Statement 1 |
The Committee is keen to hear how services link together under the umbrella of Perinatal Mental Health, including specialised perinatal mental health services, maternity services, general adult mental health services, inpatient mother and baby units, parent and infant mental health services, health visiting, clinical psychology, and midwifery services, GPs and the extended primary care team, role of the third sector and local support groups, and private providers of services
It is specifically seeking evidence on:
The Welsh Government’s approach to perinatal mental health, with a specific focus on accountability and the funding of perinatal mental health services covering prevention, detection and management of perinatal mental health problems. This will include whether resources are used to the best effect.
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Comments
Perinatal mental illnesses are common and affect at least 10% and up to 20% of women. Providing good perinatal mental health services saves lives, but also prevents long term harm to women, their families and children.
The Health Board (HB) is committed to working in partnership to improve outcomes for children and families and is currently prioritising work on the first 1000 days of life pathway and the prevention and mitigation of Adverse Childhood Experiences ACES. These are explicit priorities within our planning and strategy work. The HB is part of the Cymru Well Wales 1000 days collaborative, with a pathfinder project ongoing in Wrexham. As part of this strong focus on the early years, perinatal mental health is a priority with clear actions within the Health Board’s Operational plan for 2017-2018.
Following additional funding from Welsh Government, the Health Board is currently setting up a new perinatal mental health team. Links between services are being strengthened under the leadership of the BCUHB Perinatal Mental Health Steering Group. The group has representation from the all the relevant key stakeholders including primary care, Women’s services, children’s services, adult mental health services, CAMHS and public health. Guidance and referral processes for the new service are being developed
The new specialist team will ensure: :
· Clear clinical pathways in place and improved access to services · Universal promotion of mental wellbeing by all services involved in the care of pregnant women and their families · Support and training for frontline staff · Co-ordinated care for expectant mothers and their families and integrated working with social services under the Social Services & Wellbeing Act (2014) · Co-ordinated third sector commissioning for community-based interventions The new Perinatal Mental Health Service is establishing links with specialist CAMHS services across North Wales to explore opportunities for joint working with infants where significant need is identified. Targeting infants of parents with mental health problems, in particular where there are identified attachment problems, is a priority for prevention of later mental health difficulties.
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Statement2 The pattern of inpatient care for mothers with severe mental illness who require admission to hospital across both specialist mother and baby units (designated mother and baby units in England) and other inpatient settings in Wales. (Since 2013, there has not been a mother and baby unit in Wales).
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Comments
A referral to a mother and baby unit a long distance from home brings considerable family stresses from the travel required which can only add to distress at an already extremely difficult time. There are also other considerations for Welsh families accessing services in units outside Wales such as language for Welsh speaking patients.
Consideration should be given to establishing Specialist Clinical Networks for Perinatal Mental Health in the same way they are provided for other aspects of maternity care such as cardiac, liver, feto maternal unit (FMU) and neurology. The Health Board feel it would be timely to review the provision of tertiary level care and the existing perinatal mental health clinical networks for Welsh families in relation to volume, outcome, demand and need for this service currently.
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Statement 3 The level of specialist community perinatal mental health provision that exists in each Health Board in Wales and whether services meet national standards.
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Comments
The new perinatal mental health service is being set up in line with national standards and guidance. Some of the current standards may be challenging for the new service to meet such as the RCOG recommendation of rapid access to psychological care within 4 weeks of referral, given current levels of demand and wide geography of NW. The service will be audited on an ongoing basis to assess performance against national standards and highlight areas for improvement
The majority of perinatal mental health issues experienced by mothers are classed as mild to moderate. There will also be a need to be a focus on women and families who don’t meet thresholds for referral to the new service but who are experiencing perinatal mental health issues or struggling with low mood following the birth of a child. The current work within the Health Board is looking at this as part of the first 1000 days pathway to ensure optimum outcomes for all children and families and there is a strong awareness within the HB of the impact of ACE’s. Working in partnership with the third sector and looking at their role in supporting families is also a key aspect of this.
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Statement 4 The current clinical care pathway and whether current primary care services respond in a timely manner to meet the emotional well-being and mental health needs? Of mothers, fathers and the wider family during pregnancy and the first year of a baby’s life.
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Comments
Primary care teams have a key role in identifying and supporting women with perinatal mental health issues. The majority of mental health issues before, during and after pregnancy will be managed within primary care and not by specialist mental health teams. They have a key role is supporting the development of care plans for women with existing mental health issues and advising on appropriate prescribing in pregnancy and breastfeeding. They also have a key role in identifying issues and offering support to women attending for routine preconception, antenatal and postnatal checks in primary care and in working as part of the multi disciplinary team supporting women and families.
The link between the new perinatal mental health team and primary care teams will be key. Current and new clinical pathways being developed need to reflect this important interface. Good communication between GP’s and the wider primary care team such as health visitors, community midwives and community mental health teams is also key part of any perinatal mental health strategy and pathway. Reviews of maternal deaths have shown repeatedly the vital importance of effective and timely communication between health professionals
It would be helpful to have a platform for engagement with GPs at national, regional and local levels on perinatal mental health. The Royal College of General Practitioners (RCGP) has developed an excellent toolkit for perinatal mental health (see appendix1)
The implementation of the Healthy Child Wales Programme increases the universal contacts offered to parents from Health Visiting Services. Assessment of mental health and providing support to families will be an important part of the HCP programme.
Embedding pathways for routine pregnancy testing carried out by GPs (and/or community pharmacists) could provide an opportunity to screen for mental ill-health risk and provide appropriate care from the very start of the pregnancy (as well as timely access to other pregnancy care).
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Statement 5 Consideration of how well perinatal mental healthcare is integrated, covering antenatal education and preconception advice, training for health professionals, equitable and timely access to psychological help for mild to moderate depression and anxiety disorders, and access to third sector and bereavement support.
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Comments
All health visiting teams have been provided with one day training from MIND Cymru. In addition to this training, some Health Visitors have undertaken additional training in Maternal Infant Mental Health, with these staff providing additional support to colleagues.
The new perinatal mental health team will also have an important role to support training for key staff groups and act as an expert resource.
The Families Together Perinatal Support Service has been established in North Wales, delivered by Family Action, a third sector organisation. This project aims to provide families with personalised support to overcome challenges. This service is linked in with Health Visiting services and families are being routinely referred in.
The Health Board feel that the following are potential areas for further investment and development:
· Maximising opportunities pre-conceptually during planned and opportunistic contacts. · Training is needed for wider professional groups to raise the profile of perinatal mental health, it’s prevalence, implications and how to recognise it and signpost · The third sector have a key role and often support women with post-natal depression and anxiety, Post Traumatic Stress Disorder (PTSD) and those who have suffered bereavement. These groups are valuable sources of support and can be an important part of the care pathway for families. · Campaigns to raise awareness at the population level may have value and could link to much of the current and high profile work ongoing to reduce stigma of mental health issues and to encourage more openness and communication within families and communities. Women with perinatal mental health issues often feel particularly vulnerable about disclosing how they are feeling in case there is judgment in relation to parenting. Diagnosis is often delayed for these reasons.
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Statement 6 Whether services reflect the importance of supporting mothers to bond and develop healthy attachment with her baby during and after pregnancy, including breastfeeding support.
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Comments There has been a strong focus on infant and early years mental health work across North Wales: significant progress was made following a piece of joint work between specialist CAMHS and the Public Health Directorate in North Wales. Eleven recommendations were prioritised and ratified in February 2016 for implementation. (Appendix 2)
It would be useful if recent evidence on the prevalence and effects of Adverse Childhood Experiences (ACEs) could help to bring more prominence to the importance of preventing and mitigating perinatal mental ill-health, and also mental ill-health in the wider family. Mental ill-health in the household is one of the recognised ACEs and maternal depression is the biggest risk to early attachment and all aspects of child development especially speech and language.
The Health Board is working to UNICEF BFI guidelines, which support immediate undisturbed skin-to-skin contact after birth to strengthen bonding and promote breastfeeding initiation. UNICEF accreditation has been achieved at the highest level and work is ongoing to ensure continuous quality improvement in relation to key aspects such as skin to skin audits. An infant feeding strategy is also under development which will have a strong focus on nurturing, attachment and early brain development through skin to skin contact and supporting early responsive parenting for all parents. The strategy is intended to link breastfeeding support, early attachment and positive mental health and well being.
Wales like the rest of the UK, has some of the lowest breastfeeding rates in the world and these have not changed significantly in more than a decade despite our best efforts. Women who want to breastfeed and who do not end up breastfeeding have approximately double the risk of Perinatal Mental Health Problems. In North Wales, we consistently see a high drop off in Breastfeeding in the first 10 days. There is a link with this pattern and Perinatal Mental Health - both in terms of the negative impacts on the continuation of breastfeeding for women experiencing mental health issues and the increased risk in mental health issues arising for women who want to continue breastfeeding but aren’t able to through lack of early support or other reasons. (Appendix 3 – article on link between breastfeeding and mental health/well being)
There is a general need to address prescribing in lactation within primary care as mothers experiencing Perinatal Mental Health issues regularly report that they have been told to stop breastfeeding in order to take medication. . |
Statement 7 The extent to which health inequalities can be addressed in developing future services.
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Comments
Poor mental health is strongly linked to inequality both as a cause and consequence. Loving, secure and reliable relationships with parents, foster a child’s emotional and mental wellbeing, capacity to form and maintain positive relationships with others, language and brain development, and ability to learn. Providing universal services is key to tackling inequalities with an understanding that enhanced provision is required to support populations in greater need. The full Implementation of the Healthy Child Wales programme will enable a universal offer of services with additional service provision if required following assessment of need. There are challenges in relation to recruitment of health visiting staff but the HB is committed to full implementation of the HCP. Health services which routinely engage with families are well placed to identify emerging issues and coordinate care. Identification and early intervention is key.
In addition to the implementation of the Healthy Child Programme in North Wales the following is planned: · Access to ongoing training for Health Visiting services · Specialist CAMHS teams to promote the Five Ways to Wellbeing, working in partnership with Local Authorities and Third Sector colleagues · Promotion of the same and consistent messages across all service areas – universal health visiting, perinatal mental health services, adult mental health services and specialist CAMHS.
The public health directorate have recently led on the development of a successful social media campaign targeting young girls. Dream Big aims to raise aspiration and provide advice on well being and emotional health for young girls. Equipping young people to be emotionally resilient and prepared for parenthood will help to improve mental health and well being and improve outcomes in the long term
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Responses in person to the panel
Names of staff members identified as willing to provide evidence in person
Please contact us if this is required and staff will be identified
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Appendix 1
RCPG toolkit for Perinatal Mental Health
http://www.rcgp.org.uk/clinical-and-research/toolkits/perinatal-mental-health-toolkit.aspx
Tools to Promote Well Being
http://www.bftalliance.co.uk/wp-content/uploads/2014/02/wellbeing-plan-with-NICE-and-RCGP.pdf
The charity Pause http://www.pause.org.uk/ specifically looks at improving the lives of women subject to serial high risk pregnancy & serial child removal proceedings to break the cycle.
Appendix 2
Infant and early years mental health work is in development across North Wales. Significant progress was made following a piece of joint work between specialist CAMHS and the Public Health Team in North Wales. Eleven recommendations were prioritised and ratified in February 2016 for implementation.
Approved at Emotional Health and Well-being Service Board February 2016
Specialist CAMHS and the Early Years (children aged 0 – 7 years)
Current provision remains highly variable across North Wales for children in the early years. Public Health Wales led a working group in 2014 which completed an emotional health and wellbeing needs assessment focused on the early years. These findings led to the recommendations below. A draft summary report was presented to Service Board December 2014, final report available August 2015. Eight themes in total were identified, these are collapsed into three broad themes for the purpose of developing next steps in specialist CAMHS
Recommendation
That the Emotional Health and Wellbeing Service Board considers and supports the following recommendations for implementation in specialist CAMHS – further details are outlined in table 1 below and in the attached final needs assessment document:
Table 1: Specialist CAMHS and the Early Years
No |
Key findings by Theme
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What is needed? (Public Health Wales led working group)
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What needs doing in Specialist CAMHS? |
R/A/G |
3.1 |
Supporting parental mental health and wellbeing
Supporting parent-child interaction and attachment |
a) adopting 5 ways to wellbeing as means of engaging staff and parents in discussion about helpful ways to look after own mental health and wellbeing recognising that detecting and intervening with early stage emotional health difficulties is important |
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b) Ensuring that AMH service providers recognise that many of the people they support are parents and may need specific support for their parenting role in addition to treatment for their mental health
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c) Providing consistent advice to all parents on the importance of positive interaction, play, talking and reading with infants and toddlers |
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d) Ensuring that all parenting programmes · Have robust evidence base · Are implemented appropriately with support and supervision for staff delivering them · Use valid and consistent measures to demonstrate outcomes |
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e) Develop the capacity of universal services to identify vulnerable infants children and parents |
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e) Intervene where appropriate to promote secure attachment and positive care giving |
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e) Refer to specialist services to support the development of parent child relationship when necessary |
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3.2 |
Prevention and early intervention
Recognising and responding to circumstances that increase vulnerability |
f) Ensuring that parental mental ill health does not adversely affect parent-child relationship and attachment |
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g) Health Visitors, School Nurses and the Early Years workforce are able to support parents ability to attend to emotional health needs of young children and identify and respond effectively to factors that may pose a risk to child’s emotional health and wellbeing |
1. Support implementation through Specialist CAMHS SPoA, and individual and group based consultation 2. Deliver targeted and clinical interventions as required
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h) Provide effective interventions for behavioural, feeding, toileting and sleep problems in very young children through Tier 1 services with input from specialist CAMHS and other practitioners where appropriate |
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i) Access to specialist CAMHS practitioners for children and young people with chronic and/or life limiting conditions (cancer, Type 1 diabetes, cystic fibrosis, epilepsy) as part of on-going care |
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j) Offering classroom based emotional learning and problem solving programmes to children aged 3-7years where classroom populations have a high proportion of children identified as at risk of developing CD or ODD – develop clear protocols to identify classes at high risk and multi-agency care pathways |
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k) Use video interaction guidance where appropriate to improve maternal sensitivity and mother-infant attachment |
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l) Use parental self help interventions (books/audio/TV/web) to improve child behaviour |
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3.3 |
Provision of specialist CAMHS interventions
Advice and support to staff working in Tier 1 services |
m) Timely access to address attachment difficulties developmental trauma and provision of emotional support/mental health services for children looked after |
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m) If no specialist CAMHS practitioner CAMHS teams should identify a lead professional (i.e. Clinical Lead) to help responsible authorities to carry out duties in addressing emotional and mental health needs of children looked after |
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n) Alerting health and social care professionals in primary care, education and community settings to possible anxiety disorders in children |
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n) Specialist CAMHS should contribute to the assessment of children and their parents and deliver effective interventions directed at both parent and child |
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o) Children with depression should have diagnosis confirmed and recorded |
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o) If depression is moderate or severe specialist CAMHS staff should manage the intervention |
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o) Children should be given age appropriate information about their condition |
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p) sleep difficulties in children with a learning disability and/or autism should be actively screened for and evidence based sleep programmes should be implemented |
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q) following a diagnosis of ADHD in their child all parents should be provided with relevant information evidence based self instruction manuals and other materials based on positive parenting and behavioural techniques |
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p) For children with more severe behavioural problems / conduct disorders the provision of group programmes to support parents and carers is recommended. Only when parents are unable to participate in groups should one to one parenting support be offered |
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r) Increasing specialist CAMHS involvement in multi-disciplinary teams including community child health and paediatric services that provide services for children with behaviour problems, conduct disorder, ADHD, learning disability or autism to provide assessment and treatment of possible psychiatric co-morbidities and to ensure evidence-based interventions. Where indicated parents/carers should also be assessed |
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Link to a recent article by Kathleen Kendall-Tackett (acknowledged expert in this field) regarding the protective effect that Breast Feeding has on Mental Health both in mothers & their children
https://womenshealthtoday.blog/2017/02/17/neuroscience-shows-breastfeeding-is-not-just-milk/