19.  Providing care for the most vulnerable members of society can be extremely pressurised and emotionally demanding. Compounding these pressures are capacity and staffing problems, which can lead to some neonatal units regularly exceeding 100% cot occupancy and high numbers of closures to new admissions; on average, one closure per week.[33]

20.  Care in neonatal units is underpinned by guidelines from the British Association of Perinatal Medicine (BAPM), the professional body providing clinical leadership. BAPM has recommended that the nurse to baby ratio for babies requiring intensive care is one-to-one. Only 24% of neonatal units stated that they met this ratio. Of these, only four level 3 units, the type which provide the most intensive care, stated they met the standard.[34] The Department neither endorses independent staffing guidelines such as BAPM, nor sets its own minimum standards as it considers that staffing requirements are best determined locally, based on clinical needs.[35] An example of this is the West Midlands, which covers three networks. These networks undertook a joint review and increased funding in order to employ five advanced neonatal nurse practitioners across their level 3 units.[36]

21.  Notwithstanding the limited ability of neonatal units to provide one-to-one nursing, each unit had, on average, three vacancies against their current establishment for nurses qualified in neonatal care. The number of vacancies increased as the intensity of care provided by the units increased (Figure 3).[37] In total there were 459 nursing vacancies against current establishment in England in 2007.[38] Even if the current establishment was at full strength, previous research has shown that the shortfall in meeting the BAPM nursing guidelines was 2,285 nurses across the UK in 2006.[39]

LEVEL OF UNIT	AVERAGE QUALIFIED NURSE VACANCIES
1	1.3
2	1.8
3	4.7
3 PLUS SURGERY	8.3
AVERAGE ACROSS TOTAL	2.9

22.  Recruiting neonatal staff has always been a challenge but this is compounded by the lack of reliable data on how many neonatal nurses are currently practising. The Department now intends to maintain data on neonatal nurses nationally through the new electronic staff record.[40] The Department is also responding to the increased birthrate by asking health organisations to look in detail at both their maternity and neonatal staffing and develop plans to increase staff numbers.[41] The aim is to address nursing shortages, including the problem of the ageing workforce, in a concerted way across the whole of the NHS.[42]

23.  There are challenges in ensuring nurses are properly trained and that their skills are up to date as neonatal nursing is a post registration specialty, requiring a specialist training course. There are, however, insufficient specialist post-registration training programmes and staff can find it difficult to find time to attend training, a problem exacerbated by existing staff shortages.[43] On the job training, for example competency based training, and developing relationships between NHS trusts and local universities, are crucial to delivering training in flexible ways.[44]

24.  The implementation of the European Working Time Directive will impact on neonatal services. There is currently an interim 56-hour maximum working week, with a final deadline of August 2009 for implementation of the 48-hour working week.[45] The Department accepts that, whilst this Directive will impact most on medical staff, there will be a knock-on effect for nursing staff, particularly in areas like neonatal services where they work so closely together. To mitigate this risk, the Department has asked all Primary Care Trusts to examine the likely effects of the European Working Time Directive on their neonatal unit staffing^.[46]