Institute of Health Visiting

Royal Society for Public Health

John Snow House

59 Mansell St

London

E1 8AN

15/05/2017

The Institute of Health Visiting response to National Assembly for Wales’ Children, Young People and Education Committees Inquiry into Perinatal Mental Health

The Institute of Health Visiting, (established in 2012) is a charity, academic body and professional organisation whose charitable objectives are to improve outcomes for children and families and reduce health inequalities through strengthened health visiting services.

The iHV provides professional leadership for and on behalf of all health visitors across the UK. The work of the Institute is supported through:

• Education and training

• Quality assurance processes

• Research

• Creating new leadership in the profession

• Working in partnership

The iHV really do believe that there is “no health without mental health” and have been very conspicuous in the campaign for improved perinatal mental health services across the UK. Indeed staff involved have worked in this arena for at least 20 years. Our national actions include but are not limited to:

• Being an active member of the operations and stakeholders groups of the Maternal Mental Health Alliance

• Creation of PMH Champions *

• Creating face to face perinatal mental health (PMH) Champions Forums in the 12 Strategic Clinical Network Regions across England

• Being a member of NHS England Clinical Reference Group for PMH

• Attending annual Ministerial round tables on perinatal mental health

• Founding member of the All Party Parliamentary Group (APPG) Conception to Age 2: the first 1001 days’

• Being a member of the Steering Group for RCGP Clinical PMH Programme

• Partnership working, for example with the RCOG and RCM in a project led by NHS England Benchmarking to collect data focused on PMH provision in universal health services

• Representation on Health Education England national stakeholder group for PMH

• Co-writing of national curriculum for all professionals working with MH

• Contributing to national frameworks e.g. a national job description for Perinatal and Infant specialist health visitor posts

• Supporting a range of research projects to develop the evidence base in PMH

• Having effective working alliances with national and international organisations (e.g. UK and International MARCE Society, The WAVE Trust, 1001 Critical Days, and the All Wales Perinatal Mental Health Steering Group) with an interest in improving the perinatal mental health of infants, fathers and mothers

• Supporting PhD research – What constitutes a ‘listening visit?

The iHV welcomes the opportunity to share our learning and contribute to this consultation, our response is detailed below. As we currently don’t have a Welsh officer or department our remarks will be general rather than specifically related to the Welsh context.

It is known that between 10 and 20% of women develop a mental illness during pregnancy or in the first year after having a baby. If untreated, these perinatal mental illnesses can have a devastating impact on the women affected and their families.  Suicide is the leading cause of death during the perinatal period which is shocking but preventable.

As the only professionals who have home based as well as clinic contact with nearly all families during both pregnancy and the early years, health visitors are in an inimitable position to influence health outcomes for every mother, every father and every baby. They are critically important to the effective prevention, detection and treatment of perinatal mental illness.

Health visitors’ universal reach into every family whatever their social and citizen status, together with their skills and understanding of physical, social and mental health, and their ongoing relationships with families, make them ideally placed to promote the emotional wellbeing of parents and babies; to raise awareness about perinatal mental health/illness early and to tackle stigma. Furthermore to identify women who are at risk or suffering from mental health problems early and to ensure these women get the support they need promptly. Health visitors are increasingly working with fathers affected my perinatal mental illness and should always be alert to any fall out from the parents illness on their ability to both care for, and bond with their infant.

The iHV welcomes the much needed attention on perinatal mental health services across the UK. Perinatal mental illness rarely occurs as an isolated need and effective interagency working is crucial. Reflecting on the involvement we have had within England, we would like to draw attention to the need for specialist services to be linked into an well integrated pathway of care, supported by effective universal services that can identify and refer women at the earliest opportunity. Specialist perinatal mental health services can only support women with the most severe mental health problems. Around 75% or more women with perinatal mental health problems will not meet the thresholds for these services. Health visitors can help these women, either through offering brief interventions and support directly, or through referring women to other services, such as IAPT and/or GPs.

Initiatives such as the iHV PMH Champions training programme* and Specialist Health Visitors in Perinatal and Infant Mental Health are expected to play a valuable part in reducing the incidence and impact of PMH problems– creating savings on child and adult mental health services, and improved public health. However if health visitors do not have the sufficient time, skills and resources to offer a meaningful service to all families, many of these women will fall through the gaps, with potentially devastating short and long term consequences.

We were delighted to see that two of the aims of the new HCP in Wales relates to PMH and IMH:

· To promote bonding and attachment to support positive parent-child relationships resulting in secure emotional attachment for children.

· To promote positive maternal and family emotional health and resilience.

Recommendations

· The iHV commends the positive collaborative approach that the All Wales PMH Steering Group utilise and believe they are in a good position to facilitate consistent high quality standards across Wales- whilst still retaining some of the flexibility that is required at a local level.  It is our understanding that support of the development of this group into a formal managed network with representation from across the spectrum of PMH care would be a positive move for Wales.

· The iHV supports training in perinatal and infant mental health for all health visitors as part of the core training, mandatory updates, annually or biannually according to the rate at which the evidence base develops.  Furthermore enhanced training in practice as part of continuing professional development. This training should be based on an agreed national curriculum such as that currently being written by the iHV. This will help ensure that prevention, early recognition and early intervention form a strong backbone for the development of the body of perinatal mental health care services across Wales. Health practitioners in some parts of Wales, particularly those within Flying Start areas, have already benefited from the very successful iHV Perinatal Mental Health Champions model* and it is recommended that this be considered for further implementation across Wales.

· The iHV has been impressed by how the Welsh Assembly is enhancing support for parents through Flying Start and their enhanced Healthy Child Wales programme.  The iHV would however advise the Welsh Assembly that it is good practice by health visitors to assesses a mothers (and fathers) mental health at 6 weeks and 3-4 months postnatally as these are peak times for early identification of mental illness.  Currently the guidance is to only do this formal assessment at 6 months which we believe is too late and will lead to unnecessary negative consequences for the whole family.

· We would advise that any additional perinatal mental health services being made available to Flying Start families are made available to all families as perinatal mental illness cuts across all social categories.

· The iHV also supports inter-agency perinatal mental health training as when practitioners at a local level come together- good things begin to happen at a local level. Effective interagency training is the basis of effective interagency perinatal mental health teams, “Those that work together should train together” (Better Births, 2016).

· The iHV supports combined multi agency perinatal AND Infant mental health training that is family centered.

· The iHV supports the plans for a Mother and Baby Units in Wales led by a perinatal psychiatric teams who could also act as a source of specialist support for politicians and professionals across Wales.

· No mother should be needlessly separated from her baby during such the perinatal period and Mother and Baby Units prevent this.

· The team around the mother and her family is most effective when it includes specialists to receive referrals, primary care workers (GPs, HVs, MWs) and the third and voluntary sector to offer on-going support beyond what an be offered by professionals.

· Both individual and group approaches should be invested in.  Group approaches have the benefit of creating a social circle for the mother, loneliness can have significant impact on the development and recovery from perinatal mental illness.

· Opportunities for physical activity, such as those currently being showcased in Powys (Pram Walks) should also be encouraged [such as the iHV ‘Ready Steady Mums’ scheme which] is mum led and HV supported and serves to get mothers out of the home benefiting their emotional and social as well as their physical wellbeing.

· The iHV recognises the diverse geographical terrain of Wales and the challenges this represents in terms of families being able to access services within rural communities. The iHV is aware of innovative programmes currently being implemented by PMH services (‘Mind Mums Matter’) which are designed to tackle these inequalities.

· The importance of the role of fathers and PMH is also recognised and the iHV encourages the current formation of Fathers' Groups nationwide, which support the needs of fathers who may be suffering themselves from the effects of perinatal mental illness.

· Finally new opportunities need to be created to audit and evaluate local services with the results fed back to and owned by staff who should drive improvements.

Conclusion

The iHV welcomes the opportunity to shape the mental health of women and their families in Wales through this inquiry into perinatal mental health. The developing mental health landscape provides a window of opportunity for commissioners, service users, policy makers, frontline practitioners and the wider public health workforce across Wales to rework health and social contracts to deliver a successful perinatal mental health action plan. A strategic plan that is perceptive, proactive and fully engaged.  A plan that will effectively and efficiently translate into improved health outcomes. A plan that meets the needs of the population today and at the same time considers the health and well-being of future generations. A plan that will deliver the right care at the right time by the right people.

*iHV Champions programme

The iHV has a very credible track record for delivery in up-skilling health visitors and others such as midwives, GPs, obstetricians, mental health nurses in PMH so that they are able to:

· recognise those that may be at risk of, or are suffering from perinatal mental illness (PMI)

· detect PMI at the earliest opportunity

· understand how PMI may affect the parent-infant relationship and child outcomes across the life-course

· know how to manage mild to moderate PMI

· confidently refer mothers and fathers/partners to the right service in a timely manner

· feel confident to recognise and manage risk in relation to; suicide, self-harm, risk to others and safeguarding

Since 2013 the iHV have created over 550 HV PMH Champions. Feedback from the iHV HV PMH Champions highlighted the value of a multi-agency approach to PMH training and the need to integrate the importance of the parent-infant relationship and developing infant mental health, so as to facilitate the right care for all members of the family, available at the earliest opportunity at every local level. In response we have created and delivered a two-day perinatal and infant mental health (PIMH) combined multi-agency Champion training. In addition the iHV has also trained 261 HV Infant Mental Health Champions. Following an initial pilot training in 2015, we now have 435 multi-agency Champions (with several commissions ongoing). They come from a range of backgrounds including; health visiting, psychiatry, general practice, midwifery, obstetrics, social workers, primary care and voluntary sector practitioners. Therefore, we have trained over 1000 perinatal and infant mental health Champions with further training dates ongoing.

A Champions remit is to cascade the learning and be an ambassador for perinatal mental health within their local area. A survey in 2014 demonstrated that HV PMH Champions were cascading the training and they had become local leaders and local champions for increasing parity of esteem for PMH. Champions were developing integrated pathways and new services, such as parental support groups. The survey showed Champions were leading transformational change for PMH in their local communities, by reducing stigma, raising awareness and forming meaningful clinical networks. We know that iHV HV PMH Champions have cascaded the learning to over 10,000 public health practitioners.

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