Introduction
1. The Welsh NHS Confederation welcomes this opportunity to respond to the Children, Young People and Education Committee’s inquiry into perinatal mental health services. This inquiry forms part of the Committee’s wider work on the First 1,000 Days.
2. The Welsh NHS Confederation represents the seven Local Health Boards and three NHS Trusts in Wales. We support our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.
Overview
3. Perinatal mental health refers to a woman’s mental health during pregnancy and the first year after birth. This includes mental health conditions that existed before pregnancy, as well as illnesses that develop for the first time or become greatly exacerbated during the perinatal period. Examples of such conditions include postnatal depression, antenatal depression, anxiety and postpartum psychosis. It is accepted in policy documents from across the UK that between 10% and 20% of mothers will experience a perinatal mental health condition. There were 33,279 live births in Wales in 2015, which could mean that between 3,328 and 6,656 new mothers will experience a perinatal mental health issue each year.
4. It is worth mentioning also that in instances where a mother experiences a perinatal mental health condition, the likelihood that a child will experience behavioural, social or learning difficulties increases also. The interrelationship between perinatal, parental and infant mental health suggests we should be addressing these issues holistically. Improving well-being and the provision of perinatal mental health services has a role to play in achieving improved population level health outcomes generally, but must be supplemented by wider preventative, population level interventions which consider the family as a whole.
5. In 2015, the Minister for Health and Social Services announced that the Welsh Government had made available £1.5m of recurrent funding to develop community services for women with perinatal illnesses, their babies and their families. The funding was to reflect the number of births in each Health Board. Before any funding was released however, Health Boards were required to submit detailed plans for approval that set out how they intended on utilising the additional funding.
6. There is currently no mother and baby unit in Wales after the service, which was based at Cardiff’s University Hospital of Wales, was closed down permanently in November 2013. The closure was due to an insufficient number of women using the service to enable staff to maintain skills. The Welsh Health Specialised Services Committee (WHSSC) has therefore been commissioned to fund inpatient care at mother and baby units in out of area beds in England. All placements are funded using the individual funding patient request (IPFR) on a cost per case basis from English providers designated to provide such services. There is a task and finish group of the All Wales Perinatal Mental Health Steering Group (AWPMHSG) which is currently reviewing Tier 4 specialist services and is chaired by the Director of Nursing at WHSSC. A final report will be presented to Child and Adolescent Mental Health Services (CAMHS) Network on June 23rd and recommendations will be considered in an update to the Joint Committee of WHSSC on June 27th.
7. Our response will address the terms of reference of the inquiry in turn.
The Welsh Government’s approach to perinatal mental health, with a specific focus on accountability and the funding of perinatal mental health services covering prevention, detection and management of perinatal mental health problems;
8. Following the Welsh Government’s funding announcement in 2015, Health Boards have established dedicated multi-professional teams who work directly with perinatal mental health patients and their families to ensure they experience integrated care pathways. These teams also provide enhanced support to all the relevant staff who work within Obstetrics, Gynaecology and Sexual Health teams as well as Mental Health Directorates. Generally, these teams will consist of a Specialist Perinatal Mental Health Practitioner and a Specialist Perinatal Mental Health Midwife as well as a number of dedicated sessions from a Consultant Psychiatrist, a Clinical Psychologist and a staff grade Doctor.
9. However, there remains a degree of variation within Health Boards around the provision of perinatal mental health services. In Abertawe Bro Morgannwg University Health Board for example, the Perinatal Response and Management Service (PRAMS) provided dedicated specialist mental health assessment and treatment for women experiencing perinatal mental health conditions within the Bridgend locality; but for women experiencing the same conditions living in Swansea and Neath Port Talbot, assessment and treatment was accessed via conventional mental health services in line with existing eligibility criteria (with some informal links and ad-hoc consultation provided to secondary care in Neath Port Talbot). Since January 2017 however, this is no longer the case as dedicated teams are now operational in the Swansea locality. A similar scenario may be noted in Hywel Dda University Health Board, where the Perinatal Mental Health team is fully operational in Pembrokeshire. In Carmarthenshire, the service delivery model is due for roll out by the end of May 2017. Mapping exercises are underway in Ceredigion as some of these services will be delivered via a networked approach with the Carmarthen service.
10. Health Boards recognise the significance of placing prevention and early identification of illness as the key priorities of their individual strategies for perinatal mental health conditions. This is done by delivering the right care at the right time in community settings with the provision of care being tailored to meet the individual requirements of each patient. Delivering care in the community not only alleviates demand on hospitals, but also allows for smaller multi-disciplinary teams to integrate their approaches, thereby enabling them to establish more personal relationships with patients and encouraging greater patient involvement in the treatment process.
11. For those who have been diagnosed with a serious perinatal mental health condition, some Health Boards have established multi-professional team working systems to facilitate discussions between the patient, midwives, the Health Visitor and colleagues working in the primary and secondary care sectors. Midwives and Health Visitors in particular are encouraged to engage in informal discussions with their colleagues in mental health teams before a referral is made so as to ensure that an appropriate and timely response is made.
The pattern of inpatient care for mothers with severe mental illness who require admission to hospital across both specialist mother and baby units (designated mother and baby units in England) and other inpatient settings in Wales;
12. Wherever possible, a community based specialist service is the preferred option of care for women and their families. However, there are occasions where, due to the extent of risk and the acuteness of the illness being experienced, this is not possible. It is clearly recognised by the NHS in Wales that access to and provision of specialist inpatient services is of critical importance. These services must be of the highest standard and sustainably provided. Work is underway to examine what the options are for NHS Wales in commissioning and providing such services in future. Currently, there is no inpatient provision in Wales, which has caused inconvenience for some mothers particularly for those living in rural and western areas. The closest inpatient facilities of this type are in Bristol, and whilst this is not an extensive journey for those living in the South and South East, it is a significant journey for those living elsewhere in Wales.
13. It is essential that there is good access to inpatient beds on an emergency basis. There have been occasions where beds in a specialist unit have been temporarily unavailable, prompting a contingency action of mothers being admitted to mental health units at a local hospital. This unfortunately means them being separated from their new born baby.
14. In some Health Boards, a threshold has been adopted where a patient will be admitted to a specialist inpatient unit in cases where all other alternatives to admission have been considered and there exists a significant risk to the mother and her baby. This threshold is being lowered during the perinatal period to ensure patients who require more urgent attention are treated accordingly. Health Boards are currently working to improve data collection of patterns for inpatient services to support planning and service provision. This includes a mapping of the data that identifies all admissions of women within the perinatal period and the reason for admission.
The level of specialist community perinatal mental health provision that exists in each Health Board in Wales and whether services meet national standards;
15. Historically, resource and capacity limitations have meant that not all Health Boards have established specialist roles for Midwives, Health Visitors, Community Psychiatric Nurses or Occupational Therapists with a specific perinatal mental health focus or any dedicated psychology support. Despite this, recent developments have included the setting up of a perinatal/pre-conceptual clinic in some Health Boards which aim to raise awareness of such conditions, particularly among pregnant women and women already known to mental health services within the Health Board.
16. In designing the service models for specialist community perinatal mental health provision, Health Boards undertook a number of mapping exercises to plot existing services and collaborate with key health professionals in maternity units to ensure an integrated model of service delivery was developed. Moreover, audits against the Quality Network for Perinatal Mental Health Services have been completed in some Health Boards – the deficits identified are then used to inform the Perinatal Service Delivery plan over a period of three years. The standard of these services therefore adhere to those established by the Royal College of Psychiatrists.
The current clinical care pathway and whether current primary care services respond in a timely manner to meet the emotional well-being and mental health needs of mothers, fathers and the wider family during pregnancy and the first year of a baby’s life;
17. Health Boards have established pathways with stakeholders within the primary care workforce based on open, effective communication channels and clear referral and care pathways. The role of the Consultant Psychiatrist within this process is crucial in ensuring the provision of expert advice to the team and offering timely out-patient appointments where appropriate.
18. Health Boards recognise that a key component in achieving effective clinical care pathways lies in identifying those most at risk of perinatal mental illness and doing what is possible to ensure that services are in place to respond to these patients in a timely manner. To this end, a pilot project is currently under way in Powys Teaching Health Board where women already known to the Health Board’s mental health service and of childbearing age are offered advice and guidance about the likely impacts of pregnancy on their physical and emotional well-being. More specifically, Midwives and Health Visitors are expected to discuss the patient’s well-being throughout their pregnancy and during their postnatal period while maintaining a family approach (recognising the likely impact on the mother’s partner and family). For those considered to be experiencing mild to moderate antenatal/postnatal depression and anxiety, the Health Visitor or Midwife is expected to offer the patient listening visits and a referral to the Health Board’s new community service. This provision has been in place since April 2017.
19. The general trend across Health Boards is that referrals are accepted within 4-5 weeks, but priority will likely be given to patients who show symptoms of serious perinatal mental health conditions, such as post-traumatic stress disorder (PTSD), schizophrenia or signs of suicidal ideation. For women under the age of 18, the Health Board’s perinatal mental health team will work alongside CAMHS throughout the treatment process.
Consideration of how well perinatal mental healthcare is integrated, covering antenatal education and preconception advice, training for health professionals, equitable and timely access to psychological help for mild to moderate depression and anxiety disorders, and access to third sector and bereavement support;
20. Health Boards have made significant progress in progressing the integration of perinatal mental health services. In particular, the roles of the Specialist Perinatal Midwives and Clinical Nurse Specialists have enabled joint working with other health professionals which has increased their knowledge and skills and enabled the provision of specialist advice and support at a single point of contact. Perinatal mental health services also work closely with District General Hospital (DGH) Psychiatric Nurses and third sector charities which has resulted in more timely assessments and treatments. Close links with the DGH Psychiatric Liaison Team in particular has facilitated effective partnership working by enabling the maternity unit to access advice and support much quicker than would be the case via traditional service models with specialist input from the Health Board’s perinatal mental health service.
21. By integrating and aligning perinatal mental health services with other services available to pregnant women, new mothers and their families, Health Boards are also working to reduce the stigma associated with mental health services in general. These initiatives, particularly when developed in collaboration will colleagues in public health teams, promote the normalisation of perinatal mental health conditions. Moreover, there is evidence across some Health Boards of a willingness among the primary care workforce to undertake further training for treating patients with a perinatal mental health condition. Powys Teaching Health Board in particular has responded to these requests by securing the provision of further training schemes over the course of the next year, which will be delivered by integrated teams involving Psychiatrists, Midwives, Health Visitors and Nursery Nurses. It is worth mentioning also that Powys Teaching Health Board has shared the Royal College of Physicians’ toolkit for perinatal mental health with its GPs, Practice Nurses, Local Mental Health Practitioners and Obstetric Physiotherapists. The Health Board is also encouraging their Mental Health Practitioners to attend midwifery and health visiting meetings so that their knowledge around self-help strategies and best practice can be shared with colleagues. A similar initiative is also underway in Abertawe Bro Morgannwg University Health Board, where training and information sessions are held between the Health Board’s perinatal mental health services and their colleagues in midwifery/health visiting teams to support the development of new knowledge and skills in the early identification of women/families with increased risk factors.
Whether services reflect the importance of supporting mothers to bond and develop healthy attachment with her baby during and after pregnancy, including breastfeeding support;
22. The importance of supporting mothers to bond and develop a close attachment with their babies is reflected in the Healthy Child Wales programme and the National Flying Start programme. On a Health Board level, these commitments are delivered by Health Visitors and seek to enhance the social and emotional development of new mothers, their child and their family. There is evidence across Health Boards of some staff members receiving further training to encourage close interaction between mother and child and explore the relationship between a baby and its caregivers.
23. Midwifery and health visiting services across Health Boards recognise the importance of working together to provide effective support to mothers in developing healthy attachments with their babies both during and after pregnancy. A simple example of these initiatives can be found in Abertawe Bro Morgannwg University Health Board, where face-to-face post-natal depression groups are provided by the Health Board’s perinatal mental health team. It is concerning however that between January and February 2017, 50% of women who would otherwise have attended these sessions were unable to do so due to a lack of transport. While there is currently no funding within the Health Board’s perinatal mental health service to provide for transportation costs, the Health Board has begun to identify a number of suitable venues within localities with the highest prevalence of such cases and are preparing to pilot a post-natal depression group which will enable mothers to attend with their babies and support mothers who may be breastfeeding.
24. Some Health Boards have also developed specific breastfeeding groups designed to support new mothers in deciding which feeding option is best for them. A number of Health Boards have confirmed their strong commitment to these responsibilities by Level three accreditation of UNICEF’s baby friendly initiative through the work of their midwifery and health visiting teams and the distribution of information leaflets. It is recognised also that in some cases, feeding choice will impact on a mother’s own emotional health. Staff are therefore encouraged to respect a mother’s perinatal choice whatever it may be and to support new mothers throughout this process.
The extent to which health inequalities can be addressed in developing future services;
25. Currently, the initial phases of service development for Health Boards are largely focused on implementing an equitable operational service across their localities. It is intended that the effective integration of multi-disciplinary teams and increased staff training sessions will enable the perinatal mental health workforce to develop altogether new skills and experiences to drive further therapeutic options for perinatal mental health patients and their families in future.
26. Health Boards also recognise that many of the factors that contribute directly to poor perinatal mental health are ultimately population health concerns too – domestic violence, adverse childhood experiences (ACEs), social isolation, poor housing, poor employment prospects, etc. Powys Teaching Health Board in particular has recognised this observation and encourage Midwives and Health Visitors to report any concerns to their colleagues in social services to identify areas of need more effectively.
27. It is clear however that the greatest challenge Health Boards face in developing future perinatal mental health services to address health inequalities is the financial restraints. While Health Boards recognise that the Welsh Government’s funding formula was based on the birth rate within each Health Board, it did not take into account what perinatal services each Health Board already had in place – in some cases, Health Boards had no existing services. Therefore the funding allocated to those Health Boards with particularly high levels of deprivation, mental illness and poor well-being has limited the services the Health Board can provide. Against this background, some Health Boards would welcome a review of the Welsh Government funding arrangements.
Conclusion
28. Health Boards across Wales are adopting innovative approaches to the provision of perinatal mental health services. Developing multi-disciplinary teams within community settings are central to enabling the effective provision of such services across Health Boards in Wales.
29. By recognising the unique skill sets within specialist teams and encouraging the sharing of good practice among colleagues, there is the potential for achieving real progress in this area. Health Boards are continuing their drive towards the further integration of services and the provision of targeted treatment plans tailored to the specific requirements of the new mother, her baby and her family throughout the perinatal period.