Start Well: a dynamic approach to integrated perinatal mental health care – NW Boroughs

The Start Well integrated pathways project aims to maximise benefits of the implementation of an integrated perinatal mental health pathway by enabling healthcare practitioners across the Trust’s physical and mental health services to skill-share to deliver a higher ceiling of care.

The Start Well integrated pathways project group worked together to formulate a collaborative approach to early intervention and targeted support through the development of one integrated perinatal mental health pathway across universal child health services, psychological therapies, child and adolescent mental health services, primary and secondary mental health services, midwifery services and third sectors organisations.


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


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

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What We Did

The Knowsley Borough Joint Strategic Needs Assessment for 2015/16 highlighted that referral pathways across care systems are unclear and the current criteria for accessing services needed reviewing. The Trust took this opportunity to work with partners to review separate service and provider pathways to develop integrated pathways across adult services, maternity, adult mental health, children’s services, IAPT, child and adolescent mental health services, and children’s centres, which are now dynamically linked. The Start Well project was established to support this aim with initial focus on the perinatal mental health pathway.

The Start Well integrated pathways project aims to maximise benefits of the implementation of an integrated perinatal mental health pathway by enabling healthcare practitioners across the Trust’s physical and mental health services to skill-share to deliver a higher ceiling of care.

The Start Well integrated pathways project group worked together to formulate a collaborative approach to early intervention and targeted support through the development of one integrated perinatal mental health pathway across universal child health services, psychological therapies, child and adolescent mental health services, primary and secondary mental health services, midwifery services and third sectors organisations.
The group recognised the need to combine several existing clinical pathways to harmonise procedures and enable early warning signs of deterioration in emotional health and wellbeing in the antenatal and postnatal period to be recognised. This triggers the delivery of early targeted interventions to support person-centred care in the perinatal period across physical and mental health services.
A literature and best practice review at the onset of the project identified a number of national strategies and evidence-based approaches which would support achieving of better outcomes for children, young people and families whilst supporting women through the perinatal period. The following identified a summary of the key considerations in the development of this pathway:
• Department of Health (2014) Early Years High Impact Areas Transition to parenthood and the Early weeks and Maternal Mental Health (Perinatal Depression)
• Think Family approaches (Department of Education, 2009)
• ‘Falling through the gaps’ (Khan 2015) Royal College of GPs’ report which identified that early intervention significantly reduces the impact of disorders on the mother, her child and family
• Parental mental health is a risk factor for conduct disorder in children (Centre for Mental Health, 2014)
• Need for seamless services across professions and urgent need to improve perinatal mental health training (DH 2015)
• Kings Fund, 2016 recommendation for the need for integrated care between physical and mental health
• Local research of young people (aged 16-19) in Knowsley estimates 1,100 (350 male and 750 female) with a neurotic disorder, with females more likely to suffer from anxiety and depressive disorders as well as phobias. Knowsley also has a higher rate of teenage and young adult pregnancy
• North West Coast Clinical Network had successfully developed an integrated care pathway giving consideration to services from pre-conception to school entry
• NICE Clinical Guideline 192
An integrated perinatal mental health pathway for Knowsley women and their families has been developed by the project group using the North West Coast and NICE Clinical Guideline 192 as a blueprint. This interagency whole system co-design project has had a significant impact in strengthening communication and enhancing the working practices between psychological therapies, child and adolescent mental health services, health visitors, family nurses, midwives and primary and secondary care mental health services. This is delivering improved outcomes for women and their families.

This has led to a significant increase in collaborative working and consultation across each of the services, particularly between health visiting and psychological therapies, to share knowledge and support women’s services.

We have strengthened relationships with the named midwives from maternity services across the footprint, including improving communication systems for supporting mothers with significant mental health problems or illness, plus closer working around cases where there are safeguarding issues.

We have developed systems to support inter-professional supervision and partnership working between child and adolescent mental health services, psychological therapies, health visitors and family nurses and implemented inter-professional training between all services.

We have developed an emotional health and wellbeing range of tools and coping strategies to support women early in the antenatal period and have seen an increase in uptake of antenatal visits by health visitors and early help assessments completed.

The difference it has made is to break down the barriers of silo working, identify the skills gaps to undertake whole person care and to reduce multiple hand-offs between services.
We have developed a culture of multidisciplinary care and reduced the number of access points to services for women, children and their families so they don’t have to repeat their story. The pathway has resulted in a reduction in waiting time for psychological therapies from 14 weeks to four weeks in accordance with NICE guidelines; and staff in health visiting have enhanced their skills, enabling the delivery of low level cognitive behaviour therapies, reducing the need to refer to psychological therapy services (IAPT). The spectrum of delivery of psychological therapy has widened across the whole pathway to enable women to access this support at any point in the perinatal mental health pathway.

Wider Active Support

We initially reviewed the integration between physical and mental health services. A number of issues were identified including, a lack of unawareness amongst staff of availability of services, referral criteria and pathways, and roles and responsibilities of teams. In addition, communication channels were inconsistent between services; there was a lack of prioritisation by some services for women needing support for mental health issues in the perinatal period and a lack of multiagency education and training to skill up practitioners

Our partners across community services include: Family Nurse Partnership, Health Visiting, School Health, Knowsley Carers’ Centre

In primary care: Improving Access to Psychological Therapies (IAPT) Service, GPs

External partners include: hospital midwifery and community public health midwives; Building Bonds; Attachment Service; Liverpool Women’s Hospital midwives, Specialist Perinatal Mental Health Team; Children’s centres; Southport and Ormskirk Maternity Services

Secondary care services include: Assessment and Home Treatment Team, Recovery Team; Psychiatric Liaison; Mersey Care, psychological therapies, child and adolescent mental health services, primary and secondary mental health services, midwifery services


We listened to the experiences of women, children and families by scoping and mapping their journey through services to determine the current local picture by review of case studies.

Using both qualitative and quantitative survey methods, the views and experiences of staff were captured in relation to how effective communication systems were with other professionals, including GPs, and their experience of multiagency working across the professional boundaries to support women and families.

Service users were also engaged through the children’s community nursing service communications and marketing group where their views were sought on the sharing of key messages on social media. Services users have shared experiences of their journey through services with the project group.

A comment from a parent receiving regular listening visits from her health visitor: “It is a relief to be listened to and this has given me the confidence to self-refer to IAPT”

Engagement with staff took place to gather their experience through staff surveys and questionnaires at emotional health and wellbeing conferences. Emerging findings demonstrated areas of good practice, however, it also highlighted many gaps existed.

Third sector services were also engaged in the development of the pathways, for example, Knowsley Carers’ Centre.

Looking Back/Challenges Faced

We would have had wider scoping and understanding of the roles of the range of disciplines engaged to reduce delay in engaging with the most appropriate staff to enable the project to progress to timescales.

There were initial difficulties in engaging some partners and sustaining their involvement in the project in the early stages of the project. However, relationships were developed and strengthened throughout the course of the project and this has led to a more cohesive and collaborative approach to support women, children and their families.

There was an element of scope creep due to extending the initial scope to include the emotional health and wellbeing of children.


The project has transitioned to business as usual. Part of this process has been to ensure ongoing improvement is embedded in the culture of care.

We are in the process of moving to an integrated community locality model across the borough. This will facilitate co-location and integration of physical and mental health services, both statutory and third sector. It is anticipated this development, based on four localities, will ensure patient-centred care is provided and coordinated to meet the needs of individuals, families and local communities within each locality, and support the sustainability of the Start Well project beyond the scope of the initiative.

Regular case review meetings have been strengthened and attended by representatives from midwifery services, health visiting and primary and secondary care services. Through this forum, we will be working with patients and their carers to develop a suite of patient-related outcome measures.

A training programme has been developed for all staff groups including a 60-minute briefing to provide practitioners with initial training at induction and programme of targeted training has been developed. This will be is refreshed annually.

Perinatal champions have been identified within teams to continue to support this agenda.

The Trust has secured funding to develop a Specialist Perinatal Community Mental Health Team across Cheshire and Merseyside which is being established as part of the Cheshire and Merseyside Sustainability and Transformation Plan. Key messages and relationships forged as part of the development of the Start Well integrated pathway will support the future development of a specialist team.

Evaluation (Peer or Academic)

A public health midwife from a local maternity provider commented:
“I think the exercise has been useful in that it has provided a platform for other agencies to promote the support and services they provide. Using the integrated pathways provides clear advice to professionals of what should happen to women and their families in the perinatal period. The pathways support all the Department of Health documents and reports regarding early identification and assessment so, as a professional, I feel it is useful. I now think there are clear guidelines that highlight to the practitioner where to refer and the perinatal journey that the woman should take.”

Feedback from a psychological wellbeing practitioner from the IAPT Team:
“Following support given to a parent who received a number of listening visits, the mum reported this to the IAPT team as having helped her build the confidence to refer herself to the team.”


The spectrum in providing cognitive behavioural therapy interventions has widened across the entire pathway from the low level provided by health visitors which seamlessly interfaces with IAPT interventions, and on to specialist psychological therapies.

The listening visits resources used by health visitors and family nurses at the 6-8 week postnatal visit have been reviewed and shared with staff. This has led to a more standardised approach to implementation of the listening visits using resources such as a guide to mindfulness, a mood diary, cognitive behavioural therapy guide to concentration and ‘STOPP’ leaflet which is illustrated below:

S – Stop!
Just pause for a moment

T – Take a breath
Notice your breathing as you breathe in and out

O – Observe
What thoughts are going through your mind right now?
What is your focus of attention?
What are you reacting to?
What sensations do you notice in your body?

P – Pull back- Put in some perspective
What’s the beiger picture?
Take the helicopter view
What is another way of looking at the situation?
What advice would I give a friend?
What would a trusted friend say to me right now?
Is this thought a fact or opinion?
What is a more reasonable explanation?
How important is this? How important will it be in 6 months’ time?
It will pass

P – Practice what works – proceed
What is the best thing to do right now?
Best for me, for others, for the situation?
What can I do that fits with my values?
Do what will be effective and appropriate

An emotional wellbeing plan ‘My Pregnancy and Postnatal Wellbeing plan’ has been developed by the project team to promote positive mental health and to enable women to recognise early signs of emotional health difficulties and seek early help. This will support discussion with the health visitor visiting in the antenatal period and later at 6-8 weeks postnatal when screening is carried out for emotional health difficulties.

Inter-professional training delivery across all disciplines involved in the project has enabled collaborative working across services, leading to standardised, consistent, high-quality care across the borough and extended across the Trust. The IAPT component of the service has been reviewed and mothers are now escalated and prioritised for access to IAPT.

Self-referral for IAPT is a requirement, however, a communication with the health visitors and family nurses has been built in to enable them to receive feedback and close the loop on following up when a mother has not responded to the opt in letter.

We have enhanced the awareness and ability to provide bespoke care under perinatal mental health within our Access and Home Treatment Team, and pregnant mothers are fast-tracked and seen by a consultant in secondary mental health services within 72 hours.

Further developments in joint working between child and adolescent mental health services and school nurses include a monthly networking meeting to discuss cases and provide training, guidance and support to practitioners.

Service user case history 1:
Service user X is a 28-year-old with a past history of accessing mental health services following the birth of her first child, which was delivered by caesarean section, from which she experienced post-traumatic stress. She had been referred to IAPT by the health visitor following completion of a series of listening visits delivered by child health, but had been too anxious to engage with the service or opt in, leaving her with high anxiety and untreated post-traumatic stress.

She is now pregnant with her second child and, at her antenatal appointment, identified to the midwife her fear of a repeat caesarean on the birth of her second child.

Following the integrated perinatal mental health pathway, the midwife processed a referral to the FINE clinic for on-going midwifery by a specialist perinatal mental health midwife. A multiagency meeting was set up with the service user, health visitor, psychological wellbeing practitioner, and specialist perinatal mental health midwife.

A personalised care plan was developed with service user X. The health visitor undertook an assessment of her psychological health and wellbeing using the enhanced skills provided by inter-professional training. The health visitor was then able to offer a series of extended listening visits. These visits had been improved by joint working between health visiting, IAPT and the mental health assessment team to include tools and coping strategies, including the ‘STOP’ approach. Wrap-around care was also facilitated with a range of providers in the community to support her wellbeing.

At the end of this initial support, service user X reported her care “was so different to last time. I am feeling more in control. I have been given choices about how to cope and better able to care for my family”.

Service user case history 2:
Service user Y is a 38-year-old with two children. One is four weeks old. She has a history of mental illness (depression). She showed no sign of depression at her birth visit from the health visitor, but two weeks later was feeling isolated and had low mood. Her husband was concerned about her wellbeing and the impact of this on the children. Her breastfeeding peer support worker was also concerned about her emotional health and contacted the health visitor.

Following the perinatal mental health pathway, the health visitor undertook the Edinburgh Postnatal Depression Scale (EPDS) and Generalised Anxiety Disorder scale (GAD2 mental health assessments. The health visitor discussed mental health assessment outcomes with the IAPT psychological wellbeing practitioner. A series of listening visits were arranged by the health visitor to provide emotional health, support, mental health first aid and utilisation of self-help tools.

The listening visits supported Y to continue to breastfeed her baby and look after her child, and interventions supported improvement in her wellbeing. Y was reassessed at the end of her listening visits. Her depression had lifted and she was feeling much better. Y is pleased she got through this short period without the need for referral back into mental health services.

In terms of outcomes for this service user, mental health first aid training received through inter-professional training to the peer support worker supported early identification of signs of depression and anxiety. The perinatal mental health pathway screening tools identified when clinical assessments and intervention should take place. The content of listening visits was enhanced by joint work with IAPT and the health visitor. The enhancements of skills delivered by inter-professional training reduced handoffs and the ceiling of care was raised. There is evidence of a developing culture of integration and improved communication between practitioners.


The lessons learned from implementation of the new integrated pathway in Knowsley has locally are being used for development of a Trust-wide pathway as part of the development of a dedicated perinatal mental health team.

Start Well forms part of the Trust’s clinical transformation programme and the Trust is committed to supporting the developing of integrated care pathways.

We have shared the development of integrated perinatal pathways with Clare Murdoch, National Mental Health Director at NHS England, during her visit to Warrington Clinical Commissioning Group.

The Trust has recently commissioned an attachment service called Building Bonds to deliver perinatal and infant mental health services. The project group has worked closely with the Building Bonds service and is an integral part of the antenatal pathway.  A presentation was delivered to the local safeguarding children’s board to promote the development of the pathway and to share how the pathway would support learning from serious care reviews.

Discussions have taken place with public health commissioners at Knowsley Council who welcomed the development of the integrated approach which followed the award of the contract for the 0-19 children’s services.

Is there any other information you would like to add?

Physical and mental health services are delivered by North West Boroughs Healthcare NHS Foundation Trust. This provides the unique opportunity to offer a strengthened integrated approach to physical and mental health care services in order to deliver whole person care across the life span, starting in the crucial perinatal period.



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