The Community Perinatal Mental Health Team (CPT) provided by Hertfordshire Partnership University NHS Foundation Trust (HPFT) is a new Hertfordshire-wide team that has been set up following a successful application for funding to NHS England. The bid to set up a new team was submitted by Herts Valleys CCG, East and North Hertfordshire CCG and was supported by Hertfordshire County Council (HCC) and HPFT. Under the leadership of a Perinatal Consultant Psychiatrist, a functioning operational service managed by HPFT has been created within four months from a baseline of only very limited perinatal outpatient time.
What we did
The Community Perinatal Mental Health Team (CPT) provided by Hertfordshire Partnership University NHS Foundation Trust (HPFT) is a new Hertfordshire-wide team that has been set up following a successful application for funding to NHS England. The bid to set up a new team was submitted by Herts Valleys CCG, East and North Hertfordshire CCG and was supported by Hertfordshire County Council (HCC) and HPFT.
Under the leadership of a Perinatal Consultant Psychiatrist, a functioning operational service managed by HPFT has been created within four months from a baseline of only very limited perinatal outpatient time:
- All posts have been recruited to (with everyone due to start by August 2017).
- A three day induction was held for the team which was very well received by the team (including attendance from staff yet to begin their new role). The induction included information from all key stakeholders within the perinatal mental health pathway. As such the team felt sufficiently trained to start seeing perinatal service users.
- The new team was officially launched in April 2017 at the second Hertfordshire Perinatal Mental Health celebration conference.
- Joint clinics established at local hospitals
- Clinics established at children’s centres across Hertfordshire
The CPT works with women, their baby and family from pre-conception up to 12 months postpartum who are experiencing a range of metal illnesses, from mild to severe, and cannot effectively be managed by primary care.
The bid for NHSE funding came as a result of extensive mapping completed by Hertfordshire’s Perinatal Joint Commissioning Group (PJCG). 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.
Feedback from all professionals has been positive with all identifying how it will benefit their families having specialist professionals available. The necessity of the team is reflected through the large number of referrals that CPT receive weekly.
The objectives of the CPT are to:
- Offer early intervention.
- Work collaboratively with key stakeholders both within, and external to, HPFT to offer families the best care.
- Put mums, their babies and families at the centre
- To prevent:
- deterioration in mental state – keep women well
- subsequent emotional, cognitive, social developmental problems in children resulting from PMH disorders.
- Be responsive within timeframe of pregnancy.
- Be a specialist service working across spectrum of risk and need.
The service offers:
- Telephone triage and early face to face assessment
- Preconception Counselling for high risk women
- Telephone Liaison for GPs / Midwives / Obstetricians / Health Visitors / other mental health professionals
- Joint Antenatal Clinics
- Birth care planning for high risk women
- Assessment / Follow up and Care coordination for new presentations up to 1 year postpartum. These can take place in non-clinical community venues such as children’s centres
- Specialist psychological, nursery nurse and occupational therapy interventions
- Joint working with other involved services
- Support for fathers / partners
Two mothers who have used the CPT have told us about their experiences:
For Louise the negative feelings spiralled. “I just wanted him out. I hated feeling him kick and when I said that to the midwife, they stepped up the interaction.”
The resulting community support helped, both during and after pregnancy. She saw consultant psychiatrist Dr Sarah Cohen, from Hertfordshire’s Community Perinatal Team, and had extra visits from midwives and full support from the local children’s centre.
“…the support I’ve had has made a huge difference.” (Louise)
Jenny commented: “I think early help is crucial. Unfortunately, it can feel like a failing to ask for help, but the services are there to provide support. I certainly wouldn’t be where I am today without them. I hope by sharing my story other women will realise it’s OK to ask for help.” (Jenny)
Wider Active Support
- Hertfordshire’s partners
To develop perinatal service in Hertfordshire, a Perinatal Joint Commissioning Group (PJCG) was formed, made up of key commissioners from both Hertfordshire’s Clinical Commissioning Groups (CCGs) and Hertfordshire County Council (HCC) (including Children’s Services, Adult Services and Public Health). It was important that the CPT developed strong relationships across Hertfordshire and within both CCG areas (Herts Valleys and East and North Hertfordshire). The effectiveness of the PJCG has enabled a whole system approach enabling partnerships to have developed across the county with:
East and North Hertfordshire NHS Trust and West Hertfordshire NHS Trust:
Hertfordshire Community NHS Trust
- Health Visitors
Hertfordshire County Council
- Intensive Family Support Team
- Specialist and Safeguarding Services
- Children’s Centres
Hertfordshire Partnership University NHS Trust (who deliver CPT):
- Wellbeing (IAPT) Services
- Crisis Assessment and Resolution Service
- RAID (Acute psychiatric liaison)
- Effective partnership working
The CPT has built on existing strong relationships with partners across the continuum of need, meaning partnership working has been established quickly. Successes achieved to date include:
- Joint clinics run at key hospitals in partnership with obstetricians
Outcome: high risk families can get support at locations convenient to them. Families get the best level of support from key professionals to support their recovery. Women are able to have their mental health needs and obstetric needs met in one appointment and location, and services are able to work collaboratively to provide a joined up integrated care plan
- Clinics run at children’s centres in key locations across Hertfordshire
Outcome: families with moderate levels of need can access support at non-threatening locations. Families can also engage with the children’s centres to receive a range of support alongside the CPT.
- Perinatal MH directory of services created. Currently being transferred into an online directory in Families First portal hertfordshire.gov.uk/familiesfirst
Outcome: CPT have access to all other PMH services in the county and can direct professionals and families to the most appropriate support.
- Conference held to launch CPT:
Outcome: professionals aware of CPT, the thresholds and how to refer.
- All key partners aware of the CPT:
|Voluntary sector||· Member of (PJCG) and HPFT met with key voluntary sector organisations delivering perinatal MH services||· Clear referral pathway between voluntary sector and CPT|
|Children’s centres||· Kept informed via communications of the progress of CPT through eNewsletters and presentations at events|
· All children’s centre approached to host joint clinics
· Member of PJCG attended CPT induction to give full information about children’s centres
|· Clinics being run through children’s centres at key locations across the county|
|Early Years providers||· Kept informed via communications of the progress of CPT through eNewsletters||· Early years settings aware of referral process and threshold for CPT|
|Families First (encompasses a range of stakeholders within early help)||· Attendance at CPT team meeting to give overview of Families First referral pathway|
· Induction of CPT included key information about Families First approach in Hertfordshire
|· Training arranged for CPT in the Families First Assessment Module|
· CPT aware of Families First approach assessment process
|GP||· GPs communicated with regularly via GP bulletin||· GPs aware of referral process and threshold for CPT|
|Midwifery||· Presentations at midwifery team meetings in east and west|
· Presentation at University of Hertfordshire midwifery students
|· High number of referrals being received by midwifery|
|Obstetricians||· Capitalised on existing working relationships been psychiatrist and obstetricians at east and west||· Joint clinics with obstetricians running at key locations across the county|
|Health visitors||· Kept informed of the progress of CPT through meetings with Head of Health Visiting and the Perinatal Mental Health Champion manager|
· Presentations at Team Lead events
· CPT team members attending all health visitor locality meetings
|· Health Visitors have clear information about referral pathway and threshold|
|Adult mental health teams (IAPT, RAID, CATT, FEP)||· Internal communications within HPFT||· Clear referral pathway between existing mental health teams and CPT|
|Thumbswood mother and baby unit||· Internal communications within HPFT||· Clear referral pathway between CPT and Thumbswood MBU.|
· CPT are fully aware of current capacity at Thumbswood meaning referrals can be directed as appropriate.
|Specialist and Safeguarding Services (Hertfordshire County Council)||· MASH team manager presented at CPT induction|
· Kept informed via communications of the progress of CPT through eNewsletters
|· Teams aware of referral process and threshold for CPT|
|Intensive Family Support Team||· Member of PJCG presented overview at CPT induction|
· Kept informed via communications of the progress of CPT through eNewsletters and presentations at events
|· Teams aware of referral process and threshold for CPT|
CPT development: Involvement, input and feedback from experts by experience ( women with personal experience of mental ill-health this field) informed the development of Specialist Community Perinatal Mental Health Team (CPT) and the bid to NHS England, this included:
- Discussions with discharged families from Thumbswood Mother and Baby Unit (at bi-annual coffee mornings).
- New parent focus groups held across the county.
- Maternity Service Liaison Committees.
- The need to ensure information and support is available to dads/partners as well as mums.
- Families felt uninformed and unprepared for the impact having a baby has on their lives as well as the negative impact their own mental health issues has on the
- Parents were unsure where to look for help.
The CPT has been developed to meet these needs. In addition, the two admin staff who job shared are both experts by experience. During the implementation of the new service experts by experience were involved in several aspects, including:
- Promoting the service – sharing their journey through services; pre- and post-development of the CPT; case studies have been shared as press articles, at the Hertfordshire Perinatal Mental Health Conference (1st held in February 2016 and now run annually) and mothers have spoken on local radio about their experience. (please see news release attached).
- Co-production of all CPT literature (eg: posters, professional and service user leaflets).
- Expert by experience on all CPT interview panels
- The recruitment of two administrators – both experts with lived experience.
Staff: Significant time has also been spent collecting views of professionals (including midwives, health visitors, obstetricians and psychiatrists) about the kind of service that would best meet the needs of families with perinatal mental health issues. The majority of professionals shared the view that a dedicated team, available across the county, was needed to pull together specialist knowledge and create training capacity.
A full evaluation of the service will take place after a year as well as ongoing evaluation of the services, and mothers and partners will be encouraged to participate through:
- Peer Experience Listening projects.
- Having Your Say (HYS) Feedback forms (including the Friends and Family Test)
- Mothers and partners input into the accreditation process for RCPsych Quality Network for Perinatal Mental Health Services.
- Bi-annual coffee mornings.
- Sharing their experiences at the Hertfordshire Perinatal MH Conference.
Looking back / Challenges faced
The service was officially launched in April 2017, however it had already begun running a limited outpatient service (since January 2017) whilst the team was being fully recruited (the majority of staff are now in place, and the remainder will be in post by August 2017). The challenges that have been faced are outlined below – along with the actions to overcome them and learning.
|Challenge||How we overcame it||Learning|
|The limited service initially has struggled to cope with demand. The number of referrals has clearly demonstrated a demand and need for the service, however the number and type of referrals has put pressure on the team to triage large number of referrals, many of which are not appropriate for a specialist team.|
Clinics are already full and the team are very busy, whilst still having to still develop networks and relationships, develop wider pathways etc.
|Tight telephone triage system set up, with some cases not taken on but referred back with advice given. The team are trying different ways of working to triage and assess referrals.||Phase promotion of the service. The service was advertised to all GPs and other professionals early on. Whilst self-referrals are also accepted, the majority of referrals come from GPs and other professionals, therefore a phased period of promotion and information sharing may have helped to ease demand initially.|
|Delay in administrator post being recruited meant that tasks to set up the office and systems that ideally would have been completed before the team went live to a high volume of referrals.|
|Additional admin support has been sought within HPFT to maintain the high priority tasks such as clinic letters and booking appointments.||The administrator post is key to maintaining smooth running of the service and to support initial implementation.|
Recruiting early to this post is key.
|Difficulty capturing data for performance measures on Electronic Patient Record (EPR).||Developed a local spreadsheet to collect data, although this is time consuming to complete.|
We plan to develop a bespoke perinatal form to do this, later in 2017.
Commissioners recognise that the team need time to embed and collect data.
|Consider data collection up front prior to implementation & ensure process for capturing the data is in place / in development. If staff are completing this information from the start they are more likely to continue.|
Within the model, one WTE Consultant Psychiatrist and one WTE trainee doctor will work exclusively in the CPT. The Consultant Psychiatrist is in post, and leading development and implementation of the team; the trainee doctor will come into post in August 2017, as part of the trainee doctor rotation.
The trainee doctor position provides a perinatal development opportunity. Currently there is a recognised lack of trained perinatal psychiatrists in the UK, which has happened due to a lack of training positions. The Royal College of Psychiatrists is trying to build up workforce capacity to meet upcoming service demands. This is a positive development for the CPT and for new trainee psychiatrists.
Succession planning began from the start of the CPT for our Team Leader role. The CPT currently has an Interim Team Leader, who will be in post for six months to support implementation. It was important to have the team leader post filled early with an experienced person who could lead on implementation, so a decision was made to second an interim team leader with significant perinatal experience into this post.
The permanent post was successfully recruited to in May 2017 (from within the team), promoting one of the care coordinators who has a good understanding of the functioning of the team, and is passionate about the work being done. The new team leader will have a six week handover from the interim team leader to allow for smooth transition.
The CPT is part of a wider service improvement for perinatal mental health in Hertfordshire. The PJCG is strengthening the whole pathway to ensure families get the right support at the right time. This will help manage the demand for CPT and ensure the team is sustainable.
The CPT is registered with the Quality Network for Perinatal Mental Health Services, an initiative of the College Centre for Quality Improvement (CCQI). Given the embryonic nature of the CPT, it is not due for peer evaluation until November 2017.
HPFT also manages Thumbswood Mother and Baby Unit which is an accredited member of the Perinatal Quality Network. The experience and learning from this will help inform and support the CPT in self-evaluation prior to the peer evaluation, to ensure that the service has the best chance of accreditation.
Outcome measures for the CPT are set out below. The service is currently designing unique forms on our electronic patient record (EPR) to ensure that we can collect the service specific information (which means we are currently unable to report on all measures). In addition, the Royal College of Psychiatrists are developing Clinically Relevant Outcome Measures (CROMs) which the service will use once published.
The CPT are part of the working group that is operating in Hertfordshire to develop a Perinatal Mental Health Outcome Star (working title). Following a successful pilot, the PMH Outcome Star will be available to all professionals who work with families in the perinatal period. The star will measure progress against key areas that contribute to perinatal mental health.
|Early intervention with timely assessment to prevent escalation into specialist services|
|Number of women taken on by the service after triage assessment||EPR||Monthly|
|New diagnoses for women referred to the CPT|
|Number of women receiving pre-conception counselling||EPR||Monthly|
|% of routine referrals triaged within 2 working days||EPR||Monthly|
|% of urgent referrals telephone triaged/urgent advice given same day|
|Number of pre-delivery care planning meetings||EPR||Quarterly|
|Number of women co-managed by Crisis Team and CPT|
|Number of external staff trained|
|Pre- and post-training self-evaluation questionnaires of knowledge and skills staff receiving PMH training|
|Delivering care closer to home in a community setting||Number of women referred to the service in each quadrant of Hertfordshire|
|Electronic Patient Record (EPR)||Monthly|
|Breakdown of ethnicity data|
|Organisation referrer (to target publicity and training)||EPR||Quarterly|
|Enabling appropriate, timely and supportive discharge from services, including appropriate onward referral to other services|
|Number of women re-admitted to an MBU (excluding for prophylactic admission)|
|Discharge destination after treatment|
|Reduction in number of days leave for Hertfordshire mothers from Thumbswood MBU.|
|Reducing the risk of poor attachment so that parents can emotionally support the infant / children enabling them to thrive.|
Empowering women to be aware of their emotional wellbeing and seek early help
|Number of partners of mothers receiving an intervention from the CPT|
|ERP / Manual||Quarterly|
|Number of Whole Family Assessments||EPR||Quarterly|
|Number of incidents|
|PROMS & CROMS (see below)||ERP||Quarterly|
|Improving the women’s experience by reducing the stigmatisation of MH and supporting families to become resilient.|
|Friends & family test||HYS & HPFT Staff Survey||Quarterly|
|Feedback via bespoke HYS to be developed||HYS||Quarterly|
|Informal feedback (see Evaluation & participation for more information)||Coffee mornings, peer experience listeners||Quarterly|
|Improve the physical health of the pregnant woman and infant||Case studies||Annually|
Through development of the CPT, access to specialist community perinatal MH provision has already been provided to over 100 women (between January 2017 and April 2017) increasing capacity for early intervention.
Despite a significant demand on the service, of the referrals received (since a core team was in place), 65% of contacts were made within 24 hours of referral and 89% were within 2 weeks.
Hertfordshire’s CPT is committed to sharing our learning with others, in particular those organisations that are also developing new services within our region. Through the East of England Clinical Network, we will share the work and learning we have taken from implementation with other EoE commissioning bodies and provider organisations. Our learning had provided valuable insight for other providers; for example through sharing the challenges discussed above – and what we could have done differently. In addition, the consultant psychiatrists from each team meet quarterly to share and discuss best practice, clinical pathways, referral criteria and clinical documentation. This helps to ensure consistency across the EoE region, in particular supporting cross-border working.
The CPT consultant psychiatrist has also presented at several local forums, to sharing our work and learning across partner organisations. This will continue as the CPT staff start to take on this role and develop relationships with partner providers.
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April 2017 – NEWS RELEASE
New team supporting new and expectant mums with mental health problems in Hertfordshire
Two mums who suffered mental ill-health during pregnancy have thanked the new Hertfordshire team who supported them through their difficulties.
Both said they received ‘invaluable’ support from the community perinatal team, which is being officially launched at a celebration event on Monday 24 April.
Mum-of-two Jenny Wickett, 41, from St Albans, couldn’t even contemplate having a second child after suffering from postnatal depression following her 7-year-old son Henry’s birth.
“I didn’t even want to think about it or talk about it,” she explained. “My biggest fear was that I would get ill again and what if I didn’t recover or worse, if I took my own life?”
Last year, she and husband Andrew had joint counselling to help them recover from the trauma and decided to go for it, with support from the community perinatal team. Baby Samuel is now five months. “Second time around was so much better. I hope by sharing my story other women will realise it’s OK to ask for help. Early help is crucial. The services are there to provide support. I certainly wouldn’t be where I am today without them.”
Figures suggest that at least 400 women in Hertfordshire have severe mental health needs in the weeks before and after birth, with another 1,375 having mild to moderate needs.
The county’s two NHS clinical commissioning groups (CCG) received national NHS funds to develop a specialist service offering pre-pregnancy counselling to women with mental ill health and supporting new mums with conditions like severe postnatal depression, as well as their babies and partners.
New mum Louise, 34, from Hemel Hempstead, found the team’s support invaluable, during and after pregnancy. “I wasn’t excited. I wasn’t happy to be pregnant,” she explained. “When we first found out, it had happened so quickly, I just felt stunned and numb. And then I hated it. I didn’t tell people because they would expect me to be excited and I wasn’t. Consequently, I lost contact with my friends because I didn’t want to tell them and became more and more reclusive, which didn’t help.”
Local mental health services provider, Hertfordshire Partnership University NHS Foundation Trust (HPFT) has developed the community perinatal team, working alongside GPs, obstetricians and gynaecologists, midwives and health visitors already supporting women to prevent their condition deteriorating.
Statistics reveal that between 10 and 20% of women develop a mental illness during pregnancy or within the first year after having a baby.
On Monday 24 April, around 150 Hertfordshire professionals who work with expectant parents and new families will attend a conference updating them on national and local developments in infant mental health and perinatal mental health, including the official launch of Hertfordshire’s community perinatal team.
The CCGs and Hertfordshire County Council are working together to deliver Hertfordshire’s £2m child and adolescent mental health services (CAMHS) Transformation plan to improve emotional wellbeing services for children and young people over five years. One priority is to improve perinatal mental health services. You can read Hertfordshire’s CAMHS Transformation plan, Healthy Young Minds in Herts 2015-20 here