Options to increase mother and baby unit capacity: consultation analysis

Options for the Provision of Additional Mother and Baby Unit Services

66. The consultation paper noted that Delivering Effective Services (2019) recommended that Scotland could benefit from an additional four Mother and Baby Unit beds.  These additional beds could be created by expanding one or other of the existing Mother and Baby Units, or through creating a new, third, Mother and Baby Unit in the north of Scotland.  

67. The north of Scotland was identified as a potential site for a third Mother and Baby Unit as there were concerns about equity of access for women who live significant distances from the existing Mother and Baby Units within the central belt. A Mother and Baby Unit in the north of Scotland would be sited in one of NHS Highland, NHS Grampian or NHS Tayside.

68. The next question asked:

Q4: ‘What do you think is important to women and families when considering admission to an MBU?’ 

69. Almost all respondents (224) made comments at this question.  A number of key themes again which often mirrored those espoused at the previous question.  The largest numbers – one in two spread fairly evenly across all respondent types – wanted access to their families (partners, older children and / or other close relatives) and family support network, requesting, for example, open visiting arrangements.  Being in close geographic contact with their families and friends was also desired, specifically in terms of bonding with new babies being seen as important for all family members; difficulties were perceived in this respect for those in the Highlands or those not in the central belt.  Nearly as many respondents cited the location, distance or accessibility from home of the MBU as important.  An NHS / Health Board summed up these factors thus:

“Being as close as possible to family and loved ones, while also knowing that partners will be made welcome and to feel included and supported. Consideration to the wider needs of the wider family for example the potential stress that family members could place under by employers if there is prolonged time away from the workplace and for mums with older children the possible lack of childcare, looking after pets etc.  The distance from the unit; this could also include infrastructure with regards to accessibility of public transport for those who live locally.”

70. Furthermore, a significant minority (one in ten) thought that family support facilities within the unit would be important, with suggestions for overnight accommodation and facilities for older children.  Having the baby in situ was also pinpointed by similar numbers of respondents, for bonding and breastfeeding purposes for instance; there were also a couple of recommendations for support for babies as well as mothers within MBUs.  A small minority cited concerns over the impact on other family members such as changed childcare arrangements.

71. One in four respondents, including more than half of the responding organisations, focused on the quality of care provided or the type of support available; it was mooted that this should include comprehensive round the clock treatment, readily available specialists to provide appropriate care, properly organised care and treatment plans and individual-centred care.  In connection with this, a significant minority requested good communication regarding care, specifically in terms of the support offered, evidence-based pathways, honesty about outcomes, communication with the wider family and medical and pharmaceutical knowledge and options; it was intimated that these kinds of information would help take away fears over support implications.

72. Other points were made about perceived important aspects about treatment and care by a few or small numbers of respondents as follows:

• Ongoing or follow up discharge planning (e.g. what outpatient, community care or local support can be offered after leaving the MBU, since recovery can be slow).
• The predicted length of time spent at the MBU (e.g. for the greatest therapeutic gains).
• Ease of access to services in terms of transport and parking.
• Speed of access to treatment (e.g. availability of beds, length of time a referral will take).

73. Significant minorities (roughly one in eight) across the full range of respondents desired a welcoming environment at MBUs in order to feel comfortable, with suggestions that they should be as homely as possible and supportive of the mother and baby bond; small units were suggested to aid this.

74. Similar numbers wished for a safe environment, including requests for privacy and safe places to talk, and a desire to be safe in the knowledge that the child will not be taken away.  Reassurances that staff are there for support were also requested.

75. A few respondents each wanted to see the following characteristics regarding staff at MBUs:

• Empathetic, listening, kind, compassionate and understanding staff (so as to be able to trust them, and feel listened to and understood).
• Not being judged / perceived as being a bad mother (e.g. not being in fear of being stigmatised).
• Well trained, experienced staff (in specific conditions, or in perinatal mental health). 
• Ability to see familiar professionals while at the MBU (e.g. health visitors, social workers, community teams); there were also a couple of requests for patients to have a single identified contact or key worker.

76. A few respondents across most types cited the importance of cost implications against benefits from treatment, noting the financial costs incurred by family members visiting, travelling or staying nearby.  A very small number wished to see financial support for these purposes.

77. Finally a very small number of individuals stated a preference for mothers to be supported at home or a local maternity unit, with admission to an MBU only if these patients cannot receive care in a community setting.

78. The next question asked:

Q5a: What do you imagine would be the benefit(s) of increasing the number of beds in existing units (choose all that apply)

• Access for women and families across Scotland
• Cost
• Safety
• Sustainability of the service
• Other

Q5b: Can you tell us your reasons for thinking this? 

79. As demonstrated Table 2, access for women and families across Scotland (69%), sustainability of the service (58%) and safety (52%) were all perceived to be benefits by more than half respondents.  

Table 2: Benefits of increasing the number of beds in existing units

	Total		Organisations		Individuals
	Number	%	Number	%	Number	%
Access for women and families across Scotland	163	69	9	56	154	70
Sustainability of the service	137	58	12	75	125	57
Safety	123	52	13	81	110	50
Cost	93	39	7	44	86	39

80. There were a small number of references to improved outcomes for mothers and their babies, fewer mothers on general mental health wards separated from their babies and increased specialist knowledge or expertise in Scotland.  That said, a few respondents also commented on a need for more MBUs to benefit both families and professionals rather than just expanding the number of beds in existing units.  

81. A total of 163 respondents then opted to provide reasons for their response about the benefits of increasing the number of beds in existing MBUs. The key benefit across almost all respondent sub-groups and offered by around a third of respondents was that this would enable more women to be able to access the service and the support it offers when it is needed. Linked to this, around one in ten respondents noted that women in general mental health wards do not receive the same level of specialist care and that being separated from their baby can increase the amount of stress for the mother.  

82. Around a quarter of respondents across most respondent sub-groups noted that it would be more cost effective and sustainable to increase the number of beds in existing MBUs, although some noted a proviso that this has limited value to women living outwith the existing areas or that cost should not be a priority when making decisions about where to create new beds.  Allied to this point, around a third of respondents noted a desire to have new units in different geographic areas in order to create equity of access for all women.  Slightly higher proportions of those wanting to see new units in different geographic areas were respondents based in greater Glasgow and Clyde, Highland and Grampian health board areas.

83. Other benefits noted by smaller numbers of respondents were that this would:

• Offer access to skilled staff with specialist expertise rather than general mental health wards where there is a lack of expertise.  The opposite of this was that health professionals in the rest of Scotland would not have the opportunity to upskill.
• Offer expansion and sustainability to the current workforce and offer centres of excellence with nearby access to related specialist services.
• Make existing MBUs more sustainable.
• Offer easier access to the required specialist staff in the central belt.  
• Help to increase awareness of MBUs and reasons for accessing their services.
• Offer support in development of the mother and baby relationship and lead to positive outcomes for both.

84. Respondents at one of the consultation events noted that managing only two units would be more sustainable.  There would continue to be a regular flow of patients which might not be possible in a new unit.  

85. Having ascertained the benefits of increasing the number of beds in existing units, the next question asked:

Q6a: What do you imagine would be the challenges / drawback of increasing the number of beds in existing units (choose all that apply)

• Access for women and families across Scotland
• Cost
• Safety
• Sustainability of the service
• Other

Q6b: Can you tell us your reasons for thinking this? 

86. As shown in Table 3, the key challenge / drawback of increasing the number of beds in existing units was perceived to be cost (cited by 53% of all respondents). This was followed by access for women and families across Scotland (42%), sustainability of the service (22%) and safety (18%).  The highest numbers of respondents citing access for women and families across Scotland as a challenge or drawback were based in the Highland health board area (three in five).

Table 3: Challenges / drawbacks of increasing the number of beds in existing units

	Total		Organisations		Individuals
	Number	%	Number	%	Number	%
Cost	125	53	8	50	117	53
Access for women and families across Scotland	100	42	8	50	92	42
Sustainability of the service	53	22	6	38	47	21
Safety	42	18	2	13	40	18

87. Only small numbers of respondents referred to any other challenges / drawbacks of increasing the number of beds in existing units.  These included staff recruitment and retention, resources to support an increase in the number of beds, finding suitable premises and continuing the staff:patient ratio that is currently offered in existing units.  A small number of respondents also noted that increasing the number of beds in existing units would not increase the geographical coverage of the units.

88. A total of 146 respondents made comments to question 6b.  By far the largest numbers – exactly half from across all types– made the point that increasing the number of beds in existing units does not tackle the issues faced by those in the north of Scotland or outside the central belt.  These respondents cited problems previously discussed such as geographical, financial and travel barriers and existing units still being far apart from families making access difficult, thereby exacerbating fears over isolation from relative support networks.  Further comments expressed a desire for a unit further north or more local geographical cover generally.  There were also a very small number of comments surmising that it would not be as easy for patients to work with the community network once home.

89. Again relating to women and family access, a significant minority of respondents (one in eight) from across the all types foresaw that women would not accept an MBU place if it was too far from home, thereby putting their safety at risk if they did not receive the most appropriate care for their needs.

90. Relating to cost issues, nearly one in five respondents foresaw funding challenges in increasing the number of beds.  Respondents raised ongoing government funding issues relating to the health system generally and for mental health in particular, with a couple of fears expressed that funding more MBU beds may lead to cuts in other areas.

91. Similar numbers predicted increased staffing and service costs arising from catering for more beds.  Small numbers foresaw increased costs arising from the necessity of training or recruiting staff; a few pointed out the costs from additional building work and refurbishment in order to set up new bed areas and extensions to existing units.

92. A few respondents however thought that the extra support for new mothers will be cost beneficial in the long run, pointing out reduced risk factors through improved outcomes, thereby helping to reduce costs in other services such as child development and community mental health; a couple of respondents commented that the long term costs of not treating conditions appropriately has been demonstrated.

93. Regarding safety drawbacks, there were a few concerns that expansion of beds would adversely affect the quality of service delivery, due to a perception of having to cope with more patient demand with more thinly spread resources.  A very small number focused on the need to ensure an appropriate staff to patient ratio.

94. Regarding sustainability, roughly one in eight respondents (and in particular half of clinicians in the maternity / neonatal care field) voiced concerns over adequate staffing for the units, given that staffing in general is currently a challenge; a few respondents were particularly worried over the provision of specialist, trained staff, pointing out that nursing staff will require specialist training.  There were also a small number of concerns about new beds not being used, in which case they might be removed; it was deemed essential to let service users know about these.

95. A couple of potential other drawbacks were pointed out by very small numbers of respondents as follows:

• Concerns over a possible lack of personal attention at a bigger unit, combined with worries that the larger size of unit can make it harder to recover when there are more mothers present e.g. “Creating a more hospital feel than a secure facility where people can try to live a normal life…” Clinician, Maternity / Neonatal Care
• Concerns over the capacity or space to expand current MBU building facilities, with it postulated that there would be a need to reconfigure neighbouring wards or build a brand new unit instead; both the existing MBUs in NHS Lothian and NHS Greater Glasgow and Clyde were mentioned in this respect.

96. Additional disadvantages noted at the consultation events included continued delays in access to a unit, that consideration needs to be given to safety because of adverse weather when travelling to the central belt from further afield and concerns over continuity of care for the mother on her return home.  There were also references that geographical travel costs would be passed onto the relevant health boards and that midwives need access to professional advice and support, for example, in being able to authorise patient transfers.

97. Having asked for views on the benefits and challenges / drawbacks of increasing the number of beds in existing units, the next questions went on to ask about the benefits and challenges of developing a new unit in the north of Scotland.  Question 7 asked:

Q7a: What do you imagine would be the benefits of developing a new unit in the north of Scotland (choose all that apply)

• Access for women and families across Scotland
• Cost
• Safety
• Sustainability of the service
• Other

Q7b: Can you tell us your reasons for thinking this? 

98. As Table 4 demonstrates, the key benefit and cited by almost all respondents (96%) was access for women and families across Scotland.  Around two in three respondents (67%) cited safety as a benefit, followed by just under half (46%) referring to sustainability of the service.  Cost was cited by least numbers of respondents (19%).  In terms of sub-group differences, organisations focused more on cost, while individuals focused more on safety and sustainability of the service.  

Table 4: Benefits of developing a new unit in the north of Scotland

	Total		Organisations		Individuals
	Number	%	Number	%	Number	%
Access for women and families across Scotland	227	96	15	94	212	96
Safety	159	67	8	50	151	69
Sustainability of the service	109	46	4	25	105	48
Cost	46	19	5	31	41	19

99. Only a very few respondents mentioned any other benefits of developing a new unit in the north of Scotland.  These focused on women being able to stay near their existing support networks, support for mothers and their babies to be kept together, less distance to travel to access and MBU, better patient outcomes and the development of specialist skills for staff.   

100. A total of 150 respondents opted to provide commentary in support of their initial response.  The key benefit, identified by around a third of respondents fairly evenly spread across all respondent sub-groups, was that mothers and their babies need access to local care and that a new unit would remove the barrier of distance to be travelled.  That said, a few respondents – mostly organisations – felt that there would need to be more than three MBUs across Scotland to offer good geographic coverage of this service.  At a consultation event, a respondent noted this would offer quick access to care if there is a need to return to the unit at short notice when out of the unit on a pass. 

101. Just over a quarter of respondents noted that mothers would be close to other family and friends which in turn makes family visits easier and reduces the stress on partners and families; and around one in ten noted that mothers would not be isolated from their support networks. 

102. The availability of beds across a greater area of Scotland was cited by around a quarter of respondents, with reference to more women being able to access the service and having more admissions from outwith the central belt.  Around one in five respondents also noted that some women choose not to use the existing units because of the distance to travel which in turn increases the risk to a mother suffering from perinatal mental health issues.  

103. A respondent at a consultation event also noted that it would help to make the discharge process easier as mothers would not have to stay in hospital longer than necessary because it is too far to travel home to see how they cope.

104. Around one in five respondents commented on the need for equity of access for all women across Scotland, with reference to the current two unit scenario being a postcode lottery for many women.

105. Other benefits outlined by around one in ten or less respondents included:

• Increased safety for mothers and their families.
• Less pressure on family members in terms of travel and reduced travel costs.
• Helping mothers and their babies to develop a relationship as they are kept together, and improved outcomes for mother and baby.
• Increased specialist knowledge across Scotland, with more professionals having opportunities to upskill and develop their expertise in perinatal mental health.  Linked to this, less pressure on local community mental health services and fewer women having to use non-MBU mental health services.
• Better knowledge of what local support and advice is available on an ongoing basis to mothers on discharge, although a consultation event respondent noted the need for family specialists to assist on offering advice and support.
• Longer term savings to the NHS as mothers are more likely to recover rather than being reliant on the NHS long term for support and advice.
• Improved quality of care in the north of Scotland.  

106. In summarising some of the benefits of an additional unit in the north of Scotland, a professional body / association noted:

“Development of inpatient specialist knowledge, training and workforce would strengthen the provision of community services. Conversely, for a mother and baby unit to be successful, it needs to be embedded in sustainable, well-resourced community services, that have a sustainably recruited workforce that is retained over time, including substantive perinatal psychiatry posts. The existence of an experienced and well-developed community perinatal service is likely to improve appropriate inpatient admission experience and facilitate timely admission.”

107. Having asked respondents to provide their views on the benefits of developing a new unit in the north of Scotland, respondents were then asked about potential challenges / drawbacks to this new service.  Question 8 asked:

Q8a: What do you imagine would be the challenges / drawback of developing a new unit in the north of Scotland (choose all that apply)

• Access for women and families across Scotland
• Cost
• Safety
• Sustainability of the service
• Other

Q8b: Can you tell us your reasons for thinking this? 

108. As Table 5 shows, the key challenge / drawback of developing a new unit in the north of Scotland was cost (cited by 71% of respondents fairly evenly across all sub-groups). A quarter of respondents referred to sustainability of the service (highest among organisations); and less than 5% referred to access for women and families across Scotland or safety being a challenge / drawback.  

Table 5: Challenges / drawbacks of developing a new unit in the north of Scotland

	Total		Organisations		Individuals
	Number	%	Number	%	Number	%
Cost	167	71	13	81	154	70
Sustainability of the service	59	25	9	56	50	23
Access for women and families across Scotland	10	4	5	31	5	2
Safety	8	3	4	25	4	2

109. Very few other challenges / drawbacks were cited by respondents at this question although staffing, a lack of experienced staff and staff training were concerns for small numbers of respondents.

110. A total of 119 respondents provided comments in support of their initial response at Question 8a.  The key challenge / drawback cited by a significant minority of respondents (two in five spread fairly evenly across sub-groups) was the cost, planning and setting up of the new unit.  A few respondents noted that this new unit would have to be created from scratch.  Conversely, a few respondents felt that provision of a unit in the north of Scotland and the quality of the service should be a priority that outweighs any costs in setting up a new unit, although there were some acknowledgements of the lack of resources within the NHS at present.  This latter issue was noted primarily by respondents within the Grampian health board area.

111. Around a third of respondents across most sub-groups also referred to the issue of staff recruitment and retention, with a small number of comments that recruitment and retention of staff is already challenging in some specialist areas in the north of Scotland.  A small minority of respondents – one in ten, primarily organisations – also commented on a lack of staff with specialist perinatal mental health experience across the north of Scotland.  For example, one respondent noted that currently there is no specialist perinatal psychiatrist in their health board area.  Linked to this issue, a small minority of respondents also referred to issues with staffing costs and staff training, particularly if staff have no skills or experience within the area of perinatal mental health.

112. While travel to the existing units in the central belt was perceived to be an issue for many potential patients in the north of Scotland, a small minority of respondents noted there could still be issues with travel to an MBU within the north of Scotland for some individuals.  A few respondents also noted that public transport links across the north of Scotland are poor.  At consultation events, concerns were raised over transportation links and travel safety.

113. A few respondents referred to the importance of equity of access and the need for the north of Scotland to have the same services and resources as the central belt.  In terms of location of a new unit, there was a suggestion that that bigger health boards may have more capacity for specialist staff and good links with bank staff access.  

114. A professional body / association noted that MBU beds would need to have access to wider perinatal expertise as well as community support and care and that there will be a need to ensure this is developed if it is not already available.  A health board noted that if there are not good community perinatal services, this could create problems with the admission and discharge of patients.

115. A small number of respondents noted that it is recommended that an MBU should have a minimum of six beds, rather than a four bed unit as suggested.  A six bed unit was perceived to be more cost effective, assuming the demand is there, with a health board noting that units smaller than six beds are likely to be less viable.  One health board commented that it might be difficult for staff to develop or maintain clinical expertise if the unit does not run at full capacity.  One individual noted:

“The pool of staff for perinatal is small so recruitment and retention of staff is a long term concern. A remote unit may often not be full given the geography of the unit so this leads to safety concerns – how can an empty ward provide a therapeutic peer support environment. Potential high staff turnover leads to concerns about sustainability of the service. Having 3 MBU’s with few admissions at certain times of the year will impact on recovery of patients.”

116. The next question went onto ask:

Q9: ‘Do you think there is a different way to provide care for those women with severe illness, and their infants, who might otherwise need to be admitted to hospital?’ 

117. 184 respondents commented at this question.  The largest numbers (approximately two in five respondents spread fairly evenly across all types) disagreed that there are other ways to provide care for women with severe illness and their infants.  These respondents said that a specialised unit solely catering to mothers and babies is the best way forward for those who would otherwise need hospitalisation, pointing out the advantages of trained staff giving 24 hour care in a therapeutic and safe environment.  

118. Further comments were made by one in ten respondents about the need to keep mothers and babies together where possible, and voicing disagreement that proper care at home or in the community was possible for severe conditions (e.g. suicide risk or psychosis), since adult mental health teams do not have the capacity for this.  Small numbers of comments advocated the need for expanding MBU beds in terms of both number and location, along with very small numbers voicing a need for more support on discharge from MBUs to help prevent readmission.  

119. However, a large minority of one in four respondents from across sub-groupings did advocate the use of more intensive community-based support in general, albeit with some stating that this should be an option only if the illness was not too severe.  To this end there were requests for more community care resources, though there were also notes of recent investment in this area.  Many of these respondents did not go into further detail, but a significant minority described specific forms this might take, pinpointing more specialised community and local mental health care as a possible option, with more community health teams, community perinatal nurses and community on call perinatal teams all also specified in this respect.  A few respondents postulated a need for extra training regarding perinatal mental health for staff working in home care services (e.g. GPs, midwives).  Respondents at a consultation event also noted that not all localities will have access to a community perinatal health team and this could impact on women presenting in crisis.  There was a suggestion of a need for intensive crisis teams and a better skills mix within the community.

120. A significant minority (one in five) perceived care at home as being an option, again with some suggestions that this should depend on the severity of the illness.  Further to this, there were calls to improve the home support facets currently available, such as providing intensive home visiting, daily therapies, 24 hour support availability and proper care linkage between GPs, crisis teams, specialists in existing units and third sector organisations.  The main advantage foreseen was that staying at home would ensure the family unit remained together.

121. The other main theme espoused by one in six respondents (and more than two in five organisations) was the need for easier and quicker access or referrals to services and support.  This was seen as a preventative approach to help head off worse problems thus reducing the need for hospital or MBU admissions.

122. A few respondents suggested the following additional ways to provide care^[3]:

• (Local) Day care or satellite units providing daily or outpatient care and support, with intensive support available, for instance within local hospitals, or taking the form of baby clinics where patients can converse with other mothers.
• Further use, development or expansion of Perinatal and Infant Mental Health Teams (PNIMHT) across the country.
• More provision of support and education to families and personal support networks (e.g. about how to recognise problems and risks, or to enable being at the forefront of clinical decision-making).
• Examine how other countries provide perinatal mental health care (from a consultation event).

123. Additionally, small numbers of respondents suggested implementation of a ‘house’ setting for care as opposed to a hospital setting, with the advantages of a less clinical appearance and less stigma being attached to these; and incorporating more specialist care into local maternity units or hospitals (thus allowing mothers to stay rather than be moved before or after birth).

124. A very small number of other mentions were made of hospitals being the most effective means of care; and of a need for more crisis teams within perinatal services.

125. At some consultation events, attendees were asked what would help women and families with travel to an MBU, either an existing unit or a new unit.  A need was noted for improvements to transport times for the non-emergency transport service.  The use of multi-disciplinary meetings involving both patients and their partners was also suggested as a useful element of support.  On a more logistical level, there was a suggestion for mothers to have access to carry cots.