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Impact of managed clinical networks on NHS specialist neonatal services in England: population based study

BMJ 2012; 344 doi: (Published 03 April 2012) Cite this as: BMJ 2012;344:e2105
  1. C Gale, clinical research fellow,
  2. S Santhakumaran, statistician,
  3. S Nagarajan, data analyst,
  4. Y Statnikov, data analyst,
  5. N Modi, professor of neonatal medicine
  6. on behalf of the Neonatal Data Analysis Unit and the Medicines for Neonates Investigator Group
  1. 1Section of Neonatal Medicine, Department of Medicine, Chelsea and Westminster Campus, Imperial College London, London SW10 9NH, UK
  1. Correspondence to: N Modi n.modi{at}
  • Accepted 7 February 2012


Objective To assess the impact of reorganisation of neonatal specialist care services in England after a UK Department of Health report in 2003.

Design A population-wide observational comparison of outcomes over two epochs, before and after the establishment of managed clinical neonatal networks.

Setting Epoch one: 294 maternity and neonatal units in England, Wales, and Northern Ireland, 1 September 1998 to 31 August 2000, as reported by the Confidential Enquiry into Stillbirths and Sudden Deaths in Infancy Project 27/28. Epoch two: 146 neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit, 1 January 2009 to 31 December 2010.

Participants Babies born at a gestational age of 27+0-28+6 (weeks+days): 3522 live births in epoch one; 2919 babies admitted to a neonatal unit within 28 days of birth in epoch two.

Intervention The national reorganisation of neonatal services into managed clinical networks.

Main outcome measures The proportion of babies born at hospitals providing the highest volume of neonatal specialist care (≥2000 neonatal intensive care days annually), having an acute transfer (within the first 24 hours after birth) and/or a late transfer (between 24 hours and 28 days after birth) to another hospital, assessed by change in distribution of transfer category (“none,” “acute,” “late”), and babies from multiple births separated by transfer. For acute transfers in epoch two, the level of specialist neonatal care provided at the destination hospital (British Association of Perinatal Medicine criteria).

Results After reorganisation, there were increases in the proportions of babies born at 27-28 weeks’ gestation in hospitals providing the highest volume of neonatal specialist care (18% (631/3495) v 49% (1325/2724); odds ratio 4.30, 95% confidence interval 3.83 to 4.82; P<0.001) and in acute and late postnatal transfers (7% (235) v 12% (360) and 18% (579) v 22% (640), respectively; P<0.001). There was no significant change in the proportion of babies from multiple births separated by transfer (33% (39) v 29% (38); 0.86, 0.50 to 1.46; P=0.57). In epoch two, 32% of acute transfers were to a neonatal unit providing either an equivalent (n=87) or lower (n=26) level of specialist care.

Conclusions There is evidence of some improvement in the delivery of neonatal specialist care after reorganisation. The increase in acute transfers in epoch two, in conjunction with the high proportion transferred to a neonatal unit providing an equivalent or lower level of specialist care, and the continued separation of babies from multiple births, are indicative of poor coordination between maternity and neonatal services to facilitate in utero transfer before delivery, and continuing inadequacies in capacity of intensive care cots. Historical data representing epoch one are available only in aggregate form, preventing examination of temporal trends or confounding factors. This limits the extent to which differences between epochs can be attributed to reorganisation and highlights the importance of routine, prospective data collection for evaluation of future health service reorganisations.


  • We thank the staff from neonatal units involved in capturing electronic data and Richard Colquhoun, Neonatal Data Analysis Unit manager, and Surbhi Shah for administrative support.

  • Contributing neonatal units and clinical leads

  • Airedale Hospital; Andrew Gallagher, Alexandra Hospital; Donal Manning, Arrowe Park Hospital; Tim Wickham, Barnet Hospital; M Saeed, Barnsley District General Hospital; Ruth Wigfield, Basingstoke and North Hampshire Hospital; N Brookes, Bassetlaw District General Hospital; Raghavan Kadalraja, Bedford Hospital; Mike Watkinson, Birmingham Heartlands Hospital; Imogen Morgan, Birmingham Women’s Hospital; S Oddie, Bradford Royal Infirmary; Manesh Babu, Broomfield Hospital; Meera Lama, Burnley General Hospital; E Crosbie, Calderdale Royal Hospital; Tim Wickham, Chase Farm Hospital; Gary Hartnoll, Chelsea and Westminster Hospital; Cheltenham General Hospital; Julie Nycyk, City Hospital; Sarah Dalton, Colchester General Hospital; Graham Whincup, Conquest Hospital; Stephen Brearey, Countess of Chester Hospital; John Chang, Croydon University Hospital; Abdul Hasib, Darent Valley Hospital; S Subramania Krishnamoorthy, Darlington Memorial Hospital; Julian Lawson, Derriford Hospital; P Adiotomre, Diana Princess of Wales Hospital; Nigel Brookes, Doncaster Royal Infirmary; Phil Wylie, Dorset County Hospital; Vivien Chan, Ealing Hospital; K Abdul Khader, East Surrey Hospital; Graham Whincup, Eastbourne District General Hospital; Ruth Shepard, Epsom General Hospital; Fairfield General Hospital; Abdus Mallik, Frimley Park Hospital; Owen Galt, Furness General Hospital; J Holman, Gloucester Royal Hospital; Mike Watkinson, Good Hope Hospital; Stanley Zengeya, Great Western Hospital; Morag Campbell, Guy’s and St Thomas’ Hospital; Andy Butterfill, Hereford County Hospital; Hilary Dixon, Hinchingbrooke Hospital; Prof Kate Costeloe, Homerton Hospital; Justin Sims, Horton Hospital; C M Wood, Hull Royal Infirmary; M James, Ipswich Hospital; Vasantha Jayalal, James Paget Hospital; Eleri Adams, John Radcliffe Hospital; B K Sharma, King George Hospital; Prof Anne Greenough, King’s College Hospital; Vibert Noble, King’s Mill Hospital; Dwight Lindo, Kingston Hospital; M Lama, Lancashire Women and Newborn Centre, Burnley; A Thirumurugan, Leighton Hospital; A Raffles, Lister Hospital; C W Yoxall, Liverpool Women’s Hospital; P Sivakumar, Luton and Dunstable Hospital; Ignatius Losa, Macclesfield District General Hospital; Hamudi Kisat, Maidstone General Hospital; B Mohamad, Manor Hospital; Aung Soe, Medway Maritime Hospital; Jasper Katumba, Milton Keynes General Hospital; Vimala Gopinathan, Newham General Hospital; Mark Dyke, Norfolk and Norwich University Hospital; Yonas Cherinet, North Devon District Hospital; North Manchester General Hospital; Lesley Alsford, North Middlesex University Hospital; Paul Mannix, Northwick Park Hospital; Stephen Wardle, Nottingham City Hospital; Stephen Wardle, Nottingham University Hospital (QMC); Tim McBride, Ormskirk District General Hospital; Seif Babiker, Peterborough City Hospital; Minesh Khashu, Poole General Hospital; Than Soe, Princess Alexandra Hospital; Mike Hall, Princess Anne Hospital; Philip Amess, Princess Royal Hospital; Shaun Walter, Princess Royal University Hospital; C Groves, Queen Alexandra Hospital; Dennis Bosman, Queen Elizabeth Hospital, Gateshead; Susan Rubin, Queen Elizabeth Hospital, King’s Lynn; Shaun Walter, Queen Elizabeth Hospital, Woolwich; Queen Elizabeth II Hospital; Mohsin Malik, Queen Elizabeth the Queen Mother Hospital; Shaun Walter, Queen Mary’s Hospital, Sidcup; VK Sharma, Queen’s Hospital, Romford; Rochdale Infirmary; A Ogilvy-Stuart, Rosie Maternity Hospital, Cambridge; C J Harrison, Rotherham Distric General Hospital; Vibha Sharma, Royal Albert Edward Infirmary; Greg Boden, Royal Berkshire Hospital; Royal Bolton Hospital; Paul Munyard, Royal Cornwall Hospital; John McIntyre, Royal Derby Hospital; Vaughan Lewis, Royal Devon and Exeter Hospital; Schapira, Royal Hampshire County Hospital; Owen Galt, Royal Lancaster Infirmary; Royal Oldham Hospital; Richa Gupta, Royal Preston Hospital; Charles Godden, Royal Surrey County Hospital; Philip Amess, Royal Sussex County Hospital; Alan Fenton, Royal Victoria Infirmary; A Mohite, Russells Hall Hospital; Jonathon Moise, Salford Royal Hospital; Shirley Kinsey, Salisbury District Hospital; Julie Nycyc, Sandwell General Hospital; M Qunibi, Salisbury District Hospital; Arfa Khan, Southend Hospital; Sandra Calvert, St George’s Hospital; Ruth Shephard, St Helier Hospital; S Butterworth, St Mary’s Hospital, Isle of Wight; Anthony Emmerson, St Mary’s Hospital, Manchester; J Tooley, St Michael’s Hospital; Peter Reynolds, St Peter’s Hospital; Anil Garg, St Richard’s Hospital; K K Tewary, Staffordshire General Hospital; Carrie Heal, Stepping Hill Hospital; Gail Whitehead, Stoke Mandeville Hospital; Majd Abu-Harb, Sunderland Royal Hospital; Jacqueline Birch, Tameside General Hospital; Rebecca Mann, Taunton and Somerset Hospital; E Pilling, The Jessop Wing, Sheffield; M Hird, The Royal London Hospital; Stefan Schulze, Torbay Hospital; Hamudi Kisat, Tunbridge Wells Hospital; Mark Sellwood, University College Hospital; K Blake, University Hospitals Coventry; Jauro Kuna, University Hospital Lewisham; S Subramania Krishnamoorthy, University Hospital of North Durham; K Palmer, University Hospital of North Staffordshire; Ian Verber, University Hospital of North Tees; Faisal Al-Zidgali, University Hospital of South Manchester; Ned Rowlands, Victoria Hospital, Blackpool; Ms Joan Oliver, Wansbeck General Hospital; Delyth Webb, Warrington Hospital; CA Ramesh, Watford General Hospital; Hashir Ariff, West Middlesex University Hospital; R Sanghavi, Wexham Park Hospital; Caroline Sullivan, Whipps Cross University Hospital; L Amegavie, Whiston Hospital; E Broadhurst, Whittington Hospital; David Long, William Harvey Hospital; Andrew Gallagher, Worcestershire Royal Hospital; Anil Garg, Worthing Hospital; G Whitehead, Wycombe Hospital; Megan Eaton, Yeovil District Hospital

  • Members of the Neonatal Data Analysis Unit and Medicines for Neonates Investigator Group

  • N Modi (lead), J Abbott, D Ashby, P Brocklehurst, K Costeloe, E Draper, A Majeed, J Kemp, A Young, S Petrou, A Wilkinson. The Medicines for Neonates Steering Board is chaired by Michael Goldacre.

  • Contributors: CG conceived the study; CG, SS, SN, YS, and NM contributed to defining the study; SN and YS prepared data for analysis by SS; CG wrote the first draft of the paper; this and subsequent drafts were revised by NM; all study authors reviewed the paper, suggested revisions, and approved the final version submitted; NM is guarantor.

  • Funding: The Neonatal Data Analysis Unit is supported by a Programme Grant for Applied Research (RP-PG-0707-10010) from the National Institute of Health Research (NIHR) and unrestricted funding from the Department of Health, Danone, and Abbott International. The study funders had no role in study design, collection, analysis, and interpretation of data, writing of the report, or in the decision to submit the article for publication

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare financial support for the submitted work from the National Institute for Health Research (NIHR) through a Programme Grant for Applied Research (RP-PG-0707-10010). SN receives part funding from the Royal College of Paediatrics and Child Health (RCPCH) National Neonatal Audit Programme. CG receives part funding though an unrelated award to NM from the Child Growth Foundation (CGF) and support from the Westminster Medical School Research Trust. SS and YS are funded by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the RCPCH, CGF, Westminster Medical School Research Trust, NHS, NIHR, or Department of Health.

  • Ethical approval: This study was carried out with the National Neonatal Research Database (REC 10/H0803/151) as part of the NDAU National Neonatal Surveillance Programme undertaken with permission from NHS Trust Caldicott Guardian.

  • Data sharing: Permission is held to share data for purposes approved by a National Research Ethics Committee.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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