Essex Perinatal Mental Health Service - HC - #MHAwards18

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

In September 2016 an application, led by North East Essex CCG, was put forward to NHS England to secure funding for specialist perinatal mental health community services. It was announced in December 2016 that the application was successful, and £2.6 million would be made available over three years to set up and run these much needed services across the whole of Essex.

The new specialist service is delivered by the newly merged Essex Partnership University Trust and is commissioned through a collaborative arrangement with Essex’s seven clinical commissioning groups. The development of the new specialist service requires close collaboration with existing services such as health visiting, IAPTs and midwifery as well as mental health service and will contribute to the development of knowledge, skills and pathways to support women needing support in the perinatal period across partner services and organisations.

What the service does The Perinatal Mental Health Service is an Essex-wide specialist community service providing care and treatment for women in the perinatal period at risk of or with serious mental illness or complex disorders in the community who cannot be appropriately treated by primary care services. The service contributes specialist perinatal expertise to the care of women to enhance the care of community mental health service and support existing perinatal mental health pathways in maternity services, health visiting and other services across the health and social care system in Essex. The PMH Service will work with approximately 3% of women in the perinatal period (conception to 1 year postnatal) in Essex who are at the most moderate to severe risk of serious perinatal mental illness. This is expected to be around 700-800 women per year, with the remaining 2-5000 women with lower levels of risk cared for by universal services and primary care.

What makes your service stand out from others? Please provide an example of this.

Mobilised and designed a new specialist service at scale across a newly merged Trust and multiple complex essential interfaces and travelling across long distances into towns, rural communities and coastal areas with an extremely stretched but dedicated team.

How do you ensure an effective, safe, compassionate and sustainable workforce?

NHS England commissioned Tavistock and Portman NHS Foundation Trust to develop universal competencies for all professions working with women with mental health conditions in the perinatal period. Our service carried out a gap analysis across the new team to identify areas for training. One challenge was that there was limited information nationally available to identify appropriate courses to meet the competencies required. Our service created a training matrix in line with the Tavistock and Portman competencies to prioritise the key courses available for specialist training. Fortunately the service was able to use funds within resource to train the new workforce. The training that has been commenced or completed includes: • Video Interactive Guidance (VIG) – teaching simple interventions to improve mother and baby interaction. • ITSIEY Specialist Parental Mental Illness (Anna Freud Centre) – essential skills and knowledge for specialists working in parental mental illness. • Infant Mental Health Online (IMHOL) – a 16 week online course delivered by Warwick University. • Perinatal Mental Health The National Training Course – yearly refresher training aimed across disciplines delivered by Winchester Perinatal Services. Several bespoke training sessions have also been delivered including Enhanced Child Safeguarding given the proportion and depth of involvement of PMH clinicians with contributing to manage child safeguarding risk. Training to be attended later in 2018: • Parent Infant Observation Scale (PIOS) – training in competence to use an advanced assessment tool to measure parent infant interaction • Perinatal Training for Community and Inpatient Perinatal Mental Health Team Managers – skills and knowledge for leaders in this specialist area delivered by Tavistock and Portman Other local specialist training to be arranged includes the Dynamic Maturation Model to enable care to be informed by understanding of adult attachment, and bespoke training in Domestic Abuse which is a common risk within this group.

Who is in your team?

Current service resource Consultant Psychiatrist Consultant 2.0 Speciality Trainee CT 1.5 Clinical Psychologist 8a 1.0 Service Manager 8a 1.0 Clinical Lead B7 2.0 Psychologist B7 1.0 PMH Practitioner B6 11.0 PMH Counsellor B5 0.4 Administrator B4 2.0 Administrator B3 1.0 Total WTE 17/18 22.9 Posts due for recruitment 18/19 Social Worker B6 1.0 Occupational Therapist B6 1.8 Total WTE 18/19 2.8 Final WTE 25.7

How do you work with the wider system?

The PMH Service has ongoing engagement with an extensive range of clinical interfaces and partners across Essex, this is ongoing through care interfaces and formal and informal meetings. In the first year there have been scores of meetings and interface development is ongoing and live with care delivery. As pathways develop, feedback and liaison with partners is informing adjustments to processes and sharing of key perinatal risks and red flags are discussed routinely to raise awareness in partners. – Specialist midwives across the five acute hospitals in Essex have met formally with the service and work closely in partnership, attending service clinical MDT meetings regularly. – Obstetricians across five acute hospitals are at various stages of liaison with Consultant Psychiatrists about how liaison be effective. – Specialist Health Visitors in some areas or lead health visitors developing in Essex meet formally with the PMH service and with the service to inform interface development. Health Visiting attendance at clinical MDTs is also beginning. – Single point of contact access teams vary across the merged Trust.

There is ongoing development of the interface and raising awareness of perinatal red flags. – Community mental health teams with different specialisms based in localities across Essex – Emergency Psychiatric Liaison and Crisis Services align to acute hospitals and localities, formal meetings and sharing of guidance is ongoing with these services. – Three different IAPT providers across Essex are engaged with the PMH Service and attend clinical MDT in some areas. – Rainbow Mother and Baby Unit are a key partner where close working is required for women under their care. – Other services such as psychotherapy, Adult Social Care, Children and Young People Services – Strategic links such as Local Maternity System, STP planning and Maternity Voices sit across three footprints. The PMH Service is linked and involved with these forms at various stages across the three STP footprints. Training provided to bespoke professional groups, bespoke to locality groups, through Clinical Network. First large scale training aimed at all professions across the pathways on 6th July with over 70 professionals now booked included local peer network / community group leads.

Do you use co-production approaches?

Co-production has been a strong value and theme through the development of this service with close working the Healthwatch Essex and the Mental Health Ambassadors working alongside to inform the service design from the outset through the bid and forming the vision of equitable access to specialist services for all mums across Essex. Engagement with local mums with lived experience has taken place across the year on specific pieces of work and there are plans to engage with mums more regularly and in a coordinated way to create a regular space or forum for conversation and exploring how people would like to engage with the service and other mums through co-production. Examples of co-production include: • Mental Health Ambassadors with lived experience of poor perinatal health had input to recruitment process for roles across the service. • The service patient leaflet was designed with the involvement from mums under the care of the Rainbow Mother and Baby Unit. • A Mum with lived experience was guest speaker at the PMH service launch event, and further links will develop to her support awareness of her website and videos. • The CEO of Best Beginnings also attended the PMH Service launch as a guest speaker presenting the Baby Buddy App and it’s videos, and other work carried out in perinatal mental health by Best Beginnings. • Mums currently receiving care attended the PMH service launch with family and babies • Excerpts from a book written by mum who received service was shared at PMH Service launch event. • The design of a local questionnaire to review experience of pilot care pathways was designed with a local mum with lived experience. • Drafts of leaflets for older children in families affected by perinatal mental illness have been reviewed by mums with lived experience. • Local informal meetings with local perinatal peer network and community representatives have taken place for engagement and co-design of service. • Sessions to raise awareness of Perinatal Mental Health to local peer networks have been delivered in response to peer network requests. • The service was also able to share the feedback of the Essex Patient Experience Survey commissioned by the East of England Perinatal Clinical Network to inform local pathways of experience of women giving birth from 2014 to 2017 prior to the new PMH Service. The team are very grateful for the input of local mums and interest shown in engaging with the service and look forward to more conversation and understanding how mums wish to develop this over the next year.

Do you share your work with others?

The team is actively involved in local, regional and national perinatal mental health networks. • The Essex Perinatal Clinical Network is chaired by one of the lead Specialist Perinatal Consultant Psychiatrists in the community service and the Rainbow Mother and Baby Unit brings together clinicians in all disciplines and services from across Essex. Recent ‘spotlight sessions’ at these meetings is rotating training around disciplines and services to share knowledge, skills and good practice across specialist and universal pathways. • Membership of and contributions to the East of England Strategic Clinical Network for Perinatal Mental Health support links with other perinatal mental health services in the region. The service model was presented at the last regional annual event on 14th December 2017. • Strong links with national developments at the Royal College of Psychiatrists are in place through the role of East of England Regional Advisor for the Perinatal Faculty, held by a service Consultant Psychiatrist. • NHS England Community Services Development Fund events bring together all of the national sites developing services with Wave 1 funds. The PMH Service is always represented and also presented the service model nationally to peer services on 1st December 2017. • Membership of the Perinatal Quality Network, overseen by the Royal College of Psychiatry is now in place with a Peer Review visit expected in the autumn of 2018 as part of working towards accreditation to the CCQI standards. The innovative models designed by the service are being shared at regional and national network forums.

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

CORE-10 The Royal College of Psychiatry carried out an audit of the new Wave 1 specialist community sites during autumn 2017 following little national or professional guidance as to the most appropriate clinical or patient reported outcomes for these new specialist community services. The CORE-10 was one of the few recommended and validated clinical outcome measures relevant to specialist perinatal MH community services and therefore identified as the main clinical outcome measure for this service. The PMH service built this outcome measure into the SystemOne record to enable electronic and automated reporting for outcomes with clinicians starting to use this measure from January 2018. Given the timescales since implementation for recording and follow up scores this data is not yet available to quantitatively demonstrate clinical outcomes, however it is hoped that initial data at meaningful levels will be available during the first 6 months of 2018/19. Perinatal POEM – Patient Outcome Experience Measure Colleagues at the Winchester Perinatal Mental Health service lead the way with women with lived experience in recent years with the development of the ‘Perinatal POEM’, a Patient Outcome Experience Measure. Through contacts and networking with the Maternal Mental Health Alliance and other peer services this outcome measure has been identified and implemented for use at the end of the episode of care since January 2018 in our PMH Service. Initial results from 20 mums across Essex have been encouraging and comments from women having completed their care with our service have been included within this report. The charts with the service demonstrate a clear improvement in well-being from the beginning to the end of care with the PMH Service with a majority considering themselves to have been very unwell or extremely unwell at our first contact and well or very well at the point of discharge. PIOS The service is also training in use of PIOS in June 2018 with implementation across the summer.

Has your service been evaluated (by peer or academic review)?

Membership of CCQI. Peer review dates are pencilled in for autumn dates to be confirmed in 2018.

How will you ensure that your service continues to deliver good mental health care?

Monthly meetings with lead commissioners. Robust data Promotion of service through training events. Promotion through booked filming with BBC Look East for summer 2018. Invitation to MP Jackie DOYLE Smith, local MP and PMH national lead to visit our community services following a visit to the MBU last year. Support to commissioners to make the case for continued investment. Service leads all closely involved in development to ensure sustainable leadership.

What aspects of your service would you share with people who want to learn from you?

A Perinatal Care Pathway and the concept of a ‘Perinatal Timeline’ were developed to set out a framework of key care milestones, interventions, contacts and risk management along the pregnancy and postnatal journey in line with: o CCQI Quality Perinatal Standards o Recommendations for risk management from MMBRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) o NICE guidance for antenatal and postnatal mental health The full pathway detail is set out in Appendix 3. Innovation and design: Brief Intervention The range of perinatal conditions, emerging presentations and unknown risk calls for flexibility and bespoke packages of perinatal care. Some women with higher risks require longer term intervention and support postnatally and may follow the full care pathway described above, however some moderate risk can be managed in a shorter episode of care taking all holistic and risk factors into account for each case. This lead to the development of a Brief Intervention which consists of similar principles described above for up to 12 weeks, depending on gestation and individual factors. Innovation and design: Perinatal Toolkit A range of interventions have been identified to draw upon to be included in the options for perinatal care. These interventions include specific sessions such as anxiety management, emotional regulation, self-compassion.

Practitioners have a range of therapeutic training and skills to offer a variety of sessions and training is planned to develop Dialectical Behavioural Therapy Groups which has been identified as potentially meeting a need for a significant proportion of women receiving care. Arrangements are also underway to deliver Video Interactive Guidance for mother and baby intervention by psychologists. Innovation and design: Psychology service With limited Psychology resource a model for psychology has been designed to maximise direct clinical care whilst also providing consultative advice to inform care across the caseload. Based on current resource the psychology model includes i) individual therapy,ii) formulation groups for the team to support formulation informed care plans iii) MDT consultative advice iv)consultative advice to other therapeutic professionals v)joint assessment with practitioners/psychiatry. As above, psychologists will also deliver DBT groups and VIG interventions. Innovation and design: Development of Perinatal Clinical record The PMH Service has carried out an extensive design of a Perinatal Clinical record within SystemOne in line with the designed pathway to support clinical recording, communication, service processes and contractual reporting. Innovation and design: Various Many other areas have been developed to inform practice such as Perinatal Red zoning, templates for care planning and risk assessment, guidance with perinatal red flags for other services and communication systems within the service. Numerous challenges and lessons learned to share with Wave 2 sites.

How many people do you see?

Over 400 new women accessed the service with face to face contact since April 2017. The number of referrals to the PMH Service per month from April 2017 to March 2018 totals 1019 across the period. There is clearly and upward trend over the year which correlates to the phased roll out approach taken towards a formal launch in October 2017. This represents a clinical triage of 1019 cases, a large proportion of which will have gone onto to comprehensive assessment and an episode of care. Referrals at the beginning of 2018 are averaging around 100 per month across Essex. Due to the current development phase, referral numbers are expected to rise across 2018/19.

How do people access the service?

Referrals are currently from any health or social care professional.

How long do people wait to start receiving care?

Confidential Maternal Deaths Enquiries have shown that during the perinatal period there can be rapid deterioration, emerging conditions and development of serious conditions and therefore the service needs to respond quickly according to clinical need a assessed risk and within its resource. The PMH Service aims to assess routine referrals within 2-6 weeks and will aim to assess those most at risk within a few days of referral if possible where this is needed. This may be in collaboration with crisis services where needed. The development of data collection and validation is underway and once established will allow waiting times to be accurately monitored. However, it is observed that the vast majority of referrals are assessed within 4 weeks with a significant proportion assessed within 2 weeks.

How do you ensure you provide timely access?

Managing caseloads of practitioners. Screening and comprehensive triage. Clinical needs led allocation to first assessment Joint assessment or liaison with crisis and emergency psychiatric services. The service is reaching capacity and will be proposing a RAG rated service status with escalating actions to take in order to safely manage the caseload whilst remaining accessible to new referrals.

What is your service doing to identify mental health inequalities that exist in your local area?

Engaging with local groups representing groups underrepresented in the service. Work planned to provide training to forums or organsations with contact with underrepresented groups.

What is your service doing to address and advance equality?

Adherence to legislation Engaging with groups Seeking advice in specific cases Culturally sensitive care Awareness in relevant issues for perinatal such as FGM or diversity factors such as partners in LGBT relationships

How do you identify the needs of a person using the service ?

Bespoke Perinatal assessment designed by the service in line with CCQI Service Standards 3rd Edition:Perinatal Community Mental Health Services (Royal College Psychiatry Perinatal Quality Network for Perinatal Mental Health Services)) Bespoke Perinatal Triage assessment also designed by the service. Bespoke Perinatal Risk assessment also designed by service and in line with CPA level comprehensive risk assessment. Parent Infant Observation Scale assessment will be implemented in Summer 2018 Condition specific assessment carried out by Psychologists working with mums.

How do you meet the needs of people using the service and how could you improve on this?

Aligning model with recommended care and risk in line with o CCQI Quality Perinatal Standards o Recommendations for risk management from MMBRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) o NICE guidance for antenatal and postnatal mental health and other relevant NICE guidance We would like to improve to location of venues / options for mums to be seen in more accessible venues such as Children Centres or Maternity Units and are developing relationships with partners to explore this. With the logistics of so many partners these types of arrangements are likely to be started in a small area and rolled out as the scale of relationships building from scratch is immense. We have plans to work more closely with local mums with lived experience through regular café / chats where we can hear about experience and improve the service The patient reported outcome measure also is reviewed to improve the service. We will also design a feedback mechanism for referrers. We are aiming for accreditation with the CCQI across 2019.

What support do you offer families and carers? (where family/carers are not the service users)

Carer assessment for partners. Advice and support for partners. Family or couples therapy where relevant to psychology intervention although our psychology resource is extremely limited. After the pace of service development calms and core service processes are well established, we want to work with local fathers/ partners on how our service can work with them and support their journey.

Further information

Please allow us to share our Service Evaluation Report to fully demonstrate our commitment, learning and progress for local mums. Outstanding progress has been made by the EPUT Perinatal Mental Health Service in developing and delivering a new and wonderful specialist community service for pregnant and postnatal mums across Essex. With achievements across many important areas it is difficult to communicate the scale and significance of this work. Contributing to the national commitment by NHS England to increase access to specialist perinatal community services, in the last 18 months, the service advanced from securing funds, planning and intensive recruitment in early 2017, through to service design and full mobilisation and delivery of specialist care to over 300 new mums in Essex across the summer and winter of 2017/18. Blessed with dedicated, skilled and hardworking individuals from clinical and non-clinical backgrounds, both new and established staff have joined an amazing rollercoaster journey of expanding and developing services with hopes that mums accessing care and professional colleagues will experience their compassion, heart and commitment for mums and their babies. Aiming for accreditation with the RCPsych CCQI Standards for Perinatal Community Services, over the last year the multi-disciplinary team has intensively focused on designing and delivering a model that achieves good outcomes and experience for mums and their families, and are quickly moving closer to meeting these professional standards.

Without ‘off the shelf’ models, the service joins other new wave teams to innovate ways to deliver evidence based care and share their model and learning at national forums through NHS England and at regional clinical networks, supporting other services and informing national approaches to wave 2 services in 2018/19. Collaboration with mums, colleagues and commissioners, supportive relationships with NHS England and the Maternal Mental Alliance, has been essential to informing the model and improving patient experience and service interfaces, with an emerging culture of seeking feedback, listening, improving and exploring how to work more closely with mums and more seamlessly with colleagues. Sharing expertise, advising, promoting and developing awareness and pathways for maternal mental health across essential partners in maternity, health visiting and mental health services is moving forward as a result of developing integrated working and through leading and contributing to the Essex PMH Clinical Network. Overcoming many challenges as one of the first services to navigate a new Trust, through personal and professional flexibility, resilience and creativity the team has also negotiated infrastructure and logistical obstacles, built bespoke clinical records into System One, and is developing relationships across a changing and complex multi-organisational pan-Essex landscape of health and social care with much to learn and develop across perinatal mental health. This is just the beginning. Learning together and building friendships with services under increasing pressure, the service is grateful for the patience of colleagues as pathways are navigated and built over coming months and years with mums experience and outcomes at the centre. With much work to do, this group of wonderful people deserve recognition for their efforts, expertise and dedication as they strive to do their best for local mums and their families.

Hours the service operates *

Mon – Fri 9-5

Population details

Brief description of population

The service is in a particularly unique position of developing a service across such wide and varied geographical footprint of Essex which includes remote rural areas, coastal towns, areas of relative affluence, with deprivation widespread in some urban areas as well as in more remote areas. To manage coverage of a large area with a small service, the teams operate from a hub within the Linden Centre, Broomfield, covering North Essex (North East Essex, Mid Essex and West Essex CCGs), and a Rochford Hospital based hub now covering all of South Essex (Southend, Castle Point and Rochford, Basildon and Brentwood and Thurrock CCGs). With a birth rate in excess of 23,000 per year across five acute hospitals, three local authorities and seven CCGs, along with a significant variation in service provision and providers across the health and social care system, Essex represents one of the most complex and larger footprints of UK sites developing with the NHS England Wave 1 funds. Together with mums under the care of the service and their families, multiple interfaces include: • Specialist midwives across 5 Acute Trusts • Obstetricians across 5 Acute Trusts • Health Visitors across 3 Local Authorities • GPs & commissioners across 7 CCGs • IAPT services across 3 providers • Psychiatric liaison across 5 A&E teams • MH Access Points across 7 localities • Multiple triage routes inc MIND • Mental Health and Childrens Social Care across 3 LAs • Multiple community mental health adult and children/young peoples teams across over 20 services • Other specialist services covering issues such as Substance Misuse, Domestic Violence, Rape Counselling, Female Genital Mutilation • Psychotherapy teams • Local peer networks and community groups • Other peripheral interfaces such as Neonatal Units, Paediatric Services, Breastfeeding services Other contexts also increase local complexity: • Developing across a newly merged MH Trust • New provider and transformation of Health Visiting Services in Essex • Variable triage and crisis configurations • Variable Perinatal pathways across localities in primary care • 3 STP footprints, with 2 crossing borders out of Essex • Separate Maternity voices and Maternity Services Liasion Committees influencing developments in maternity care • MSLCs

Size of population and localities covered:

Whole population of Essex , Southend and Thurrock Birth rate of around 23000 per year 7 CCGs 3 Local authorities 5 Large acute hospitals and maternity units 3 providers of Health Visiting Newly merged Mental Health Trust

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): *

7 CCGS, Southend, Thurrock, Mide Essex, North east Essex, West Essex, Basildon and Brentwood, Castle Point and Rochford

Provided by (e.g. name of NHS trust) or your organisation: *

Essex Partnership University Trust

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Essex Perinatal Mental Health Service – HC – #MHAwards18

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