Background
In recognition of the unique treatment needs and heightened and complex risk factors in PMH, small CPMHTs consisting of at least a specialist consultant psychiatrist and mental health nurse, began in the 1980s. With growing awareness of the need and success of these teams, the 5 Year Forward Plan provided £365M to ensure CPMHTs were equitably provided across England.22 Further investment in 2019 in the Long Term Plan supported the expansion of teams to provide a comprehensive mental health service delivered by multidisciplinary staff, with a particular aim to extend the treatment time period to 2 years postnatally and increase evidence-based psychological and parent–infant intervention provision.23 In 2015, the Royal College of Psychiatrists published a report (CR-197) outlining a service and staffing model (per 10,000 deliveries) for CPMHTs.18 The proposed multidisciplinary team structure incorporated the need for a range of psychiatric and psychological and relational interventions, with an emphasis on strong collaborative and integrative working with other health services. At the time of publication, it was estimated that 85% of localities did not have specialist PMH services to the level recommended in NICE guidelines.
The aim of this WP was to develop a taxonomy of CPMHTs across England which would inform sampling in subsequent WPs.
Methods
Developing a programme theory of change in community perinatal mental health teams
To develop the taxonomy, we first developed a programme theory describing proposed mechanisms in CPMHTs that support improving perinatal women’s mental health and their relationships with their baby (Figure 1). The development of the programme theory followed the first two steps described by Pawson:24 eliciting the implicit theories and formulate the initial middle-range theory. To elicit implicit programme theories, we undertook the following:
FIGURE 1 ESMI-II programme theory. PREM, patient reported experience measure. (Figure not reproduced here; see the original article.)
- Synthesised relevant policy documents on CPMHT structures, including the 5 Year Forward Plan,22 the Long Term Plan,23 Royal College of Psychiatry CR197,18 2014 NICE Antenatal and Postnatal Mental Health Guidelines,19 Health Education England Perinatal Mental Health Competencies,25 NICE Antenatal and Postnatal Quality Standards,26 RC Psychiatry Perinatal Quality Network for Perinatal Mental Health Services Standards for Community Perinatal Mental Health Services, 4th edition,27 British Psychological Society Position Paper 8, ‘What does good perinatal mental health provision look like?’28
- Compiled information from systematic reviews about:
- barriers and facilitators to PMH treatment
- access to PMH treatment
- effectiveness of PMH interventions.
- Conducted iterative stakeholder and patient and public involvement (PPI) discussions, including:
- NHS England perinatal team members
- NHS England Perinatal Strategic Network members
- Health Education England
- Members of:
- Royal College of Psychiatry
- British Psychological Society
- Royal College of Midwifery
- Royal College of Obstetrics
- Institute of Health Visiting
- Perinatal Mental Health Academics
- Perinatal Advisory Group (PAG)
A preliminary list of components relevant to understanding what makes a good perinatal service was developed, discussed among the team and with our stakeholders and PAG group, and organised into a conceptual framework (see Figure 1).
Data collection
We aimed to characterise CPMHTs along the relevant dimensions outlined in the programme theory. With input from our Patient Advisory Group (PAG) we operationalised domains from the programme theory using system-related factors in CPMHTs and created a typology matrix (Table 1). We contacted the 55 CPMHTs in England asked them to complete the typology matrix. To supplement information we received from services, we also obtained data from NHS Benchmarking (2015–8), the Royal College of Psychiatry Perinatal Quality Network, the National Maternity and Perinatal Audit (2017 and 2019) and from the web pages of CPMHTs (e.g. service specifications). Data were collected between July 2019 and April 2020.
| Collaboration and coworking with maternity services (co-location) | Evidence of links across the perinatal care pathway (e.g. obstetric-liaison clinics, outreach specialist PMH provision, in-reach/out-reach service to mother and baby unit, GP education/liaison, specialist health visiting links). |
| Where the service is located (i.e. within maternity services, within community)? | |
| Evidence of relationships with other services (e.g. third sector, specialist services). | |
| Training across the different services on PMH. | |
| Time set aside for teamwork and building collaborative relationships. | |
| Provision (home/remote) | Where appointments are offered – for example at home, over phone, at a clinic – appropriate for the geographic spread of the patient population. |
| Psychological intervention | What type of psychological interventions are offered? |
| Are the interventions offered evidence based? | |
| Who (i.e. which staff member) provides the interventions? | |
| Mother–infant intervention | What mother–infant interventions are offered and who delivers them? |
| Evidence of training of staff on mother–infant interventions. | |
| Skill mix of team | Workforce type and %WTE – as covered by CR197. |
| Additional workforce that are employed on the service that is above and beyond CR197. | |
| Customer service | Friends and family question. |
| Patient experience questionnaires. | |
| Communication between staff and patients. | |
| Preconceptual care | The numbers of mothers provided with preconceptual care advice and by whom |
| Access/retention | Pathways of referrals and knowledge of pathways. |
| Evidence of timely referrals and acceptances (wait time). | |
| Engagement of women to the service (i.e. DNA rates post first appointment) – retention. | |
| Skills and support (competency) | Training and supervision within the PMH team – who is trained in what. |
| What supervision is provided to the staff trained in the psychological interventions. |
Data analysis
We conducted descriptive analyses on service area birth population, workforce and whole time equivalent (WTE) percentages to determine if services met CR197 staffing requirements, a component underpinning the programme theory. The following formula was used: Service area birth rate/10,000 × CR197 WTE.
Results
In 2020, there were 58 mental health trusts across England, and 55 of them had CPMHTs. We were able to obtain data from 33 of the 55 CPMHTs for the typology matrix. The data collected were characterised by a large amount of missing information and were largely descriptive and qualitative in nature, so we were unable to quantify and reliably compare information across services. The most consistently reported and quantifiable information was on workforce. We therefore used this information to develop typologies. Of note, at the time of data collection none of the services met full CR197 workforce WTE for a comprehensive CPMHT. We consequently characterised CPMHTs in terms of:
- offering a ‘basic’ service, consisting of the presence of a psychiatrist, psychologist and specialist community nurse
- offering a broader staff mix consistent with the aims of a ‘comprehensive’ service, defined as CPMHTs who had the presence of the following multidisciplinary staff members: psychiatrist, psychologist, specialist community nurse, nursery nurse and occupational therapist.
Of the 33 services, the following met criteria (Figure 2):
FIGURE 2 Maps of basic and comprehensive CPMHTs within England. (Figure not reproduced here; see the original article.)
- basic 28/33 (84.8%)
- comprehensive 21/33 (63.6%).
We used the ‘basic’ definition to characterise the presence of at least minimal CPMHT services for WP4. For WP3, we also used the qualitative, descriptive data to purposively sample services for variation on domains from our programme theory that we hypothesised were related to women and babies’ outcomes (e.g. provision of parent–infant, collaborative care) (Table 2).
| Typology characterisation | Service | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
| Collaboration and coworking with maternity services (co-location) | X | X | X | X | X | X | X | X | X | X |
| Provision (home/remote) | X | X | X | X | X | X | ||||
| Psychological intervention | X | X | X | X | ||||||
| Mother–infant intervention | X | X | X | |||||||
| Skill mix of team | X | X | X | X | X | |||||
| Customer service | X | X | X | X | X | |||||
| Preconceptual care | X | X | X | X | ||||||
| Access/retention | X | X | X | |||||||
| Skills and support (competency) | X | X | X | X | X | |||||
Overall, the data suggested there was still considerable variability among CPMHT offer (Table 3). In relation to the domains we specified in the programme theory, the following trends emerged:
| Collaboration and coworking with maternity services (colocation) | Secondary healthcare services: maternity, midwifery, psychiatry (78.8%) |
| Primary care: GPs, health visiting (66.7%) | |
| Community care: social care, children’s centres (27.3%) | |
| Third sector: charity organisations (27.3%) | |
| Provision (home/remote) | Provision of care (pre-COVID) was highly variable across services. Twenty-four services provided information on the settings women were seen in which included: |
| Maternity (joint clinics) – 44% | |
| Mother and baby unit – 4.2% | |
| Community: Children’s centres, local charities, supermarkets, libraries – 70.8% | |
| Woman’s home – 91.2% | |
| Psychological intervention | Nineteen (57%) of services provided data on the type of psychological interventions offered within their service. Services varied with how many interventions were offered: |
| 0–2 interventions offered: 5 services (26.3%) | |
| 3–5 interventions offered: 8 services (42.1%) | |
| 6 and more interventions offered: 6 services (31.6%) | |
| CBT-based treatments | |
| CBT: 13 services (68.4%) | |
| Behavioural activation: 3 services (15.8%) | |
| Dialectical behaviour therapy: 9 services (47.4%) | |
| Acceptance and commitment therapy: 1 service (5.2%) | |
| Compassion-focused therapy: 5 services (26.3%) | |
| Trauma-based interventions | |
| EMDR: 7 services (36.8%) | |
| Cognitive analytic therapy: 4 services (21.1%) | |
| Attachment-based interventions | |
| Circle of security therapy: 1 service (5.2%) | |
| Interpersonal-based interventions | |
| Interpersonal therapy: 1 service (5.2%) | |
| Dynamic interpersonal therapy: 1 service (5.2%) | |
| Family-orientated therapy | |
| Systemic family therapy: 3 services (15.8%) | |
| Couple therapy: 4 services (21.1%) | |
| Mother–infant intervention | Parent–infant assessments and interventions (19 services provided data) |
| Assessments | |
| Brazelton – Newborn Observation: 8 services (42.1%) | |
| Parent–Infant Interaction Observation Scale: 4 services (21.1%) | |
| Interventions | |
| VIG: 12 services (63.2%) | |
| Watch, wait and wonder: 1 service (5.2%) | |
| Here’s looking at you baby: 3 services (15.8%) | |
| Dynamic maturation therapy: 1 service (5.2%) | |
| Mentalisation-based therapy: 1 service (5.2%) | |
| Baby-oriented psychoeducation or generic interactions | |
| Gro-Brain: 1 service (5.2%) | |
| 5 to Thrive: 1 service (5.2%) | |
| Play-based group sessions: 1 service (5.2%) | |
| Seeing is believing: 1 service (5.2%) | |
| Skill mix of team | Basic (psychiatry, psychology and nursing) WTE met: 27/33 (81.8%) |
| Comprehensive (basic plus occupational therapy, nursery nursing) WTE met: 20/33 (60.6%) | |
| Customer service | Twenty-two (67%) services discussed using a variety of patient reported experience measures, patient reported outcome measures and clinician reported outcome measures including: |
| HoNOS (n = 5) | |
| POEM (n = 11) at the initial assessment and upon discharge | |
| Friends and Family (n = 7) test upon discharge. | |
| CORE-10 (n = 5) | |
| Clinical Outcomes in Routine Evaluation – Outcome Measure (n = 2) | |
| Post partum bonding questionnaire (n = 1) | |
| Parent–Infant Mothers’ Object Relations Scale (n = 1) | |
| Clinical Global Impression Scale (n = 1) | |
| HYS (n = 1) | |
| Parent–Infant Interaction Observation Scale (n = 2) | |
| Alarm Distress Baby Scale (n = 2) | |
| Peer support and co-production (n = 13) | |
| Preconceptual care | Fifteen services provided preconceptual care (45.5%) |
| Access/retention | Twenty-three services mentioned accepting referrals from all pathways from GPs, midwives to heath visitors, midwives, specialist midwives and NHS Talking Therapies. Wait times from referral to assessment varied: |
| 4/11 reported < 2-week wait for assessment. | |
| 6/11 reported a 4- to 6-week wait for assessment. | |
| 1/11 reported a 7- to 11-week wait for assessment or treatment | |
| Skills and support (competency) | Twenty-six out of 33 services provided information around training and supervision of staff (see Appendix 1). |
- Collaborative working: there were higher rates of collaborative working with statutory health providers compared to social care and the voluntary care sector.
- Delivery: there were high rates of providing care in women’s homes and children’s centres, some CPMHTs were also delivering joint maternity clinics. Few, pre-COVID, were using remote delivery.
- Psychological and parent–infant interventions (see Appendix 1, Tables 21 and 22 for training in treatment): We only received data on these areas from 57% of services. Of these, most (41%) offered between three and five types of psychological interventions, but it is notable that 26% only offered up to two. The most common psychological interventions were cognitive–behavioural therapy (CBT), dialectical behaviour therapy, and eye movement and desensitisation and reprocessing (EMDR). Parent–infant interventions were rarely offered, although 63% provided Video Interaction Guidance (VIG).
- Outcome measures. There was wide variability in what was used. The Health of the Nation Outcome Scales (HoNOS), Patient-rated Outcome and Experience Measure (POEM) and Clinical Outcomes in Routine Evaluation – 10-item version (CORE-10) are recommended as a minimum set of measures for CPMHTs.29 Of the reporting CPMHTs, 22% used the HONOS and CORE-10 and 50% used the POEM.
- Preconceptual Care: Only 46% of CPMHTs were offering preconceptual care.
- Wait times: Wait times for assessment from referral varied between CPMHTs, ranging from < 2 to 11 weeks.
Strengths and limitations
We had excellent engagement and responses from CPMHT services across the UK. The Maternal Mental Health Alliance also generally supported our data collection efforts. However, the quality and missingness of data across services and the mode of reporting were widely variable, limiting our ability to make reliable comparisons across services. We therefore adopted a conservative estimating approach, using consistently reported staffing data to discern service provision across the country.
Conclusion
The provision of perinatal care across England has grown substantially with transformational funding from only 10 services operational in 2013 to all Clinical Commissioning Groups (CCGs) providing the basic level of care by 2020. By 2020, none of the 33 services in our study met full CR197 criteria for staffing levels, and only 60% of the services had sufficient psychiatry, psychology, nursing and occupational therapy care in place. Workforce time did not meet CR197 standards, suggesting that, in many circumstances, provision performed by some staffing types was still minimal. The organisation, composition and delivery of community PMH services in England varied considerably. The categories used to map out service provision included nine areas and there was variation across services in all aspects apart from collaboration and coworking with maternity. Greatest uniformity existed across reported collaboration with other statutory services, though even this varied considerably, with few examples of joint clinics held with maternity, for example. There were notable gaps in collaborative working with social care and voluntary sector organisations, but best practice existed in some places. For example, some services provided examples of good collaboration between organisations through joint clinical meetings, assessments and/or clinics being run within the community through children centres or other public services (e.g. local libraries), and educational sessions provided to organisations.