The Perinatal Mental Health Service for women in Ealing, Hounslow and Hammersmith & Fulham has been transformed from a secondary care focused service to a specialist community focused and community based service with integrated pathways and clear alignment to maternity and children’s services
What We Did
All women who access antenatal services will be screened for new or known mental health problems and will have rapid access to the appropriate mental health service, e.g. IAPT. We know from speaking and engaging with service users and carers that prior to the new model of care, mental health issues were not recognised or addressed. Often the pregnancy experience was poor with service users and their families experiencing longer term mental health and family issues.
In summary North West London and West London Mental Health Trust (WLMHT) have demonstrated: Collaborative commissioning and innovation through wide stakeholder engagement, co-produced service models and determination to improve. Service users are at the centre of the service – their stories were listened to and drove change; Committed clinicians who want to improve outcomes and experiences for women and their families; Flexible models of care which integrate primary, community and specialist services, and are aligned to maternity and children’s services; Robust pathways from maternity to mental health services, with rapid access to psychological therapies; Service delivery in community settings, including children’s centres to enable patient choice.
Wider Active Support
The new perinatal model of care was developed through a robust process of engagement and co-production. Three stakeholder workshops were held with the views of service users and carers prominent in all workshops and discussions. Partners included: Like Minded (the mental health strategy for NW London); WLMHT and CNWL (the Trusts); GPs; Consultant Perinatal Psychiatrists from our two local Mental Health Trusts (WLMHT & CNWL); Service Managers from CAMHS and Child & Family Therapy; Service Users and Carers; Health Visitors; CCG Commissioners; Midwives; Specialist Perinatal Midwives; Children Centre Managers; IAPT providers; Voluntary Sector colleagues.
Service users and carers have been at the centre of the new model of care with the service specification and quality & outcome measure being developed in partnership. Staff from both Trusts, WLMHT and CNWL have also been fully consulted and involved in the new model of care. The three stakeholder workshops provided a forum that brought together key partners so that from the outset the engagement process was open and encouraged the sharing of experiences. In December 2015 a dedicated focus group for service users and carers was held as part of the review process for Central and West London CCG. This meeting was both powerful and moving, as service users shared their experiences of local perinatal services and set out the requirements for a new service model. Discussions were captured and a graphical pathway created (available on request). The engagement process has been mindful of the diversity and different cultures that are apparent in NWL. As a consequence, listening to the experiences of service users where English is not the first spoken language or where family cultures are male dominated has ensured that the service model and service developments take into account the need for a diverse service.
The following statement is an extract from a service user (1) who attended a focus group session in December 2015: 1. “Prior to becoming pregnant I had already been diagnosed with depression and anxiety and was on medication for this. When I found out I was pregnant I was really pleased, but before long I started to feel very low and anxious. My midwife didn’t refer me to any support services and referred me back to my GP who kept informing me that it was natural to be feeling this as I was already suffering with depression before becoming pregnant. This was about five months into my pregnancy and by this time I was becoming really anxious and severely depressed. When my GP did finally take me seriously on account of threatening to commit suicide I was referred to the IAPT service. By the time I was seen by IAPT I was in the eighth month of my pregnancy. I want my experience fed into the perinatal group as I don’t want others to suffer like I did; things need to change for both the mum and the whole family.”
The following are details from a telephone conversation with a service user (2) who could not attend the focus group and wanted to be involved in the process:
- A young mum with a learning disability shared her experience. She had experienced maternity services on two occasions. During her first pregnancy she endured a still birth delivery after eight months of pregnancy. What she experienced following this, she explained as being ignored of her real feelings such as her bereavement. She explained that her family, GP and HCP did not identify her as someone who had lost a child but as someone with a learning disability, who they often referred to as a child. She became pregnant for a second time and this time she was allocated a support worker/ advocate who worked with her closely during her pregnancy, acting on her behalf and ensuring that her voice was heard. Mum and dad are both living together and have a nine month old baby who is healthy. She explained that it was important for her to be listened to and to have control over the birth, and that any actions and decisions were in her and her child’s interest.
Finally, a case study of a mum (3) who had unforeseen complexities with her pregnancy and how the new service would help her. The new mum is an anaesthetist living with her husband, a GP, and her in-laws. She was always a bit of a worrier, but she wasn’t someone with mental health history or risks. Her pregnancy was welcome but happened sooner than they expected, and together with well-meaning interventions, admonitions and comments from her circle made her mood low, feeling pressure and loss of control. At 34 weeks the baby measured smaller than expected and as she was always a high achiever, she met this with a sense of guilt and failure. The decision to induce at 38 weeks further contributed to her sense of loss of control. In the event she went into labour naturally but two epidurals failed and she had an emergency forceps delivery. The baby was fine, but the resulting tear meant she was in surgery and away from her baby for the first 2.5 hours of his life. She was in extreme pain because of the tear and was also incontinent. At the same time she was struggling to breast feed and the baby was crying a lot. Family visits were fraught with guilt and feelings of inadequacy.
In the new service, at around 11-12 weeks she would book in with the midwife, who would ask a couple of specific questions about low mood and lack of pleasure in life. Her GP would be able to advise, offering guided self-help or referring to IAPT. She would be seen rapidly by IAPT due to her condition and they could offer a low level intervention such as brief CBT. This would help her put her feelings in context and allow her to judge if they were proportional and appropriate to the situation. Her midwife, having had MH training, would be sensitised to her feelings and refer her to the Perinatal Service. They would assess her and if necessary offer more treatment sessions. She would be reassured by the midwife that the baby would be ok and that it is important that she receives medical attention for herself. The midwife would give advice on breast feeding and reassure her that her struggles are normal. If appropriate, and with her agreement, the family could be asked to restrict visits. The midwife would have a few minutes alone with her so she can express her feelings and any difficulties.
Looking Back/Challenges Faced
Reflection and learning is an integral part of service review in NWL. When embarking on the review of Perinatal Mental Health Services, the NWL approach was to widely consult on service developments and hence NWL adopted the stakeholder workshop approach. This approach has been deemed to be successful, and has been adopted and adapted by CCG colleagues. In particular Central and West London CCG have used this approach, have enhanced it with a dedicated event for service users and carers, and captured in graphical format the service requirements and service pathway. The decision to use the graphical approach arose from reflecting on a similar process when reviewing dementia services. Many stakeholders including service users and carers found service pathways difficult to follow and over-complicated. Mindful of the feedback from the dementia review and testing out the use of graphics in other work streams with positive feedback, this approach is deemed to fit the purpose and would be carried out as part of future perinatal transformation projects.
Our original vision specification had to be pared back slightly due to financial constraints. Originally, the desired outcome was for one year of post-natal support, but due to the money available this ended up as six months of support. Although this is deemed enough to make the difference we require, with more finances we could offer women in NWL even more support. Although the approach taken in the perinatal review has been successful, NWL will review the process and listen to partners and in particular service users and carers at every key milestone and will amend plans and methods based on the feedback received.
There have been some challenges in turning the vision into reality, particularly with securing estates to support community access. All estate issues have now been resolved and venues sourced. In the main, challenges have been minimal as the commitment from all stakeholders to improve perinatal mental health services in NWL and the willingness to change has been constant throughout the process.
Perinatal services in NWL will be reviewed for quality, safety and value for money via the formal contractual monitoring review process, as part of monitoring business as usual. Informal monitoring will be via the feedback NWL receives and seeks out though co- production as part of a continual process of review.
The longer term Sustainability and Transformation Plan will place perinatal services as key area in this agenda, with the vision and aim that perinatal mental health services across NWL are innovative, NICE compliant, reflective of quality and meet the needs and demand of NWL.
Evaluation of the project is currently being planned – this will be overseen by the Strategic Implementation & Evaluation Board co-chaired by Dr Beverly MacDonald. The Board discussed the evaluation for the first time on 20th May and agreed to support the process.
Full evaluation of the pilot will begin in November 2016 and will draw together both quantitative and qualitative data including service user satisfaction, use of pre-birth care plans, postnatal reviews of parent and infant mental health and many others. This full evaluation will then be used to inform future commissioning decisions.
Since the pilot project, we have been using the knowledge, information and learning to support the development of a Perinatal Model of Care in Central & West London CCGs. Hillingdon CCG is also interested and we are supporting them to review the capacity and demand of current service. Brent and Harrow are also reviewing the current service provision and model. NWL manage the Perinatal Innovation and Design Group, an active and committed forum for overseeing perinatal service developments at a national, regional and local level across NWL, which will hold quarterly events to network, share knowledge and experience, and help innovate the service for future.