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Type and Title of Submission


Title:

Sefton maternal mental health

Description:

From undertaking a Health Equity Audit of the HV service, maternal mental health was identified by HV's across Sefton as being a key concern both in terms of the frequency of occurrence and their perceived lack of skills in prediction, detection, assessment and management of mental health difficulties. Furthermore, an audit was undertaken using the NICE Audit criteria to monitor local practice in respect of antenatal and postnatal mental health. This audit revealed a real disparity in terms of assessment across the PCT and an action plan was put in place to address this. Alongside this was the introduction of the Healthy Child Programme and it was decided to use this as a vehicle for implementation of the guidance in relation to antenatal and postnatal mental health. This piece of work only looked at the guidance in relation to prevention, prediction, detection and initial management as HV's are part of the public health workforce and focused on primary and secondary prevention.

Category:

2010-11 Shared Learning examples

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG45 - Antenatal and postnatal mental health

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

There have been several research studies highlighting the long term impact of maternal mental health difficulties on the woman, her infant and wider family. The aim of this initiative was to ensure that all mothers received a high quality mental health assessment regardless of where they lived, by staff who were equipped with the necessary skills to undertake an assessment and in most cases, initial management. The principle was that with timely intervention, the potential impact of mental health difficulties on a mother, her infant and family could be minimised. Therefore a pathway was developed that would guide a practitioner through from assessment to intervention. Historically, Health Visitors, if utilising an assessment and monitoring tool would use the Edinburgh Postnatal Depression Score (EPDS) yet from meetings with Adult Psychological Services and CAMHS it was clear that this was not a universal tool and their preferred tool was the Hospital Anxiety and Depression Scale (HADS). It was therefore decided that the HADS would be the HV service's assessment tool of choice for two reasons, firstly that it would make referrals easier between services as they would share the same language and secondly that the tool helped to interpret anxiety and depression levels separately as opposed to the EPDS which only gives a combined assessment. Additionally, a new requirement came in from the Department of Health (DH) in 2010 that all mothers had to have had a postnatal depression assessment by 12 weeks post delivery. We therefore needed to ensure a uniformity of the assessment across the PCT.

Objectives

There were several key objectives in order to implement the NICE guidance effectively;- - Establish small working group of HV staff to examine best way to implement the guidance, this was pivotal to its success - Work with individual HV teams to ensure they were aware of the relevant NICE guidelines and be clear about how to utilise them in practice - Agree on how compliance with the NICE guidance is recorded within health records in order to meet new DH monitoring requirements - Purchase copyright to use HADS - Provide training for staff on how to undertake HADS Assessment - Map out existing services across the borough that support women and families with mild to moderate mental health difficulties and promote mental wellbeing - Develop resources for staff to use with mothers that support the guidance - Develop resources for staff on how to use the guidance in practice - Re audit compliance with NICE guidance one year post implementation.

Context

Sefton is situated on the North West coast and has large areas of deprivation with smaller pockets of relative affluence. Sefton PCT was formed from 2 smaller PCTs merging which led to a wide variation in Health Visiting practice across a small geographical area. From undertaking a Health Equity Audit of the Health Visiting Service, maternal mental health was identified by Health Visitors across Sefton as being a key concern both in terms of the frequency of occurrence and their perceived lack of skills in prediction, detection, assessment and management of mental health difficulties. Furthermore, an audit was undertaken using the NICE Audit criteria to monitor local practice in respect of antenatal and postnatal mental health. This audit revealed a real disparity in terms of assessment across the PCT and an action plan was put in place to address this.

Methods

Initially, prior to the small working group being set up there was a multi agency group with a keen interest in postnatal depression which had been in existence since 'Sure Start' began. This multi agency group organised two training days for staff which introduced the NICE guidance and addressed key issues within the guidance such as the use of the Whooley Questions, assessment and monitoring tools such as HADS and the purpose of a 'Listening Visit'. Unfortunately not all staff were able to attend the training days due to capacity issues within their teams which led to a wider variation in practice. Therefore it was decided that a small working group of HV staff would look at the implications of the NICE guidance from a HV viewpoint only. The working group looked at how the guidance could be used in practice and developed a pathway of care for a woman both in the antenatal and postnatal period. This pathway was simple to use and ensured a standardised assessment across the PCT. The main barrier to the implementation was staff capacity to attend training, so it was decided that the training needed would be done on a team by team basis to ensure the maximum number of staff would be able to attend. Therefore it was decided to implement the guidance over a three month period. Resources were developed to help implement the guidance and ensured a consistency of service across the area. After undertaking an internet search on resources for families we found a leaflet developed by Manchester PCT and they kindly agreed to us utilising and adapting their leaflet for use by our families. There were obviously some costs to this but it made a real difference to service delivery as it helps to open discussion on mental health with women. The leaflet also refers to the Whooley Questions so mothers know they will be asked these as part of a standard assessment. Another cost incurred was the purchasing of HADS copyright, although this was minimal.

Results and evaluation

As the DH require the collection of the percentage of postnatal depression assessments, we worked with our Child Health Department to look at how we collect this data. Additionally, we decided that as part of this data collection we would also look at the amount of HADS assessments we undertook to begin to build up a picture across the PCT of possible 'hot spots' of mental health difficulties to enable services to be developed according to need. Child Health are monitoring the amount of assessments we undertake and these figures are slowly increasing. This is not to say that the assessments aren't taking place but that our data collection systems are still under development. At the moment it is difficult to say what cost savings have been made as often these can only be assessed further down the line in terms of reduction of families referred to CAMHS due to relationship issues although there have been studies demonstrating the cost benefits that early intervention can have. In terms of differences for patients, all mothers are being offered a quality assessment which allows for the early identification of mental health difficulties and early intervention to minimise longer term impact on the whole family.

Key learning points

Our initial stumbling block was due to us trying to implement the guidance on too grand a scale. We tried to work together with our maternity providers and neighbouring PCTs but everyone had a slightly different way of doing things which stopped the work from moving forward. We therefore decided to start small and focus the guidance on what we as a Health Visiting service within our PCT could do. However, like many HV?s they are often so busy dealing with their caseloads that any change is challenging. Acknowledge that change to practice take time and, takes a longer time to embed and become the norm. I think the key to success for us was having the implementation of the Healthy Child Programme and a core programme which referenced the NICE guidance as an integral part of it. This made staff take notice and give it more consideration. It was realised that trying to undertake training en masse was unsuccessful so it was decided to deliver training on a team by team basis which allowed staff to ask questions and clarify how the guidance could be used. It could be seem as time consuming for the trainer but it ensured that the vast majority of staff were available and the training was delivered at a time to suit the team. As part of the training each staff member was given a pack containing the pathway, a copy of HADS and guidance notes to accompany the pathway.



This submission was shortlisted for the 2011 Shared Learning Award.

View the supporting material

Contact Details

Name:Steph Griffiths
Job Title:Public Health Development Nurse/Health Visitor
Organisation:Sefton NHS
Address:Merton House
Town:Liverpool
Postcode:L20 3DL
Phone:Tel:01704 387075
Email:steph.griffiths@sefton.nhs.uk

 

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This page was last updated: 14 February 2011

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.