This submission is about how a small specialist perinatal mental health service is implementing the key priorities of the NICE antenatal and postnatal mental health (ANPNMH) guideline.
This example was originally submitted to demonstrate implemention of NICE guideline CG45. This guideline has now been updated and replaced by CG192. The practice outlined in this example has been reviewed and is consistent with the updated NICE guidance. The updated guidance should be referred to if replicating practice described in this example.
Aims and objectives
The aim of the initiative was to set up a service that would improve health outcomes for women in Sheffield who had mental health problems and were pregnant, who were thinking of becoming pregnant, or who had given birth in the last 12 months.
The service was commissioned to provide perinatal mental health care for women in Sheffield, but will see women living outside the area if agreed with their PCT. It aims to provide a flexible service that meets the needs of the women and their families who have been referred. Appointments are offered in a number of locations, such as antenatal clinic, home visits, Sure Start premises, as well as at the perinatal mental health service office base, the Michael Carlisle Centre. There is no waiting list and appointments are offered quickly, usually within a month.
The service uses the ANPNMH NICE guideline on a daily basis and promotes its implementation. The service has a plan covering all the key priorities: Prediction and detection. The care pathway is based on the integration of the NICE guideline stepped care model with the IAPT stepped care model. The care pathway gives clear guidance on when, to whom and where to refer. The service has a training plan, most of which has been delivered. A baseline audit of midwives knowledge and confidence before training and of their use of the Whooley questions was completed in 2010 and will be repeated to measure the effectiveness of a rolling programme of training for midwives. Psychological treatments. The service has no psychologists currently working within it but has a good relationship with specialist psychology and has several case studies of women helped to access treatment and the health improvements.
The service has a consultant psychiatrist available who provides expert medical advice by face to face consultation, at CPA meetings, by telephone; to the women themselves, their GPs and to other prescribing doctors in the trust. The service has a draft leaflet on medication in pregnancy and breastfeeding based on NICE guidance. Management of depression. All women referred to the service are discussed within the multidisciplinary team and the outcome sent by letter to the referrer. Two thirds of the women are offered an assessment at a joint care clinic held at the antenatal clinic of the maternity hospital, where they can choose to see the specialist midwife. Organisation of care. The service has been at the forefront of promoting a managed care network. The service works in partnership with a newly formed group of past service users who have set up an organisation called Light to support women across the city. They are raising awareness and are also getting involved in giving feedback to the commissioners.
Reasons for implementing your project
The service was initially set up in April 2001, funded by the local health authority. Prior to this time, there was no specialist provision in Sheffield for pregnant and postnatal women with mental health problems. Evidence demonstrating the need for the service was presented to the health authority by a multiagency group consisting of more than 15 different disciplines that met from 1994 onwards. The evidence presented included data contained in numerous national documents alongside a local needs analysis. The service was set up on the premise that the funding for the service would come from savings on the use of mother and baby beds.
There had been a maternal suicide and a local audit of child deaths found that a third of all deaths involved mental health, with children under one being most at risk. The service was closed in 2007 following the departure of the consultant psychiatrist, but was re-opened within months after (unsolicited) representations from service user groups, the maternity hospital and health professionals.
How did you implement the project
The service was set up in 2001 with a budget of £50,000 p.a. to cover all staff and office costs. Funding was later increased to include the appointment of a part-time psychiatrist. The service was structured to enable a small staff team to manage all pregnant and postnatal women in Sheffield with mental health problems. This was achieved by setting out a clear care pathway, accompanied by a comprehensive training plan. The service originally had a maternal mental health strategy implemented through a multidisciplinary steering group but now has an implementation plan for the NICE guideline for antenatal and postnatal mental health. The Trust has a NICE implementation group covering all the relevant NICE guidelines and our service attends and reports to this group.
A detailed audit has been undertaken recently which shows outcomes for the service. The main finding is the cost saving on the use of bed days compared with other services, as specified in the NICE ANPNMH guideline. Other findings are access for women from BME communities, with the service seeing a slightly higher proportion of BME women than the Sheffield profile.
A service user questionnaire sent to all women discharged from the service over last year showed a high level of satisfaction with the service. Outcomes demonstrated over 10 years: Safety: No maternal deaths, infanticides or serious untoward incidents. Effective: Positive feedback from patients/fulfilled lives. 1 formal complaint. Cost effective: benchmarked with comparable services. NICE compliant / evidence based practice. Lower than average bed-use. Meets activity targets in timely manner, no waiting lists, low DNAs. Personalised: Flexible appointments, different days, different times, different locations including home visits. Fair: Equality of access demonstrated by data analysis of access by postcode compared to deprivation stats, and comparison with BME percentage data. Health improvement: Improved HONOS scores, Diagnoses audited.
Key learning points
The NICE guidance for ANPNMH has provided support for the use of the care pathway, which in turn has clarified professional roles and the patient journey. It has provided clear guidance on identification of mental health problems, which we have been able to audit and present back to the maternity unit staff. Women experience improved access to psychological treatments. Evidence from the guideline is essential for the use of medication in pregnancy and breastfeeding women and valued by the women and their families. The guideline can be implemented and improve outcomes even in a tiny service like ours, with dedication to making continuous small improvements rather than with large meetings and grand plans.