Managed clinical networks in neonatal care

A large body of evidence supports the concept of regionalising neonatal intensive care. Both mortality and serious morbidity are significantly reduced for high risk infants who are born in hospitals that have a high volume of cases, tertiary level obstetric services, and neonatal intensive care units (NICUs).1 2 Although these benefits are most pronounced for the highest risk infants, such as those with extreme prematurity or major congenital anomalies, evidence suggests that benefits extend to all at risk deliveries and possibly to low risk ones as well.3 It is also much better to move women with high risk deliveries to these high volume tertiary centres than to move critically ill neonates after delivery.4 5

In a linked paper (doi:10.1136/bmj.e2105), Gale and colleagues study the effects of the reorganisation of neonatal services in England that occurred as a result of this evidence.6 In 2003, neonatal services in England were formed into managed clinical networks. The changes improved access to NICUs and put specific emphasis on transferring women at high risk of preterm labour to a specialist centre before delivery, so reducing the number of babies who needed acute postnatal transfer. Gale and colleagues use data from before and after the reorganisation to examine the effects of the changes in care on infants with a gestational age of 27-28 weeks. They report an increase in the proportion of 27-28 week deliveries that occurred in designated tertiary hospitals after 2003—from 18% to 49%—but note that there is still a long way to go to achieve full regionalisation of care for high risk newborns.

One factor that may have contributed to the limited success of this reorganisation is that it affected only NICUs. Because successful regionalisation requires that all high risk deliveries are moved to the designated tertiary hospitals, full participation of obstetric providers is also essential. High risk cases need to be identified early enough for mothers to be safely moved to the designated tertiary hospitals for delivery so the reorganisation needs to be expanded to include obstetric services.

It is possible to achieve much higher levels of regionalisation of obstetric services; studies of services in Portugal, Finland, and the Cincinnati metropolitan area have reported that 90-95% of very preterm (<32 weeks) or very low birthweight (<1500 g) infants are delivered in designated tertiary hospitals.7 8 9 The Portuguese experience shows the potential of improved regionalisation. In 1990 the Portuguese health service closed all small delivery services and small NICUs and put in place an effective system of regionalisation, which resulted in more than 90% of all deliveries of very low birthweight infants taking place in designated tertiary hospitals.8 Neonatal mortality in Portugal decreased from one of the worst in Europe to well above the median. England is a geographically compact country without serious barriers to travel. There is therefore no reason why England cannot match the 90% plus levels of regionalisation that have been achieved in other regions.

In addition to the challenge of putting systems in place to shift all high risk deliveries to designated tertiary hospitals, England faces a second challenge that will require political support. Even if almost all high risk deliveries were shifted appropriately, England probably has too many NICUs. Gale and colleagues also examined data on NICU size and found that almost none of the NICUs studied reached the patient volumes that have been associated with the best outcomes. The most recent data show clear gains in reduced mortality up to a volume of at least 100 deliveries of very low birthweight infants a year.10 Although improved regionalisation would increase the patient volumes in some English NICUs, many would still be below 100 deliveries of very low birthweight infants. The policy implication is clear—smaller high risk obstetric services and NICUs should be consolidated with geographically proximate services to create a smaller number of larger tertiary centres.

Such changes will be difficult to implement politically. Capital investments will probably be needed to expand some existing units, successful merging of staff from different units will be a challenge, and the closure of hospital services may meet resistance. Political opposition recently forced Germany, which is even more deregionalised than England, to abandon a policy to force the closure of small NICUs. Full regionalisation of neonatal care is the correct thing to do, however. Portugal faced similar political opposition to the closure of NICUs and delivery services in 1990, but policy makers stood firm and the country has reaped the benefits.

England has made a good start on improving the regionalisation of neonatal care, but it has a long way to go before neonatal care can deliver the best possible outcomes for all high risk deliveries.