Developing a Perinatal Mental Health Service across 2000² miles : is it prudent? Title of Presentation:   Developing a Perinatal Mental Health service across 2000 square miles: is it prudent? Abstract – 300 words max. Powys is the largest county in Wales, covering a quarter of the nation. Providing specialist services equitably across the county is a challenge, particularly when wanting to provide services close to those who use them. In 2016 funding was provided to all Health Boards to develop their specialist perinatal mental health services. Mental ill health during pregnancy and post-birth is believed to affect up to 20% of women and 10% of men and can have lasting negative consequences for the family unit and the infant if not addressed. The majority of those experiencing problems will have mild to moderate poor mental health and will, if supported appropriately, recover without the need for specialist mental health services. However, a small minority will need referral to secondary mental health services. Given the geography, the Powys approach to developing perinatal mental health services has been to focus on growing the knowledge, skills and confidence of our primary and community-based staff, namely Midwives, Health Visitors and Nursery Nurses. A direct referral pathway to secondary mental health services and perinatal mental health awareness training was developed. This enables staff to identify, assess and engage with those that they support who may be experiencing mild to moderate mental ill health and provide individualised support according to the needs and preferences of the woman. Using our primary and community-based staff means that women are being supported by a professional that they have already developed a trusting relationship with. It also means that support is provided in or near the woman’s local community, which in turn can help to increase local connections and social support. This early, local, support reduces the potential intrusiveness of services during this special time in a woman’s life, and, importantly, reduces the poor impact of mental illhealth on the mother, child and family. Sophia Bird & Sharon Fernandez, Powys Perinatal Mental Health Steering Group Sophia.bird@wales.nhs.uk Rural Health and Care Conference, Nov 2017

Background 1/5 women suffer from depression/ anxiety/ psychosis when pregnant or post-birth 1/10 men also experience MH problems during the perinatal period 12% experience depression 13% experience anxiety 20% suffer postnatal depression/anxiety 1-2 in 1000 suffer puerperal psychosis Only 50% are currently diagnosed Early diagnosis and treatment can mitigate the effects Negative impact can be profound and long lasting on the family and infant Many suffer both

Child birth – risk to mental health Women are 23 x more likely to be admitted in the first few weeks after the birth of their first child than the general population. Women are 23 x more likely to be admitted in the first few weeks after the birth of their first child than the general population. You should refer to a specialist service in the following cases: Where pre-conception and early pregnancy advice is necessary in women who have or have had severe mental illness, even if the woman is currently well For women with severe mental illness in pregnancy For women who have complex psychiatric morbidities, including personality disorders and drug and alcohol problems, post-traumatic stress disorder or OCD Where the woman or her family express concerns Where there is uncertainty about the diagnosis Eliciting that a woman feels hopeless and pessimistic about the future for herself, her family and/or infant should trigger an urgent assessment of suicide risk. This involves asking her about: Thoughts she may be having about wanting to die, not wanting to wake up, about wanting to end it all. The thoughts can be present for long periods or just fleeting Images that may accompany thoughts, often violent, of seeing herself dead Urges or impulses to harm herself or her infant Plans to harm herself or her infant If any violent thoughts, images, impulses or plans are elicited, they should be taken seriously and explored in detail; then a plan to keep the woman and her infant/children safe should be implemented. The risk to the infant must be fully recognised and local safeguarding procedures followed. If there is any indication that the woman has suicidal or infanticidal thoughts, plans or fleeting ideas or impulses, she should not be left alone by her family or carers. This is because there is a grave risk to both her and the baby [4,22]. Admissions to a psychiatric unit in the weeks before and after delivery

(Welsh) Expected and actual rates for the Powys population Female Perinatal Mental illness Rates per 1000 Likely rate in Powys Post puerperal psychosis 2 2.4 Chronic serious MI Severe depression PTSD 30 36 Mild to moderate depression and anxiety 100-150 110-180 Male Perinatal depression 100 110 1200 births per annum in Powys As we can see, 2014-15 reported (to Midwives) rates are lower than the literature suggests they should be. *** Work out % into numbers Literature rates of risk: Powys Births per annum =1250 15% of pregnant women= 187.5 Powys women 20% of pregnant women= 250 Powys women 35% =437.5 33% = 417 50% = 625 Implications for Powys:

Why does it matter? PNMH costs £8.1 billion in UK: 72% relates to learning difficulties or behavioural disorders in the child Costs relating to the mother (28%) The cost of PNMH problems is 5 x cost of improving services Mental health starts in the womb maternal mental ill health has significant and long lasting negative impacts on the woman affected, the child, family unit and the community”. Existing situation was that if MW or HV was concerned about a woman’s MH they would advise her to see her GP. If they were concerned they would refer to the CMHS to PMHSS. Assessment target of 28 days, then on waiting list to be seen. BUT, timeframes not appropriate if someone is pregnant – remember the chart re post-birth admissions? The evidence shows that early intervention and support is vital to limit/ mitigate the effects.

The principles of prudent healthcare Here’s reminder of the 4 principles of prudent health care Public and professionals are equal partners through coproduction Care for those with the greatest health need first Do only what is needed and do no harm Reduce inappropriate variation through evidence-based approaches

Multi-disciplinary Perinatal Mental Health steering group formed 2014 The Powys Approach Multi-disciplinary Perinatal Mental Health steering group formed 2014 Early identification and intervention Normalising asking about anxiety and depression form start of pregnancy Reduce stigma of anxiety and depression Powys have been looking at perinatal mental health since 2014. Powys believe that a multi disciplinary approach to perinatal metal health is needed given the geography of the county and scope of the issue. The perinatal mental health steering group was formed and consisted of midwives, health visitors, cpn, consultant psychiatrists, etc and importantly service users. This meant: Training for MWs and HVs Supporting women to take a proactive approach to their mental health, eg Utilising the Boots family trust ‘my pregnancy and postbirth wellbeing plan MWs and HVs wanted a clear referral pathway for women they had concerns about

Priorities for the steering group Proactive approach to mental health in pregnancy and post-birth: Multi disciplinary working Education and training for health professionals Early identification and early intervention Clear Perinatal mental health referral pathway Norm to ask about anxiety and depression in pregnancy Reduce stigma of anxiety and depression Raise awareness of mental illhealth during pregnancy and post-birth Closer links with Adult mental health services Audit of current caseloads and practice Do more Our midwives and healath visitors wanted a clear referral pathway for women they had concerns about. The focus of our service user was to normalise asking about anxiety and depression in pregnancy and raise awareness of antenatal depression. More is spoken of postnatal depression. Our health professionals wanted more training on PNMH. We also felt it is important for women to take a proactive approach to their mental health. Utilise the boots family trust ‘my pregnancy and postbirth wellbeing plan. Closer links with primary mental health including primary mental health counsellors Our focus was on Early identification and early intervention Normalising asking about anxiety and depression form start of pregnancy Reduce stigma of anxiety and depresssion

Steps taken in 2015 PTHB antenatal and postnatal MH guidelines developed and implemented Joint clinical referral pathway for MW/HV developed and implemented with CMHTs 1 and 2 day training on Perinatal Mental Health delivered to MWs, HVs, NNs and A4C staff Scenario based mental health training for midwives/HV/NN included listening visits delivered in partnership with CPNs Feedback from the audit showed us that health professionals wanted more information on perinatal mental health. We put on 2 separate training for perinatal metal health. Funding was sourced for a 1 day and 2 day training, specific to PMH. The feedback was extremely positive. When the revised guideline was launched , we made it mandatory for all midwives HV and nursery nurses to attend a PMH scenario based workshop . Again the feedback was extremely positive.CPN involvement increased the mw, hv and NN confidence in asking questions such as suicidal tendencies, intent, plans and what to do with that information. Feedback from the training…. Use of scenarios/ case studies to make it more personal

2016 developments WG funding to develop specialist perinatal MH services Development a community focused model of care: Focus on mild to moderate anxiety and depression Funding secured, which lead to ... 6month part time project lead secondment All staff to be upskilled so they can provide support to those with mild-moderate mental ill health Funding being used for additional nursery nurse hours to help families affected by parents with anxiety and depression. NN model adds capacity to the system, they are supervised by HVs to provide additional support to universal services. Band 7 post going to be advertised shortly. Specifically designed to NOT be profession-specific. Aim is to identify someone with expert knowledge and commitment who can provide guidance and support to professionals working with PNMH cases.

Steps taken in 2016 6 month p/t project lead development post: Re-audit of staff and service users Audit of perinatal caseloads in primary and secondary MH services PNMH awareness training for MH practitioners developed and delivered Communications plan developed and implemented:Press releases/Display boards/ bump talk , HV facebook page- key messages Awareness raising amongst other health professionals Clinical Supervisor (developing the nursery nurse role within PNMH) Antenatal poster produced for waiting rooms, guided by Service user Nursery Nurse Pathway developed Additional nursery nurse hours Additional nursery nurse training Presentation to GP Clusters to raise awareness, & GP information sheet, resulted in a GP joining the steering group PNMH Awareness training devised and trialled with Ystrad PMHSS, with good feedback Press releases drafted to tie in with national campaign days, eg, Maternal MH day, Infant MH day, World MH day.

Developments in 2017 GAD questions EPDS now used antenatally PNMH Sub-groups formed Further development of nursery nurse role Perinatal mental health awareness training Working to support fathers Working with primary care counsellors Mums matter programme delivered by Mid and South Powys Mind GAD questions are being asked as per NICE quidance. Gad is specific to anxiety. whooley are specific to depression. asked at booking and throughout pregnancy and by health visitors at first visit etc. if positive responses we ask the EPDs.

Snapshot of what MWs, HVs & NNs do in Powys Booking :Past history of mental health/Family history Whooley /GAD Boots wellbeing plan Antenatal: ask GAD and Whooley at each antenatal visit If positive responses to Whooley/GAD an EPDS is undertaken Outcome of EPDS: 0-10 universal support 10-12 repeat in 2 weeks/NN 13-15 Listening visits/NN 16-19 GP / Primary care counselling/NN 20+ Referral to CMHT/CPN GAD questions are being asked as per NICE quidance. Gad is specific to anxiety. whooley are specific to depression. asked at booking and throughout pregnancy and by health visitors at first visit etc. if positive responses we ask the EPDs. Sharon is doing some work on fathers and perinatal mental health. Awareness training with the mental health teams. We continue to aim to raise awareness amongst the community. The sub groups will link in with the community to talk about perinatal mental health.i.e WI; farmers markets. Sharon can tell you about the nursery nurses.

Still more to do……. More training & communication Continue awareness training to mental health service providers across Powys Continue to work closely with primary mental health services (counsellors) Preconceptual advice Continue to reduce stigma of anxiety/depression Continue to evolve role of nursery nurse Improve communication Specific CPN training on PNMH Better communication between all health professionals Explore role of specialist midwives and health visitors Exploration of development of infant mental health service Nursery nurse role commenced. It is a starting point. This service will be shaped and evolve as feedback is received from staff, parents and colleagues.

Powys strengths….. Great working relationships between colleagues Smaller workforce Multi Disciplinary approach Great working relationships between colleagues CMHT/CPN Pick up phone for advice Named MW/HV Continuity of care

Is our service prudent? Public and professionals are equal partners through coproduction Service user key member of steering group Professionals work WITH parent to identify most appropriate support needed Care for those with the greatest health need first Primary care pathway ensures that those in need are referred directly by their midwife or health visitor to CMHT services without having to go back to their GP. Do only what is needed and do no harm Midwives and Health visitors in Powys confident and competent to provide early assessment and input Reduce inappropriate variation through evidence-based approaches Identification, assessment and intervention now happening earlier and systematically.

Summary Community focused model of care Focus on mild to moderate depression Service user input from the beginning Robust clinical referral Pathway Multi disciplinary approach Raise awareness and reduce stigma Focus on prevention and early intervention Additional nursery nurse hours Introduced additional screening tools Working with fathers And the steering group now sits under the Powys Public Service board mental health sub-group. But, still lots more to do.......... Service user input helped gain engagement across MW & HVs & CPNS Helped shaped pathway Adult MH services in Powys have been complicated which hasn’t helped with pathway development, some were employed by other HBs Need to ensure Primary MH services link in fully and that their National targets don’t override the NICE guidance re assessment and treatment timeframes Still lots more to do to raise awareness and reduce stigma This a picture of the display at the royal welsh this summer. Also had display boards in all birth centres on AN and PN depression and Infant mental health to tie in with Adult and Infant mental health week

Further reading Children, Young People and Education Committee Perinatal mental health in Wales NAW, October 2017 www.assembly.wales/SeneddCYPE NICE guidance (CG192) Antenatal and postnatal mental health : Clinical management and service guidance, revised 2014 https://www.nice.org.uk/guidance/cg192