Summary
• We welcome the focus on addressing health inequalities, as disadvantaged groups are significantly more likely to experience mental health problems.
• We encourage a focus on the perinatal period because support during this phase can pay long term dividends for the mental health of parents and their babies, and because this is a unique time when almost all individuals, even the most disadvantaged, will be in contact with health and care professionals.
• Frontline professionals such as GPs, midwives, obstetricians and children centre workers should be supported through training and supervision to screen for mental health difficulties; engage with disadvantaged groups and earn their trust so they are comfortable disclosing mental health issues.
• A stepped care approach can be valuable in targeting support to disadvantaged groups. These schemes provide universal services in disadvantaged communities to avoid stigma, and create a platform to identify individuals with greater needs.
• It is crucial to provide specific support to fathers, and focus on the whole family rather than exclusively targeting mothers.
• Disadvantaged groups particularly benefit from continuity of care from a named midwife or other care professional, to develop trust, communication and improved relationships with services.
We would like to focus on one particular point of the Children, Young People and Education Committee Inquiry:
· The extent to which health inequalities can be addressed in developing future services.
1. We strongly support the committee’s effort to address health inequalities in future services. Disadvantaged groups are significantly more likely to be affected by mental health issues, and addressing inequality is a key means to lower the risks for these groups and prevent mental health problems from occurring.
2. We would include a range of individuals as belonging to disadvantaged groups. This could include families where parents have mental health problems, may have been in care themselves, have a history of substance abuse or long-term unemployment. Disadvantage takes a different character in different social, cultural and economic contexts. In Wales we would particularly expect to target those living in poverty, with long-term unemployment, low educational attainment, teenage parents, single parents and those who are geographically isolated.
3. The perinatal period offers a particular opportunity for safeguarding wellbeing in the long term. Whilst disadvantaged groups are generally the least likely to access or maintain contact with services, during the perinatal period even the most disadvantaged individuals have contact with health and care professionals. Crucially, these contact points are not experienced as stigmatising (as contact with mental health professionals can be). This is also the period when both mums and dads report being most open to change in terms of dealing with their own mental health. The experience of becoming a parent can reactivate people’s own experience of being parented themselves, and parenthood often inspires motivation for self-improvement as new mums and dads resolve to become better people for their children.
4. Effective early intervention to support carers and babies can pay dividends for mental health outcomes throughout childhood, adolescence and into adulthood. Initiatives from the Mental Health Foundation and our partners demonstrate how health inequalities can be addressed in perinatal mental health. These offer key lessons for good practice which could be readily applied to Wales.
5. For example, our Mums and Babies in Mind[1] programme works in four areas of England (Blackpool, Haringey, Southend and Gloucestershire) to improve care and quality of life for mums with mental health problems during pregnancy and the first year of life, and their babies. In each area we aim to identify the barriers to service improvement, and to inform and support effective solutions. This will result in good quality, evidence-based care pathways including information, support and treatment, at the right time, for all mums who need it. We capture the work we do and share our learning through online tools and communications that inform and inspire those who commission and provide services across the UK.
6. Mums and Babies in Mind works with frontline professionals such as GPs, midwives, obstetricians and children centre workers to ensure that they make the most of contact opportunities in the perinatal period. We improve their training on how to screen for mental health difficulties, how to engage with disadvantaged groups and earn the trust of individuals who may not trust professionals or have had negative past experiences with services. Those from disadvantaged groups are often reluctant to disclose mental health difficulties out of fear that their children will be taken away from them. Our training focuses on how to create safe spaces for individuals to speak candidly; understand the barriers to disclosure that different groups may face; and how to provide screening services in a sensitive and supportive way.
7. The programme supports perinatal mental health services to deliver evidence-based interventions – particularly those that improve parental mental health and parent-infant relationships – such as video-feedback approaches. Working in partnership with a range of local services such as Children and Adolescent Mental Health Services (CAMHS), local councils and Home-Start teams, as well as with GPs, midwives and health visitors, we have been providing evidence-based recommendations to improve provision across statutory services, the voluntary sector and primary care.
8. The programme has highlighted the importance of cultural sensitivity. This field would benefit from further research on how to design screening tools in different languages, and how to validate mental health screening in different cultural contexts.
9. Mums and Babies in Mind connects with Better Start[2], funded by the Big Lottery, which specifically targets disadvantaged areas. In Blackpool this programme has been particular successful in providing perinatal education on a universal basis within disadvantaged local areas, through the Baby Steps[3] programme (a programme that has also been successfully delivered in Swansea and Brigend). With universal access within a particular community, these services have been seen as less stigmatising because everyone is offered the same support. This creates a platform for identifying people who are having more difficulties and can be offered progressively more intensive forms of support.
10. We would encourage Welsh services to use such a stepped care approach, providing some basic services universally; some on a universal basis within disadvantaged communities; and then tiers of tailored supported for those in higher needs. This minimises the challenges of stigma whilst targeting services at those most at risk, and helping ensure those most in need of support are identified and providing more intensive services as required.
11. There is a tendency for perinatal initiatives to be focused on mothers. We encourage initiatives which are as family focused as possible and highlight the importance of providing specific support to fathers. Whilst there is a higher prevalence of single parents amongst disadvantaged groups, parents are likely to be in a couple during pregnancy and providing support to fathers can have benefits for the whole family. Our work focuses on building social capital for disadvantaged groups, replicating the support which middle-class parents often gain from schemes like NCT. Our experience is that peer support is generally more acceptable to parents and leads to higher levels of engagement, and therefore strongly advocate evidence-based peer support programmes for parents experiencing perinatal mental health difficulties. This is particularly relevant for geographically isolated areas, such as the Welsh valleys.
12. We also support broader efforts to ensure services target health inequalities and meet the needs of vulnerable and socially disadvantaged groups. Third sector, community agencies and peer support are often key for engaging with this demographic, who may be less likely to access or maintain contact with formal services. Communication issues are critical and access can be significantly improved where local areas take an active approach to engagement. This might involve ensuring that information about treatment and care is culturally appropriate; publishing in languages other than English; making independent translators available; or addressing additional needs relating to physical, sensory or learning difficulties. Clinical and service staff often benefit from specific training on working with women from a range of backgrounds, and in understanding the individual barriers to engagement.
13. Issues of trust, communication and confidence of disadvantaged groups in dealing with professional services make it particularly important to have consistency of care. Having a named midwife or another individual who is regularly supporting expectant parents throughout their pregnancy and birth can make a significant difference to their willingness to talk about their needs and build relationships with services. After all, people from disadvantaged groups are all different and have all sorts of different issues, challenges, opportunities and desires. There is no replacement for getting to know them as individuals.
If you require further information or would like to discuss our submission, please do not hesitate to contact Dr Amy Pollard, Senior Policy Officer, APollard@mentalhealth.org.uk .