Article Text

Download PDFPDF
Workload and costs associated with providing a neonatal surgery service
  1. David M Burge1,
  2. Melanie Drewett2
  1. 1Paediatric Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  2. 2Department of Neonatal Medicine and Surgery, Princess Anne Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  1. Correspondence to David M Burge, Department of Paediatric Surgery, G level, East Wing, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK; david.burge{at}uhs.nhs.uk

Abstract

Aim To identify the workload related to provision of a neonatal surgical service in a UK neonatal network in order to inform local and national service commissioning.

Method Data relating to neonatal surgical admissions to a level 3 perinatal centre serving a network with 36 000 births per year collected prospectively over a 5-year period were analysed to identify annual activity. Daily dependency was assessed prospectively over a 6-month period and service costs calculated using existing local tariffs. Admissions from outside the network were excluded from analysis, and allowance was made for refused network admissions.

Results On average 140 admissions required 2137 cot-days per year. At 80% occupancy, the service requires seven neonatal cots suggesting that there is a national requirement for one neonatal surgical cot per 5000 births. Intensive care, high care (HC) and special care accounted for 37%, 46% and 17% of cot-days, respectively. This equates to an annual service cost of £2m, about £250 000 per 5000 births.

Conclusions This assessment of the facilities and costs required to provide a neonatal surgical service in a level 3 perinatal centre in the UK may be used to inform network and national commissioning.

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

Neonatal surgery (NS) is a regional service being a subspeciality of paediatric surgery. In the UK care is provided in a variety of settings.1 There are few if any publications reporting the activity performed by a unit undertaking NS. Such activity is important to contracting arrangements and commissioning of specialist services. Current recommendations are that NS should be commissioned separately from neonatal medicine2 3 to ensure that all commissioned activity remains in the neonatal network. Nationally nearly 20% of activity has to be transferred out of network.4 Wherever neonatal services are commissioned through block contracts, commissioners not only pay for the local service, but when this service is unable to admit, will also pay another network for the care of the baby. In effect, commissioners may pay twice for such patients. In addition, there are huge implications for infants and their families in having to travel to another network centre to visit their babies.

Analysing NS activity is made complicated in many centres because such activity may spread across various inpatient settings. Almost no two services are configured the same in the UK. Variations include combined NS and neonatal medicine units, stand-alone NS units, children's hospitals with NS wards but no neonatal unit and NS cots on paediatric intensive care (IC) units. Many centres rely on a combination of the above.1 This complicates the task of accurately commissioning NS services.

What is already known on this topic

  • About one in five surgical neonates require transfer out of network because of lack of surgical cots

  • The Neonatal Toolkit advises that surgical services be commissioned separately from neonatal medicine

  • There are no published data on the workload and costs of providing an NS service to inform commissioning

What this study adds

  • Provision of NS services in a level 3 perinatal centre will require one surgical cot per 5000 live births

  • Dependency calculations suggest that the annual cost per cot will be about £250 000

This study reports the activity in a single NS regional service recorded prospectively over a 5-year period and attempts to estimate likely costs for commissioners based on daily dependency data collected prospectively over a 6-month period. The service analysed conforms to the model recommended by the Neonatal Taskforce 2009.3

Methods

The study was in two parts. First, data were analysed from a prospective database maintained by the NS service at University Hospital Southampton NHS Foundation Trust over 5 years, January 2006 to December 2010. This is the surgical centre serving Central South Coast (South) neonatal network. In order to define the workload inherent in the local neonatal network population (36 000 births per annum), babies admitted from centres outside the network were excluded. Patients known to have been transferred out of network were included by assuming average activity for each according to diagnosis.

The NS service in our centre is provided in two main clinical areas, the neonatal unit and the paediatric IC unit. Most admissions, and all preterm babies, are primarily admitted to the neonatal unit. For the benefit of this analysis it is assumed that all admissions would be to the neonatal unit.

The case-mix of the service is similar to other NS services in the UK comprising in main gastrointestinal surgery, thoracic surgery and urology. Other surgical specialities (cardiac, neurosurgery, ophthalmic, Ear, Nose and Throat surgery (ENT), orthopaedic and plastic surgery) were not included. All activities requiring the input of the NS service have been included. This incorporates cot-days for preterm infants who were medical patients on the neonatal unit before or after their need for surgical input or both for the duration of surgical team involvement. Babies were deemed to have finished their episode of surgical care when the NS service input was no longer required, even if the baby remained on the neonatal unit. In our centre, infants with acquired conditions such as pyloric stenosis, inguinal hernia and soft tissue abscesses are not included in the neonatal surgical workload.

In the second part of the study, the level of care (LOC) required for surgical patients was entered into a database each day for the 6-month period 1 July to 31 December 2010. The levels recognised were IC, high care (HC) and special care (SC). LOC was allocated based on the British Association of Perinatal Medicine (BAPM) criteria2 but with some modifications. These included modifications currently under consideration by BAPM – for example, infants with abdominal wall defects with a silo in situ and infants with oesophageal atresia and a Replogle tube in place were classified as IC.

Infants admitted from outlying networks were excluded from analysis. Estimated cot-days and LOC were included for infants refused admission based on our median data for their surgical condition.

Costs of providing the service were based on the daily neonatal tariffs currently in use in our hospital: £1070 for IC or HC, and £432 for SC.

Results

During the 5-year study period, there were 765 total admissions (including 67 readmissions), 680 of which were from within the network. There were 18 network patients refused admission making a total of 698 network patients who required NS services. This equates to an annual workload of 140 patients. Network patients stayed a total of 10 460 days and with estimates for the refused admissions the total requirements for the network was 10 684 days. This equates to an average of 2137 days per year. As an aid to assessing our case-mix with other centres, the annual average number of cases by diagnosis over the 5-year period is shown in table 1.

Table 1

Annual average number of cases by diagnosis

During the 6-month dependency study, there were a total of 1227 cot-days recorded. The LOC data, annual equivalent figures and costs based on tariff are shown in table 2.

Table 2

Estimated care costs

The figure of 1277 cot-days for 6 months returns a significantly higher annual level of activity (2557) than was estimated in the 5-year study (2137). Although our data suggest that there is an increase in activity over the last few years, the costs can be recalculated on the basis of the 5-year average figure using the same percentages for IC, HC and SC as shown in the table. This gives an annual service cost of £2 054 811.

There were 673 surgical procedures (including 15 estimated procedures for refused admissions) carried out in the 5-year period excluding minor procedures such as rectal suction biopsy. Service cost estimations should therefore allow for about 135 procedures annually (37 per 10 000 births), although these costs are small in comparison to daily costs.

Discussion

Provision of a neonatal surgical service is a key aspect of both a regional neonatal service and a regional paediatric surgery. Current national service provision for NS is inadequate as evidenced by fact that 20% of infants requiring surgery need to be transferred to a more distant neonatal surgical service.1 This is in part due to a lack of surgical cots but also a result of the fact that NS services are not commissioned separately, as is recommended.2 3 In addition, with the development of managed neonatal networks,5 there has been an increase in the transfer of babies at the extreme limits of prematurity from level 2 to level 3 neonatal units. This has resulted in an increased competition for level 3 cots between tertiary services (such as surgery and cardiology) which have been traditional users of these cots, and the new influx of extremely premature babies. There are also additional pressures on level 3 cots with the increasing development of fetal medicine services. These issue needs to be acknowledged by commissioners and appropriate resources provided for neonatal surgical capacity.

Because of the diversity of service organisation and provision in the UK,1 it is difficult to collect accurate data to assess the service requirements. This is made more challenging by the frequency with which surgical admissions are refused, necessitating admission to centres outside the network. The catchment area in our network is well defined and referral practices are well established. Data have also been available on patients refused admission and transferred to other networks. This allows a unique assessment of NS workload and service requirements.

Practices with respect to surgical involvement in very preterm infant with surgical pathology vary throughout the UK, often as dictated by the availability of suitable neonatal cots. Thus, NS units in children's hospitals may provide surgical care only in the immediate perioperative period (24–48 h) as the baby requires to be transferred back to the referring neonatal unit.1 This practice will reduce costs to the NS service in these areas, and it will be borne by the referring neonatal unit.

This study shows that about 2000–2500 NS cot-days per year are required to provide for a network with 36 000 deliveries. This equates to six, seven or eight neonatal cots to run at 100%, 90% or 80% occupancy, respectively. For national service calculations, about one neonatal surgical cot is required for each 5000 deliveries. The dependency data identify that only a minority of activity will be SC and over one-third of activity will be IC.

These figures may help national planning of NS services. In an average centre1 with 30 000 deliveries, six cots are required including 2.5 IC cots. Given there are 700 000 deliveries annually in England and Wales, about 140 NS cots are required nationally.

Calculation of the cost of providing the NS service is difficult. A recent publication from the National Health Service, Department of Health (NHS/DH) neonatal taskforce3 has commented that commissioning of neonatal services falls outside payment by results and that current funding practices vary considerably. The National Audit Office6 detailed many of the current tariffs in use which vary enormously from trust to trust, and recommends that there should be a single contract with each provider with clear definition of activity within the three care levels. Neonatal critical care is due to be included in payment by results from April 2011,7 and this is likely to impact on contracting.

Estimating the cost of an NS service is made more complicated by a lack of accuracy in defining levels of care for surgical neonates. It is our experience that surgical neonates are often assigned an inappropriately low category of care. Our calculations, based on a tariff which may well be lower than used in many centres,6 suggest that providing our NS service costs about £2m. This equates to about £250 000 per 5000 births annually.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.