The Kent and Medway Partnership Trust (KMPT) Mother and Infant Mental Health Service (MIMHS) is a highly specialist community service for perinatal mental illness working across the boundaries of primary and secondary care in a consultation, liaison and advisory model.
We work in various localities across Kent and Medway with a staff of a full time service lead (myself), 3 part time perinatal consultant psychiatrists, 6 clinical nurse specialist, and admin support. The service was first established as a local pilot in West Kent in 2001, from the aspiration of myself (as a CPN at the time) and a psychiatrist colleague to provide a dedicated service for this client group. Through evidencing our outcomes in partnership work with commissioners we were able to expand the service into other localities, with the current staffing establishment, in 2010.
The following assessment and treatment are provided: Preconception advice for women with previous or existing moderate to severe mental illness; Liaison, advice and consultation regarding women experiencing perinatal mental illness within primary care and IAPT; Assessment in conjunction with secondary mental health services of women with history of severe mental illness, for the risk of relapse during the perinatal period; Management and treatment of severe mental illness during the perinatal period in conjunction with secondary MH services. MIMHS takes a specific focus on working with the mother and baby together to encourage healthy attachment, and to optimize the infant’s development, wellbeing and safety.
The strong emphasis on liaison, education and partnership working across the perinatal mental health pathway means that the MIMHS team complete the following additional roles: Provision of training, supervision and consultancy to Midwives, Health Visitors, Social workers, acute hospitals and GPs to enable them to identify women with both mild and moderate to severe mental ill health and signpost them to the right service. Provision of advice, support and supervision to generic mental health services who see women with moderate to severe mental disorder during the perinatal period (including CRHTs, EIP, acute inpatient wards, liaison psychiatry and CMHTs.); For women who require an inpatient stay, close working with out of area MBUs in assessing for and arranging admission, discharge planning, and supporting transition back to local services.
The service makes a difference to women by helping them feel empowered around their birth and medication choices, giving them hope of recovery, ensuring that their role as a mum is taken account of by all professionals involved in their care, and being flexible enough to visit them at home when leaving the house is difficult. At a recent service user focus group feedback about the benefits of the service included:
“The service meant we were put at ease, knowing that everything was planned in preparation for the ‘worst case scenario’. It was great to have regular contact with the same person and we were given plenty of helpful advice” “Frequent contact, the friendliness of staff and having the feeling that there was always someone we could contact. The afterbirth support continued longer than I expected which was really comforting, as we settled into life as a new family.”
“The home visits. Having knowledge about medication to change on to that was safe for pregnancy and breastfeeding”. “Peace of mind! Having a care plan in place in case the worst happened. As a partner, I felt fully included and supported in decision making, as well as my wife.”
One of our perinatal psychiatrists said that the difference working in the service makes to her is: “Prevention of a relapse (serious perinatal mental illness) is what is so attractive in this work, the idea that the treatment is – whenever possible – without a separation from the baby, and that family is thought about as a unit as a part of a routine work.”
One of the clinical nurse specialists said “I love working for MIMHS as I am able to work very closely with our clients. A very quick and trusting working relationship is often established with clients who are mostly appreciative of the work we do. One of my cherished goals is to work with a client who is at high risk of a mental health relapse during the postpartum period and to achieve a positive outcome for mum and baby without a relapse of her mental health. I value been able to offer a high level of support to my clients which is supported by the team.”
The service is highly valued by local partner organisations. Last year we took the initiative, without additional funding, to set up a local perinatal MH network which is regularly attended by NHS and local authority commissioners, health visitors, midwives, GPs, and voluntary sector partners. Through this we have worked in partnership with commissioners to map the full local perinatal MH provision and gaps. I am an active member of the local maternity patient safety forum where I advise on perinatal MH action plans. I also work in active partnership with maternity units and health visitors, sitting on their interview panels for MH related posts within their service and running case discussion clinics with health visitors. MIMHS staff are also active members of local safeguarding panels, providing expert clinical advice and leadership. We meet regularly with NHS England specialist commissioners to discuss use of out of area MBU beds and issues arising from this. We have recently worked with an IAPT provider and health visitors to help establish a Mum’s mental health support group and we also input regularly into local Young Mums groups. One of our local authorities, KCC, has recently completed a maternal MH needs assessment which recommends the continuation and MDT expansion of our service. In 2015 we won an award for partnership work at the staff award ceremony within our trust.
There are weekly team meetings where MIMHS staff feedback is discussed and ideas for service improvement are discussed and developed. There are also two team away days per year to allow dedicated time for developing service improvement plans. This included the introduction of subtly coded stickers to place on patient held maternity notes, which highlight to maternity staff that the mum is being seen by the MIMHS service for her mental health needs.
We have had feedback from CMHT colleagues about their difficulties with caseload size and problems in overseeing cases where the main needs are only for MIMHS consultation. In response we are piloting the “snowden” model, which changes the way we interact with care coordinators for women requiring specialist consultation only. A former user of our service, who developed severe postnatal mental illness after both her pregnancies, is now employed within KMPT as a programme manager, and takes active leadership in our service development programme as well as coordinating our perinatal MH clinical network. She is connected to national service user groups, provides peer support in a major perinatal mental health charity, and regularly tells her own story at our training events as well as externally, including in national broadcast media. Last year she supported another former user of our service to present to her own personal story to our trust board and at a national perinatal psychiatry conference which we hosted locally. She coordinates our service user focus groups and advises on peer support, and is now working to set up a local service user reference group to feed into both local and regional perinatal MH clinical networks.
Service user feedback is routinely collected in a discharge questionnaire. This is reviewed by the service manager and discussed at team meetings to identify areas where improvement is required. Where there are specific individual concerns or complaints the service manager makes direct contact with the respondent to review their concerns and agree how these can be best addressed.
To further enhance our understanding of patient experience we are currently in the process of holding service user focus groups in every locality to gain more detailed feedback and ideas for service improvement. The most recent was held on 29th April 2016, attended by 6 Mums and 2 of their partners. Once we have collated the feedback from all sessions we will produce an action plan in response to the feedback and meet again with the families to review whether our suggested responses are appropriate, and to invite their ongoing involvement.
I have worked with the peer support lead in our trust to develop to a job description for employing a peer support worker within the service, which are we now seeking funding for. As detailed in some of the service user feedback given above, Dads are included as partners within both our clinical work and our engagement around patient experience and service improvement.
I think we could have achieved even more if we consistently had dedicated protected non clinical time to promote and develop the service, as at times of high demand and/or staff shortage it has been difficult to find time for proactive outreach to commissioners and other partners to develop innovations. It would also have been beneficial to have consistently kept better data on patient experience and outcomes as without this it is challenging to get others to understand the value of the service and the gaps that require additional funding.
As a service that needs to straddle organisational structures across maternity, children and families social care, and mental health services, relationships are key to effective clinical provision and service development. It has therefore always been challenging to maintain and develop the service through multiple changes in the commissioning environment and within other partner organisations. We are proactively establishing our new local perinatal MH clinical network to bring together commissioners and providers. It has been particularly challenging for new commissioners to understand how the specialist service model brings value compared to generic teams – we are collecting more data on patient experience and outcomes, and presenting detailed presentations on this at contract meetings and dedicated events for commissioners.
Another challenge has been a lack of readily available appropriate training to maintain and develop the highly specialist skills of MIMHS clinical nurse specialists. We are developing peer to peer training within the team and obtaining funding to bring in highly specialist experts to train the team in new techniques relating to attachment.
Overall the biggest challenge has been maintaining a passion and resilience to keep providing this service with very limited resources, whilst seeing families with young babies go through such traumatic times. I’ve maintained my passion primarily through support of colleagues within our very close team, and maintaining some clinical time myself so I have direct experience of the worthwhile difference we make to families.
Robust data collection, including patient experience, is now in place to evidence the value of the service, so commissioners will continue to fund it. Through our local network we have established a momentum for ongoing improvement and expansion of specialist perinatal MH services, with many local champions who would campaign to ensure the service continued.
Internally clinical staff are being skilled up to develop leadership skills in active succession planning – as specialists they view the provision of perinatal MH care as a career vocation, and as such all their ongoing professional development is based around being able to continue working in this area and sustaining the service.
In 2013, in conjunction with our trust audit and evaluation department I completed an audit of our patient experience feedback, based on contents of our discharge questionnaire. A service evaluation has also been commenced to determine the difference our service has made to the use of out of area Mother and Baby Unit beds.
We set up a local perinatal MH clinical network for Kent and Medway, which commenced in July 2015, before the NHS England funding and mandate for these networks was established. We held a local mapping event to help commissioners understand the current pathway and provision for perinatal MH, through our own service and that of other local providers. Now that our region has obtained formal strategic funding, and networks are being established for all counties in our region, one of our perinatal psychiatrists has taken clinical leadership on the regional programme, and myself and the network coordinator are meeting regularly with the regional programme lead to share our learning.
We run at least 2 training days a year for the Kent Children’s Safeguarding Board, targeted at local health, social care, police and housing professionals to train them in the impact of maternal mental illness. We also contribute to the core health visitor and midwife training programmes of our local university to improve student knowledge of perinatal MH.
Last year we hosted a national “travelling circus” event for perinatal MH psychiatrists from across the UK, where we presented the work of our service, including a service user’s experience and recovery journey. In January this year I was interviewed, along with a former service user, for our local BBC regional news programme, to highlight the importance of specialist perinatal MH provision.
We are proud to have been innovative in establishing a specialist perinatal MH team to serve local families before the current national interest and evidence. We are also proud that we reached out from our own initiative to establish a local perinatal MH clinical network to support partnership working prior to our region gaining formal funding to do so. The strength and importance of that network has been recognised by commissioners and our new regional network team.
