National Assembly for Wales’ Children, Young People and Education Committee Inquiry in to Perinatal Mental Health and Well being:
The ABMU Perinatal Response and Management Service current provision
(April 2017)
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. This will include whether resources are used to the best effect
PRAMS currently have an ABMU Perinatal Mental Health Stakeholder Development Group which meets quarterly, chaired by PRAMS, with representation from Maternity Service, Health Visiting Service, Psychological therapies and Mental Health. The is a review of membership with a view to including Service User representation, Primary Care (GP) and 3rd sector involvement.
ABMU PRAMS are represented at the All Wales Perinatal Mental Health Steering Group, from both a mental health and Maternity perspective. ABMU have directly requested, via the steering group, that a nationally agreed data set be finalised, the discussion remains ongoing.
There is ongoing work nationally to establish an agreed clinical care pathway of best practice for meeting Perintial mental health Needs and ABMU PRAMS are involved with this work which is being led by Andrea Gray, Mental Health Development Lead for Public Health Wales.
Prior to January 2017 PRAMS had no robust data collection methods or reporting processes in place, the Service is currently working to establish a regular data set in order to report clinical activity within the health board, this will also be reported within the local Stakeholder steering group and fed in to the All Wales National Steering Group. Reporting will include qualitative information from service users regarding their experience during the Perinatal period as well as data around activity.
Maternity lead for Perinatal Mental health and the ABMU PRAMS service manager meet regularly to enhance cross department links and to share themes arising from service user and clinician experiences/feedback, with the aim to directly inform and improve clinical practice and the experience of women and their families during the Perinatal period.
PRAMS are currently strengthening the process for gaining service user/family feedback to inform service development and quality. This month we have adopted the Wales Friends and Family Test as a means of offering women and families opportunities to provide their feedback online and feed into organisational governance structures. We are currently in the process of developing a bespoke service user questionnaire to enable women and families to have an opportunity to shape the development and delivery of services through their detailed experience and feedback.
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Perinatal Response and Management Service (PRAMS)
The data below relates to the number of referrals to Bridgend Perinatal Response and Management Service (PRAMS) from April 2013 to March 2016
The Bridgend Service received an average amount of 38 referrals per month, or 459 referrals per annum.
Until the recent allocation of WG monies to improve perinatal services there was not a dedicated team in either Neath Port Talbot or Swansea. Women with perinatal issues were cared for by generic mental health services.
The new teams, established during 2016/17, have been added to our patient information system and data has been recorded from the 28th of January 2017.
The referral data below relates to Bridgend, Neath Port Talbot and Swansea. From February 2017, the average monthly referral has increased to 56, equating to an average of 672 referrals per annum.
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. (Since 2013, there has not been a mother and baby unit in Wales).
ABMU health board has approximately 6000 live births per year. Until January 2017 there was an inequality of Perinatal Specialist mental health service provision across the ABMU Health Board locality. This included the Perinatal Response and Management Service (PRAMS) providing dedicated specialist Mental Health Assessment and Treatment for women presenting with Perinatal Mental illness within the Bridgend locality, however for women presenting with perinatal Mental illness in the Swansea and Neath Port Talbot locality, assessment and treatment was accessed via generic Mental Health services in line with existing generic eligibility criteria (with some informal links and ad-hoc consultation provided to Secondary Care/CMHTS in the Neath Port Talbot locality by the PRAMS consultant psychiatrist).
Following WAG ring-fenced perinatal mental health funding in 2016 a dedicated service is currently being rolled out across Neath Port Talbot and Swansea, with the remit to establish an equitable and high quality dedicated Perinatal Mental Health Service across the Health Board area.
Prior to the roll out of dedicated perinatal mental health services there was no robust data collected from within mental health services across ABMU re: the pattern/number of women being admitted to psychiatric hospital specifically during the perinatal period presenting with a severe mental illness.
Between January 2016 and January 2017 the ABMU perinatal service (Bridgend) received approximately 544 referrals.
Since January 2017 recorded 3 acute admissions to psychiatric hospital for women presenting with severe mental illness (x2 postnatal depression and x1 acute relapse of existing psychotic illness) during the perinatal period. None of these admissions resulted in transfer to mother and baby specialist unit. The available Recorded data reflects that since April 2013 there has been only one admission to a mother and baby unit (England), it is highly likely that there have been other admissions to acute in patient units in wales linked to perinatal metal illness in recent years however the data is not centrally available for this. Work currently ongoing to establish more robust data collection process – with the aim being that perinatal MH service is notified of all admissions for women within the perinatal period and the reason for admission to collate data and identify patterns.
The level of specialist community perinatal mental health provision that exists in each Health Board in Wales and whether services meet national standards.
ABMU Perinatal Response and Management Service – Provides pre-conception advice, professional advice and consultation, facilitating multi-agency birth planning for women with existing mental illness/history of serious perinatal illness, specialist mental health assessment, Perinatal mental health and well-being focussed interventions (including specialist Occupational Therapy intervention, psychologically based interventions and group interventions) and sign posting to appropriate services (Statutory and/or 3rd sector) where appropriate.
Current skill mix (PRAMS):
1 WTE Band 7 Team Manager
1 WTE band 7 Occupational Therapist
1 WTE Band 6 Occupational Therapist
2.4 WTE Band 6 Mental Health Nurses
0.2 band 8a Clinical Psychologist
0.6 WTE consultant psychiatrist (split allocation of 0.2 WTE for Bridgend locality and 0.4 WTE for Swansea/Neath Port Talbot, the health board is currently in process of recruitment for 0.4 wte consultant psychiatrist for Swansea/NPT locality)
1.8 WTE band 3 administrator
Maternity Services:
1 WTE Band 7 Public Health Midwife with a lead role for Perinatal mental Health
Since the allocation of WAG monies for the development of perinatal services, work has been undertaken to roll out the dedicated perinatal mental health service across Swansea and Neath Port Talbot localities, which went live in January 2017.
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.
All women are risk assessed at their initial assessment with the midwife and those women identified with a risk of Perinatal mental health illness are offered a referral to the Perinatal services. The developing operational policy and clinical care pathway includes local service level agreement that assessment of women presenting to generic mental health services (including LPMHSS) during the perinatal period will be prioritised. Within ABMU women presenting to perinatal mental health service reporting mild to moderate symptoms of mental illness will access formal specialist assessment within 28 days, local mental health pathway enables women to access emergency assessment of acute mental illness or acute onset of significant risk within same or next working day through psychiatric liaison and crisis home treatment services.
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.
Providing support during pregnancy and assisting women with making choices in relation to their care and birth is given by the maternity services. This can assist women experiencing anxiety during pregnancy. Women experiencing antenatal anxiety disorders which require specialist input can be referred to the Perinatal services.
The ABMU Perinatal mental health service offers an advice and consultation service for any professionals working with families experiencing difficulties linked to poor mental health and well-being.
PRAMS currently run an email advice and consultation service for GP’s/psychiatrists/obstetricians/midwives to enable them timely access to best practice guidance in the prescribing and monitoring of psychiatric medication to pregnant /breastfeeding women.
Established local care pathway and the supporting departmental operational policies developed in collaboration between maternity, health visiting and mental health services.
Collaborative multi agency local steering group established to consult on operational arrangements. Currently reviewing membership to include GP’s and service user representation during 2017.
Collaborative training events and information sessions undertaken between midwifery/health visiting colleagues and PRAMS to support the development of knowledge and skills in the early identification of women/families with increased risk factors for poor early attachment and wellbeing.
PRAMS offers preconception advice for women diagnosed with a significant mental illness. This advice can be accessed by professionals involved in the existing care team or women can be referred directly to PRAMS for face-to-face preconception advice with a PRAMS clinician.
Women presenting with PTSD relating to recent birth trauma are able to gain timely access to specialist assessment and when indicated commence EMDR therapy with the PRAMS clinical psychologist within 3 months of referral. Maternity services provide clinical input when required to discuss the birthing experience, using the maternity records to clarify any of the events. In some cases the Perinatal team will attend as a support for the woman.
Whether services reflect the importance of supporting mothers to bond and develop healthy attachment with her baby during and after pregnancy, including breastfeeding support.
PRAMS and local maternity and health visiting services work collaboratively to support women in developing early positive attachment to unborn babies through antenatal and postnatal care, delivering psychoeducation and adopting principles of encouraging positive early attachment into all interactions with families.
50% of women invited to attend PRAMS post-natal depression treatment group during January and February 2017 were unable to attend as they were unable to find suitable child care/leave babies due to breastfeeding and/or lack of transport. There is currently no funding within the PRAMS budget for access to suitable childcare or nursery nurses, however in collaboration with health visiting services/flying start and maternity services we have been able to identify suitable venues within some of the areas of highest prevalence of need and are preparing to pilot a post-natal depression treatment group which will enable mothers to attend with their babies and support mothers who maybe breastfeeding their babies and enable a focus on bonding and attachment to be included into the intervention group in an effort to improve access to treatment and wellbeing outcomes for mothers and babies.
The extent to which health inequalities can be addressed in developing future services.
Currently the initial phase of service development is focussed on implementing an equitable operational service across the ABMU locality
The service plans to be able to increase the therapeutic options accessible to women and their babies across the ABMU locality over the next 12 months as the specialist perinatal metal health service new work force develop the appropriate skills, training and experience.