Perinatal mental health services: needs assessment and recommendations

4. What does Scotland have now?

4.1 Mother and baby units

4.1.1 Current provision

There are two regional 6-bed mother and baby units (MBUs), at St John’s Hospital, Livingston and Leverndale Hospital, Glasgow, giving a total of 12 beds for Scotland. They provide care for women with severe mental ill health, alongside their infants. There are different arrangements for the commissioning and oversight of each MBU. All but two NHS boards have formal arrangements for admitting to one or other MBU. NHS Grampian and NHS Forth Valley access beds on an ad hoc arrangement. The two MBUs work closely together to ensure that women in need are admitted to a unit irrespective of area of residence, though there are no underpinning formal arrangements.

Staffing levels varied significantly between the two MBUs. Neither unit is resourced across all disciplines to provide fully comprehensive care.

Current MBU staffing

Discipline	WTE St John’s Hospital, Livingston	WTE Leverndale Hospital, Glasgow
Consultant Psychiatrist	0.8	0.5
Junior Psychiatrist	0.5	0.5
Nurse Consultant	-	0.2
Senior Charge Nurse (Band 7)	1.0	1.0
Charge Nurse (Band 6)	2.0	1.0
Clinical Psychologist (Band 8C)	0.48	0.5
Occupational Therapist (Band 6)	0.13	0.5
Social Worker	0.4	0.5
Mental Health Nurse (Band 5)	8.6	6.8
Nursery Nurse (Band 4)	3.72	3.7
Health Care Assistant (Band 3)	3.28	1.0
Health Visitor (Band 6)	0.2	0.2
Administrative staff (Band 4/3)	0.4	0.5
Total WTE	21.51	16.9

Together, the two MBUs had 115 admissions per year (averaged over 3 years). Activity levels were similar for each unit (54 admissions to St John’s; 62 admissions to Leverndale). The average lengths of stay were 27.0 days (St John’s) and 29.25 days (Leverndale). There was clear evidence that MBUs were often full and unable to take admissions. For example, the St John’s MBU was fully occupied for 49% of the time between January 2016 and November 2017. The Leverndale MBU had 44 patients who could not be immediately admitted in 2018.

NHS board source and rate of admissions is given below. There are higher rates of admission for boards which host an MBU, which may be a reflection of improved detection, local awareness of the service or ease of access for women and families.

MBU admissions by board of residence

NHS board	Total admissions 2016-2018	Average admissions per year	Births numbers (2017)	Rate of admissions per 1,000 births per year
Ayrshire & Arran	10	3.3	3,281	1.0
Borders	7	2.3	989	2.3
Dumfries & Galloway	1	0.3	1,248	0.2
Fife	20	6.7	3,465	1.9
Forth Valley	7	2.3	2,907	0.8
Grampian	19	6.3	5,917	1.1
Greater Glasgow & Clyde	138	46	12,126	3.8
Highland	4	1.3	2,754	0.5
Lanarkshire	29	9.7	6,763	1.4
Lothian	87	29	9,037	3.2
Orkney	0	0	184	0
Shetland	0	0	218	0
Tayside	19	6.3	3,757	1.7
Western Isles	0	0	215	0
Other UK and unknown	4	1.3	-	-
Total	345	115	52,861	2.2*

*Calculated excluding other ‘UK and unknown’ admissions

Overall, there was a high level of satisfaction across partner NHS boards with the care provided by the regional MBUs, and good liaison between MBUs and local clinicians in the management and discharge planning of women admitted with their infants. Both MBUs have accreditation from the Royal College of Psychiatrists’ Perinatal Quality Network.

4.1.2 Common themes

Boards hosting a regional MBU

• There was very limited, or no, specialist infant mental health input to the MBUs.
• There was limited capacity to provide a range of mother-infant psychological interventions.

Boards with formal MBU access

• Beds were not always immediately available. There was a perception in some board areas that lack of availability could be due to MBUs accepting admissions from boards without a service level agreement.
• For some boards, distance from an MBU was a disincentive for women and their families to take up offer of admission.
• For boards with very limited community provision, ensuring timely support for periods of leave from hospital and for discharge could be a problem.

Boards without formal MBU access

• There was a recognition of lack of equity of access given that MBUs would prioritise admissions from boards with whom they have a contract. MBUs may also not give a ‘last bed’ to a board without a service level agreement.

4.2 Specialist community perinatal mental health services

4.2.1 Current provision

Four NHS boards currently provide multidisciplinary specialist stand-alone teams for perinatal mental health. However, none is resourced across all disciplines to provide fully comprehensive care. Two of the

4 fall significantly short of recommended provision both in terms of staffing and function. All other boards, with the exception of those with very low birth numbers, have some provision, though this is not always ring-fenced or specifically funded.

Description	Boards	Birth numbers
Boards with multidisciplinary specialist community teams	Greater Glasgow & Clyde Lothian Lanarkshire Grampian	12,126 9,037 6,763 5,917
Boards with protected multidisciplinary sessions and a core team	Forth Valley	2,907
Boards with one or more members of mental health staff identified as having a special interest in perinatal mental health	Tayside Fife Ayrshire & Arran Highland Dumfries & Galloway Borders	3,757 3,465 3,281 2,754 1,248 989
Boards without special interest provision for perinatal mental health	Shetland Western Isles Orkney	218 215 184

4.2.2 Common themes

Boards with multidisciplinary specialist community teams

• No service was resourced across all disciplines to provide comprehensive

Boards with protected multidisciplinary sessions and a core team

• Provision of a core dedicated team with protected time for workers in CMHTs
  provided a robust service model

Boards with one or more members of mental health staff identified as having a special interest in perinatal mental health

• Most special interest posts in perinatal mental health, with notable
  exceptions, were not ringfenced either for clinical time or clinical supervision.
• Staff had very limited or no opportunity to meet for peer supervision and
  learning.
• There was often a lack of clinical leadership for perinatal mental health.

Boards without special interest provision for perinatal mental health

• Community mental health staff had very limited or no access to specialist
  advice or supervision.
• There was enthusiasm for improved regional links and use of telemedicine.

Other themes

• There was very limited, or no, infant mental health provision in most NHS
  board areas.

4.3 Infant mental health

Health visitors and family nurses (Family Nurse Partnership, FNP) attended a number of the board visits. Health visiting provides a universal service and has a central role in addressing the mother-infant relationship and infant development. A universal pathway was launched in 2015 to ensure continuity of care from the antenatal period to pre-school age for all families, with an emphasis on prevention and early detection of difficulties (Scottish Government, 2015). This work is underpinned by the Getting It Right For Every Child (GIRFEC) model of practice, which should inform all professionals in their care of infants and children.

Family Nurses have a supervision structure which allows them to support women and infants with complex needs, with a focus on the mother-infant relationship and infant development. However, the role is currently restricted to engagement with first-time mothers aged 19 years and under.

There is a range of provision focussing on the mother-infant relationship, and on infant development, within existing perinatal mental health services. Team members have additional training in infant mental health, including undertaking the NES e-learning module, Solihull Approach training and, in some areas, providing infant massage, video interactive guidance and other interventions.

It is clear however, that the lack of appropriately skilled practitioners within teams prevents access to parent-infant interventions for more complex difficulties and to address preparation for parenthood and parenting in women with significant mental disorder.

Outwith perinatal mental health teams, child and adolescent mental health services (CAMHS) rarely, if ever, had the capacity to assess and manage children under one year. A small number of NHS boards had developed parent-infant mental health services, often driven by enthusiastic and skilled individuals, but these services remain vulnerable and, in some cases, unsustainable.

4.4 Specialist midwives

Three NHS boards have appointed specialist midwives in perinatal mental health (NHS Grampian, Lanarkshire and Tayside). There was a lack of clarity about the role in two areas. Only NHS Grampian provided the specialist midwife with a formal link into the local perinatal mental health service and supervision for their mental health role. However, at the time of visiting, this link was vulnerable given lack of sustainability of the specialist team.

Other board areas had made provision for midwives with a special interest in vulnerable pregnancy, particularly (though not exclusively) with regard to substance misuse (e.g., Special Needs in Pregnancy Service (SNIPS) in Greater Glasgow and Clyde, Vulnerable in Pregnancy (VIP) Project in Fife and PrePare Service in Lothian). These services are multidisciplinary in nature and respond to the needs of women who will often have significant social disadvantage and comorbid mental illness.

There are a number of midwives throughout Scotland who have developed a special interest in perinatal mental health, often driven by individual enthusiasm but not provided for in a sustainable way by boards.

4.5 Maternity and neonatal psychological services

Maternity and neonatal psychological services provide interventions which address psychological need for parents with previous or current pregnancy and neonatal complications, or who have mental health problems which directly affect maternity care. Where these services currently exist, they are provided by a single professional discipline, clinical psychology. Most board areas make no specific provision for psychological interventions within maternity or neonatal services and only NHS Greater Glasgow and Clyde has dedicated provision for maternity services.

Current maternity and neonatal psychological therapies provision

NHS board	Service	Staffing (WTE)
NHS Ayrshire & Arran	Neonatal Psychology	0.5	Band 8B
NHS Greater Glasgow & Clyde	Maternity and Neonatal Psychology	3.3	(1.3 Band 8C; 1.0 Band 8A; 1.0 Band 7)
NHS Grampian	Neonatal Psychology	0.2	Band 8A
NHS Lanarkshire	Neonatal Psychology	0.4	Band 8A
NHS Lothian	Neonatal Psychology	0.1	Band 8A

4.6 Primary care mental health

General practitioners will provide expert management of mild to moderate psychological distress and disorder and should usually be the initial source of advice and assessment where such difficulties arise in the perinatal period. There was clear feedback from visits however, that GPs would benefit from additional education and training in prescribing during pregnancy and breastfeeding.

NHS provision of evidence-based interventions for mild to moderate mental distress and disorder at universal/primary care level is very variable throughout Scotland. Board responses include the provision of dedicated primary care mental health teams, integration of mental health nurses within GP services, and development of third sector links.

Where specific services exist, they do not always make adjustments for the distinctive presentations in the perinatal period or the timescales imposed by pregnancy and critical periods in child development. Few NHS boards ensured rapid access to appropriate interventions for pregnant or postnatal women.

4.7 Third sector and peer support

There is a range of service provision within the third sector in Scotland directed at providing practical and emotional support, counselling and psychological interventions to women and their families, where there is parental mental distress or disorder. They may also provide interventions to enhance the parent-infant relationship and improve infant outcomes. There are examples of excellent practice, both from Scottish and UK wide organisations, and from local third sector providers.

The main issues arising from the Network’s consultation were ‘short-termism’ in funding structures which can lead to the withdrawal of existing well-functioning services, and the need for improved links between the third sector and perinatal mental health services within the NHS. It was also evident that the sector could benefit from a co-ordinated structure which would strengthen its voice in helping plan equity of counselling provision and development of women led and peer support worker roles in Scotland.

Peer support workers provide help to others based on their shared lived experiences. They can be volunteers or paid employees and can be supported through third sector or NHS structures. Peer support and women led initiatives are an underdeveloped resource in mental health services generally and in perinatal mental health provision in particular. What was evident from those we spoke to during the visits, is that those providing peer support may require support themselves at times. They also need to know what other resources are available when peer support alone is not sufficient, and how to access them. Properly provided, peer support may be an invaluable resource for women and their families.

The Network worked closely with the Maternal Mental Health Scotland Change Agents, a group of women (and, in some instances, their partners and other family members) who campaign for service development and provide a network of informal peer support. We observed a number of examples where individual members engaged in innovative peer to peer initiatives.