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Commissioning Summary

There must be strategic commissioning of perinatal mental health care based on need

Every local area must develop and deliver a perinatal mental health strategy As this report demonstrates, identifying and addressing maternal mental illnesses requires there to be a range of high quality services in place in every area. Tackling perinatal mental illnesses and mitigating their effects requires joint working between mental health services, psychiatry, midwifery, primary care, children’s services, obstetrics, paediatrics, adult services and the voluntary sector. Therefore it is important that there are local strategies to secure sufficient, high quality, joined up services and clear care pathways in each place. All commissioners and providers of care for women with perinatal mental health illnesses must participate in the development of these strategies. Each local strategy should set out clear pathways of care for women with mild, moderate and severe mental illnesses and their families. These will need to include specialist perinatal services, which may be commissioned by NHS England, rather than local partners. Local strategies should also set out plans for developing the knowledge, skills and resources necessary for the detection and prompt and effective treatment of perinatal mental illnesses across the local area. These strategies do not currently exist in many areas. Research in 2011 suggests that 64% of PCTs did not have a strategy for commissioning perinatal mental health services.125 Changes to local commissioning arrangements provide an opportunity for local partners to come together and create or refresh their local strategies.
Every Health and Wellbeing Board must ensure that there is a local perinatal mental health strategy in the area, and that it is properly resourced and delivered.
Commissioning of Perinatal Mental Health Services In April 2013 the responsibilities for commissioning health services changed.  From now on: Clinical Commissioning Groups will commission midwifery and tier 1-3 mental health services. NHS England will commission specialist tier 4 mental health services, GPs, Family Nurse Partnership and Health Visitors (although Health Visitors will move to Local Authorities in 2015). A concerted effort will need to be made by all partners in order to coordinate support for women.
There must be local clinical leadership in each area to champion the needs of women with perinatal mental illnesses Specialist perinatal mental health professionals not only provide a high quality specialised service to women, but can also bring wider benefits to their local area. They can champion the needs of women with perinatal mental illness, and use their expertise and passion to drive up the quality of local services. These professionals should include, as a minimum, a specialist mental health midwife and a consultant perinatal psychiatrist. They can work to share their knowledge and expertise with other local professionals, and inform and drive the local perinatal mental health strategy. In 2011, 67% of health trusts who responded to a freedom of information request by the Patient’s Association in 2011 had a lead clinician for perinatal health services. The grade and profession of these people varied. In some areas the lead was a consultant psychiatrist, but in others it was a GP, nurse or NHS manager.

Key people from all services working with women affected by perinatal mental illness in a local area should form a clinical network, which can work to ensure successful implementation of the local perinatal mental health strategy.
Clinical leads with sufficient expertise in perinatal mental illness should be identified in each local area. A Clinical Network should be created in each area, bringing together key services who are working with women with perinatal mental illness.
In addition to clinical leaders, it is also important to ensure that local commissioners have the expertise that they require to commission perinatal mental health services. A survey of 500 GPs in 2010 showed that more than four in ten (42%) said they lacked knowledge about specialist services for people with severe mental illnesses such as schizophrenia and bipolar disorder.126 It is important that commissioners draw on the expertise of local clinical leads, and ensure that commissioning decisions are based on evidence and informed by expert opinion.
Commissioners should have training to help them to understand perinatal mental illness, and should draw on experts when developing their local perinatal mental health strategy.
There must be accurate data about women’s needs to inform local commissioning and service planning In order to ensure that there are sufficient services in the right areas to meet the needs of women with perinatal mental illnesses, commissioners need accurate information about levels of need. Without this information, it is also not possible to tell whether women with mental illness are being identified and helped, and whether there are sufficient services in place. Data can also help providers to assess local need, plan care and improve the quality of services.
Commissioners can use research about the prevalence of perinatal mental illness to estimate the number of women affected in their local area. However it would be preferable to find ways to collect up-to-date data about local levels of need. A report about joint working between adult and children’s services published by Ofsted in 2013, described the differences in recording between drug and alcohol services, and mental health services. Drug and alcohol services have to collect information on the number of service users who live in households with children, or who are pregnant women, and report this to local commissioners and to the National Treatment Agency (now part of Public Health England). Systems have been established to achieve this. No similar requirements or systems currently exist for adults with mental illness.127 Data on the incidence of perinatal mental illnesses is not currently routinely collated. Freedom of Information requests for the Patient’s Association in 2011 revealed that only 22% of PCTs who responded knew the number of women who had used postnatal depression services in their area (which clearly is not the same as the number who might have needed these services, but is an important start). A similar request by 4Children the same year showed that only 9% of 150 PCTs and other health trusts in England could provide information regarding the number of women diagnosed and/or treated with postnatal depression within the trust boundary.128 The low response rate was also accompanied by ‘wildly divergent’ figures which suggested that trusts were not holding accurate information. It is very positive that the Government has said it is investigating the feasibility and appropriateness of adopting a measure of maternal mental health into the Public Health Outcomes Framework, as recommended by the Children and Young People’s Mental Health Forum.129 There are a number of things that might be done to improve data collection around perinatal mental illnesses. For example: •    Routine information about mental health collected by midwives and health visitors could be recorded in a way that provides standardised information to a central source.

•    ICD codes could be amended to include specific codes for perinatal depression and postpartum psychosis.

•    Adult mental health services, including IAPT, could routinely collect data on whether patients are pregnant or parents, and the ages of their children.

Government should bring together experts in this area – including Royal Colleges, Public Health England and provider representatives – to find ways to improve data on perinatal mental illnesses.
Commissioning and funding arrangements for specialist perinatal mental health services must support preventative work There are a small group of women who are known to be at significant risk of developing severe perinatal mental illness. Women who have suffered from postpartum psychosis before, for example, have a 50% chance of developing the illness in a subsequent pregnancy, compared to a risk of 0.1% in all women.130 With the proper care from expert services, further episodes of mental illness in these women can be prevented. To do this work, specialist mental health services must be able to work with women who are currently well and would not normally meet the thresholds for care. There are concerns in the sector that the introduction of payment by results could make it more difficult to provide effective preventative care for women at high risk of perinatal mental illness. It is important that arrangements for commissioning and funding mental health services enable this longer term preventative work.

When commissioning and funding mental health services, NHS England and Clinical Commissioning Groups must have prevention in mind.