Created in 2017 to address an unmet need, the Hertfordshire Community Perinatal Team (CPT) is a multidisciplinary specialist mental health service. The CPT works with women who are experiencing or at risk of developing a range of mental illnesses, as well as their babies and families, from pre-conception up to 12 months post-partum
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
Created in 2017 to address an unmet need, the Hertfordshire Community Perinatal Team (CPT) is a multidisciplinary specialist mental health service. The CPT works with women who are experiencing or at risk of developing a range of mental illnesses, as well as their babies and families, from pre-conception up to 12 months post-partum. Early intervention can help keep mothers mentally well and also prevent their children from experiencing the emotional, cognitive and social developmental problems that can arise from perinatal mental health (PMH) disorders in their mothers. Community perinatal mental health services were very limited prior to creation of this new team. Extensive mapping was completed by Hertfordshire’s Perinatal Joint Commissioning Group (PJCG) in 2016. The availability of services at that time was well understood and the gap in specialist community support was identified as an area that needed to be addressed. The need for the CPT has been evident since it was launched. It was anticipated that the team would see 300 women per year as resourced by the original Wave 1 funding. However the team has far exceeded expectations in its first year both in terms of its activity level and outcomes. The team received approximately 1600 referrals in its first year and saw 700 women.
Specialised interventions such as pre-conception counselling, pre-birth care planning, and joint clinics with obstetricians have all been established as well as perinatal specific psychology OT and Nursery Nurse interventions and advice and training for other health professionals. Positive feedback has been received and best practice is being shared. The team has recently been successful in its bid for additional funding to expand the service further. A full list of the activities is below: • pre-conception counselling and pre-birth care planning for women at high risk of perinatal mental health problems • clinics held at local hospitals and children’s centres throughout Hertfordshire, as well as home visits • joint antenatal/psychiatric clinics • early telephone triage; assessments;, follow-up and care coordination • specialist interventions from nursery nurses, psychologists and occupational therapists • prescribing advice for pregnancy and breastfeeding • advice and joint working with other mental health professionals and other relevant teams especially midwives, health visitors and children’s services • close liaison with the local mother and baby inpatient unit (MBU) including supporting home leave and safe early discharge • education, training and advice on perinatal mental health and prescribing for GPs, mental health professionals, Midwives and others, including students. The service has made a difference by achieving the following so far: • an evaluation of 70 service users showed their average initial Clinical Global Impression (CGI) to be 4.11 (moderately unwell). At discharge their average score improved to 1.3 (very much improved) • average wait time from referral to telephone assessment is 6.48 days and for a face to face assessment is 31.89 days • women in Hertfordshire can now access specialised PMH treatment. This has kept high risk women well in the perinatal period, and allowed for appropriate care tailored to the needs of the woman. • four joint clinics established monthly addressing a woman’s mental health needs and pregnancy care in an integrated fashion, allowing for joined up care in non-stigmatising environments.
What makes your service stand out from others? Please provide an example of this.
The CPT is one of 20 new services funded with Wave 1 funding. The service was set up and became operational very quickly (within 4 months of funding being won) and was one of the earliest of the newly funded teams to do this. The joined up commissioning structures behind the CPT and the close working between commissioners and providers has facilitated and enabled the CPT to be successful so quickly. A large focus of the work of the CPT is on integration and joint working with other services including antenatal services, health visiting and children’s centres. All clinics are held in accessible and non-stigmatising environments, and most of the other work is done in families’ homes. The CPT has close working relationships with all other local professional partners who work with women in the perinatal period, both in Hertfordshire and on it’s borders where Hertfordshire residents give birth outside of Hertfordshire.
How do you ensure an effective, safe, compassionate and sustainable workforce?
All new staff receive an intensive induction programme which has already been developed and was delivered to existing CPT staff. This will include three days of specialised perinatal training and followed by opportunities to shadow staff in the MBU and the CPT. As the provider of inpatient and community perinatal services, HPFT have extensive experience and knowledge in the area of perinatal mental health. In addition, strong partnerships are already embedded between the CPT, the two local maternity units and the community trust to deliver information and learning across the perinatal pathway to support new and existing staff. A benefit of already providing a specialist PMH service is the ability for new staff to shadow not only existing staff in the CPT and Thumbswood MBU, but also staff members in partner organisations (as appropriate). This not only helps them to understand how the team works through on the job training, but new staff members also bring fresh thinking and potentially be able to suggest positive changes to enable greater efficiencies in the team. We ensure new staff receive specialist training including for example: • The new Consultant Psychiatrist will attend the Royal College of Psychiatrists Perinatal Masterclass training. • Nursery Nurses will attend specific training in infant massage and the Solihull approach • The Psychologists will receive training in Schema therapy, Circle of security, EMDR, Emotional Coping Skills (ECS) and adapted DBT for perinatal. • Several staff have completed or are enrolled in IMHOL (Infant Mental Health Online) training • A range of staff will receive training in Video Interactive Guidance. Staff all receive regular supervision and there is a reflective practice group held monthly, facilitated by one of the psychologists. Feedback from women with lived experience is already used to inform practice and development of the team. There are plans to develop peer support groups across the county over the next 6 months.
Who is in your team?
Consultant x 1 1.0WTE Reg x 1 0.7WTE Team leader x 1 band 7 – 1.0WTE Community psychiatric nurses x 3 band 6 – 0.8WTE Social worker x 1 band 6 -1.0WTE OT x 1 band 6 – 0.8WTE OT x 1 band 7 – 0.8WTE Nursery Nurse x 1 band 4 – 1.0WTE Psychologists x 2 band 8a – 0.5WTE Admin x 1 band 4 – 1.0WTE
How do you work with the wider system?
There are key touchpoints along any woman’s perinatal journey where there must be engagement with a health professional as part of the clinical maternity care. These professionals are key in assessing and referring to the CPT: TOUCHPOINT Midwifery and Obstetric Services ROLE Assess women during antenatal and postnatal check ups INVOLVEMENT 1. The Consultant Psychiatrist, Speciality Doctor and Obs & Gynae Consultants from both Hertfordshire Acute Trusts deliver joint antenatal clinics. 2. The Consultant Psychiatrist and Team Leader have established bi-monthly interface meetings with Obstetric and midwifery leads. A CPT CPN also attends a monthly meeting with the midwifery team at Barnet general hospital Regular meetings are being set up at Princess Alexandra Hospital, Harlow; Luton and Dunstable and Stoke Mandeville Hospitals H TOUCHPOINT Health Visitors ROLE Assess women and infants during postnatal check-ups INVOLVEMENT The CPT Consultant Psychiatrist and Team Leader have established bi-monthly interface meetings with the lead Health Visitor for perinatal mental health. TOUCHPOINT Children’s centres ROLE To register all families in area INVOLVEMENT The CPT staff members deliver clinics/group sessions across Hertfordshire’s Children’s centres working alongside them to maximise accessibility, reduce stigma and promote integration into the local community. TOUCHPOINT GP ROLE Register new births 6 week postnatal review of mother and infant INVOLVEMENT GP locality meetings, GP newsletter through the CCGs, GP training events. In addition, the wider mental healthcare system also engages with families in the perinatal period (all services provided by HPFT): • Thumbswood MBU • IAPT (providing psychological interventions) • Crisis Teams • RAID (liaison psychiatry) • Community MH Teams
Do you use co-production approaches? If so, please illustrate how you involve individuals, families and carers to drive improvement and deliver services?
Some of the positive comments received so far: o “they do a brilliant job” o “I’m always able to talk to someone” o “I’m really impressed with the speediness of the CPT” • priority will be placed on gathering feedback from women with a lived experience and their family as well as staff and referrers. Additional funding will enable the following participation: o A survey of mothers and their partners who have been seen by the CPT – The East of England Network has commissioned a specialist piece of engagement work with CPT service users in Hertfordshire led by a patient experience rep. This involves gaining feedback on the service to help formulate ongoing service design, in particular the design of interventions. Following this work, service users will be invited to participate in an ongoing service development group o The Peer Experience Listening Team will work with mothers, their partners and families, and staff to gather qualitative feedback in interview style settings. These experts by experience will co-produce a specific project; evaluating progress, and the impact of the expanded CPT o Mothers and their partners will be offered the opportunity to share their experience at HPFT Board meetings and CCG governing body meetings o Peer Support Groups will be set up and co-facilitated initially by the OT and nursery nurses, with some initial focus on adjustment to parenthood in the context of mental illness. The CPT will work with HPFT’s service user inclusion and engagement team to train up mothers who wish to be involved to co-facilitate this group going forward o The CPT will work with New Leaf Wellbeing College, HPFT’s recovery college to develop a programme to support mothers and fathers recovering from perinatal mental illness.
Do you share your work with others? If so, please tell us how.
At Hertfordshire Clinical Commissioning Group’s (CCG) Perinatal Mental Health conferences, a virtual multi-disciplinary network has been established for sharing learning with partner organisations. The CPT has been the first community perinatal team in the East of England to be set up following funding from NHS England. Through the East of England Perinatal Clinical Network, the CPT has shared its successes, challenges, learning, policies and documentation with the two other perinatal services funded in Wave 1 NHSE perinatal funding and has offered to support the other 3 new East of England perinatal teams funded in Wave 2 NHSE perinatal funding The CPT received a ‘highly commended’ award at the 2017 Positive Practice in Mental Health awards. As a result, other organisations contacted the team and information has been shared with them to assist with developing their own community perinatal service. CPT learning is and will continue to be communicated via: • liaison meetings with midwives and health visitors; • engagement and training events with GPs; • medical CPD; • sharing Good Practice newsletters & conferences; • Lunch and Learn events; • social media – including PMH groups on Twitter; • learning notes (summaries of incidents and recommendations).
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
Referrals are being triaged quickly, with clinics no more than a 30 minute drive away from service users homes. Working in partnership with mental health teams and other services in contact with women has enabled clinics to be established in various community settings including children’s centres and all of Hertfordshire’s obstetric units. Information, counselling, care coordination and specialist interventions are available for women, their partners and families. Full details of the many positive outcomes are listed below: • team was created from scratch, fully recruited and began clinical work in March 2017 • team is cohesive, hard-working and happy • 1600 referrals received and triage attempted in the first 12 months (against expected/resourced 300) • 300 service users taken on • joint working established with community mental health teams, Crisis and Liaison teams, Child and Adolescent Mental Health Services (CAMHS), Eating Disorders team • use of a variety of community locations including clinics and children’s centres across the county means no service user has to drive more than 30 minutes to access the service (and many home visits also undertaken) • eligibility criteria mean that the mother (and her baby) is the focus of care provided • all staff have been trained on infant emotional development • joint antenatal/psychiatric clinics are held at all of Hertfordshire’s obstetric units • close liaison with Thumbswood mother and baby unit (MBU), facilitating home leave, earlier safe discharge and preventing relapses • providing pre-conception counselling • working in partnership with other mental health teams and services in contact with women (antenatal services; primary care; health visitors, children’s social services).
A swift referral process and partnership approach has enabled earlier diagnosis, recognition and intervention. • providing information, care coordination and limited provision for specialist interventions e.g. perinatal psychology, nursery nurse and occupational therapy interventions for pregnant women and their partners/families • positive feedback received from service users, carers, healthcare professionals and other agencies • sharing best practice with East of England network as perinatal services are developed in other areas • group training sessions provided to community mental health teams, midwives, health visitors, and other training/education for individuals • NHS England has recognised the team’s achievements and funded expansion of the team • local commissioners have agreed to continue funding the expanded service after the initial funding ends.
Has your service been evaluated (by peer or academic review)?
The CPT is registered with the Quality Network for Perinatal Mental Health Services, an initiative of the college Centre for Quality Improvement (CCQI). The CPT meets the CCQI Perinatal Community team standards and is National Institute for Health and Care Standards (NICE) compliant. The service commenced the accreditation process with the CCQI for PMH Services, with a very positive peer review in November 2017. An accreditation visit is anticipated for end of 2018 / early 2019. The service is confident it is delivering care and interventions in line with national evidence-based standards and guidance. The CPT is already integrated with Thumbswood mother and baby unit (MBU), out of area MBUs and Hertfordshire maternity services; therefore meeting the recommendations in both the MH5YFV and the national maternity review, Better Births The CPT has undergone an interim evaluation as part of it’s commitment to NHS England and the final evaluation will be due in 2019. The team is currently embedding regular outcome measures at assessment and discharge.
How will you ensure that your service continues to deliver good mental health care?
NHS England has recognised the team’s achievements and awarded further funding that will enable the following: o consultation liaison with GPs to support women being managed in primary care and prevent deterioration o specialist training for other mental health teams, midwives, GPs and health visitors; this is a recognised gap o provide support for fathers/partners of the unwell mother o greater capacity to respond to urgent and emergency presentations with perinatal specialist clinicians o greater care co-ordination capacity reduced caseload numbers allowing staff to work safely and effectively as well as increasing overall caseload capacity o greater capacity for Consultant Psychiatrist consultation, allowing time for emergency home visits and shorter waiting lists o timely provision of pre-conception counselling o video Interactive Guidance (VIG) training and delivery o specialist provision through the increase in Speciality Doctor, Psychologist and Occupational Therapist (OT) whole time equivalents (WTEs), allowing for greater caseload capacity and specialist interventions such as Emotional Coping Skills groups and Circle of Security o increased Nursery Nurse provision providing preventative work. • local commissioners have agreed to continue funding the expanded service after the initial funding ends • recruitment of the new posts has already begun and is anticipated to be completed by the end of Summer 2018, with Induction planned for end of September 2018.
What aspects of your service would you share with people who want to learn from you?
The service has encountered the following challenges: • service demand has exceeded capacity of the team, leading to high pressure of work. Increased funding has been received to recruit more clinical and administrative staff • inappropriate referrals are being reduced by using increased funding for: o delivery of a training programme to increase awareness and knowledge and upskill primary care o additional consultant time allowing for increased telephone liaison with GPs and antenatal services • some women are reluctant to ask for perinatal mental health support from professionals with whom they have little/no relationship. The service has been developed to deliver more care in family’s homes, and non-stigmatising community and acute healthcare settings as well as other centres the mothers are already attending • 72% of women taken on are seen within 6 weeks. The main delay for others is access to psychiatric assessment. This is being addressed by doubling the medical input with the additional funding.
Brief description of population (e.g. urban, age, socioeconomic status):
Size of population and localities covered:
The service covers families in Hertfordshire experiencing or at risk of moderate – severe mental health problems during the perinatal period. The perinatal period is the period of time during pregnancy and up to the child’s first birthday. ONS data gives a birth rate of 14,500 lives births annually in Hertfordshire, with an expected prevalence of 725 women (5%) having moderate – severe mental health problems per year. As an organisation HPFT provides health and social care for over 400,000 people with mental ill health, physical ill health and learning disabilities across Hertfordshire, Buckinghamshire, Norfolk and North Essex.