18/19 19/20 20/21 18/19 19/20 20/21 18/19 19/20 20/21
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7.3 CM Surgical Activity
Table 7.3.1 shows the neonatal surgical activity (care days) at Alder Hey for the period 2010/21, which took place both on the Neonatal Unit and other surgical care
wards. Only data from the NNU is recorded on the neonatal Badgernet system so additional data for PICU, HDU and other wards has been provided by the LNP - AHCH
Grand Total 455 478 398 437 371 436 467 344 335 377 457 421 4,983 Table 7.3.1
Table 7.3.2 shows the demand (D) for cots based upon activity at Alder Hey as reported in Table 7.3.1(IC Proxy for non NNU care days factored in).
Surgical Activity at Alder Hey 2017/18
Care Days 2017/18
Cot Demand 2018/19
Care Days 2018/19
Cot Demand 2019/20
Care Days 2019/20
Cot Demand 2020/21
Care Days 2020/21
Cot Demand
HDU & Special Care (Both within & outside NNU) 4,029 13.8 4,128 14.1 4,298 14.7 3,903 13.4
IC Care (NNU IC + IC Proxy for care outside of NNU) 631 2.2 635 2.2 1,098 3.7 1,073 3.7
Total Care Days (Both within & outside NNU) 4,660 16 4,763 16.3 5,396 18.4 4983 17.1
Calculation method which include 80% capacity: Cot Demand = (Number of care days/365)/0.8 Table 7.3.2
As it is not possible to derive full care levels for the non NNU activity a proxy of invasive ventilation has been used as an indicator for some intensive care activity,
therefore care days are included for babies who meet the following criteria:
• All babies (excluding cardiac) <60 weeks Post Conceptual Age at admission.
• Only babies where source of referral is a recognised neonatal unit With the proxy for Intensive care being babies which were receiving IC where we used ventilator support:
1. Days: Invasive ventilation via endotracheal tube 2. Days: Invasive ventilation via tracheostomy tube
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3. Advanced ventilation support (Jet or Oscillatory ventilation)
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7.4 CM Activity and workload
7.4.1 CM NICU activity and workload data
In-line with the recommendations included as part of the Neonatal Critical Care Transformation Review
(2019) all NICUs should, as a minimum, look after at least 100 very low birth weight (VLBW) infants per year
and be delivering >2000 intensive care days (Health Resource Group definition, 2016 & BAPM Optimal
Arrangements for Neonatal Intensive Care Units in the UK, 2021).
Table 7.4.1 shows all NICU activity, regardless of episode number, but excludes surgical care at Alder Hey.
Table 7.4.1
7.4.2 CM LNU & SCU Unit Activity and Workload Data
In-line with the recommendations included as part of the Neonatal Critical Care Transformation Review
(2019) all LNUs should aim to undertake a minimum of 500 days of combined intensive and high dependency
care, which is the minimum requirement to maintain expertise. LNUs providing ongoing HD should be
working towards delivering 1000 combined ITU/HD days per year, in the longer term (i.e. 5 years from
publication of NCCR in 2019). Units designated as LNUs should also admit >25 infants annually (BAPM Optimal
arrangements for Local Neonatal Units and Special Care Units in the UK, 2016).
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7.5 Cot Activity
Table 7.5 shows the demand (D) for cots based upon activity within each of the providers against actual (A) cots. Care Levels are based upon HRG 2016 codes but are
referred to as IC, HD & SC cots as these are the commissioned cots in each category
Calculation method which include 80% capacity: Cot Demand = (Number of care days/365)/0.8 as it is a leap year
Total 21 20 18 26 27 27 26 42 81 71 71 88 129 118 115 156 Key: Short by 1 or more cot = Red, over by 1 or more cot = Yellow Table 7.5
See Appendix 1 for Cot activity against BAPM 2011 categories of care
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7.6 Cheshire & Merseyside – Summary
Dr Nim Subhedar, Clinical Lead for CM & Kelly Harvey, Lead Nurse for CM
Summary
• Sustained trend in decreasing births, admissions (including out of area) and activity across
network units
• Excess capacity, low occupancy in majority of units (except LNP-AHCH)
• Decreasing admissions/activity at APH (now well below BAPM activity threshold)
• LNUs (except Chester) meet current BAPM activity thresholds
• Significant proportion of babies <27week GA babies still being born in non-NICU units
(17%)
• Nursing/medical workforce shows a diminishing nursing shortfall but widespread non-
compliance with BAPM medical workforce standards
• A sustained reduction in term admission over the last 3 years • 27% of term admissions have a length of stay < 24h (range between units of 20-41 %) • Reduction in out-of-ODN postnatal transfers into C&M by 25%
CM specific recommendation
• Re-distribution of cot designation at STHK and LNP-AHCH. Changes to IC/HD/SC configuration only and not total cot numbers.
(Addditional recommendations are incorporated within the joint Key Recommendations shown
on page 7)
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8. Lancashire & South Cumbria Activity & Workload
8.1 LSC Activity by Level of Care
Table 8.1 and 8.1a show the total care level days by unit and across the LSC locality. XA04Z care if delivered in TC is not included.
HRG 2016 XA01Z XA02Z XA03Z + XA04Z + XA05Z Total
Unit Name 18/19 19/20 20/21 18/19 19/20 20/21 18/19 19/20 20/21 18/19 19/20 20/21
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8.4 LSC Cot Activity
Table 8.4 shows the demand (D) for cots based upon activity within each of the providers against actual (A) cots. Care Levels are based upon HRG 2016 codes.
Calculation method which include 80% capacity: Cot Demand = (Number of care days/365)/0.8 as it is a leap year
Lancashire & South Cumbria Cots D: Demand , A: Actual
02T NHS CALDERDALE CCG 03M NHS SCARBOROUGH AND RYEDALE CCG
02W NHS BRADFORD CITY CCG 03N NHS SHEFFIELD CCG
02X NHS DONCASTER CCG 03Q NHS VALE OF YORK CCG
02Y NHS EAST RIDING OF YORKSHIRE CCG 03R NHS WAKEFIELD CCG
03A NHS GREATER HUDDERSFIELD CCG 13Q NATIONAL COMMISSIONING HUB 1
03E NHS HARROGATE AND RURAL DISTRICT CCG 15F NHS LEEDS CCG
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Appendix 2: Medical Staffing Review in LNUs and SCUs
A Review of Medical and ANNP Workforce in LNUs and SCUs in the NWNODN (March 2021)
Dr. Nim Subhedar, Neonatologist, Clinical Lead, Cheshire & Merseyside
Background
A skilled medical and nursing workforce is essential for delivery of high-quality neonatal care. Standards
relating to medical staffing were originally published in 2009 and recent recommendations were made
specifically for LNU/SCU staffing in 20181. A survey of workforce in September 2019 revealed a large
proportion of shifts below rostered level at tier-1 and tier-2 and significant reliance on locum cover2. Non-
compliance with national standards was high with fewer than half of LNUs/SCUs meeting out-of-hours
staffing recommendations. However, there is little robust local network-level data. A C&M medical/ANNP
workforce review in October 2016 showed the majority of local neonatal units in C&M were non-compliant
with national standards at tier-1 and 2 levels. Similarly, a more recent NWNODN GIRFT report showed that
fewer than 10% of network units were BAPM-compliant and that the North-West was one the most poorly
ranked networks for medical workforce3.
Aim
The purpose of this review was to re-assess compliance against BAPM standards across all NWNODN LNUs
and SCUs.
Methodology
A link to an online survey (Survey Monkey) was sent to all local neonatal unit clinical leads in March 2021
(appendix 1) with a request to complete a snapshot survey of medical/ANNP workforce in their unit. The
findings were collected and collated by the NWODN team. Compliance was assessed against the BAPM
2018 LNU/SCU standards (summarised in appendix 2).
1 Toolkit for High Quality Neonatal Services (DH, 2009); A Framework for Practice: Optimal arrangements for LNUs and SCUs in the UK including guidance on staffing (BAPM, 2018). 2 A Snapshot of Neonatal Services and Workforce in the UK (RCPCH, 2020). 3 Getting it Right First Time (NWNODN report, 2020).
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Key findings4
Unit Designation Tier 1
compliant? Tier 2
compliant? Tier 3
compliant?
Chester LNU No No Yes
Leighton LNU No No Yes
Macclesfield* LNU N/A N/A N/A
Ormskirk LNU No No Yes
Warrington LNU No No Yes
Whiston LNU No Yes Yes
Blackpool LNU No No Yes
Lancaster LNU No No Yes
Furness SCU Yes No Yes
North Manchester
LNU Yes Yes Yes
Stockport LNU No No Partial **
Tameside LNU No No Yes
Wigan LNU No Yes Yes
Wythenshawe LNU Yes No Partial***
* Macclesfield was not open throughout this period (2020/21)
** Not all consultants on-call have daytime neonatal unit commitments
***24/7 separate consultant rota, but 1:5 on call frequency
Comments
1. Only three units declared full compliance with tier-1 staffing with 24/7 dedicated availability to the
neonatal service, although many other units were partially-compliant in that dedicated tier-1 staff
were available on weekdays/daytime, but not out-of-hours.
2. Four units declared full compliance against tier-2 standards and the rest were partially-compliant
with dedicated tier-2 staff being available at least for weekday/daytime duties.
3. Two units (Wythenshawe and NMGH) were able to deliver a totally separate neonatal tier-3 rota.
Units typically each had one or two consultants who declared a special interest in neonatal
medicine; one unit had five such consultants (Wythenshawe).
4. All units had NIPE-trained midwives contributing to newborn examinations.
Summary
In this self-reported survey, there was generally poor compliance among NWNODN LNUs with current
BAPM medical/ANNP workforce standards, particularly at tier-1 and tier-2 levels.
Only one unit declared full compliance against all tier-1, 2 and 3 standards.
4 Two units (Macclesfield and Furness) are designated SCUs; all others are LNUs. Activity in all LNUs was below 1000 respiratory care days and <400 IC days in 2020/21.
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Units were least compliant against tier-1 standards where immediate availability of dedicated staff is
required 24 hours a day. This was presumed to be the consequence of out-of-hours cross-cover
arrangements with the paediatric service.
The questionnaire also asked for information about ongoing work towards achieving compliance. Several
units reported initiatives including recruitment of ANNPs and overseas doctors through MTIs to support
tier-1 and tier-2 neonatal rotas as well as APNPs to support the paediatric service, releasing shared staff for
neonatal duties. Some units had bids/plans in place to augment their consultant workforce and increase
tier-3 availability.
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Tier-1 1. Do you have immediately available at least one resident Tier 1 practitioner (ANNP/ Doctor) dedicated to providing emergency care for the neonatal service at all times, day/night? 2. If the answer to Q1 is no, how many hours a week is there a Tier 1 practitioner dedicated solely to covering the neonatal unit?' 3. Do you have midwives trained in delivering NIPE assessment? If not, is this the sole responsibility of the tier 1 doctor or ANNP? Tier-2 4. Do you have an immediately available resident Tier 2 practitioner (ANNP/ SPR-grade doctor) dedicated solely to the neonatal service, 24/7? 5. Do you have an immediately available resident Tier 2 practitioner (ANNP/ SPR-grade doctor) dedicated solely to the neonatal service in the daytime (between approx. 09.00-22.00), 7 days a week? 6. If the answer to Q5 is no, how many hours a week is there a Tier 2 practitioner solely dedicated to covering the neonatal unit? Tier-3 7. Do you have a separate, Tier-3 consultant rota dedicated solely to the neonatal unit 24/7? 8. If the answer to Q7 is no, how many hours a week is there a consultant solely dedicated to covering the neonatal unit?' 9. Day time Tier-3 rota: a. How many consultants contribute to Tier-3 cover (total number)? b. How many of these consultants have a declared special interest in neonatology? 10. Night-time tier-3 rota: a. What is the frequency of the (neonatal cover) Tier-3 on-call rota? b. How many consultants contribute to Tier-3 cover (total number)? c. How many of these consultants have a declared special interest in neonatology? d. Do all consultants covering the neonatal at night also have daytime commitments to the neonatal unit?
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Appendix B
BAPM Standards (2018) - Optimal Arrangements for LNUs and SCUs
Tier 1 LNU SCU
Standard 1 Immediately available at least one resident Tier 1 practitioner dedicated to providing emergency care for the neonatal service 24/7.
SCUs should provide a resident Tier 1 practitioner dedicated to the neonatal service in day-time hours on weekdays and a continuously immediately available resident Tier 1 practitioner to the unit 24/7. This person could be shared with a co-located Paediatric Unit out of hours if this does not reduce quality of care delivery and safety to the neonatal unit assessed using national standards
Standard 2 Provision of newborn infant physical examination should not be the sole responsibility of this individual and midwives should be trained to deliver this aspect of care.
SCUs delivering higher than recommended activity levels should provide a dedicated Tier 1 practitioner as required for LNUs
Standard 3 In large LNUs (>7000 births) there should be two dedicated Tier 1 practitioners 24/7 to support emergency care.
In stand-alone SCUs without co-located paediatric services this resident Tier 1 practitioner would be dedicated to the neonatal service alone
Tier 2 LNU SCU
Standard 1 LNUs should provide an immediately available resident Tier 2 practitioner dedicated solely to the neonatal service at least during the periods which are usually the busiest in a co-located Paediatric Unit e.g. between 09.00-22.00, seven days a week .
SCUs should provide a resident Tier 2 to support the Tier 1 in SCUs admitting babies requiring respiratory support or of very low admission weight <1.5kg. This Tier 2 would be expected to provide cover for co-located paediatric services but be immediately available to the neonatal unit.
Standard 2 LNUs undertaking either >1500 RCDs or >600 IC days annually should have immediately available a dedicated resident Tier 2 practitioner separate from paediatrics 24/7.
SCUs delivering higher than recommended activity levels should provide a Tier 2 practitioner as required for similar activity levels in LNUs.
Tier 2 LNU SCU
Standard 3 LNUs undertaking either >1000 RCDs or >400 IC days annually should strongly consider providing a 24/7 resident Tier 2 dedicated to the neonatal unit and entirely separate from paediatrics; a risk analysis should be performed to demonstrate the safety, timeliness and quality of care delivery to both paediatrics, delivery suite, maternity unit and neonatal services if the Tier 2
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is shared at any point 24/7 in these units. Considerations should include the level of activity of any Paediatric Unit including peak activity times and the geography of the site including the location of A&E and the Paediatric wards.
Standard 4 The Tier 2 should be immediately available at all times to the neonatal unit and the labour ward. If the site of the paediatric unit makes this immediate response impossible separate Tier 2 rotas are required.
Tier 3 LNU SCU
Standard 1 Units designated as LNUs providing either >2000 RCDs or >750 IC days annually should provide a separate Tier 3 consultant rota for the neonatal unit.
In SCUs there should be a Lead Consultant for the neonatal service and all consultants should undertake a minimum of continuing professional development (equivalent to a minimum of eight hours CPD in neonatology).
Standard 2 LNUs providing >1500 RCDs or >600 IC days annually should strongly consider providing a dedicated Tier 3 rota to the neonatal unit entirely separate from the paediatric department; a risk analysis should be performed to demonstrate the safety & quality of care if the Tier 3 is shared with paediatrics at any point in the 24 hours in these LNUs.
Standard 3 All LNUs should ensure that all Consultants on-call for the unit also have regular weekday commitments to the neonatal service. This is best delivered by a ‘consultant of the week’ system and no consultant should undertake <4 ‘consultant of the week’ service weeks annually.
Standard 4 No on-call rota should be more onerous than one in six and all new appointments to units with separate rotas should either have a SCCT in neonatal medicine or be a general paediatrician with a special interest in neonatology or have equivalent neonatal experience and training.
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