9.  The year on year increases in birth rates since 2001 and improvements in survival rates have placed increasing pressure on the capacity of neonatal services and in some instances led to babies being transferred long distances to receive appropriate care. A 2003 review of neonatal intensive care services commissioned by the Department found that neonatal care was provided in a widely dispersed manner with limited capacity in the larger units providing care for the most ill babies. There was also a lack of national data on outcomes, major challenges in nursing recruitment and a need for agreed national standards of care. The report proposed the re-organisation of neonatal services into managed clinical networks so that units in each network would provide virtually all the care required by mothers and babies without the need for long distance transfers.[18]

10.  Most of the 180 neonatal units organised themselves into 23 formal geographical networks (Figure 2). The Department consider that the concept of a network is a fluid one and should reflect local needs and circumstances and it is important therefore that local organisations determine the structure, role, responsibilities and budgetary arrangements for their network. As a result, the pace of implementation has varied widely. A typical network comprises a group of neonatal units linked by a supervisory management structure. It includes a designated lead clinician and a funded manager, with at least one unit capable of providing the whole range of neonatal care, including the highest level, intensive care, and the remainder providing special and high dependency care.[19]

11.  In April 2003, alongside publishing the report on the review of neonatal services, the Department announced that it was allocating an additional £72 million over three years to Strategic Health Authorities to support the establishment of neonatal networks. It is not clear, however, whether this money was spent as intended. The Department agrees that it is not been easy to pin point how this money was used due to the 2006 re-organisation of Strategic Health Authorities and Primary Care Trusts[20] but that around an extra £150 million has been spent on neonatal care.[21]

12.  Not all units have the skills and expertise to provide ongoing intensive or high dependency care although they should be able to stabilise a baby prior to transfer to a more suitable unit. Networks have largely achieved the objective set by the 2003 Review of treating the majority of babies within a network, but the remainder of the Review's objectives have only been partly achieved. As a result, networks have yet to realise their full potential in the provision of effective neonatal care.[22]

13.  Two networks, Essex and the Northern network, have yet to establish a formal network. The Northern network is not structured as a formal network, although it has been delivering care in a co-ordinated fashion since 1983. The Essex network has no manager and is not functioning as a network due to a lack of agreement as to which unit should provide intensive care and take the lead role in the network. The Department is committed to establishing formal networks across all of England.[23]

14.  One area of the Review which has not yet been achieved is the key process of re-designating units.[24] Three-quarters of networks have reviewed the designations of all or most of their units, but re-designation has not been implemented in full, largely due to vigorous debate about which units should take which roles. Without meaningful re-designation processes, networks may find it difficult to provide appropriate capacity to meet demand safely.[25]

15.  A further complication is the blurring of some designations. Twelve units across nine networks described their designation as '2 plus', meaning they are officially designated as level 2 units but often provide intensive care (level 3). Where this is being done, it is in most cases a pragmatic way of maintaining skills and capacity across networks.[26] It is important to maintain clinical excellence across all levels of the service and the Department does not envisage a significant rise in level 3 units at the expense of level 2 units but intends to examine the relationships between level 2 plus and level 3 units^.[27]

16.  One of the key objectives set by the 2003 Review was the establishment of specialist transport services. The Department has, however, made limited progress in achieving this and performance is variable across England. Currently, around half of the 23 networks can provide a service on a 24 hour, seven days a week basis, and a further three have access to such a service. Three of the other eight networks are not meeting the objective, although a further five networks are planning to introduce this service shortly.[28] The Department is committed to improving transport services through its new Task Force.[29]

17.  The Department established a National Cot Locator in order to ensure that cots were allocated to babies on an efficient basis, but, only 20 out of 23 networks actually use this facility. In addition, networks have made progress in reducing the number of babies needing to transfer across the country, meaning that there is less of a need for a centralised service. The Department is now planning to review the use of the National Cot Locator.[30]

18.  Five years after the introduction of neonatal networks, some of the problems identified in 2003 have yet to be fully addressed.[31] The Department explained that this was because changing any kind of clinical service is complex and can take a number of years. The Department believes that neonatal networks have saved lives but acknowledged that there is more to do. It intends that its new Task Force will assist the NHS in addressing all of the problems still facing the neonatal service.[32]