The maternity perinatal mental health project – Leeds

The maternity perinatal mental health project, established in Jan 2016 to take forward work to improve services across all stakeholders and at a citywide level. The project was established as a work stream under the Leeds South & East CCG Maternity Programme Board, which is overseeing the implementation of the Maternity Strategy.

Co-Production

  • From start: Yes
  • During process: Yes
  • In evaluation: No

Evaluation

  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

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What We Did

The maternity perinatal mental health project, established in Jan 2016 to take forward work to improve services across all stakeholders and at a citywide level.
The project was eThe maternity perinatal mental health project, established in Jan 2016 to take forward work to improve services across all stakeholders and at a citywide level.
The project was established as a work stream under the Leeds South & East CCG Maternity Programme Board, which is overseeing the implementation of the Maternity Strategy.stablished as a work stream under the Leeds South & East CCG Maternity Programme Board, which is overseeing the implementation of the Maternity Strategy.

 

  • The process of the project has included:
    • Background research to establish: the evidence base, Public Health assessment of need in general and in Leeds, evidence of good practice and good service design
    • Understanding of the current position of services in Leeds, including relationships between services, service delivery and mapping all services, including specialist PNMH services through to general support services in the community
    • Workshops to understand the mapping (see appendix 9.2 for participants) information, drawing in a wide range of practitioners from across maternity, mental health, early start, council and the voluntary sector
    • Interviews with key individuals from organisations across the city and from different sectors (see appendix 9.3)
    • Ensuring that links were established to other work taking place in support of the Maternity Strategy, in particular work on the priorities of Personalised Care led by Leeds Teaching Hospitals Trust.
    • Working closely with the Strategic Commissioning Lead for Mental Health to ensure that developments planned in community mental health care in the city were reflected
    • Ensuring the work continued to take account of developments at a regional and national level
    • Establishing a multi-agency, multi professional working group to undertake the work to develop the Pathway for Perinatal Mental Health Care, chaired by the consultant in Perinatal Mental Health from Leeds and York Partnership Trust
    • Establishing work streams, with named leads to take forward the work looking at stigma associated with perinatal mental illness and to engage service users in the co-production of work under the project.
  • Places the women/mother, her baby and family at the centre of care, from pre pregnancy to the end of the first year of the baby’s life.
    • Supports early identification of mental health need and supports delivery of care through an emphasis on prevention and early support services.
    • Matches care and services to the individual needs of women, babies and families.
    • Promotes provision of consistent information for parents to enable them to access appropriate universal support services.
    • Supports individual, flexible and personalised care and continuity, providing seamless services and smooth transitions between different service elements.
    • Supports partnership between maternity, mental health, early start, local authority children’s and voluntary sector services.
    • Supports clarity of communication between professionals, partner organisations and families.
    • Clarifies and supports confidential information sharing as required between professionals.
    • Clarifies and supports consistency in terminology across services and partners.
    • Clarifies the roles and responsibilities of different professionals and services, including the role of the lead professional/coordinator of care.
    • Is supported by a training and development framework to ensure confident and competent practitioners who recognise the potential impact on the infant, as well as the women, of perinatal mental health.
    • Is supported by and establishes links to other relevant pathways (including: Early Start Maternal Mental Health, Responsive Parenting and Infant Mental Health Pathways, Drug and Alcohol in pregnancy, Learning Disability, Asylum seekers and refugees, Teenage Pregnancy, Domestic Violence, Bereavement, PTSD and Birth Trauma and Safeguarding Children and Vulnerable Adults).Infant Mental Health Service (IMHS)
    The Infant Mental Health Service is a citywide service working with pregnant women and infants up to 24 months, where there are serious concerns about the attachment relationship. It is a multi-disciplinary team including Consultant Clinical Psychologist, Infant Mental Health Practitioners, and Health Visitors.

    Infants with a parent who has a mental illness, including depression or anxiety are at an increased risk of experiencing difficulties in the caregiving relationship, which can result in attachment difficulties.

    • The service offers training, face-to-face and telephone consultation, joint visits and direct work with those families with an identified need for higher level therapeutic intervention. Psycho educational intervention focuses more on the infant with explicit attention to parent-infant interaction and relationship building. Understanding of babies is promoted with regard to their states, behaviour and cues. Resources used may be the ‘Understanding Your Baby’ Booklet, The Social Baby DVD and NCAST tools including video feedback.
    • Where there are maternal health issues that are impacting negatively on the attachment relationship, parent-infant psychotherapy such as CBT (Cognitive behavioural Therapy) CAT (Cognitive Analytical Therapy) and ‘Watch, Wait and Wonder’ are examples of interventions most commonly adopted.
    • Relationship difficulties between the primary caregiver and infant maybe identified via the Early Attachment Observation carried out by Health visitors at the 6-8 week contact, or during routine Maternal Mood Assessments.
    • Referrals for direct specialist work with families can come from midwives, health visitors, CAMHS practitioners and specialist community pediatricians. It is recommended that referrers telephone first for discussion and advice, prior to sending a referral.

    Mindwell
    MindWell is the single internet based place for information about mental health in Leeds. It provides a portal for anyone living or working in Leeds, including all professionals, to get quick, easy and direct access to up-to-date mental health information, including:
    • Clear, accurate information about support and services available in Leeds, including a section specifically for pregnant women and their partners and new parents.

    • Information about a range of common mental health problems such as anxiety and stress.
    • Self-help tools and information including downloadable resources, videos and animations.

    MindWell is city-wide and brings together resources, materials and knowledge from across the NHS in Leeds, Leeds City Council and the third sector.
    https://www.mindwell-leeds.org.uk

    IAPT
    The Leeds IAPT service provides psychological support and treatments (sometimes called talking therapy) for adults, including women in the perinatal period, with common mental health problems, such as depression and anxiety. The range of psychological therapy interventions offered follows NICE guidelines and types of therapy to be offered are discussed during initial assessment/screening. This can be online, telephone or, where needed, face to face. Following this advice is given as to the best treatment for that individual. This may also lead to referral on to other more appropriate services.

    If the presenting problem is IAPT suitable then treatments range from step 2 psychoeducational classes, computerised CBT and guided self-help, to step 3 therapies, that include CBT, IPT, DIT, Counselling for Depression and EMDR.

    The service:
    • Prioritises women who are pregnant or in the first year after the birth of their baby, within the generic pathway for screening and treatment. It offers a flexible approach to providing effective psychological therapy to mothers, including appointments at varied venues, times and days of the week and always tries to accommodate an individual’s needs, while taking into account their level of priority.
    • Provides timely screening and assessment for women in the perinatal period, which can be online at the convenience of the woman (this will be reviewed within five working days), telephone or face-to-face.
    • For women in the perinatal period the aim is to start treatment within 4 weeks of assessment.
    • Leeds IAPT is at the early stages of developing a specific perinatal group.
    • While waiting for individual therapy, woman are encouraged and directed to various resources, either written or online to assist in managing their difficulties in preparation for therapy. They can also access online seminars for CBT and IPT found on the Leeds IAPT website.
    • If a women is close to delivery she would still be offered therapy but if it is mutually agreed that the timing of this may increase her stress, or a break in therapy would occur, the service might advise a ‘pause’ or discharge with a fast track back into the service once the women is able and ready to engage. If a woman feels unable to engage at this time, the focus would be on stabilisation of emotions and support in liaison with midwifery and early start services. Encouragement will be given to re-engage with the service after the birth, which should be supported by Early Start and HV services.
    • Children present in therapy are likely to interfere with the woman’s ability to focus on therapy therefore reliable childcare is desirable. However, if this is not available it does not always exclude a woman from attending her appointment. In the event that it is not possible to arrange childcare, for example, breastfeeding women, the clinician will discuss this with the woman and with their line manager to agree on a case-by-case basis, a plan to facilitate access to treatment. This may include for example and where appropriate, cCBT or allowing attendance as a temporary measure. Due consideration should be given to the age of the child and the impact on the success of therapy. It is however not possible to accommodate children in a step 2 class or step 3 group or appointments with Northpoint Wellbeing.
    • Therapy is limited to 20 weeks.
    • Leeds IAPT do not routinely offer home visits but if there are clinical indications that this would be the most appropriate intervention at the start of therapy this will be considered on a case by case basis.

    Community Mental Health Teams (CMHT)
    • GPs, and other health and social care professionals can make a referral to the CMHT via the Leeds and York Partnership NHS FT Single Point of Access (SPA). Referrals of women with severe mental illness will normally be made directly to the specialist perinatal mental health services. Women with long standing mental health needs will usually be managed by CMHT with the specialist perinatal services providing input as appropriate.
    • CMHT duty desk will offer same day triage and allocation for assessment for appropriate referrals. The referral information required to ensure a robust allocation process would include reason for current referral, previous mental health history, current and historical risk, details of pregnancy and any related physical health issues, current medications, details of other children and details of other professionals involved. If the referrer does not provide this information, the CMHT duty desk will prioritise gathering this to inform an appropriate triage decision.
    • A routine assessment will be offered within 14 days to an expectant mother with a history of mental illness or perinatal/post-natal mental health issues, even where there are lower risks However if there are clear identified risks, an allocation for more urgent assessment will be made.
    • Following assessment and formulation, the care programme approach (CPA) is the framework utilised to support effective care planning, coordination of joint working with other agencies such as the HV team, midwife, Early Start Teams, Children’s Centres, schools and social services, risk assessment and crisis planning.
    • The CMHT will liaise with or refer to the specialist perinatal service where appropriate.
    • Should risks related to the expectant mother’s mental state increase, the care coordinator will increase contact and liaise with the multidisciplinary team and other agencies as appropriate, including safeguarding.
    • The CMHT will offer an assessment of support needs for carers/partners and signpost to appropriate agencies.
    • Women of childbearing potential that are already engaged in treatment with the CMHT, will proactively be offered preconception advice about how their mental health problem and how its treatment might affect them or their baby if they become pregnant. Prescribing of any psychotropic medication for women of childbearing age will take into account up to date safety information. As a minimum CMHT standard, preconception information will be provided during the annual CPA care plan review. For service users who become pregnant or are actively considering become pregnant, an appointment would be proactively offered with a consultant psychiatrist to support this with appropriate liaison with specialist perinatal mental health team and pharmacy services.
    • The CMHTs will provide a named perinatal mental health leads and link to each Early Start Team, to ensure close working and coordinated care

    Psychology and Psychotherapy Services (PPS)
    The Psychology & Psychotherapy Service is integrated into the CMHTs within Leeds & York Partnership Trust. The main focus of the service is to both enhance and provide psychological input in the care pathway of people referred into the CMHTs. The service also continues to offer a step four level of intervention within the IAPT pathway. It offers an assessment and therapy service for people experiencing more severe levels of mental health difficulties and with more complex presentations. The service does not provide direct referral access to GPs, other primary care practitioners and other NHS staff.

    Within the CMHT role, the service offers access to psychological consultation, assessment and therapy to the Specialist Perinatal Mental Health Service.

    Psychological therapies offered by the service include: Cognitive behavioral psychotherapy (CBT), psychodynamic psychotherapy, cognitive analytic psychotherapy (CAT), family therapy, interpersonal psychotherapy (IPT), EMDR, Acceptance and Commitment therapy (ACT).

    For referrals of women who are pregnant or in the first 12 months post-partum, through CMHTs, Specialist Perinatal Mental Health Team or via IAPT the following principles apply:
    • A priority appointment for a psychological assessment is offered.
    • The appropriateness of undertaking psychological therapy will be assessed in the context of the individual’s pre-existing mental health difficulties, current level of mental health stability, need for immediate psychological intervention and risk of further destabilisation of mental health functioning.
    • Where psychological therapy is subsequently offered, PPS staff will liaise with other clinicians and health and social professionals involved in an individual’s care.
    • Where psychological therapy is considered appropriate but where it is recommended that this be delayed whilst an individual focuses on the demands of pregnancy and birth, PPS staff may offer interim appointments if needed and liaise with other involved staff as appropriate until the point when full engagement in therapy is more appropriate.
    • When it is considered psychological therapy would not be appropriate or could increase the risk of further deterioration in an individual’s mental health, the service would engage with other involved staff in considering what interventions may be most helpful at that time
    • The service has as its main focus, the need to support the well-being of the mother, the family and the baby during the time of significant change and this will underpin any clinical decision-making.

    Specialist Perinatal Mental Health Service (SPNMHS) – including Mother and Baby Unit (MBU)
    Yorkshire and Humber mother and baby unit:
    This is an 8 bed regional service, which allows for the admission of women with severe mental illness along with their babies, with the aim of ensuring that women are not unnecessarily separated from their infant when a psychiatric admission is required and that access to treatment is rapid and without delay. The unit provides:
    • Appropriate physical and psychological care for mothers in late pregnancy and the first post-natal year that are experiencing serious mental illness
    • Promote the mother infant relationship by providing supervision, support and assistance to the mother in order that the physical and emotional needs of the infant can be safely met
    • A range of therapeutic interventions to meet their needs
    • The unit works with Specialised Perinatal Community Psychiatric Teams to ensure that proper follow-up support and treatment is in place once the mother has been discharged.

    Yorkshire and Humber Regional Outreach Service:
    The Outreach service comprises a multidisciplinary team with specialist skills in perinatal mental health to facilitate discharge and prevent avoidable relapses and re-admission from the mother and baby unit.

    The service provides a pre-conception counselling clinic, management advice for clinicians, primarily for high-risk pregnant women within the Region and follow-up of women discharged from the in-patient unit.

    Leeds Specialist Perinatal Community Mental Health Team
    Provides a specialist perinatal community mental health services linked to the Mother and Baby Unit and Outreach Services, for women in late pregnancy and the postpartum year who are seriously mentally ill, to ensure that the special needs and additional risks to mothers and infants will be met.

    The team provide assessment and care of women in pregnancy and the postpartum year who meet the following criteria:
    • Women discharged from the Specialist In-Patient Mother and Baby Units (3 months post discharge).
    • Women with the following conditions who are at high risk of admission to an in-patient Mother and Baby Unit: bipolar affective disorder, schizo-affective disorder and other psychoses and (in conjunction with adult community teams), severe depressive illness, severe anxiety disorders.

    Urgent Care
    Pregnant and postnatal women with mental health problems presenting to LTHT Accident & Emergency departments will be seen by the Acute Liaison Psychiatry Service team (ALPS). Women who are inpatients on maternity wards of the both Leeds General Infirmary and St James University Hospital, will normally be referred to the Hospital Mental Health Team (HMHT) except for those women who have self-harmed, who are seen by the ALPS.

    Women’s Counselling & Therapy Service (WCTS)
    Women’s Counselling and Therapy Service (WCTS) offers psychological therapies specialised for women. This can be particularly important in the perinatal period when experiences, such as gender based violence or gender specific issues are impacting on mental health.

    WCTS’s expertise is with vulnerable and ‘hard-to-reach’ women with Moderate – Moderately Severe mental health problems – often of long standing duration – and complex presentations. The service has a track record of excellent outcomes with women who struggle to access or engage with more mainstream services for a variety of reasons.

    Women in the main have significant trauma in their histories (e.g. child sexual abuse, neglect or violence; sexual assault, rape, FGM or trafficking; domestic violence; multi-generational poverty; pregnancy or birth trauma, bereavement; etc.). Women may also have complex needs. They may still be at risk of domestic violence and abuse and or have other challenges such as learning disabilities, self-harm behaviours, substance misuse issues, homelessness, debt, etc. Many have significant experience of social care involvement as a child and or as an adult; some have experienced successive removals of their children into care. The majority of women accessing the service are from deprived areas of Leeds; around a quarter are from BME communities.

    Women’s Counselling and Therapy Service (WCTS) offers psychological therapies specialised for women. This can be particularly important in the perinatal period when experiences, such as gender based violence or gender specific issues are impacting on mental health.

    WCTS’s expertise is with vulnerable and ‘hard-to-reach’ women with Moderate – Moderately Severe mental health problems – often of long standing duration – and complex presentations. The service has a track record of excellent outcomes with women who struggle to access or engage with more mainstream services for a variety of reasons.

    Women in the main have significant trauma in their histories (e.g. child sexual abuse, neglect or violence; sexual assault, rape, FGM or trafficking; domestic violence; multi-generational poverty; pregnancy or birth trauma, bereavement; etc.). Women may also have complex needs. They may still be at risk of domestic violence and abuse and or have other challenges such as learning disabilities, self-harm behaviours, substance misuse issues, homelessness, debt, etc. Many have significant experience of social care involvement as a child and or as an adult; some have experienced successive removals of their children into care. The majority of women accessing the service are from deprived areas of Leeds; around a quarter are from BME communities.

    • WCTS offers one-to-one and group therapy as well as a range of therapeutic and psycho-educational groups, and peer support activity. The service can offer limited support with wider health and social care needs where these are impacting on the therapy.
    • Practitioners are, in the main, qualified in psychotherapy to Masters level, professionally registered or accredited, and experienced. Additionally, some staff are also qualified social workers. Staff receive regular high-level clinical supervision and engage in continuing professional development. The service works towards ensuring cultural competence, particularly in reference to pregnancy, birth and parenting.
    • On referral, triaging may include contact with the women herself or others involved in her care. A face to face assessment (1-3 sessions) is offered which includes consideration of wider health and social needs alongside mental health difficulties / psychological needs. The assessment has a meaningful risk assessment at its core.
    • The service is ‘tolerant’ to disrupted engagement understanding that this might be as a result of previous experiences and will offer a range of appointments under a ‘determined engagement’ approach. We use a range of methods to engage clients and provide as accessible a service as possible including use of text messaging, telephone sessions and flexible appointments, female translators and where a woman is destitute may offer support with travel and childcare.
    • Where at triage or on assessment another service seems best placed to offer support at that time this is discussed with the woman and where appropriate support to access that service is given.
    • Where service is agreed upon, therapists liaise, often extensively, with other professionals involved in a woman’s care.
    • WCTS offers the following within the perinatal pathway: Weekly individual counselling and psychotherapy. From between six and 20 sessions (occasionally longer and sometimes with breaks around the birth period) including short-term work focused on mental health stabilisation, emotional and psychological well-being. Psychotherapies have a relational focus; psychodynamic psychotherapy, CBT, EMDR and Parent-Infant Psychotherapy (where the focus is on the relationship between parent and baby) are all offered. Creative arts methods can be employed to support women who struggle, initially or at times, to express themselves verbally.
    • The therapy aims to facilitate the expression of feelings and thoughts as healthily as possible then provides support to problem solve to manage and contain. Work around attachment is central to building attachment to the pregnancy and baby. The overall aim is to minimise the impact of mental health problems on women and babies during this critical (perinatal) period.

    Voluntary Sector Services (VCS)
    Home-Start Leeds offers a home visiting family support service for families who are experiencing difficulties. Helping parents give their children the best start, the service uses volunteers, recruited from all communities, to support parents as they increase their confidence and ability to cope and build better lives for their children and themselves. The Home-Start approach has a proven, lasting, positive impact on the development of children and the health and well being of the family.

    NSPCC
    Pregnancy in Mind is an evidence based preventative mental health service for parents-to-be. The service is designed to support parents who are at risk of, or experiencing mild to moderate anxiety and depression during pregnancy and the first year after birth. Parents-to-be are able to attend between 12 and 28 weeks gestation (the middle trimester of pregnancy).

Wider Active Support

Leeds City Council – working together on the anti-stigma project to promote the perinatal mental health pathway in a user friendly way.
Voluntary sector – home start leeds offer a home visiting service for families in need.
NSPCC – provide a preventative service

Co-Production

Service users heavily involved via a group to help shape the work of the production of the perinatal mental health pathway and also the anti-stigma project through meetings, forums online and events
Inkwell (part of Leeds Mind) have been commissioned to work with the women in the Involvement group to create creative resources to challenge stigma.
– Creating an animation to be on Mindwell that draws on user recovery stories to challenge the myths and build viewers confidence to seek help. This is being completed to complement Best Beginnings films rather than replicate.
– Create a series of photos (roughly 15) of parents ideally in their home environment with text about their experiences of emotional health and how they overcame difficulties. Due to the limited number of photos we can capture we need to work with the involvement group to make sure we capture a wide range of experiences and people of different communities, ages etc. This will be hosted on Inkwell site and linked to from Mindwell which brings together resources and materials across leeds NHS, Leeds City Council and the third sector.
Creation of a resource pack to be used in ante-natal and post-natal groups that allows participants to explore impact of stigma. This will utilise the new local animation, the Best Beginnings films and the photography project plus Mindwell content, but putting it into a format that makes it easy for group facilitators to use.

Looking Back/Challenges Faced

Since we were involved heavily with several partners carrying out multi disciplinery work along with extensive co-production/collaboration with service users, putting meetings together and working to deadlines however working as a team and negotiating meant we could work through issues to ensure we reached a common goal.

 

Sustainability

  • All staff working with pregnant women will receive evidence based training and feel confident and competent in the early identification and management of mental health and any contributing problems in pregnancy and immediately after. They will recognise the importance of quick intervention, advice and support on the emotional aspects of parenthood, as a preventative action
    • Maternity pathways have been developed to include a range of providers which offer support to women who have been identified as having emotional health needs, or who are or have experienced domestic violence or abuse and require more support than can be provided by the midwife. Clear referral guidelines in place.
    The Joint Commissioning Panel for Mental Health includes examples of good service design and sets out key messages for distribution.

Evaluation (Peer or Academic)

This is continually ongoing
Mental Health in Leeds
Leeds has both higher rates of Common Mental Health Disorders (CMHD) than the England average and a higher proportion of its GP registered population with a (recorded) serious mental illness (SMI).
Estimated rates of CMHD in Leeds are 19% compared to 15.62% for England (16 – 74 years). This equates to 115,000 people (GP registered pop, 2015).
The percentage of people with SMI known to GPs is 0.95% (Leeds) compared to 0.86% (England). This equates to 7,600 people. (Public Health Audit October 2015)
Leeds has comparable overall rates of psychotic disorder 0.40% (16+) with the national average although a significantly higher prevalence of First Episode Psychosis than is estimated nationally: 42/100,000 compared with 24/100,000 (www.fingertips.org,uk) – ages 16 – 64yrs.

Outcomes

Since this has recently been agreed, we are working towards being able to demonstrate our outcomes which we are certain will be positive given all the evidence based research that has gone into this project.

We as the commissioner will monitor implementation of the PNMH Pathway to ensure the above, including a formal review by the ‘expert’ group* no more than 12 months from final draft agreement and before being fully formalised.

 

 

Sharing

Yes, we share work across partners via meetings, events, networking, websites etc

 

 

 

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