Why Are Our Neonatal Services Underperforming Compared to Other Countries?
- Dr Svilena Dimitrova
- Apr 25
- 5 min read
“The infant mortality rate has been decreasing in all Organisation for Economic Co-operation and Development (OECD) countries since 2000. The UK has a relatively high rate of infant mortality compared with other countries presented here, with 4 deaths per 1,000 live births in 2021. The United States has the highest rate each year until 2020, while Japan and Finland have the lowest rates until 2022.”
Relevant sources:
The challenges facing neonatal care in our system are undeniably multifactorial - involving staffing, infrastructure, systemic planning, and cultural issues. However, based on lived experience, whilst infrastructure, policy, and network-level coordination all have a role to play, the greatest impact on neonatal survival lies in nursing care.
NOTE - I won’t be discussing maternity care in this particular post, but it’s important to acknowledge that every baby’s journey - and thus outcome - begins at conception, with parental health playing a significant role even before pregnancy. Maternity care is undoubtedly intertwined with neonatal outcomes, and I will address this in a separate post.
1. Nursing Skill Mix: Training vs. True Expertise
There is a growing disconnect between qualifications and competence. While units may report a certain number of QIS-trained nurses (those who are qualified to look after babies needing intensive care), this metric fails to capture actual experience. Expertise in neonatal care isn’t just about completing a course - it’s about the years of hands-on learning that follow. Previously, senior nurses brought decades of knowledge to the bedside. Today, new nurses are being promoted into senior roles within a short space of time, very often without the clinical maturity required for critical decision-making. If we were to assess current staffing based on years of specialty experience and compare it to 15 years ago, the contrast would be alarming - but no such data is systematically collected.
2. Unsafe Staffing Ratios for Critical Care
Babies requiring intensive care need 1:1 nursing ratios - and occasionally even 2:1 for our sickest newborns requiring multiple organ support. Yet, it is common for one nurse to care for two critically ill infants simultaneously – a ratio which worsens during the much needed break times for nurses (which in the UK, outrageously, are also unpaid). These unsafe ratios create high risk environments, where mistakes are more likelyand outcomes suffer.
3. Infrastructure: Units Not Fit for Purpose
Inadequate physical environments further compromise care. Most neonatal units are housed in outdated spaces, never designed for modern neonatal medicine. One of the most overlooked yet critical issues is the physical spacing between cot spaces. In many units, the cramped environment limits effective emergency response, hampers infection control, and increases stress on staff and families alike. Properly designed units with adequate spacing and modern infrastructure are not luxuries - they are necessities for safe and effective neonatal care.
4. Culture of Fear and Lack of Psychological Safety
Litigation fears and high-profile gross negligence cases have created a climate of fear. Nurses and doctors alike are now terrified not just of professional consequences, but of potential criminal charges. This results in underreporting of errors and missed opportunities to learn from them - feeding a cycle of repeated mistakes and stagnant improvement. Without a psychologically safe culture and systematic learning frameworks, units continue to experience the same errors. Patterns of failure repeat because they are not properly examined or shared.
5. Educational Support Undermined by Staffing Shortages
Practice educators are regularly pulled back into clinical duties, leaving junior staff without adequate mentorship or structured learning. This undermines long-term skill development and places undue pressure on inexperienced nurses.
6. Retention Crisis and Low Morale
Poor pay, high stress, lack of support, and an erosion of team culture have led to poor staff retention. Working conditions - both emotionally and physically - are draining. Facilities for staff are often substandard, and rest areas are insufficient or non-existent. Nurses are left exhausted, overworked, and unsupported. Staff are operating in survival mode - firefighting instead of proactively learning, too tired to rest, and too short-staffed to reflect.
7. Lack of NICU Capacity and Disjointed Transport Services
The national shortage of tertiary neonatal beds forces babies to remain in units not equipped to care for them. Transport services vary greatly across networks, with some offering early stabilisation support and others requiring full stabilisation before a transfer can be initiated.
8. Limited Support for Families and Post-Discharge Care
Facilities for parents remain inadequate in many units, as does access to breastfeeding support and post-discharge community care. These gaps directly affect both short- and long-term outcomes for infants and families.
9. Lack of Accountability at Leadership Level
One of the most demoralising realities for frontline staff is the consistent lack of accountability among those in senior leadership roles. Decisions that directly impact care quality -from understaffing to mismanagement of resources - often go unquestioned or unchallenged at higher levels. Meanwhile, staff on the ground feel exposed, unsupported, and increasingly like scapegoats. Many nurses report that the incident reporting system, intended to promote safety and learning, is instead perceived as a tool for blame. This has led to a reluctance to report mistakes at all - a dangerous direction for any safety-critical environment.
10. Nursing Pay and the Financial Burden on Nurses
The impact of poor pay on the neonatal workforce cannot be overstated. Nurses are expected to take on increasing responsibilities, often in highly stressful and emotionally taxing environments, but are compensated poorly for their expertise and dedication. The situation is further compounded by the requirement for nurses to obtain degrees - a financial burden that didn’t exist in the past. Many nurses graduate with significant university debt. Advancing up the band scale often means stepping into managerial roles, taking the most experienced nurses off the shop floor. This reduces clinical expertise at the bedside and exacerbates staff shortages. To fill these gaps, the NHS increasingly relies on bank and agency nurses, paying rates that are many TIMES the hourly rate that a permanent nurse would cost. In reality, this practice doesn’t save money - it creates a market of profiteering for bank nurse agencies, while contributing to the cycle of instability within the workforce.
Above I have listed what I believe are the current top 10 issues I think urgently need to be addressed if we are serious about improving outcomes in neonatal care.
Until these foundational problems are tackled head-on, no amount of surface-level change will bring about the meaningful improvements our babies - and the staff who care for them - so desperately need. If we want to improve neonatal outcomes, we must begin by rebuilding the nursing workforce - not just in terms of numbers or training, but in terms of experience, support, safety, and time. We must also commit to updating the environments in which care is delivered, ensuring that units are physically and functionally fit for purpose in modern neonatal medicine.
(As per the beginning of my post – I will address issues with maternity care in a separate post).
Outlines exactly what is wrong with our neonatal units. Like every other area of the NHS since 2010 ,the onus has been on cutting costs instead of saving patients.
We can’t not afford to invest in everyone’s health.