As a catalyst to improving practice, a rolling program of training was a priority. NICE CG192 (2014) guidance informed the training packages. Three packages have been developed: Multidisciplinary Perinatal Mental Health Awareness Training for GPs, health visitors, midwives, social care and council is available, which aims to increase awareness regarding perinatal mental health, referral pathways, good practice (such as perinatal mental health care plans) and interventions; the second training is Perinatal Mental Health Awareness Training for Mental Health Practitioners and is tailored for practitioners working within mental health. Importantly, the vision promotes that perinatal mental health includes parent-infant mental health and there is advanced research based Parent-Infant Relationship Training. This was also developed in-house.
Central to aiming for best practice was that universal services and mental health services across the stepped care model should recognise the mental health needs and the risk to the woman and her family during the perinatal period. As a catalyst to improving practice, a rolling program of training was a priority. NICE CG192 (2014) guidance informed the training packages.
Three packages have been developed: Multidisciplinary Perinatal Mental Health Awareness Training for GPs, health visitors, midwives, social care and council is available, which aims to increase awareness regarding perinatal mental health, referral pathways, good practice (such as perinatal mental health care plans) and interventions; the second training is Perinatal Mental Health Awareness Training for Mental Health Practitioners and is tailored for practitioners working within mental health. Importantly, the vision promotes that perinatal mental health includes parent-infant mental health and there is advanced research based Parent-Infant Relationship Training. This was also developed in-house.
The training includes neurodevelopment of the infant, infant capacity, bonding, attachment, key components of attachment, observation skills, assessment, how to deliver messages to parents and interventions. This aims to address the gap in knowledge regarding the parent-infant relationship and how to effectively meet the recommendations of NICE (2014) 1.9.12-13. Attendees are from across the health and social care economy with particular focus on Health visitors, children centres, social care and increasingly mental health. Data systems have been changed to reflect the training, encouraging health visitors to use their knowledge from the training when recording their contacts’ case notes. Almost all HV have received this training and increasing numbers of mental health staff are now attending.
The training has been evaluated via a questionnaire at the end of each session and a survey monkey questionnaire was sent to attendees 100% of the 88 respondents stated that it had positively impacted their practice. The trainings received excellent evaluations. Practitioners have asked that the trainings are made mandatory.
Resources have been designed including the New Baby New Feeling leaflets focused in antenatal and post-natal mental health and given are given out by Midwives and Health Visitors. Just Had a Baby Booklets are basic self-help and which support HV in their listening visits and IAPT services’ therapy offer.
The innovative pictorial Parent-Infant Relationship Resource Cards were designed and are used by practitioners, including all HV, to facilitate sharing the information with all families and making interventions as recommended by NICE 2014 in an accessible way. These are currently being evaluated and initial pilot feedback is excellent with mothers, as well as practitioners, liking the resource and feeding back the changes in their knowledge of their infant capacity and also impact on their parent-infant relationship. The Perinatal Mental Health Lead and a health visitor are undertaking an evaluation of this resource. This resource has national interest and was showcased at UNICEF Baby Friendly conference.
The RCGP’s ‘Practical implications for primary care of the NICE guideline CG192 Antenatal and postnatal mental health’ has been sent to all GP practices and specific GP training has been delivered. Updates regarding perinatal mental health are provided via ‘Top Tips’.
A Perinatal Mental Health Working Group was established to promote interest and disseminate information; from this champions are established within each mental health team including primary, secondary and acute care and across health visiting, midwifery and substance misuse. Champions support their teams to provide best practice care and to enhance consistency across the services.
Champions can enable innovation and improvement in services. For example Health Visiting Champions are working to embed perinatal and parent-infant mental health through developmental work focused on clinics, listening visits, antenatal visits and supervision models. This has taken the idea of iHV Champions and extended it to a model of service development and best practice support that meets the needs of this locality. The Champions aim to embed the philosophy of parent and infant emotional well-being at the heart of health visiting.
To embed training supervision consultations are offered across the locality to health visiting teams. These may be extended to a wider range of early year practitioners. Consultations aim to help practitioners provide better clinical care and recognise when to refer on. In addition to the face to face consultations to teams offered currently in six locations on a monthly basis, telephone consultations are available to all practitioners in the Trust. Consultations are well-used resources with 120 calls taken for advice in 2016.
Developing care pathways to embed NICE CG192 (2014) recommendations within practice across services, including midwifery, health visiting and mental health has encouraged consistency of practice. The Perinatal Mental Health Lead has supported services to include NICE recommendations within Standards and Guidance. For example, the NICE prediction and detection questions, measures (PHQ9 and GAD7) are now part of the assessment process within MW, HV, GP and some voluntary sector services. All those using it have been trained in the use of the tool and have access to the referral pathway. Perinatal care plans, pre-conception advice and a perinatal mental health assessment are promoted within mental health, as is a Think Family approach, keeping the infant/child and the parent-infant relationship in mind, for example Safeguarding Supervision is now delivered to secondary care and this approach is integral to the supervision.
The Perinatal Mental Health Awareness training specifically addresses the need to keep the child in mind and the impact on the whole family, engaging with the infant and recording within case notes contact with the infant. The need to assess the needs of the family (partner, child, extended family) is emphasised as is the necessity for excellent communication with GP, midwifery, health visiting, children and family centres, family nurse partnership, social care, school nurses, and other appropriate practitioners.
We have developed an internal website for all practitioners where information, national reports, resources, and contact names are available to support service delivery.
We have changed database systems so that the perinatal mental health care plan is a pro-forma on the clinical database for mental health, NICE assessment questions are included for perinatal women and auditing is possible. System changes support improved care. We have just been awarded funding for a specialist perinatal mental health team. The work we have done will continue. The champion model will ensure that practice is not just excellent within the new team but across service and we aim for the new team to upskill and support the workforce at large.
Wider Support
We have received support from the CCGs who via the Perinatal Mental Health Task And Finish Group and Maternity Network have enabled perinatal mental health to be prioritised, as well as supporting the recent funding bid. Our Trust benefits from providing Health Visiting and Child and Adult Mental Health, which ensures these services can work to provide cohesive care. We have developed working relationships with Born In Bradford whose research expertise will support the evaluation of the perinatal mental health project.
We have excellent relationships with maternity clinical leads from the two local hospitals and work to ensure that systems work across services. We have good relationships with Leeds Mother and Baby Unit, our regional unit, and also providers of Yorkshire and Humber Perinatal Mental Health Service. These are set to strengthen as our psychiatrist is receiving specialist training from Leeds and Leeds will provide mentoring supporting service design. We are working closely with voluntary agencies, for example, supporting the evacuation of MPAS in HV and providing support to Better Start services such as the Perinatal Support Service.
Co-Production
Service users, who have experienced of severe perinatal mental illness, advise on service development and we are looking to extend this once the new service is developed. We have made use of local networks events to hear about women’s experiences of perinatal services in conjunction with Maternity Partnership. We have piloted the Parent-Infant Relationship Resources Cards and gathered parents’ feedback. We have also presented service users stories at the Trust Board. We have benefited from the Action On Post-Partum Psychosis Peer Support in our service design and understanding.
The champion model via the Perinatal and Infant Mental Health Working Group has meant that there are a growing number of dedicated staff who are championing Perinatal and Infant Mental Health, creating a valuable resource and ensuring that service needs are addressed.
Looking Back/Challenges Faced
The Perinatal and Infant Mental Health Working group is something which I would recommend as an approach as it has helped ensure change across services. Having supportive management and CCGs has been hugely beneficial to keep work progressing and it is worth spending time to ensure that this is in place. Ensuring that there is a rolling programme of training and consultation has helped ensure that improvements are implemented and maintained, and ad hoc telephone consultation available whenever someone has a concern is worth providing. Building working relationships with other services takes time but is worth the investment. Service Users stories are invaluable. Persistence and passion has been useful.
Sustainability
The Perinatal and Infant Mental Health Working Group ensures the model has greater sustainability. We now are developing a specialist team which will ensure that training and consultations are embedded into the future. The CCGs have committed to having Perinatal Mental Health within the 5 Year Forward Plan.
Evaluation (Peer or Academic)
We have evaluated training and 100% of respondents to a Survey Monkey said the training had improved practice. We also evaluate the training and feedback is excellent. We have piloted the Parent-Infant Relationship Resource Cards and feedback from practitioners and parents was very positive. With the development of the new team we are setting up evaluation systems and are receiving support from Born in Bradford in this.
Outcomes
Bradford District Care Foundation Trust practice meets NICE 37 (2013) Quality Standards 9, 10, 11.
Referrals to the Leeds Mother and Baby Unit have also increased 5 fold.
The use of the consultation demonstrates that perinatal mental health is a concern to practitioners.
GPs have fed back that they have noticed a change in practice with Health Visitors both in regards to improved recording in notes and greater communication with GPs.
Maternity and Health Visiting feedback is that the referral pathway has greatly improved their referral experience.
The Formulary have received an increase in communication around perinatal prescribing since training has begun indicating that the issues with this are better understood and expert advice is being sort when necessary.
An evaluation of a pilot of Watch, Wait and Wonder (parent-infant therapy) was undertaken with excellent results including on benefiting the mothers mental health (lowering depression, anxiety scores, increasing work and social functioning, lowering parental stress, increasing self-esteem and improving the relationship between mother and child. Furthermore, the mothers’ qualitative responses were that they liked the intervention.
A Service User Story to the Trust Board has provided positive feedback regarding parent-infant therapy received, and two more have been offered for presentation. The video story was by a service user who has accessed parent-infant therapy, in particular Watch, Wait and Wonder with Video Interaction Guidance for herself and her new-born baby. The Service User spoke of her fear that she had not bonded with her son and the devastating affect this had on her mental health – she was depressed and anxious. She felt that the interventions were instrumental in her falling in love with her son and recognising his love for her. She called for parent-infant therapy to be more widely available. Work is underway to gain more insight into parents’ experience and to gather their feedback.
Training has excellent feedback, and in response to a Survey Monkey 100% of 88 respondents stating they have improved their practice. Evidence, via audit, demonstrates that perinatal mental health care plans are being provided.
Data evidence shows that HV are asking the detection and prediction questions, are taking appropriate action and are assessing the mother baby relationship.
Parents’ feedback regarding the parent-infant relationship resource cards demonstrates that the approach is welcome and has made a difference to their recognition of the infant capacities and their relationship.
It will be over a longer time period that some of the benefits of this work will be seen, work focused on auditing and evaluation continues.
Sharing
We have presented our work at the Yorkshire and Humber clinical network and their Perinatal Conference, London Perinatal Network Conference, UNICEF baby friendly conference, Begin Before Birth conference, PIP conference, iHV events and Better Start Bradford events. We are also now working with NHS England to support other services intending to bid for specialist community mental health team funding. We have also provided a NICE Shared Learning example and provided information to Royal College for GPs and NHS England.
Is there any other information you would like to add?
The work we have done is a good foundation to the new Specialist Perinatal Community Mental Health Team and furthermore ensures that all women access good care whatever their level of need.
The work has required close working relationships with stakeholders and all services with whom a woman and her family may be in contact must understand perinatal and infant mental health to ensure early intervention and prevention is effective. We have worked innovatively with no added resource and have developed a robust model and innovative resource (Parent-Infant Relationship Resource Cards). Through a Perinatal Mental Health Lead and a Working Group the whole workforce has been up-skilled resulting in better care for women, infants and families.
Our integrated referral pathway and single point of access increases access via ease of referral. Our patient outcomes improve by detection of perinatal mental health issues and risks, ensuring early intervention is in place. Innovative interventions have been effective (Watch Wait and Wonder and VIG). Up-skilling staff and continually supporting them via resources, consultation training and systems has increased their confidence, resilience and knowledge. This in turn has improved care for mothers and the increased work with the parent-infant relationship has been warmly received by parents.
