Perinatal mental health service specification

2. Service Specification

“I should have the right to good care from NHS Scotland for me, my baby and my family”.

The Women and Families Pledge (see Appendix 1) and the Infant Pledge (see Appendix 2).

2.1 Leadership and Governance

Clear and effective clinical and managerial leadership is essential in setting professional expectations, creating a culture of respectful care and ensuring that the service is responsive to the complex needs of women, infants and families.

2.1.1 Health boards should demonstrate robust governance arrangements, with clear lines of accountability, covering all aspects of the woman and infant’s journey.

2.1.2 Health boards should demonstrate a commitment to quality planning and assurance through:

a. effective data collection, including data on health inequalities

b. involving women with living/lived experience at both multi-disciplinary team and leadership level to meaningfully shape service design and delivery

c. local and national benchmarking against agreed outcomes

d. clear alignment of strategic policy objectives and implementation strategies, and routine monitoring of women’s and infants’ outcomes to inform interventions

2.1.3 Health boards should demonstrate a commitment to international human rights conventions by:

a. taking a rights-based approach to service planning and delivery, and

b. routinely informing women and families of their rights and providing comprehensive training to staff on upholding people’s rights, which is updated when necessary and appropriate to their role and setting

c. recognising and prioritising the rights of infants and children of women who are engaged with services, with child rights and wellbeing impact assessments (CRWIA) being used to demonstrate rights-based practice.

2.1.4 Women and families are given meaningful opportunities to participate in the design and evaluation of perinatal mental health services, and health boards can demonstrate where this feedback has resulted in change. This may include involvement in the recruitment and appointment of staff and the design, delivery and/or evaluation of staff training. Support and training would be required for this role.

2.1.5 There are clear and structured risk management and adverse events processes, which take into account the distinctive risks presenting in the perinatal period and recognise the importance of clinician input to decision making. They include:

a. accountability and responsibility arrangements for reporting any risks, including monitoring women and infants at risk

b. accountability, responsibility and a consistent approach to reporting adverse events, including a documented escalation process for adverse events

c. organisational learning from adverse events.

2.1.6 Information management structures and governance processes are in place to support:

a. national data collection (PMH National Dataset), benchmarking, and performance to improve patient safety and quality of care

b. referral and engagement monitoring to ensure that services reach all groups within its local population

c. the routine sharing, with fully informed consent, of identifiable personal healthcare data between care providers, and the effective collation of anonymised data in support of care governance.

2.1.7 Health boards support and encourage quality improvement including service evaluation, audit, and research to develop and share best practice.

2.1.8 There is regular review and audit of clinical environment and resources, making sure these are accessible for those with protected characteristics, sensory, and communication differences, and suitable for infants and, where appropriate, older siblings.

2.1.9 There are agreed pathways and processes, developed with women and families with living/ lived experience, to ensure:

a. accessible and responsive care

b. information is shared appropriately between public health and primary care, secondary care, maternity services, third sector, local authority, and independent healthcare sector services

c. there are resilience plans for service disruption

d. there is clear communication of risk assessments and risk management plans for both mother and infant and onward referral for management and support as necessary

e. prioritisation of those most in need (including those who may be currently well but at high risk of significant illness)

f. individuals with co-occurring considerations such as substance use problems and neurodivergent individuals, and those with complicated pregnancies or postnatal care, are adequately and appropriately supported

g. appropriate signposting to additional areas of support, including the third sector, as necessary.

2.2 Service structure

Services should be designed to prioritise the safety and welfare of women, children and families and to provide seamless, joined-up care.

2.2.1 Provide access to and liaison with expert perinatal community mental health assessment and care on a regional basis where a local service has limits to its specialist perinatal mental health provision (e.g., for small/island boards providing a regional model of community perinatal mental health team response).

2.2.2 Have well-developed relationships with regional Mother and Baby Unit teams to ensure clear pathways to referral, and that inpatient care can be accessed in a timely manner if required. These should be underpinned by service level agreements between local boards and those hosting an MBU.

2.2.3 Ensure joint protocols and clear pathways of care with other mental health teams likely to be involved in shared care of pregnant or postnatal women, or who have a distinctive expertise essential to good patient care. These may include (but not be limited to) community adult mental health teams, CAMHS, unscheduled mental health care services, liaison psychiatry, eating disorders, learning disability, neurodiversity and addictions services.

2.2.4 Ensure joint protocols and clear pathways of care with other professionals who have an enhanced perinatal mental health role, e.g., perinatal mental health midwives, specialist health visitors, family nurse practitioners, specialist obstetricians, Maternity and Neonatal Psychological Interventions and Infant Mental Health services.

2.2.5 Ensure close working relationships and clear pathways of care with all professionals (maternity and neonatal services, primary care, health visiting, social work teams) involved in the women’s and infants’ journey of care. Multiagency meetings should be held if indicated.

2.2.6 Clear protocols are in place to manage:

• risk and safety in relation to the mother and infant, and
• unattended appointments.

2.3 Access to Care

PMHS should provide a range of expert interventions to women, infants and families and should liaise with other providers to ensure that expert assessment and care is built around the woman’s and infant’s journey of care.

2.3.1 Clearly describe the roles of all professionals in PMHS and what women and families should expect of them.

2.3.2 Provide assessments and interventions which are evidence-based, trauma-informed and follow recommended practice.

2.3.3 Ensure that a range of interventions are available, including but not limited to, psychological therapies, activity-based interventions, group work and pharmacological treatment.

2.3.4 Use the Scottish Perinatal Mental Health Care Pathways, upon which to base local pathways, adapting to take into account local relationships and need.

Women who are at the greatest risk of developing new or recurring mental illness in pregnancy or the postnatal period should have access to expert advice on pregnancy planning, medication management and ways of reducing risk.

2.3.5 Provide women and their partners with expert preconception advice on risks associated with pre-existing mental illness, and the benefits and risks associated with medication and other interventions to both mother and infant, particularly regarding pregnancy and breastfeeding.

2.3.6 Ensure that advice is provided in a range of ways that allows women and their families to make informed choices about their care.

2.3.7 Provide advice and support to other professionals involved in the woman’s and infant’s journey of clinical care so that they can make informed decisions on referral into specialist care.

Psychological and other psychosocial interventions have an important role in overall management for many women experiencing perinatal mental ill health and for facilitating the parent-infant relationship. Given the particular time constraints of pregnancy and infant development, it is critical that they can be offered in a timely fashion.

2.3.8 Ensure that women, their infants and families have access to a range of individual, group, parent-infant, couple and family psychological interventions, delivered by staff with the appropriate training, skills and supervision.

2.3.9 Provide prompt access to psychosocial assessment and commencement of therapy, where indicated, aiming to begin therapeutic interventions within 6 weeks of referral.

2.4 Care of the Infant

PMHS have an absolute duty to safeguard the infant and ensure their needs are met, including supporting the developing relationship between them and their parents/carers.

2.4.1 Ensure that, in line with the national practice model (GIRFEC), the physical, emotional, developmental and welfare needs of infants are identified and addressed at all times.

2.4.2 Have clear protocols and pathways to safeguard the infant, including staff awareness of how to access advice on the infant’s wellbeing and welfare, and where required, child protection advice and assessment.

2.4.3 Ensure that the parent-infant relationship is assessed, supported and enhanced throughout contact with the service.

2.4.4 Ensure that, in inpatient settings, the infant’s contact with both parents, siblings and other close family members is maintained as far as possible. Family friendly spaces should be available for family time.

2.4.5 Ensure good working relationships and clear pathways are in place with primary care, health visiting, social work, infant mental health services and, where appropriate, paediatric and child development services, to address the physical, emotional and developmental needs of the infant.

2.5 Interfaces, Transitions and Joint Working

Perinatal mental health care inevitably requires joint working with partner agencies. The experience of care should be as seamless as possible, and women should always be clear about who is co-ordinating their care.

2.5.1 Services ensure that transition protocols are in place to support effective communication between those services. This includes external and internal service transitions with clear lines of responsibilities to support safe and coherent care. This should be supported by appropriate awareness-raising and the delivery of training to those in other services.

2.5.2 Services ensure that both joint working and transfers of care occur in a manner that is as seamless as possible for the woman, her infant and family. This applies to:

• transfers of care between MBUs and other adult mental health inpatient facilities
• transfers of care between CPMHTs and MBUs
• joint working and transfers of care between PMHS and other mental health services
• joint working and transfers of care between PMHS, universal health services and social work.

2.5.3 Perinatal mental health services should collaboratively develop a written transition or discharge plan with the woman (and her family where appropriate) and provide information and advice around transitions of care.

2.5.4 Discharge planning from an MBU setting should begin at admission and should ensure active collaboration with the local CPMHT, midwife and/or health visitor, and social work where relevant. This should include attendance at regular MBU meetings (in person or virtually) and collaborative leave planning.

2.5.5 Where a woman has ongoing mental health needs requiring secondary mental health care intervention, transition planning from CPMHT care should begin no later than the ninth postnatal month.

2.5.6 Timing of discharge from CPMHT care should take into account ongoing clinical interventions and who is best placed to deliver them, including the need for continuity of care and ongoing infant needs. For this reason, services must show flexibility which may include extending care for a period of time beyond the first postnatal year where clinically indicated.

2.5.7 Ongoing mental health care should take account the possibility of future pregnancies and include planning for this. Any discharge or transition care plan should include information on risk and supports in relation to future pregnancies.

2.6 Workforce, Education and Training

Staff working with women, their infants and families must have the knowledge, skills and attitudes which allows them to delivery safe, high quality, person-centred, respectful care. Sufficient workforce levels, professional mix and support for continuing professional development are essential to maintenance of a high-quality workforce.

2.6.1 Ensure that Delivering Effective Services and other perinatal-specific workforce guidance is taken into account in determining staffing levels. Where possible, ensure that an appropriate professional mix and range of skills necessary to deliver recommended evidence-based interventions for the mother, the mother-infant relationship, the infant and wider family are provided.

2.6.2 Ensure that team members are appropriately trained, based on recommendations in the NHS Education for Scotland Perinatal Mental Health Curricular Framework, and have acquired the knowledge, skills and attitudes necessary to provide specialist assessment and care for women with mental ill health, and their infants.

2.7 Shared and Supported Decision Making

Perinatal mental health services should work collaboratively with women, their infants and families. This is particularly important in recognising and respecting the important role that patients have as parents, and where women face difficult decisions regarding the balance of benefits and risks of interventions.

2.7.1 Ensure that women and families are provided with information in a format and language that best suits their needs on the nature of the service, the assessment process, and the range of interventions available.

2.7.2 Ensure that women receive information on the outcome of any assessment and who will be involved in her (and her infant’s) care. Usually this should be by writing/communicating directly with the woman herself.

2.7.3 Assist women to make informed choices about their care, and that of their infant, based on the information provided.

2.7.4 Ensure that women are involved in all decisions and plans that affect them, their pregnancy and their infant. This should include the joint development of care plans for both if required.

2.7.5 Involve women and families in the design, planning, delivery and review of services.

Services must be particularly sensitive in ensuring non-judgemental, compassionate and supportive engagement, recognising that the perinatal period can be a time when women feel more judged, including by professionals involved in their care.

2.7.6 Recognise the varying cultural, societal and religious differences influencing approaches to pregnancy, childbirth and infant care, and respect parents’ autonomy and choices in their parenting styles, while always prioritising child wellbeing and welfare.

2.7.7 Understand that the perinatal period may be experienced as a stigmatising time for women and ensure that women experience a supportive, non-judgemental approach.

2.7.8 Ensure that informed consent on information sharing, and its limits, in relation to the woman and to her infant, is clearly explained and documented.

2.7.9 Ensure that women and families are aware of independent advocacy services, and of the roles of the Mental Welfare Commission for Scotland and of the Children’s Commissioner, and are supported to make contact where required.

Partners and other family members often have an important part to play in supporting the woman and aiding her recovery. Those working in PMHS should engage with them and support them in this role and help them get support for themselves if required.

2.7.10 Ensure that partners and other family members are provided with information in a variety of formats (including alternative languages where appropriate) which allows them to support the woman, with her consent.

2.7.11 Ensure that partners and close family members are listened to by services and, with the woman’s consent, can contribute to her care plan.

2.7.12 Explore with partners and close relatives whether they themselves have any additional mental health or social care needs and direct them to appropriate supports if required.

2.7.13 Ensure that fathers/partners/those with parental rights are supported to be fully involved in their infant’s care, particularly when a woman and infant are admitted to inpatient care.