Putting the clock back 30 years: neonatal care since the 1991 NHS reforms.

The future of specialist services like neonatal intensive care seems to have been overlooked in the latest round of NHS reforms; yet the changes introduced by the NHS and Community Care Act 1990 may well have important consequences for such services. This paper examines the development of policy for the care of neonates, in particular the establishment of regional neonatal intensive care centres. It is based on informal interviews conducted with clinicians and policy makers concerned about the future of the services they are responsible for. The paper argues that current policy to devolve neonatal intensive care services is in opposition to established clinical opinion, and further, that it may actually contradict some of the stated aims of the white paper. In line with government thinking in other areas, the NHS white paper, Working for Patients (1989), aimed to decentralise control of health care, and encourage competition. A central tenet of the reforms was the devolution of decision making in the NHS hierarchy from region to district, and from individual districts to individual units. Whatever the ideological and/or political objections to this new look NHS (and there were many) there were some areas of health care provision where the new ideas could and, if the evidence so far is to be believed, did work.' 2 Out in the districts, providers who knew what they could provide and to whom, in relatively stable areas like elective orthopaedics, found contracting services fairly straightforward. At regional level the focus shifted towards evaluation and auditing services rather than organising and directing them. According to the white paper, supraregional specialties (such as the national heart and liver transplant programmes) would continue to require centralised funding and coordination, but, it suggested, regional and supradistrict services could be incorporated into the contracting process. The assumption that neonatal intensive care could be coordinated and funded at district level appears flawed for several reasons. The clinical evidence and literature support regional provision of neonatal intensive care. The current pattern of provision is informed by both the clinical evidence and the advice of numerous governmental committees. In addition, as this paper suggests, devolution of neonatal care may compromise patient access to services, limit specialist training, and impede the progress of medical research.