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Peri-natal and infant mental health where next?


Peri-natal and infant mental health where next? Dawn Rees National CAMHS strategic relationships and programme manager * CEMACH from Margaret ... – PowerPoint PPT presentation

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Title: Peri-natal and infant mental health where next?

Peri-natal and infant mental health where next?
  • Dawn Rees
  • National CAMHS strategic relationships and
    programme manager

What this presentation covers
  • Why Perinatal and Infant Mental Health matters
  • Where we are now in terms of delivery, what are
    our major strengths and weaknesses
  • Where we need to be
  • What support is available, nationally, regionally
    and locally

Why it matters
  • Many other creatures develop in utero and quickly
    reach maturity following birth, but not the
    higher primates.
  • Much growth of the infant brain takes place
    outside the womb physically necessitated by the
    size of the human brain
  • The range of risks to optimal development include
  • Genetic
  • Environmental (including economic, social /
    maternal lifestyle)
  • Accidental
  • Relational (attachment and bonding, safety,
    impact of the built environment)
  • Services not generally configured to deliver
    across such a range of factors infrastructure
    and delivery system (with exceptions)

Why it matters some of the risk factors
  • CEMACH 2003-5 Context is of falling maternal
    death rates in the first 3 months after pregnancy
    though still 623 pregnancy related deaths of
    which 104 were clearly psychiatric, only 7/37 of
    the suicides were in the care of a psychiatrist,
    and 57 of all psychiatric deaths had a substance
    misuse issue of whom a tiny number were being
    treated by DATs
  • Strong evidence of predisposition to post
    puerperal psychosis in cases where previous HX
    Bi-polar disorder and emerging evidence of
    previous Hx affective disorders and postpartum
    affective disorders
  • Antenatal screening of previous psychiatric
    history essential

Education, knowledge and understanding
  • Guardian 29.9.08

Other risk factors postnatally in terms of
environment, relationship and attachment thanks
to Robin Balbernie
  • PET scan of healthy 2 year old
  • PET scan of 2 year old Romanian baby
    institutionalised shortly after birth

Where we are now in terms of delivery, our major
strengths and weaknesses
  • Strengths
  • Policy has developed strongly reflecting the
    work done by AMH and CAMHS trailblazers and
  • Significant policy documents and commitments
  • NSFs for Mental Health 1999 and Children 2004
  • Every Child Matters 2004
  • Childcare Act 2006
  • NICE Guidance ANPNMH (2007)
  • Childrens Centres expansion and Early Years
  • Maternity Matters
  • Child Health Promotion Programme
  • FIPS, Think Family, Health led Parenting,
  • Facing the Future
  • Child health strategy
  • This policy reflects a consistent wish to see
    services developed and delivered holistically and
    across professional and agency boundaries within
    a model of progressive universalism. The key
    role of the health visitor in coordination of
    health services for parent and babies is

Where we are now in terms of delivery, our major
strengths and weaknesses
  • Strengths
  • Delivery of services has improved
  • Survey of Perinatal and Infant Mental Health
    Services in May 2007 showed a considerable number
    (about 70) had started since 2000
  • Specialist Commissioners have commissioned
    networks in 2 regions
  • E Midlands (Notts) Margaret Oates has led the
    development of a managed network and led by Ian
  • South Central (Southampton) Alain Gregoire has
    led the development of a perinatal network across
    part of South Central SHA
  • Both of these networks have engagement from AMHS
    but necessarily CAMHS
  • In NW preliminary development around a managed
    care network taking place. Regional informal
    network, conferences and leadership to support
    this, scoping of perinatal services has taken
    place major gap is local PIMH teams

Where we are now in terms of delivery, our major
strengths and weaknesses
  • Strengths
  • A plethora of third sector organisations
    including Royal Colleges, AIMH, Marce Society,
    Parental Mental Health and Child Welfare Network,
    etc are aware of and advocating for this issue
  • National network for safeguarding children's
    professionals in mental health and learning
    disability trusts led by Geoff Allcock and Karen
  • National perinatal and infant e-network with over
    800 members (
  • National perinatal lead in Womens and Gender
    Equality workstream (.4 wte) promoting regional
    network development of PMH services

Where we are now in terms of delivery, our major
strengths and weaknesses
  • The IAPT (Improving Access to Psychological
    Therapies) programme
  • Perinatal pilots in Salford and Hertfordshire
  • SIG has produced commissioning guidance in draft
    form this strongly stresses a joint
    commissioning approach between children's
    services and adult services and health and social
  • Family Nurse Partnerships
  • Started Sept 2006 in 10 pilot areas, a further 20
    2008-9, more in 2010-11
  • Based on work by David Olds in the USA
  • First time mothers under 20 with complex problems
    (SM/DV/housing etc.)
  • Intensive manual based approach, small caseloads
    (25 per worker)

Where we are now in terms of delivery, our major
strengths and weaknesses
  • Further work being planned by NCSS PIMH a
    priority for next years business plan plans
  • Re-audit provision of care using child health
    mapping data for the first time work alongside
    Womens Mental Health Perinatal programme to
    maximise knowledge sharing and opportunities for
    both programmes
  • Identify across network if agreement exists about
    a NICE Infant Mental Health guideline
  • Contribute to workforce planning by providing
    information and exemplars from network membership
  • Aim for network self sustainability through
    product development
  • Aim for CORC endorsement of outcome measures
  • Development of PIMH e-earning module as part of
    NCSS e-learning set

Workforce issues
  • "One of the most flabbergasting pieces of
    evidence was when we asked doctors, as against
    midwives, whether they thought they were working
    to shared goals - 28of doctors said no and 58
    of midwivessaid no.
  • "This isn't where it should be. This doesn't do
    women any favours at all if we have these tribal
    allegiances still affecting the way services are
  • Sir Ian Kennedy 10.7.08

  • Multi professional and multi agency work not easy
  • Working across systems AMHS, CAMHS, maternity
  • Sensitivities on all sides about who should lead
    this agenda in Maternity and Perinatal services
  • Continuing concern for IMH guidelines from NICE
    to supplement APMH guideline led by AIMH
  • The RCP are taking steps to bring together AMHS
    and CAMHS Perinatal Psychiatry Annual
    Scientific Meeting 28th November 2008 Together
    we Stand supporting and enhancing mother-infant
    relationships for women with mental illness
  • What would service users think? What do they

  • Commissioning making the case and getting
    commissioners to prioritise it no cost savings
    so not attractive e.g. for PBC, links to local
    government and early years agenda poor in some
    places (Sure Starts have been a base for services
    to develop though
  • Maternity services development insufficient
    capacity at regional level, low priority for some
  • Workforce lack of accredited training for
    universal, targeted and specialist workforces
    about maternal and infant mental health and ill

  • Many CAMHS still see themselves as 5-17 not 0-18
    (but see e.g. Infant PMHW Service in Bristol)
  • Evidence base
  • is variable, services have developed on an ad
    hoc basis, practice is inconsistent, there is no
    general agreement about how outcomes should be
    recorded (? need a special interest group in CORC
    working on this from an IMH perspective)
  • National ownership no one minister owns the
    agenda, impact of regionalisation on support and
    delivery chain, lack of a supporting NI or LDP

Where we need to be
  • National, regional and local leadership of
    effective and coherent programme which ensures
  • Every region has a managed PIMH network which is
    fully inclusive and supported by regional
    specialist commissioning
  • Adequate inpatient accommodation in place
  • Every local authority / PCT area has
  • A needs assessment including workforce - JNSA
  • A strategy supported by workforce planning
  • Effectively pooled budget and workforce
  • Delivering a holistic set of services against a
    clear and integrated care pathway

  • With clear and effective leadership of services
    drawn from
  • Primary care antenatally and post natally
  • Hospital services
  • Early years
  • AMHS and CAMHS
  • Social Care
  • VCS
  • Which is commissioned in accordance with WCC
    principles, has effective business support and
    is effectively performance managed
  • Provides a progressively universal service which
    is evidence based and includes effective health
    promotion, early intervention services as well as
    services for more complex problems - including
    access to mother and baby units as necessary

  • Role of commissioners is crucial
  • Look at World Class Commissioning principles
  • Access
  • Equity
  • Based on need
  • Integration
  • How engaged are commissioners
  • Which commissioners
  • Need AMHS commissioners as well as CAMHS and
    maternity commissioners

What support is available nationally regionally
and locally
  • Nationally - specific policy and programmes
    referred to above information about leads for
    various aspects of PIMH available on web, AIMH
    and RCP/RCN/CPHVA etc
  • Regionally CSIP or its successor body
  • in most places a childrens health programme will
    remain so RCAs, RDWs will continue
  • PIMH also a major public health issue and
    regional public health and specialist
    commissioning are potential allies talk to RDWs
    about how to approach these organisations
  • Locally
  • natural allies are leads in LA early years,
    health visiting and midwifery, as well as medics
    (obstetrics and AMH / CAMHS) and if possible a GP
    ally on the PCTs PEC
  • commissioners will listen to such coalitions -
    should include AMHS, CAMHS and LA

The National Perinatal and Infant Mental Health
Network David Goodban PIMH lead, CAMHS RDW
Initiated by/Objectives
  • Sheila Shribman (DH National Clinical Director
    for CYPF) and
  • National CAMHS Support Service in CSIP
  • Better support to front line staff especially
    health visitors / midwives to
  • Effectively support mental health of,
    particularly, infants in light of neuroscience,
    through better support to mothers and babies
  • Better informed and supported commissioning,
    support implementation of NICE APMH guidelines,
    plus IMH
  • Building on national conference in 2005
    showcasing a lot of good practice, but in silos,
    IMH work in Scotland, of AIMH, Marcé etc in
  • Informed by Facing the Future, Child Health
    Promotion Programme, DH
  • Fill gap in thinking about 0-5s and DCSF
    policies especially linking with Family
    Intervention Projects, Parenting Support
    programmes, early years programmes and Childrens

Story so far/Process
  • NCSS National Survey May 2007
  • 143 services, 70 of recent origin, about half
    provided service for infants, most reports from
    SW and SE
  • About 30 of workforce health visitors, main aim
    to improve mother / baby relationship
  • Very wide range of assessment and intervention
    methods variety dependent on what is being
    assessed and treated but considerable even taking
    this into account
  • Issues raised
  • Services run on a shoe string
  • Often developed through special interest rather
    than strategic planning
  • Limited outcome monitoring what to monitor,
    when and how consequent effect on commissioning

Story so far/Process
  • June Dec 07 Engagement of stakeholders
  • Decision to widen scope from infant to Perinatal
    and Infant
  • Formation of national PIMH steering group
  • Development of SLA with Jan Net and creation of
  • Launch June 08
  • Current membership 815 (Sept 1st) and rising
  • gt500 hits on website since July
  • Link with national Gender Equality and Mental
    Health group in CSIP
  • Link with Maternity Matters

  • National Steering Group comprising range of
    stakeholders from 3rd Sector (PCWN/FPI/AIMH/Marcé/
    BPS) and CSIP leads for maternity, women's mental
    health and social inclusion
  • Reporting through the NCSS Programme Manager to
    the National child mental health and emotional
    wellbeing Board (DH/DCSF) and then to DH child
    health board at ministerial level

Membership as at Aug 08 758
The future
  • Support clinical staff and commissioners to share
    emerging practice and raise issues
  • Act as a reference point for policy makers if
  • Stimulate development of evidence base re infant
    and adult mental health interventions/outcomes
  • Stimulate development of integrated commissioning
    of local care pathways
  • Become financially self sustaining, but continue
    to be nationally led and managed
  • Provide evidence to DH and DCSF policy teams

How to join
  • Go to
  • Or email Janet Cobb at
  • But also see our website

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