Cynulliad Cenedlaethol Cymru | National Assembly for Wales

Y Pwyllgor Plant, Pobl Ifanc ac Addysg | Children, Young People and Education Committee

Iechyd Meddwl Amenedigol – Gwaith dilynol | Perinatal Mental Health – Follow-up

PMH(2) 02

Ymateb gan: NSPCC, NCMH, Mind Cymru, y Sefydliad Iechyd Meddwl a’r Gynghrair Iechyd Meddwl Mamol.
Joint response from : NSPCC, NCMH, Mind Cymru, Mental health foundation and Maternal Mental Health Alliance

About the NSPCC

We’re leading the fight against child abuse in the UK and Channel Islands. We help children who’ve been abused to rebuild their lives, we protect children at risk, and we find the best ways of preventing child abuse from ever happening. Learning about what works in the fight against abuse and neglect is central to what we do. We are committed to carrying out research and evaluation to make sure the approaches we’re taking are the right ones and we share what we have learnt with partners. Abuse ruins childhood, but it can be prevented. That’s why we’re here. That’s what drives all our work, and that’s why – as long as there’s abuse – we will fight for every childhood.

About the National Centre for Mental Health

The National Centre for Mental Health (NCMH) brings together world-leading researchers from Cardiff, Swansea and Bangor Universities to learn more about the triggers and causes of mental health problems. We aim to help improve diagnosis, treatment and support for the millions of people affected by mental ill-health every year, as well as tackle the stigma faced by many. Key to achieving these aims is to engage with services and their users, the third sector and the wider public to increase understanding of mental illness, and by supporting and undertaking mental health research.

About Mind

We're Mind, the mental health charity for England and Wales. We believe no one should have to face a mental health problem alone. We provide advice and support to empower anyone experiencing a mental health problem. We campaign to improve services, raise awareness and promote understanding.

About Mental Health Foundation

The Mental Health Foundation provides information, carries out research, and campaigns to improve services for people affected by mental health problems. The Mental Health Foundation aims to help people understand, protect and maintain their mental health via a public health approach. The Foundation runs programmes with a variety of groups who are most at risk of mental ill health, including single mothers, older people, and children in care. The Mental Health Foundation campaigns to raise awareness of mental health issues in the media and raise the profile of mental health in political and social agendas.

About Maternal Mental Health Alliance, Everyone’s Business Campaign

The Maternal Mental Health Alliance (MMHA) is a coalition of UK organisations committed to improving the mental health and wellbeing of women and their children in pregnancy and the first postnatal year. This acknowledges the extensive evidence that investing in mental health at this early stage can have a dramatic impact on long-term outcomes of mothers, fathers, children, families and society. The MMHA's Everyone's Business campaign calls for all women throughout the UK who experience a perinatal mental illness to receive the care they and their families need, wherever and whenever they need it. The MMHA currently comprises over ninety organisations, including professional bodies such as Royal Colleges and organisations that represent, or provide care and support to, parents and families.

Introduction

This response is on behalf of five organisations; NSPCC Cymru/Wales, the National Centre for Mental Health, Mind Cymru, the Mental Health Foundation and the Maternal Mental Health Alliance, Everyone’s Business campaign. Together we are pleased to have the opportunity to respond to the Cabinet Sectary for Health and Social Services update on the Children, Young People and Education Committees Recommendations from the Perinatal Mental Health inquiry.

We welcome Welsh Government’s commitment to improving perinatal mental health care in Wales, and we are very pleased to see that there has been progress towards meeting some of the recommendations highlighted in the Children, Young People and Education Committees Inquiry into Perinatal Mental Health. However, we are disappointed that more progress has not been made.

Since 2016, NSPCC Cymru/Wales, the National Centre for Mental Health, Mind Cymru, the Mental Health Foundation and the Maternal Mental Health Alliance, Everyone’s Business campaign have worked together to carry out a research project which explored perinatal mental health care in Wales. The aim of the research was to map out perinatal mental health provision (statutory and voluntary) and understand more about how perinatal mental health care was being experienced by women and their partners. The research report ‘From bumps to babies: perinatal mental health care in Wales’ was launched in June 2018, and it contained 24 recommendations for improving perinatal mental health care in Wales.

The findings from our research showed that important progress has been made in the provision of perinatal mental health care to women and their families in Wales. Following investment by the Welsh Government in 2016, there are now specialist community perinatal mental health services in six out of the seven health boards and developments in the seventh in improving other parts of the perinatal pathway. These services were shown to provide invaluable support to women and their families affected by perinatal mental health conditions in Wales. This progress should be celebrated. However, our findings also demonstrated that women in Wales are still not receiving all aspects of care that they need to help them recover from perinatal mental health problems. Critical improvements are needed across the perinatal mental health pathway at universal, specialist and inpatient levels to better support women and their families facing these conditions. Improvements must be made in universal services to ensure that personal, professional and organisational barriers to the identification of perinatal mental health problems are addressed and removed.

Improvements are also needed across specialist community perinatal mental health services because there remain unacceptable inconsistencies in both the level of perinatal mental health services and the types of support provided across health boards in Wales. This means that, despite improvements, the area in which a woman lives still determines the specialist care they can access when it is needed. Further investment is needed to address the disparity in the specialist service provision between health boards in Wales. This would enable all specialist perinatal mental health services in Wales to ‘Turn Green’ on the Maternal Mental Health Alliance (MMHA) map of specialist perinatal mental health services. It is also essential that appropriate mother and baby unit provision is made available for women and their families affected by the most severe perinatal mental health conditions, as recommended by NICE guidelines. These shortfalls need to be addressed before Wales can lead the way in delivering high quality perinatal mental health care to women and their families.

Our response, will focus on the recommendations that we feel are key priorities for driving change in perinatal mental health care in Wales.

Recommendation 1: The Committee recommends that the Welsh Government establish and provide national funding for a clinician-led managed clinical network (MCN). The MCN should be provided with the necessary resource including senior clinical and administrative time, and a training budget. This will enable it to provide national leadership, coordination and expertise for the further development of perinatal mental health services and workforce, including in relation to quality standards, care pathways, professional competencies and training resources. The MCN should maintain the current Community of Practice to encourage and develop effective joint working and communication among all relevant professionals.

We are pleased to see that the Welsh Government has committed to funding for the development of an MCN, including provision for senior clinical and administrative time and a training budget. In our research, we recommended that establishing a perinatal mental health Managed Care Network should be a priority action as we felt it would help provide national leadership on implementing the National Assembly for Wales Children, Young People and Education Committee recommendations, and provide the necessary expertise to further develop perinatal mental health services in Wales.

Establishing an MCN is an important step forward, as it has the potential to foster collaboration and co-ordination across health boards to design and develop equitable evidence based perinatal mental health services; to reduce the need for tertiary and inpatient specialist care; to ensure best mental health outcomes through effective service delivery and enhanced professional expertise; to optimise early years health and development through the use of interventions which promote the mother-infant relationship; and to develop agreed protocols for access to and use of inpatient mother and baby beds[1].

It is important that membership of the network has representation from all sectors and disciplines working with women in the perinatal period. We recommend that the Welsh Government ensure that women and their families affected by these conditions, as well as relevant third sector organisations are also represented on the MCN.

Key Recommendation:

· We recommend that Welsh Government ensures that women and their families affected by perinatal mental health conditions, as well as relevant third sector organisations have representation on the MCN

Recommendation 6: That the Welsh Government, based on the evidence received, establish an MBU in south Wales, commissioned and funded on a national basis to provide all-Wales services, staffed adequately in terms of numbers and disciplines, and to act as a central hub of knowledge and evidence-based learning for perinatal mental health services in Wales.

Recommendation 7: That the Welsh Government, in light of the fact that an MBU in south Wales will not necessarily be suitable for mothers and families in mid and north Wales, engage as a matter of urgency with NHS England to discuss options for the creation of a centre in north east Wales that could serve the populations of both sides of the border. More certainty should also be established by the Welsh Government in relation to the ability of the Welsh NHS to commission MBU beds in centres in England where those are deemed clinically necessary.

As many as one in ten women experience mental ill health during pregnancy or in the year after birth, including severe depression, anxiety and in some cases postpartum psychosis, which affects 1-2 in every 1000 new mums each year. Postpartum psychosis should always be considered a medical emergency because of its rapid onset, the severe symptoms experienced, and its strong associations with maternal suicide. The most recent MBRRACE Confidential Enquiry into Maternal Deaths (2018), which was published earlier this month, showed that once again that suicide is the leading cause of maternal death for women over the 12-month period following childbirth[2]. Most women experiencing postpartum psychosis and other severe perinatal mental health conditions will need to be treated with medication and admitted to hospital for in-patient support. These women should be treated in a specialist mother and baby unit (MBU) designed and resourced to offer specialist treatment to mums for their mental health difficulties, while also supporting them to meet the physical and emotional needs of their infants and to develop healthy relationships. Wales not having a MBU is a huge concern for the safety of women and their children experiencing the most severe perinatal mental health conditions.

Our research findings also highlighted that women and their families are facing avoidable emotional and financial suffering because they were unable to access a mother and baby unit in Wales. Accounts were given of women and their families having to travel significant distances to be admitted to MBUs in Nottingham, Derby, Exeter, Birmingham, Manchester, London and Staffordshire, when they were so acutely unwell. Health professionals described the financial burden that admission to MBUs in England placed upon families. Examples were given of partners and family members having to take time away from work and having to pay to stay in hotels when visiting their partner and baby. These financial pressures were perceived to add further stress to an already traumatic experience for families. Some health professionals also raised concerns about Welsh language provision and how MBUs in England would be unable to provide services in Welsh. This was felt to be potentially harmful to families who were Welsh speaking, and did not reflect an equitable service for all women.

Though we welcome Welsh Government’s commitment to develop specialist inpatient perinatal mental health care in Wales and the work that WHSSC have carried out to identify the level of demand, we are disappointed that mother and baby unit provision has not yet been established in South Wales, nor has a decision been made about the procurement of MBU beds for women in North Wales. It is over a year since the announcement of the commitment to develop specialist inpatient perinatal mental health care in Wales and we urge Welsh Government to make sure that all women in Wales needing specialist inpatient care have equitable access to MBU provision as a matter of urgency. This provision needs to be well integrated with specialist services so women can access seamless perinatal mental health care.

Key Recommendation:

· The Welsh Government and health boards should work with the MCN to design fit for purpose mother and baby unit (MBU) provision in Wales which supports women and their families at the earliest opportunity

Recommendation 5: That the new managed clinical network (see recommendation 1) prioritises the production of guidance for professionals and information for patients on the evidence-based benefits admission to an MBU can have for mothers, babies, and their families so that more informed decisions about treatment options can be taken.

We welcome the plans to develop guidance on admissions to a MBU, and stress the importance of establishing a universal pathway for admission as part of this work to ensure that specialist provision is accessed by those that need it. We also recommend that the MCN should develop information leaflets for women, and their partners/families/supporters[3] on MBU admissions, as a way of reducing stigma about MBU admissions. The leaflets should include information about what MBUs are and why they are important, what women can expect during their stay, treatments and therapies, what women need to bring, provision for partners/families/supporters, what happens when they are discharged.

Key recommendation:

· The MCN should develop protocols for accessing MBU provision and a universal pathway for admission to ensure that specialist provision is accessed by those that need it

· The MCN should develop information leaflets for women, and their partners/families/supporters on MBU admissions, as a way of reducing stigma about admissions

Recommendation 9: That, on the basis of an ‘invest to save’ argument and following analysis of the forthcoming evaluation of services and Mind-NSPCC-NMHC research results, the Welsh Government provide additional funding to Health Boards to better address variation so that service development and quality improvement can be achieved by expanding existing teams. To enable all community perinatal mental health services to be brought up to the standard of the best, the mechanism adopted by the Welsh Government to allocate additional funding should have as its primary aim the need to address the disparity in provision between Health Boards in Wales.

As previously indicated, our research found encouraging developments in the provision of perinatal mental health care in Wales. Following investment from the Welsh Government there is now a specialist community perinatal mental health service in six out of the seven health boards in Wales, addressing many previous gaps in provision. However, findings indicated that differences in funding allocation has meant that there are inconsistencies in the model of care that perinatal services deliver across health boards in Wales. Clear differences were identified in relation to referral criteria and in who can refer into perinatal services, the period of time in which services support women, staffing and interventions available between teams. This means that despite improvements, the area in which a woman lives still determines the specialist care they can access when it is needed.

Our findings also reveal that the majority of perinatal mental health services in Wales are not able to provide all aspects of care that women need, and are therefore not able to meet all CCQI quality standards. We highlighted that further investment was needed to address the disparity in the specialist service provision between health boards in Wales and so we welcome the additional £0.5m that has been committed to perinatal mental health services by health boards across Wales as part of the mental health transformation fund. We recognise that this will contribute to improving the provision of perinatal mental health services in Wales. However, we feel it is important to determine where this additional funding has been allocated, and how it has been used to improve provision in line with the CCQI standards. We recommend that one of the first tasks of the MCN will be to update the mapping of specialist perinatal mental health services, identifying any new developments in staffing, interventions offered and service aims and objectives. This will help to identify whether additional services in Wales have ‘Turned Green’ on the Maternal Mental Health Alliance (MMHA) map of specialist perinatal mental health services and where gaps remain. It will also help to compare progress to provision in England, which is on track to have Green compliant services as a result of government investment.

Key Recommendations:

· Following additional investment from the mental health transformation fund, the MCN should update the mapping of specialist perinatal mental health services, identifying any new developments in staffing, interventions offered or service aims and objectives. This will help to identify remaining gaps in provision.

· The Welsh Government should provide additional funding to health boards to address disparity in the level of perinatal mental health service provision and to ensure that these specialist services are able to provide all aspects of care that women need to help them recover. This would enable all specialist perinatal mental health services in Wales to ‘Turn Green’ on the Maternal Mental Health Alliance (MMHA) map of specialist perinatal mental health services

Recommendation 11: That the Welsh Government ensure all Health Boards invest in signing up fully to the Royal College of Psychiatrists’ quality standards for perinatal mental health services in order to realise the benefits of peer review, shared learning and service benchmarking.

One of the aims of our research was to explore the extent to which perinatal mental health services were meeting national quality standards, as outlined in the Centre for Quality Improvement (CCQI)[4]. The assessment of the data using the quality standards framework indicate that 87 per cent of basic standards are being met by perinatal mental health teams in Wales. It also shows that almost two thirds (70 per cent) of standard type two and over half (60 per cent) of standard type three were being met by perinatal mental health teams in Wales.

In our research, we identified that two services had already signed up to the Royal College of Psychiatrists’ quality standards for perinatal mental health services for review and accreditation. The quality network works with perinatal services to improve the standards of mental health care for new mums. They support services to evaluate their performance against a range of standards and reflect on findings through a peer review process, sharing best practice, and approaches to service improvement through an active network. The Welsh Government’s response falls short of ensuring all LHBs fully sign up to the Royal College of Psychiatrists’ quality standards for perinatal mental health services. Signing up for review and accreditation will enable perinatal mental health services to benchmark their service against quality standards, as well as benefit from peer review and shared learning. We urge the Committee to press for all LHBs to invest in fully signing up to the Royal College of Psychiatrists’ quality standards for perinatal mental health services.

Key Recommendation:

· All local health boards invest in fully signing up to the Royal College of Psychiatrists’ quality standards for perinatal mental health services for review and accreditation

Recommendation 14: That the Welsh Government review information provided in standard pre- and post-natal packs given to women in Wales to ensure that it includes the necessary details about emotional well-being, perinatal mental health and where to seek help and support.

We welcome the work being done by Public Health Wales in respect of information provided to parents about well-being and perinatal mental health, and the options being considered for alternative ways to disseminate.

Findings from our research showed that lack of knowledge to recognise signs and symptoms of perinatal mental health conditions, was a significant barrier that women faced in accessing professional help or support with perinatal mental health problems. Women described having a lack of understanding about the full range of perinatal mental health conditions (beyond depression and anxiety), poor recognition of symptoms, and difficulties assessing the severity of their experiences. An absence of sufficient, accessible and good quality information resources on perinatal mental health conditions was reported to be a factor in the difficulty of recognising signs and symptoms. Only 23 per cent of women recalled being given any information or resources about perinatal mental health conditions. Over half of the women (N=44, 65 per 25 cent) and 5 out of 6 of the dads/partners indicated that they would have liked additional information on perinatal mental health problems. This included:

- Signs and symptoms of the full range and spectrum of conditions

- Local support services

- Third sector groups

- Factsheets on medication in breastfeeding

- Helpful books and websites

- Stories/case studies of women who had experienced perinatal mental health problems

- Information about how to support partners and the wider family members affected by perinatal mental health problems

We recommend that the perinatal mental health and wellbeing information being reviewed by Public Health Wales should incorporate all perinatal mental health conditions (depression; anxiety; obsessive compulsive disorder (OCD); post-traumatic distress disorder (PTSD); eating disorders and postpartum psychosis), their symptoms and prevalence. There should also be some information about the risk factors for women experiencing perinatal mental health conditions. The information should also explicitly discuss the stigma around experiencing perinatal mental health problems and the importance of talking about it and getting help early. It would be helpful if this information made to reference the new specialist perinatal mental health services in Wales and that women might be referred if they need specialist support. Similarly, it would be helpful if some information on mother and baby units was included. Such as what MBU’s are and why they are important, what women can expect during their stay, treatments and therapies, provision for partners. We also recommend including some lived experiences stories of women and their families affected. We urge Public Health Wales to develop any new information with consultation from the wider perinatal mental health community of practice and women and their families with lived experience.

Key Recommendation:

· Women and their families need clear and consistent information on the effects that pregnancy and childbirth can have upon mental health. Public Health Wales should update Bump, Baby & Beyond with the latest evidence about prevalence and signs and symptoms of the full range of perinatal mental health conditions (from mild to severe), where to obtain help, and how to promote positive mental health in the perinatal period

· All new information should be developed in consultation with the wider perinatal mental health community of practice and women and their families with lived experience

Recommendation 16: That the Welsh Government works with the relevant bodies to ensure that perinatal mental health is included in the pre-registration training and continuous professional development (CPD) of all health professionals and clinicians who are likely to come across perinatal women. The Welsh Government should ensure coverage of perinatal mental health as a discrete topic within midwifery and health visiting education is improved and forms part of the pre-registration mental health nursing programme. The Royal College of General Practitioners’ core curriculum for general practice training also needs to better equip GPs to deal with perinatal mental health problems.

In our research, a lack of training was identified as a barrier to the identification and management of perinatal mental health problems. Only 18 per cent (N= 8) of the health professionals who took part had a perinatal mental health component in their pre-qualification training. Over half of the health professionals (N= 27, 61 per cent) had received training on perinatal mental health in their current role. The content, time and method of delivery for this post registration training differed quite considerably. Some health professionals described attending university courses or specialist perinatal mental health training and others talked about receiving short mandatory updates, or completing online modules. We found that there was considerable appetite for further training in this area. 90 per cent (N=40) of health professionals reported that they would benefit from additional training in this area. Given the important role that health professionals play in the early detection of perinatal mental health problems, we recommend that all health professionals working with women in the perinatal period receive training on how to recognise and appropriately respond to the full range of perinatal mental health conditions (mild to severe).

Given the strong commitment in Wales towards ensuring that all babies have the best start in life, it is vital that all health professionals working with women in the perinatal period receive training on perinatal and infant mental health, and how to support health attachments and bonding between parents and children. Our findings showed that there are some considerable gaps in training for professionals on infant mental health. Only 6 (13 per cent) of health professionals reported having an infant mental health component in their pre-qualification training. Over half (N=27, 61 per cent) reported not receiving infant mental health training in their current role. Our findings showed that health professionals are keen to improve their knowledge, skills and training around infant mental health, with 84 per cent (N=37) highlighting that they would benefit from additional training on infant mental health. These findings highlight the need to refocus attention on the mother-infant relationship, and ensure that health professionals working in the perinatal period have sufficient training and skills to support women to build healthy relationships with their babies. We recommend a more integrated approach to perinatal and infant mental health education and training, to ensure that all health professionals working in the perinatal period can support mums to develop healthy and attuned relationships with their babies.

Key Recommendations:

· Perinatal mental health should be incorporated into pre-registration training for all mental health practitioners and all health professionals working in the perinatal period. Training should include how to recognise and appropriately respond to the full range of perinatal mental health conditions, from mild to severe, and address the association between perinatal mental health and infant mental health

· The Managed Clinical Network (MCN) should develop a standardised post-registration training course that perinatal mental health teams can deliver to all health professionals involved in the care of women in the perinatal period, as a way of building capacity within

· The Welsh Government should promote a more integrated approach to promoting and protecting positive perinatal mental health and infant mental health, with a particular focus on supporting mums affected by perinatal mental health problems to build positive relationships with their babies/children

Key Recommendations from this response:

· The MCN should develop protocols for accessing MBU provision and a universal pathway for admission to ensure that specialist provision is accessed by those that need it

· The MCN should develop information leaflets for women, and their partners/families/supporters on MBU admissions, as a way of reducing stigma about admissions

· All local health boards invest in fully signing up to the Royal College of Psychiatrists’ quality standards for perinatal mental health services for review and accreditation

· All new information should be developed in consultation with the wider perinatal mental health community of practice and women and their families with lived experience

We would be pleased to discuss any of the areas we have outlined in our response in further detail if this would be helpful to the Committee.

[2] See, Knight, M., Bunch, K., Tuffnell, D., Jayakody, H., Shakespeare, J., Kotnis, R., Kenyon, S., Kurinczuk., J. J (2018) (Eds.) Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014–16. The Maternal, Newborn and Infant Clinical Outcome Review programme: MBRRACE-UK.

[3]Action on Postpartum Psychosis have developed information for partners on MBU admissions. See Postpartum Psychosis: a guide for partners (2014) accessed via: https://www.app-network.org/wp-content/uploads/2013/12/Postpartum-Psychosis-a-Guide-for-Partners.pdf

[4] The quality network works with perinatal services to improve the standards of mental health care for new mums. They support services to evaluate their performance against a range of standards and reflect on findings through a peer review process, sharing best practice, and approaches to service improvement through an active network. See: https://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualitynetworks/perinatal/