This perinatal mental health project aimed to improve practice across universal and the mental health stepped care model by embedding NICE CG192 (2014) recommendations into practice. The project involved a central vision for perinatal, including parent-infant mental health based on NSPCC (2014) vision with principles of non-judgement, compassion (NICE 2014) as an underlying philosophy and the parent-infant relationship and Think Family at its core. Systematic, operational, structural and service level developments and innovations took place within limited resources and through consultation and building relationships with stakeholders including service users.
Example
Aims and objectives
The project was guided by NICE CG192 (2014) to develop a consistent approach of best practice for perinatal mental health despite the lack of increased financial resources available. Partnership working across the health and social care economy was a priority as it is essential to enable early identification of women and families at risk from poor perinatal mental health and to prevent mental ill health occurring or escalating. Central to aiming for best practice was that universal services and mental health services across the stepped care model should recognise the mental health needs and risk to the woman and her family in the perinatal period. The Perinatal mental health lead was tasked with improving services through training, consultations, pathways, learning from practice, resources, governance structures, promoting perinatal mental health and building relationships.
Objectives included to:
• Develop clear and responsive referral pathways which were accessible to all potential referrers;
• Develop robust training that reflected NICE 2014 recommendations for all relevant practitioners, including GPs, MW, HV, Social Care, Children Centres and mental health practitioners to increase awareness regarding perinatal mental health, referral pathways, good practice (such as perinatal mental health care plans) and interventions;
• Develop specific and advanced evidence based training to address the gap in knowledge regarding the parent-infant relationship and how to effectively make interventions in the light of NICE (2014) 1.9.12-13;
• Embed training through consultations and resources;
• Establish a Perinatal Mental health Working group to promote interest and disseminate information;
• Develop champions within each mental health and health visiting team with the aim of being a team resource, promoting best practice across the Trust, and with the aim that the champions grow the skills through training and reflective practice to become a virtual team;
• Identify a named psychiatrist with an interest in this area;
• Promote a Think Family approach to mental health,
• Promote and support parent-infant mental health;
• Support health visiting and midwifery to develop their guidelines and standards;
• Develop care pathways to embed NICE recommendations within practice;
• Develop governance structures across services that support and are impacted by perinatal mental health.
Reasons for implementing your project
There was no clear referral pathway and referrers were frustrated as they felt that they were not able to access mental health services. The lack of clarity of what the provision was and how to access it, resulted in not only the service user with mental health issues being unclear about the help available but also professionals not knowing when to refer or how. This resulted in service users being batted between services.
There was a lack of training so that practitioners were unaware of best practice and offered care was not always tailored to individual’s needs. Some practitioners lacked confidence in assessing and detecting perinatal mental health issues, this affected the quality of referrals and recognising risk. Within mental health services a lack of consistent practice resulted in areas where risk management could be improved.
There was a lack of knowledge and skills’ regarding the parent-infant relationship and the Think Family approach.
Working closely with community services, voluntary sector, local commissioners and service users the Perinatal Mental Health Lead was commissioned to write a report to ascertain current issues and to identify any recommendations. This was followed by Bradford District Care Foundation Trust (BDCFT) undertaking a NICE baseline assessment and developing an action plan which further identified specific gaps in service and recommendations for improvements.
Although there was no additional money to improve services these reports identified a number of easy cost neutral improvements which would result in much improved care for women accessing services and to increase access to women who may not otherwise have been identified. It was also recognised that early intervention and prevention could result in savings (for example prediction and detection of mental health issues, interventions aimed at improving the parent-infant relationship, responsive management of risk). We also recognised that the service had existing resources and skills that could be used to benefit the whole organisation.
Office for National Statistics (ONS) (2015) estimated 528,200 people live in Bradford District. It is an ethnically diverse area. There are approximately 8500 births per year across Bradford and Airedale and this is increasing. Some areas of Bradford suffer from the highest levels of deprivation in the country. Infant mortality is double the national average.
How did you implement the project
Service users’ views, alongside the report and baseline assessment were useful to gain buy-in from commissioners and providers. Working relationships were established with service user representation organisations.
Developing a clear integrated referral pathway, accessible to all potential referrers through a single point of access, enabled a consistent and responsive approach to perinatal mental health referrals. Practitioners at the Single Point of Access have perinatal mental health training and support via a practitioner with a special interest in this area.
As a catalyst to improving practice, training is a priority. NICE guidance informed the training packages. A 3 tiered rolling program training package was developed tailored to service needs. Multidisciplinary Perinatal mental health Training for GPs, health visitors, midwives, social care and council is available. A second training is tailored primarily for practitioners working within mental health.
The third package is a specialist package focused on parent-infant mental health enabling assessment, provision of information, basic interventions and recognition of when to refer onwards. HV have consultations and an innovative Parent-Infant Relationship Resource Cards to embed the training and enable assessment, information and interventions with families. Each mother and baby also receives an antenatal and postnatal New Baby New Feelings leaflet giving advice on mental health and self-care to the mother and her family. Just Had A Baby Facilitated Self Help Booklets is an additional intervention resource.
The perinatal mental health lead supported HV and MW in developing standards which reflect NICE Guidelines. The maternal mental health project has introduced the Whooley and GAD 2 +1 and PHQ9 and GAD7 to the assessment process to MW HV and mental health, and some voluntary sector. All those using it have been trained in the use of the tool and have access to the referral pathway.
A perinatal mental health working group, consisting of interested clinicians and managers from all relevant services support service delivery improvements in each team. These Champions are working towards developing into a virtual team, through training, supervision, and reflective practice. Care pathways are in development to facilitate consistency. Work on mental health systems to assist NICE guidance adherence to assessment, care plans and preconception counselling is underway.
The original report and recommendations was commissioned by Bradford Airedale Wharfedale and Craven CCG. The care trust received monies for the release of 2 workers to carry out the initial baseline assessment gaps analysis and to create the training. To ensure sustainability has been remodelled from within the service.
The project has now developed into a full time post who now has the above as an integral part of their role and who has created a rolling program of support and training within BDCFT.
Key findings
All training is evaluated. Evaluations have been very positive with attendees stating that the training should be mandatory. Survey monkey and dip sampling has been used to follow up the impact of training and this has demonstrated that practitioners feel more confident in this area of their work. 100% of 81 respondents to the survey monkey who had attended the training said that the training has impacted their practice for the better.
Feedback from other services has been sought:
The GP Clinical Leads for Mental Health and Women’s Health within the City and District CCG were asked for their feedback, in light of their special interest. They have noticed a change in practice with Health Visitors both in regards to improved recording in notes and greater communication with GPs.
Maternity and Health Visiting across the district state that the referral pathway has greatly improved their referral experience.
The Formulary have received an increase in communication around perinatal prescribing since training has begun indicating that the issues with this are better understood and expert advice is being sort when necessary and they have provided a newsletter focused on perinatal prescribing.
The regional mother and baby unit has seen as an increase in referrals to their service since the training:
|
Year |
In-patient bed admissions |
Advice |
Referral |
Assessment |
|
2014 |
1 |
1 |
|
1 |
|
2015 |
3 |
4 |
6 |
2 |
An evaluation of the new Parent-Infant Relationship Resource Cards is underway with initial feedback from practitioners, interpreters and parents being extremely positive as the resource embeds training into practice and enables parents to access information and support in their relationship with their baby. Focus groups and feedback regarding New Baby New Feelings leaflets and Just Had a Baby Booklets was extremely positive as they facilitate practice
Service User Trust Board Stories has provided positive feedback regarding parent-infant therapy received, and secondary care input.
Work is underway to gain more insight to parents experience and feedback.
Perinatal Champions are working to develop services (clinics, groups, information) which demonstrate the awakened interest in this area by practitioners.
Learning from practice examples has led to pathways within services being changed to be more responsive to service users.
In the longer term some of the benefits of this work will be seen both in regards to better care provided by practitioners and in regards to service users experiences. Evaluations are underway for the Parent-Infant Relationship Resource Cards, Health Visiting changes to practice including clinics, Auditing capability is underway so that figures can be gathered and service delivery investigated so learning from practice can take place. An in-depth evaluation of the new Parent-Infant Relationship Resource Cards is underway. A research project focused on parent-infant relationship is planned to begin in 2016 for 5 years.
Key learning points
Despite no extra money a huge amount has been achieved in a relatively short period.
Having a Perinatal Mental Health Lead enables a focus and cohesive approach to be taken across services, promoting perinatal mental health and ensuring skills across the trust can be benefited from. Changing practice takes bottom up and top down enthusiasm and has requires passion and persistence to ensure that all the relevant services have an integrated approach.
Training is essential to increasing awareness and improving practice, but this has to be embedded and supported for example through consultations and resources. Training is of a high quality, evidence based and delivered by the Perinatal Mental Health Lead and others with expert knowledge of the subject area including parent-infant mental health. The pressure of work and capacity of services to attend training has been overcome by offering a rolling program and consultations which go to services.
There have been difficulties within the described project: different commissioning bodies i.e. CCG and public health being given similar but remits. This was overcome by creating a joint steering group involving public health local authority’s health providers and voluntary sector and service user group. This is currently enabling a strategy to develop that integrates stakeholders’ vision.