Commissioning antenatal and postnatal mental health services

Mental disorder during pregnancy and the postnatal period can have serious short- and long-term consequences for the health and wellbeing of a woman, her baby and other family members. The detection of women at risk of developing a mental disorder and the identification of those with a current mental disorder, followed by prompt intervention at all levels of healthcare provision, can help to minimise maternal morbidity and limit adverse effects on the baby and other family members.

In an average primary care trust (PCT) with a population of 300,000, the number of women experiencing mental disorder and requiring referral for psychological therapies will be approximately 300 per year (80 per 1000 deliveries). Around 140 women per year (40 per 1000 deliveries) will require referral to a specialist perinatal mental health service and of these about 15 will require admission to a mother and baby unit. Figure 1 illustrates the likely severity of mental disorders experienced by women during pregnancy and the postnatal period and the likely service demand.

The provision of antenatal and postnatal mental health services varies considerably across England because of local factors, including the organisation of existing mental health services, the demographic profile of the population and geographical issues.

NICE clinical guideline CG45 on antenatal and postnatal mental health makes recommendations on how the components of services may be adapted to meet local needs and deliver integrated care. This can be achieved by developing managed clinical perinatal networks. Specialist mental health commissioners and providers should ensure that there are properly developed links between specialist perinatal mental health services, social services and primary care services, with commissioning agreements in place to support service reconfiguration and redevelopment.

The philosophy of care set out in the National service framework for mental health: modern standards and service models should underpin the commissioning of all mental health services, whether specialised or non-specialised.

Benefits

The potential benefits of robustly commissioning effective antenatal and postnatal mental health services include:

• improving the mother-child relationship and subsequently the developmental and emotional state of the child
• reducing inequalities and improving timely access to services in primary care, mental health and maternity services
• reducing the risk of relapse and/or recurrence of a mental disorder
• reducing the risk of women with an existing mental disorder stopping medication in an unplanned way
• reducing the number of inappropriate referrals and readmissions and the length of inpatient stays, and offering alternatives to admission
• reducing the risk of self-harm and suicide
• preventing avoidable separation of mother and baby and promoting early return if separated
• improving performance and patient-centred clinical care through implementing the recommendations outlined in NICE clinical guidelines CG45 on antenatal and postnatal mental health, CG22 on anxiety, CG90 on depression (update), CG26 on post-traumatic stress disorder, CG31 on obsessive-compulsive disorder, CG38 on bipolar disorder, CG9 on eating disorders, CG62 on antenatal care, CG82 on schizophrenia and technology appraisal guidance TA59 on electroconvulsive therapy.
• better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing effective antenatal and postnatal mental health services are:

• identifying women with common mental disorders and/or who are at risk of developing a serious mental disorder
• enabling patient choice by providing up-to-date information about the risks and benefits of treatment before conception, when pregnant and during the postnatal period
• providing timely and appropriate care and treatment for women with common mental disorders
• providing support, advice, information and training to maternity, psychiatric and primary care services through managed perinatal networks
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning antenatal and postnatal mental health services include:

• National service framework for children, young people and maternity services and National service framework for mental health: modern standards and service models
• Maternity matters: choice, access and continuity of care in a safe service
• Confidential Enquiry into Maternal and Child Health: improving the health of mothers, babies and children
• Review of the health inequalities infant mortality PSA target
• Delivering race equality in mental health care: an action plan for reform inside and outside services
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Commissioning framework for health and well-being
• World class commissioning
• The NHS in England: the operating framework for 2009/10
• Considering the impact of patient choice
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with Standards for better health.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.