The Devon Partnership Trust Perinatal Service has Four teams - North Devon, Torbay, Exeter & West Devon, we are an established service now running for 9 years. We are based in Maternity Units & work on a daily basis with Midwives, Obstetricians & Health Visitors as well as our mental health colleagues. The teams are based in maternity units to enable close collaborative working with our midwifery and obstetric colleagues, also to reduce the stigma for women
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The Devon Partnership Trust Perinatal Service has Four teams – North Devon, Torbay, Exeter & West Devon, we are an established service now running for 9 years. We are based in Maternity Units & work on a daily basis with Midwives, Obstetricians & Health Visitors as well as our mental health colleagues. The teams are based in maternity units to enable close collaborative working with our midwifery and obstetric colleagues, also to reduce the stigma for women – they come to the antenatal clinic for their scans & to see their obstetrician – they also come to the same place to manage their emotional and mental wellbeing in pregnancy. Our newest team West Devon is based in the community, we have developed other practices to reach women by seeing them in their locality in Children’s Centres etc.
We are commissioned to work with women preconceptually, in pregnancy & postnatally. Preconceptual women are referred for specific advice around prescribing in a planned for pregnancy &/or women who have experienced a more significant postnatal episode & are contemplating trying for another baby. Antenatally we work closely with midwifery services, every woman when she first books with a midwife is asked routine enquiry questions about their mental health (the Whooly questions), if women answer yes to any of these questions or if there are other mental health concerns the midwife will then complete a prediction & detection tool (developed from NICE 192 guidelines)– this information then generates a referral to the local perinatal team. Postnatal referrals are focused on women with a severe postnatal illness though we will always have a clinical conversation about postnatal women if a midwife, health visitor or GP have mental health concerns about their presentation.
We accept referrals at any stage in the antenatal period from GP’s, health visitors, mental health practitioners or women themselves. We run an open referral system in pregnancy with the explicit aim to maximise a woman’s wellbeing in this period. Once referrals are received we triage on a weekly basis with our Midwifery and Parent Infant Specialist colleagues, there are three outcomes generally, If there are mild or low level historical mental health concerns we will send a template letter with evidence based information on psychological therapies (Cognitive Behaviour Therapy – Improved Access to Psychological Therapies – IAPT), Postnatal Depression &/or medication advice in pregnancy & breast feeding (BUMPS http://www.medicinesinpregnancy.org/ ) For moderate mental health concerns or if we would like to understand more about a woman’s current mental health we will offer a telephone consultation intervention. This involves a booked telephone call to review a woman’s mental wellbeing with a reflective letter formulated & sent to the woman, copied to her GP, midwife & health visitor routinely. Women with moderate to severe mental health concerns are offered a face to face assessment with our Perinatal Psychiatrist and/or with a perinatal mental health practitioner.
During assessment there will be a specific focus on pregnancy & their emotional wellbeing/mental health; again all letters are copied to professionals. Women with complex mental health concerns/prescribing are offered a Pregnancy Planning meeting, a multidisciplinary meeting earlier in pregnancy with the woman, her partner/carer & professionals working with her – usually the midwife, health visitor & mental health worker. This is an opportunity to care plan together & review any risks or safeguarding concerns. We will come back again at 32 weeks to Birth Plan together, capturing the plan of care for the rest of a women’s pregnancy, labour & birth & the postnatal period. This would routinely include a woman’s preferences & wishes during this period and any relapse indicators with a contingency plan. All professionals’ telephone numbers are clearly documented in the plan.
Women regularly report these planning meetings as a containing, validating and an experience of being held and listened to. Postnatally we follow up with women we have birth planned with & we accept new referrals for women who meet our criteria of a more significant presentation of postnatal illness. This pathway is more tightly managed owing to capacity in the team. Our aim is always to manage women as early as possible in any relapse postnatally, early intervention enables us to reduce the risk of a more significant episode developing. Part of this work is informing and educating other professionals in this high-risk group of women.
We are now in the process of adapting & describing our joint pathway locally with the new Mother & Baby Unit Outreach Practitioners. This means women have access to more intensive interventions in the high-risk period where indicated. Throughout the development of our service we have always been actively involved with mum’s who have accessed our service, we have utilised a self-developed service evaluation form that has over the 9 years given us a wealth of feedback, acknowledgment & helped us in developing & shaping our service, we are undoubtedly a better service for this.
We will often say women are at the heart of their care, they are also at the heart of our service development. We have a closed Facebook page administrated by one of our mum’s which now has in excess of 150 mum’s contributing to interview opportunities, steering groups, the design of our new Mother & Baby Unit, in films about our service https://www.england.nhs.uk/mental-health/case-studies/new-perinatal-mental-health-mother-and-baby-unit-transforms-care-for-mothers-and-babies-in-the-south-west/ Co-production has enabled a close working relationship based on mutual respect, understanding & a shared desire to improve outcomes for other mum’s & families. With Wave 1 Funding from NHSE we now have Perinatal Psychologists & Nursery Nurses adding to the expertise & personalised offer to women. This has involved developing new care pathways across the mental health care delivery locally.
What makes your service stand out from others? Please provide an example of this.
We have always endeavoured to learn from situations in our daily work, learning from experience is a theme through much of our innovation & development. We have adapted to a changing & increasing birth rate with referrals increasing incrementally over the years, identifying who are our ‘key women’ to focus on (the top 5% of women delivering) has kept us in a regular recalibration of how we triage, our offer to women & how we say no to other women, we always wanted to ensure every woman referred experienced some advice/signposting to relevant services we could confidently recommend. Our strong care pathways devised at an earlier stage has enabled us to deliver a service of a consistent high standard, we learnt through this, joint working was essential not only from a professionals point of view but also for women & their experience of joined up services in collaboration.
It is this approach that has attracted other newly developing services to find out more about how we do what we do, we have always been very open to sharing knowledge with other teams, this is reciprocal at times. Within our pathway we have continuously added extra opportunities for women, the ‘Time for You group for Mum’s’ with emotional dysregulation who would not meet the criteria for Secondary Mental Health intervention, the New Born Baby Observation interventions we have seen have a significant impact for Mum’s who are struggling to make an attachment with their baby, our under 18’s pathway with local CAMH’s services to ensure our younger Mum’s have access to perinatal mental health services as well, the pathway for women with a history of childhood sexual abuse – we designed information leaflets for women & one for professionals, our chronic fatigue leaflet for women who’s physical condition is impacting on their mental wellbeing in pregnancy. Being adaptable & innovative to women’s needs has given us opportunity to work with them, for them to improve outcomes for women & families.
How do you ensure an effective, safe, compassionate and sustainable workforce?
All our staff have regular managerial 4-6 weekly supervision, regular peer safeguarding supervision & parent infant specialist supervision. Keeping a compassionate culture is championed by senior staff who role model this on a daily basis, in turn all staff set the standard together around mental health de-stigmatising & keeping positive about mental health & recovery. Basics like breaks being encouraged, health eating (ok so sometimes we eat cake too) & annual leave being spread across the year are prioritised. Devon Partnership Trust regularly have wellbeing initiatives we encourage staff to attend if they are interested.
We have lots of sporty staff with sporting stories they share, paddle boarding, open water swimming, marathon/half marathon running, Fitbit steps competing to name a few. Developing staff resilience is a challenge nationally, we have found talking about this, how do teams, individuals build their resilience is revealing as staff often know what they need to keep well. Encouraging access to locally provided mental health support & psychological therapy & counselling is encouraged for staff who may benefit from this, some of our staff have done so. Building time for reflective practice we know enhances consolidation of professional practice & overall wellbeing, this is a challenge with busy caseloads however clinical meetings & supervision is given priority. Registered nurses who need to provide evidence of reflective practice for their Revalidation are encouraged to take agreed time away from their clinical work to complete this.
The staff survey is actively encouraged & results do come back in anonymised reports to senior managers, where they are themes emerging actions are put in place to reduce or resolve, engaging our staff in this is essential. Each month we have Continuous Professional Development, this is our Clinical Governance meeting, then we move into Continuous Professional Development – this involves an outside speaker or one of the staff in our service who have attended a course present a brief overview of their training/conference attended. This also meets the challenge of having four spread out teams across Devon, meeting once a month maintains their sense of belonging to a larger service.
We income generate by lecturing & presenting to fund staff attending training courses & conferences, this provides opportunities for learning in a very tight financial climate. Staff being able to continue their learning we see keeps them energised & motivated. In our community teams in 9 years we have only had two staff leave which is a reflection on the work satisfaction, continued development of staff, good leadership & management. I f we were to understand what keeps the 20+ staff with us it is the working with Mum’s & being part of their recovery journey or the keeping them well in the perinatal period when there is a risk of relapse & opportunities to develop knowledge & participate in innovation projects.
We also have highly motivated leadership in our Perinatal Psychiatrist & Service Manager, we find energy & inspiration is infectious! Recruiting staff has not been challenging for us, in summary we believe this is in part the work & the reputation of the service as being innovative & always developing. We have in recent years become involved in a few national research projects as well, this is also engaging for staff & supports the notion we are contributing to the development of a greater understanding & treatment choices for women in the perinatal period. BDRN & ESME research, we also have good links with Exeter University & are in discussions about future research projects. We are entirely supported in our organisation with this.
Who is in your team?
Perinatal Consultant Psychiatrists 1.2 wte Band 8a Service Manager 1 wte Band 8a Perinatal Psychologists 2 wte Band 7 Clinical Team leader 1.8 wte Band 6 Perinatal Mental Health Practitioners 12 wte Band 4 Nursery Nurses 2 wte Band 4 Administrator 1 wte Band 3 Secretary 4 wte
How do you work with the wider system?
We deliver maternal mental health training & education to a variety of people, • Year 2 RMN students at Plymouth University – 1 day lecture • Year 2 Midwifery students at Plymouth University – 1 day lecture • Midwifery training on maternal & infant mental health across all maternity inpatient & community services. • Health Visitors – complimenting the Institute of Health Visiting Training. • Maternal & Infant Mental Health day training within our own organisation for mental health staff. • Speaking at national conferences. • Collaborating at regional perinatal network events. • Assistant Practitioner training within our organisation • GP events • A&E staff at local acute Trusts • Children’s Centres • I’m Fine Training across the Southwest (more running this year) • GRASSPIT (Global Recognition & Assessment of the Sick Perinatal patient) training (more running this year) • Charity organisations locally e.g. PANDAs We will always make time to go pretty much anywhere if relevant, this means we take the message about maternal mental health far & wide & create more awareness. One of our perinatal mental health practitioners is seconded to work a day a week with Little Bluebells, this is an excellent collaboration with Bluebell Perinatal Charity, Comic Relief & our own Little Something Charity. Our Little Something Charity also supports the Global Alliance Maternal Mental Health organisation https://globalalliancematernalmentalhealth.org/ & their research & health initiatives. Some of our Mum’s with lived experience have gone on to set up their own peer support initiatives, https://en-gb.facebook.com/craftingthroughcrisis/ which we keep in touch with, sharing the valuable resource with other Mums.
Do you use co-production approaches? If so, please illustrate how you involve individuals, families and carers to drive improvement and deliver services?
Co-design is an integral part of our service development & has been from day one, we routinely send women service evaluation forms for feedback, we also have a question which asks ‘would you like to be involved’. We have Mum’s & Dads who have supported us in interviewing staff, new starter inductions , training, designing leaflets & joining us at tea party events. One of our Mum’s facilitates a closed Facebook group, these Mum’s have been invaluable in being a forum that will answer any questions we have, review new information we want to develop & they have developed their own peer support through this. We have a new film co-produced with one of our Mum’s NHS England have just released as mentioned earlier in the application, this is the same Mum who joined us for our Mother & Baby Unit tender interview with NHS England, she was an invaluable voice in describing her journey & recovery. We have two new senior peer supporters employed on our Mother & Baby Unit, they will be working & supporting women across the care pathway, this is new territory for us & we are excited to develop their roles with them – more news to follow!
Do you share your work with others? If so, please tell us how.
- Peer support senior perinatal service/team managers across the southwest perinatal clinical network. We meet quarterly & share knowledge, challenges & ideas. • Perinatal Chat the CCQI forum, we put questions out there & ask them too. • We have been cited in the new NHS England & NHS Improvement Perinatal Care Pathway https://www.england.nhs.uk/wp-content/uploads/2018/05/perinatal-mental-health-care-pathway.pdf http://positivepracticemhdirectory.org/nccmh/specialist-assessment-devon-partnership-trust-perinatal-service-nccmh/ • On our website we have information & videos we have collaborated on. • This document is from 2016 however, we still refer to it in training, we were cited as a case study example https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Bringing-together-Kings-Fund-March-2016_1.pdf • Other resources on our Devon Partnership Trust Perinatal website are available as well https://www.dpt.nhs.uk/our-services/pregnant-women-and-new-mothers
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
We routinely use the following outcome measures, • CROM – HoNOS – Health of The Nation Outcome Scale – at initial assessment & discharge. • PREM – Royal College of Psychiatrists POEM – Patient Outcome Experience Measure. • PREM – Our own devised service evaluation form. • PREM – Friends & Family. • CROM – REQ-QOL – Initial Assessment & Discharge, used by Perinatal Psychologists. • CROM – MORS – Mothers Object Relation – when referring to parent infant team. The outcomes of these measures are shared at Clinical Governance meetings where the data is available; we are working with our informatics team to enable us to report on all outcome measures routinely. The percentage of people with complete data sets is monitored monthly; ours usually sits at 91-95%. The narrative from our service evaluations form questions is shared at clinical governance meetings monthly as well, this gives a more personalised experience of our service.
Has your service been evaluated (by peer or academic review)?
We have internal Observation of Care peer reviews annually to each team & we reciprocate by visiting other teams. • We participate in the Royal College of Psychiatrist CCQI peer review cycle. • We have had brief visits from the CQC through Maternity & a recent Devon Partnership Trust visit in Torbay.
How will you ensure that your service continues to deliver good mental health care?
We already work closely with our commissioners, in developing the Wave 1 perinatal mental health funding we have met as a programme & implementation board monthly. This has enabled a close shared understanding of our work & challenges. We report quarterly to NHS England on these developments We have received assurances there will be ongoing funding however we recognise we need to be able to evidence our outcomes in a clear, validated & evidence based way. In terms of management succession, Devon Partnership Trust offers a variety of opportunities in leadership development both internally & externally. The culture is set within the organisation to ‘grow our own’. The same applies within the Perinatal Service; both of our Clinical Team Leaders were previously Perinatal Mental Health Practitioners.
What aspects of your service would you share with people who want to learn from you?
Challenges have been varied, we think importantly we have always tried to review & see the learning that can come from those experiences. Our main challenge is capacity, as we became more known about the referral rates went up & have stayed high (25-38% of delivering women depending on which team) we are seeking to work with the top 5% however, we have learnt if you do not offer some earlier intervention many women will subsequently fall into the top 5%. We have approached this by having a consistent weekly triage meeting (urgent are done on the same day) this means we have protected time to review referrals. We developed the template letters which give women evidence based advice & leave them with an option to get back in touch if things change. We also developed the telephone consultation in our aim to be more time efficient, this meant we could reach more women in a clinically effective way. The mainstay of our work though is face to face assessments.
Offering interventions to women which are perinatal appropriate is also a challenge, we have now developed group interventions & are in the process of developing more with our Perinatal Psychologists. Our Time for You group mentioned earlier in the application is run for women with emotional dysregulation, this has supported women who have struggled in pregnancy to manage their emotions more effectively, the feedback from these sessions is really positive. Several of our staff have completed New Born Baby Observation training (NBO) this has bought about another strand of parent infant intervention, this has specific outcome measurement which we will be reporting on. Managing other professional’s expectations is always a challenge, even as you progress as a service this is still a priority. Keeping expectations realistic, achievable & transparent. Mutually respectful relationships at all times. Working with Childrens Services Social Workers at times can be challenging, this is mainly owing to their fuller understanding of the nature & presenting concerns of perinatal illness. We have worked well with Social Workers in creating a shared understanding of our work & the risks associated with women at any given time. Often it is women with intrusive thoughts that make for anxiety provoking situations, we have had to develop very clear language (non jargon) to describe the narrative of a women who has thoughts of stabbing her tummy in pregnancy, we know from our assessment the actual likelihood is very low however understandably to a safeguarding lead or Social Worker this may well seem very high risk.
How many people do you see?
April 2017 – March 2018 number of referrals 2685 Time For You group – average 6 women
How do people access the service?
Referral sources – Midwives mainly, Health Visitors, GP’s, Mental Health workers, self-referral. • Access is promoted at first booking with the Midwife if mental health concerns are identified a Prediction & Detection Tool is completed, similarly any postnatal mental health concerns identified by Health Visitors are made via an SBAR (Situation, Background, Assessment, Recommendation) this is a clear referral form with prompts to ensure appropriate referrals. • Women who find accessing our service difficult owing to their fear of stigma are invited to be seen in the antenatal clinic, the same place they are seen for their scans & obstetric appointments. We will also see postnatal women in their own home, for women who find leaving the house challenging owing to their mental health concerns this enables easy access to our service. We will find local venues we can meet with women in such as Children’s Centres, mental health bases & other community venues, this can give women a range of options which will promote engagement.
How long do people wait to start receiving care?
Women who require an urgent assessment on an antenatal, postnatal or medical ward can be seen within 4 hours, women in the community can be seen within 48 hours, if however a woman presents with urgent mental health concerns a mental health act might be arranged on the same day. In our Community Perinatal Teams women who need a sooner appointment are prioritised, seen within 2 working days where possible. Routine appointments vary, we will usually offer an appointment within 2 weeks but often women will seek to find a time that suits them, we will flex with this within our limitations. • We work to national standards & monitor waiting times at our monthly clinical governance meetings. Where there are greater delays theses are reviewed by the team managers. We are comparable to most community perinatal services with our waiting times as seen in the NHS Benchmarking reports.
How do you ensure you provide timely access?
A trained member of the team will review all referrals daily, these will all be triaged in a weekly meeting attended by a team manager, clinician, parent infant specialist & midwife. We prioritise referrals as mentioned in the previous section. • Staffing levels are maintained with limitations on staff annual leave, we use Health Roster which makes the process of leave completely transparent. Managers will bolster clinical cover to enable staff to attend training/courses.
What is your service doing to identify mental health inequalities that exist in your local area?
We work closely with a variety of agencies to ensure all women from any social circumstance, ethnic group or rural areas are able to access the right support at the right time for their mental health in the perinatal period. The main challenges we observe for women are rural isolation, domestic violence, lack of social support & difficulties accessing services. Essentially we learn from working with women what their own challenges are & will look to our local communities for support & advice to enable women to manage more effectively without deskilling them.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
Women with learning disabilities are able to access our service if they have a degree of mental health concern that meets our criteria, if they do not we would ensure a referral to the Specialist & Public Health Midwives. Interpreters are routinely sought where women require this, we aim to reduce the barriers to women receiving clearly communicated care & treatment. This can however still be a challenge for women if interpreters are not available other than by Language Line which is less straight forward to utilise.
What is your service doing to address and advance equality?
Devon Partnership Trust takes much pride in adhering to legislation on human rights, equality & the Care Act. We have mandatory training in these areas, attendance is monitored each month in clinical governance. I have talked earlier about how we reduce stigma, engaging with all women is always our priority, reducing barriers to care is something we are as a service passionate about.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
Prediction & Detection Tool – developed by NICE 45 & 192
How do you meet the needs of people using the service and how could you improve on this?
Our Operational Policy, Service Specification & Care Pathways are all developed with NICE Guidance, these are regularly reviewed to ensure we are up to date, evidence based & relevant in our aims to deliver care. The NICE quality standards & CCQI Perinatal Standards are the benchmark for our service & ensures we keep up to date with current recommendations & research findings. Women on the perinatal mental health care pathway who need Mother & Baby Unit admission receive assessment, care planning & interventions in collaboration with the community perinatal teams & the new Outreach Service from the MBU.
What support do you offer families and carers? (where family/carers are not the service users)
We offer all carers a Carers Assessment & will link them in with local support groups relevant to their needs/wishes. We will signpost partners & carers to relevant information online & with printed information if preferred. We are developing a Dadpad App https://thedadpad.co.uk/ with Dad’s involvement, this is being funded by Wave 1 investment from NHS England. We also signpost Dad’s to http://www.rcmpregnapp.org.uk/ a brilliant new app on pregnancy & child birth developed by the Royal College of Midwives.