Skimping on care of the newborn is false economy
Despite at least five national reports in the past 15 years urging improved care for the newborn,’ the government has not provided the necessary resources. Much has been achieved locally, but British neonatal care remains inadequate,6 unstructured, understaffed, and under-equipped. These failures have been exacerbated by the success of neonatal intensive care: in the best centres 80% of babies born at 28 weeks’ gestation survive, as do half of those born at 26 weeks. But achieving such results makes heavy demands on resources, and some of the best centres are particularly hard pressed because of the consequences of the Resource Allocation Working Party formula.
In 1971 the Sheldon Committee recommended that there should be one neonatal intensive care cot for every 2000 annual births and three nurses for each cot.’ By 1980 this requirement had still not been met. Meanwhile, the Sheldon recommendations had become outdated, and in 1981 the British Paediatric Association and the Royal College of Obstetricians and Gynaecologists emphasised the need for one intensive care cot for every 1000 births and four nurses for each cot.7 In 1984 the House of Commons Social Services Committee identified the inadequacies in neonatal intensive care and the shortage of nurses as the most urgent priority in neonatal care. The National Birthday Trust Fund found in 1984 that there were 641 designated neonatal intensive care cots in the United Kingdom8-88 fewer than the number suggested by the British Paediatric Association and the Royal College of Obstetricians and Gynaecologists. In fact, only 473 of these cots were equipped and staffed for intensive care, resulting in a 35% underprovision.
The chronic shortage of nurses results partly from the continued use of the outdated Sheldon formula and partly from lack of funds and is further exacerbated by increasing difficulty in recruitment. Inadequate pay is one reason for recruitment difficulties, but another is the stress caused by staff shortages: a vicious circle has been established - overwork, stress, resignation, and more work for the remaining staff.
Paediatricians have been doing their best to persuade management of the need for more resources for some years,9-"’ but the task is not easy in the present climate. To support their case the British Paediatric Association and British Association for Perinatal Paediatrics recently published categories of newborn care.’2 Three categories have been defined: routine, special, and intensive. Each is described in detail with guidelines on how each infant should be graded. Units have been recommended to audit their workload daily or twice daily (to include the night shift).
Workload can thus be related to available staffing and facilities. Early experience with the audit in Bristol has already shown that the recommendations of one intensive care cot for every 1000 births may be too low; the true requirement seems to be 1-4 cots.
Managers do not seem to accept that inadequate provision of neonatal intensive care is false economy. Neonatal intensive care is cheaper than is popularly thought"’ and is only a small fraction of the cost of the lifelong care of individuals with avoidable handicaps." Further, expert neonatal intensive care seems to reduce not only mortality but also long term morbidity.
The Maternity Services Advisory Committee Report recognised the present deficiences in newborn care but then went on to ask regions to plan improvements over the next 10 years.’ A junior health minister called this a major step forward, but the Spastics Society called it a 10 year set back.’ Paediatricians think that at most there should be two years for planning and three for implementation." For too long procrastination has been the order of the day.
BRIAN D SPEIDEL
Section: General, Medicines, Pharmacy and Therapeutics
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