This brief aims to respond directly to the Committees Terms of Reference for the Inquiry. Additional information is provided at the end which is hopefully helpful.

1. 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.

Powys Teaching Health Board provides maternity care and health visitor support to 1200 women per annum. Local data suggests that 18% of women have experienced or are experiencing mild to moderate mental health issues with <1% identifying as having major mental health illness at booking.

The additional funding allocated by Welsh Government to each health board for the development of perinatal mental health services, was based upon births. Given the relatively small birth rate in Powys, this allocation required the health board to seek imaginatively to provide a service across what is in effect a quarter of the landmass of Wales with only 4% of the population. A model which focuses on prevention and early identification, with women and their families receiving the early community support. Our service is home and community focused with the provision of care being tailored to the unique needs of every woman. This way of working has enabled us to focus on our strengths in Powys, which are ultimately about having smaller teams with close working relationships whilst having a strong community focus.

A perinatal mental health steering group, established in 2014, has been leading on the development of these services locally. The perinatal mental health steering group has successfully brought together a multi-disciplinary team including 3^rd sector and service users to identify requirements to support universal services effectively and ensure women, their partners and families receive good levels of support in relation to their mental ill health.

During the first six months of the project from April – September 2016, the appointment of a project officer led to a detailed work focusing on the needs of the population and the potential options for service delivery. This included carrying out a scoping exercise which identified the number of women within Powys, who would be affected by a mild to moderate level of perinatal mental health issues and based on this, the community based service model was developed which has been widely shared with our partners and other stakeholders.

The service aims to build upon the strong universal support already offered by midwives and health visitor. All women are asked about their emotional health and wellbeing throughout pregnancy and following the birth of the baby (up to baby’s first birthday). Further screening using the Edinburgh Post Natal Depression Scale and professional judgment enables practitioners to identify those with mild to moderate depression and anxiety. It is these women and their families who will be offered specific, additional support. Targeted and focused support from nursery nurses is a key part of the service offered. This may be related to the parent or parent-unborn, and may also include a specific baby focus. Examples of this include practical interventions such as preparing for parenthood, sessions on baby development and importance of brain development, implementing routines, reducing isolation, and interaction and play.

For those who may have an enduring or severe mental health concern, there are systems in place to ensure liaison and appropriate, timely referral to primary and secondary care colleagues. Midwives and health visitors are encouraged to instigate informal (liaison) discussions with mental health colleagues prior to referrals being made, helping to ensure that the timeliness of further support as appropriate. 

The project also provides bespoke supervision for practitioners provided by a perinatal mental health supervisor 1 day/week. The aim of this is to support practitioners to feel more confident and competent to work with mothers, mothers and babies and their families.

Internally within the health board the work of mental health services, including perinatal mental health is overseen by the Executive Committee and the mental Health and Learning Disabilities Committee. This provides a key link to the Board, enabling both support and scrutiny to take place. The Board itself heard a ’Patient Story’ specifically focused on perinatal mental health, helping to raise awareness of the real life experiences of women affected by this condition.

2. 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).

Powys THB does not provide specialist inpatient mother and baby care and has no intention to do so. Currently women identified as needing this level of specialist care receive out of county treatment. Nevertheless, though an infrequent requirement (three cases known to maternity and health visiting services since 2011), there have been occasions where specialist care has been a considerable distance from a woman’s home and family.

3. The level of specialist community perinatal mental health provision that exists in each Health Board in Wales and whether services meet national standards.

As described above the additional funding provided by Welsh government has been used to focus on prevention and early intervention. The development of effective pathways and robust multidisciplinary working however relies on excellent team working with secondary and specialist mental health services. Powys Teaching Health Board has over the last 2 years moved back to Powys the management and provision of mental health services for the resident population from Betsi Cadwalladr UHB, Abertawe Bromorgannwyg UHB and more recently (1^st June 2017) from Aneurin Bevan UHB.

There have been developments in the north of the county, led by a consultant with specialist interest in perinatal mental health, with the establishment of a Perinatal/pre-conceptual clinic. This aims to increase awareness specifically amongst child bearing women already open to mental health services. Further developments with mental health services will be subject to discussion across the health board area as the refreshed mental health service is developed.

At this stage we do not have any specialist roles for midwives, health visitors, community psychiatric nurses or occupational therapists working within the field of perinatal mental health services or any dedicated psychology support. Given the geography of Powys and the challenges of the sparsity of the population, service developments have been most successful where enhancing the roles of generalists has taken place. This position will however need to be kept under review moving forward.

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.

As highlighted above, the current service focuses on enhancing the universal services assessment and early intervention. Midwives and health visitors are expected to ask all women about their emotional wellbeing throughout pregnancy and the postnatal period. Midwives and health visitors are also actively encouraged to take a whole family approach, recognising the impact that perinatal mental health may also have on the father/ partner and wider family. The Whooley/Gad questions and use of the Edinburgh Postnatal Depression Score, alongside professional judgment, are used to screen and identify need.

A pilot project is being undertaken in the North of Powys to offer women already known to the community mental health team and of childbearing age. Advice and guidance about the impact that pregnancy may have on their mental health and medication and pregnancy is provided, and additional support offered as necessary.

For those women identified as having mild-moderate antenatal and postnatal depression and anxiety, listening visits and referral to the new community based service is offered. This new service provision went live at the beginning of April 2017. Referrals will be monitored and the following outcomes measured:

• Number of antenatal and postnatal women referred to service

• Number of visits undertaken by the Nursery Nurse

• Number of antenatal and postnatal women indicating an improved Edinburgh Postnatal Depression score following intervention with the Nursery Nurses

• Number of antenatal and postnatal women referred to the service who then required a referral to GP, commenced on medication, referred to primary care counsellor, referred to Community Mental Health Team, admitted to mother and baby unit

For those women and families who may need further support beyond that provided by the general service, referrals are made to local GPs and Local Mental Health Primary Support Services. The additionality of support sits alongside the existing community nursery nurse provision, and priority to pregnant and new mothers is given wherever possible.  Where there is a need for support from community mental health colleagues, a system is in place for practitioner to liaise with community mental health colleagues to discuss level of need and urgency of support. The Community Mental Health service makes contact with the women and her family within 1-2 working days with an appointment for enhanced assessment offered.

Whilst the new community based service is developing, the perinatal mental health steering group are leading consultation work with wide range of stakeholders across maternity, psychiatry, community care, psychology, third sector, General Practice and service users. The views, opinions and experience will be collected and discussed in the steering group to help further develop the pathways for primary, secondary care and service standards. During this development process close working with the All Wales Perinatal Health Group will take place.

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.

It is critical, particularly in the Powys context for services to be integrated. A clear focus has been on multi-professional and multi-agency working. The examples given below indicate the breadth of approach the health board has taken to enable greater focus and expertise on mental health for women during and after pregnancy.

· Perinatal mental health is discussed with women and their families by every midwife and health visitor as part of the universal care provided. Where identified as a topic for discussion by women, this is also included within antenatal groups and classes.

· Over the last year multi-disciplinary workshops have been provided for midwives, health visitors and nursery nurses. The feedback from these sessions has highlighted the value staff placed on having an opportunity to discuss key issues with other colleagues, and to understand and explain each others roles. A further 2 day perinatal mental health training has already been provided, with further training planned for May 2017.

· Primary care colleagues have identified training requirements, and specific training will be provided by a psychiatrist, midwife, health visitor and nursery nurse over the next year. The Royal College of Physicians Toolkit for perinatal mental health has also been shared with GP’s, practice nurses, local mental health practitioners and obstetric physiotherapists to enable a greater understanding and advice for this area of practice.

· The health board is in the process of identifying a suitable e – learning package and deciding how and when to incorporate annual updates for all staff.

· Adult mental health services are aiming to provide all their staff with perinatal mental health training which will be multi-disciplinary and multi-agency. The plan is for the training to be rolled out from June 2017 in the north of the county and the south to follow later in the year. A repeat audit will be undertaken early next year to identify any further training gaps.

· Access to psychology services remains a key development area across the county, in particular meeting the NICE recommendation that psychological intervention commences within one month of assessment of need. The health board has been using new and innovative ways in supporting people with depression and has been using Computerised CBT (Cognitive Behavioural Therapy) over the last 3 years funded initially by an EU grant. The service will not be suitable for everyone with mild to moderate depression, however it does provide a useful intervention for many people and is less reliant on practitioner delivered face to face service provision. In relation to face to face psychological therapy, the service is ensuring pregnant women are given priority and seek to ensure they are seen within 28 days.

· There are well developed and strong working relationships with third sector colleagues throughout Powys, with Action for Children for example playing a key role in the steering group that has developed the new service model. Furthermore, the third sector are actively involved in providing universal support through some of the community based groups which include ‘Bumps to Buggy’ walks, baby massage and ‘Sbash a Sbri’, a water based activity. The health board recognises that these activities contribute to supporting women and their families in the fundamentals of developing social networks and support.

· MIND in mid and south Powys are in the process of setting up the Mother’s in Mind project. These groups will run weekly for six weeks and support women and their families who have been identified as having mild – to moderate anxiety and depression.

· Named midwives provide support as required for miscarriage, stillbirth and neonatal death.  The opportunity to have caseloads that facilitate continuity (35-40 women per fulltime midwife) offers the opportunity for midwives to give women and their families dedicated time. Bereavement midwives from external commissioned services also provide some support.

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.

Throughout pregnancy midwives discuss and encourage women and their partners to consider their babies movements, and discuss what babies can hear in utero.   

The importance of supporting mothers to bond and develop a healthy attachment with their baby during and after pregnancy, including breastfeeding support, is reflected throughout the Healthy Child Wales Programme (HCWP) and new National Flying Start Programme, delivered by all Health Visitors. The majority of staff have received training in the ‘Solihull Approach’, a theoretical framework that underpins day to day practice, the basis of which is to support attuned relationships and a baby/child’s social and emotional development. New assessments such as the ‘Health Visitor Observation and Assessment of Infant (HOAI), as well as the mood assessment of mothers, have been introduced in to the new HCWP/Flying Start Programme in order that parent /baby relationship issues can be identified early and addressed through additional support.

Some staff have also received training in using the Newborn Observation tool, which again, provides opportunities for staff to share how a baby is born to interact with its caregivers, and encourage interaction. Community groups promote the key messages of face to face contact, nurturing touch, play, talking and singing, which enhance the parent/baby relationship. Baby massage is provided on a one-to-one basis or within groups.

Breastfeeding is supported throughout the services, Powys currently has Level three UNICEF baby friendly accreditation through midwifery and health visitor services. Midwives and health visitors also support peer led groups Bron i’r Babi across the county encouraging women to attend both before and after birth. It is also recognised that feeding choice and difficulties around this may contribute to the way in which a women feels.  Practitioners, therefore, are encouraged to respect parental choice and to support women in which ever feeding choices they make.

7. The extent to which health inequalities can be addressed in developing future services.

Staff are encouraged to support not only the whole family but also to recognise the factors that may be impacting on a family as a whole. It is essential to recognise the factors that may contribute to perinatal mental health include domestic violence, history of abuse, trauma and childhood experiences; housing, employment, social isolation and the quality of relationships that individuals may have. The model also asks practitioners to indicate the presence of adverse childhood experience (ACE). The intention is to develop further work with colleagues who support women and their families in these areas of identified need.

Robust audit of the new service and the development of an integrated care pathway, will enable the health board to identify further gaps and needs. This information and feedback from service users, practitioners and referrers will help shape what the future services may look like.

The perinatal mental health steering group are working towards a ‘hub and spoke’ model with the county split into five distinct areas (hubs). Each hub will have a designated midwife, health visitor and nursery nurse acting as perinatal mental health champions. The champions will be the local point of contact for advice and support as well facilitating effective relationships with the primary and secondary adult mental services. A consultant psychiatrist with a specialist interest in perinatal mental health will be available for county wide telephone advice to support the mental health, health visitor and midwifery teams and general practitioners

The ‘everybody’s business’ approach ensures that all practitioners are able to make a contribution to the perinatal mental health service with the aim that all women, their partners and their families during pregnancy and early parenthood, feel not only supported in their own communities but reduce the necessity for admission to tertiary care, potentially without their baby.

There is further work to do on understanding engagement patters in services and to shape the way in which practitioners work to support those with the greatest health or social inequality. A Health Inequalities Strategic Plan has been developed and recently approved by the Board. This will form a focus for future work.