Peri-natal and infant mental health where next

1. Peri-natal and infant mental health where next? Dawn Rees National CAMHS strategic relationships and programme manager Dawn.rees@csip.org.uk

2. 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

3. 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)

4. 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 CEMACH from Margaret Oates presentation to RCOG September 08 Suicide pushed into third place by the rise in cardiac failures mainly in immigrant populations CEMACH from Margaret Oates presentation to RCOG September 08 Suicide pushed into third place by the rise in cardiac failures mainly in immigrant populations

5. Education, knowledge and understanding Guardian 29.9.08 5

6. PET scan of healthy 2 year old PET scan of 2 year old Romanian baby institutionalised shortly after birth Other risk factors � postnatally in terms of environment, relationship and attachment � thanks to Robin Balbernie Many people will have seen this slide of Robin Balbernie�s. Point here is temporal lobe activity which governs expression and processing of emotion: development is negligible in response to extreme neglect � brain will not regenerate where grey matter has atrophied. Some limited compensation possibleMany people will have seen this slide of Robin Balbernie�s. Point here is temporal lobe activity which governs expression and processing of emotion: development is negligible in response to extreme neglect � brain will not regenerate where grey matter has atrophied. Some limited compensation possible

7. 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 researchers. Significant policy documents and commitments include 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 Foundation 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 acknowledged National Service Framework for Mental Health (1999) Children Act (2004) Every Child Matters (2004) National Service Framework for Children, Young People and Maternity Services (2004) Public Health White Paper Choosing Health: making healthier choices easier Our Health Our Care Our Say Update of NSF Standard 9 (2006) Childcare Act (2006) NICE guidance for ante natal and post natal mental health (2007) Expansion of Childrens Centres in current PSR Facing the Future (review of health visiting) (2007) Maternity Matters Cabinet Office/DCSF Think Family policy document and Family Pathfinders programme (2007-8) Family Intervention Projects (Respect) Parenting Academy (2007) Health Led Parenting pilots 2007-10 Early Years Foundation Stage workforce training and development Child Health Promotion Programme Delivery Standard (CHPPDS) http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009598 http://www.opsi.gov.uk/acts/acts2004/ukpga_20040031_en_1 http://www.everychildmatters.gov.uk http://www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks/ChildrenServices/Childrenservicesinformation/index.htm http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094550 http://www.dh.gov.uk/en/Healthcare/Ourhealthourcareoursay/index.htm http://www.everychildmatters.gov.uk/EP00244 http://www.opsi.gov.uk/acts/acts2006/pdf/ukpga_20060021_en.pdf http://www.nice.org.uk/CG45 http://www.surestart.gov.uk/surestartservices/settings/surestartchildrenscentres http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075642 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312 http://www.cabinetoffice.gov.uk/social_exclusion_task_force http://www.everychildmatters.gov.uk/parents/pathfinders http://www.respect.gov.uk/members/article.aspx?id=8678 http://www.everychildmatters.gov.uk/napp http://www.everychildmatters.gov.uk/parents/healthledsupport http://www.standards.dcsf.gov.uk/eyfs/site/index.htm The Policy Framework � Recent policy initiatives have emphasised the need for a perinatal mental health strategy in every locality. �The National Service Framework for Mental Health recognises promoted the identification and treatment of postnatal depression within Primary Care and required protocols for its management to be agreed between primary care and specialist mental health services. The NSF for Mental Health also states that training with Health Visitor, can use their routine contacts with new mothers to identify postnatal depression, and treat its milder forms. Maternity and support staff can do much to help. The Maternity Standard of the National Service Framework for Children, Young People and Maternity Services recommended �All those concerned with the care of women and their families at this stage need to be familiar with the normal emotional and psychological changes that take place during pregnancy and the postnatal period�. The Confidential Enquiries into Maternal Deaths 1997-1999 and 2000-2002 found that suicide and psychiatric causes were a leading cause of indirect maternal death in the United Kingdom. The reports highlight the need for availability of perinatal mental health services for all women who need them. Maternal suicide has fallen since then The updated Child Health Promotion Programme that was published in March this year places a greater emphasis on emotional health and well-being of child and mother and the importance of early identification. Progressive universalism: a core programme for all children, with additional services for children and families with particular needs and risks Department of Health & Department for Education and Skills. (2004) National Service Framework for Children, Young People and Maternity Services. The Stationary Office, London National Institute for Health and Clinical Excellence (2007) Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. NICE Department of Health (2000) National Service Framework for Mental Health: Modern Standards and Service Models, London , Department of Health Department of Health (2004) National Service Framework for Children, Young People and Maternity Services, London, Department of Health � National Service Framework for Mental Health (1999) Children Act (2004) Every Child Matters (2004) National Service Framework for Children, Young People and Maternity Services (2004) Public Health White Paper Choosing Health: making healthier choices easier Our Health Our Care Our Say Update of NSF Standard 9 (2006) Childcare Act (2006) NICE guidance for ante natal and post natal mental health (2007) Expansion of Childrens Centres in current PSR Facing the Future (review of health visiting) (2007) Maternity Matters Cabinet Office/DCSF Think Family policy document and Family Pathfinders programme (2007-8) Family Intervention Projects (Respect) Parenting Academy (2007) Health Led Parenting pilots 2007-10 Early Years Foundation Stage workforce training and development Child Health Promotion Programme Delivery Standard (CHPPDS) http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009598 http://www.opsi.gov.uk/acts/acts2004/ukpga_20040031_en_1 http://www.everychildmatters.gov.uk http://www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks/ChildrenServices/Childrenservicesinformation/index.htm http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094550 http://www.dh.gov.uk/en/Healthcare/Ourhealthourcareoursay/index.htm http://www.everychildmatters.gov.uk/EP00244 http://www.opsi.gov.uk/acts/acts2006/pdf/ukpga_20060021_en.pdf http://www.nice.org.uk/CG45 http://www.surestart.gov.uk/surestartservices/settings/surestartchildrenscentres http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075642 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312 http://www.cabinetoffice.gov.uk/social_exclusion_task_force http://www.everychildmatters.gov.uk/parents/pathfinders http://www.respect.gov.uk/members/article.aspx?id=8678 http://www.everychildmatters.gov.uk/napp http://www.everychildmatters.gov.uk/parents/healthledsupport http://www.standards.dcsf.gov.uk/eyfs/site/index.htm The Policy Framework � Recent policy initiatives have emphasised the need for a perinatal mental health strategy in every locality. �The National Service Framework for Mental Health recognises promoted the identification and treatment of postnatal depression within Primary Care and required protocols for its management to be agreed between primary care and specialist mental health services. The NSF for Mental Health also states that training with Health Visitor, can use their routine contacts with new mothers to identify postnatal depression, and treat its milder forms. Maternity and support staff can do much to help. The Maternity Standard of the National Service Framework for Children, Young People and Maternity Services recommended �All those concerned with the care of women and their families at this stage need to be familiar with the normal emotional and psychological changes that take place during pregnancy and the postnatal period�. The Confidential Enquiries into Maternal Deaths 1997-1999 and 2000-2002 found that suicide and psychiatric causes were a leading cause of indirect maternal death in the United Kingdom. The reports highlight the need for availability of perinatal mental health services for all women who need them. Maternal suicide has fallen since then The updated Child Health Promotion Programme that was published in March this year places a greater emphasis on emotional health and well-being of child and mother and the importance of early identification. Progressive universalism: a core programme for all children, with additional services for children and families with particular needs and risks Department of Health & Department for Education and Skills. (2004) National Service Framework for Children, Young People and Maternity Services. The Stationary Office, London National Institute for Health and Clinical Excellence (2007) Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. NICE Department of Health (2000) National Service Framework for Mental Health: Modern Standards and Service Models, London , Department of Health Department of Health (2004) National Service Framework for Children, Young People and Maternity Services, London, Department of Health �

8. 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 Rothera 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 National safeguarding network led by Geoff Allcock (Geoff.Allcock@bsmhft.nhs.uk) and Karen Johnson (Karen.Johnson@DerbysMHServices.nhs.uk) National safeguarding network led by Geoff Allcock (Geoff.Allcock@bsmhft.nhs.uk) and Karen Johnson (Karen.Johnson@DerbysMHServices.nhs.uk)

9. 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 Johnson National perinatal and infant e-network with over 800 members (www.pimh.org.uk) 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 National perinatal lead : Cathy.Freese@londondevelopmentcentre.org (based in Derby) E network : Janet.Cobb@pimh.org.uk National perinatal lead : Cathy.Freese@londondevelopmentcentre.org (based in Derby) E network : Janet.Cobb@pimh.org.uk

10. 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 care 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) IAPT Notes Case Study- Hertfordshire IAPT Pathfinder. Perinatal mental health was identified by a joint commissioning needs assessment as an area the local PCT wanted to develop further. Stevenage and Letchworth Enhanced Primary Care Mental Health Services (EPCMHS) were commissioned �to develop a pilot service for �mild to moderate anxiety and depression in the perinatal period within the overall IAPT service. � In the first 8 months of setting up the IAPT service, 11% of the referrals to Stevenage Enhanced Primary Mental Health Services and 5% of referrals to the Letchworth EPCMHS were perinatal. This represents a significant percentage of overall referrals to the IAPT service and suggests that commissioners need to develop services that are effective for those individuals with perinatal mental health problems and essentially to provide an unmet need that has major implications for the future health of parents and their children. A major concern was that many of the perinatal referrals were at step 3 (complex) and were only referred after other health professionals (such as health visitors) had �gone as far as they could� within existing services. IAPT pilot Salford The Perinatal Mental Health Project � Project Summary � The Perinatal Mental Health Project is a partnership between Salford Primary Care Psychology Service (Bolton, Salford & Trafford Mental Health Trust), Midwifery Services (Salford Royal Hospitals Trust) and Sure Start Salford. � The Perinatal Project was set up in November 2004 to address the higher than average rates of postnatal depression in the five relatively deprived Sure Start areas of Salford. Referrals are taken from midwives, health visitors and GP�s who have identified women as suffering from, or at risk of developing depression antenatally or up to one year postnatally. The project currently comprises a full time Perinatal Mental Health Worker, 0.5wte Clinical Psychologist and 0.2wte Counsellor. The team provides rapid access to a range of psychological therapies, signposting to support groups and other services, and consultancy to health care professionals, as well as providing training to Health Visitors and Midwives on the recognition and management of perinatal depression. � Following referral women receive a psychosocial assessment by the Perinatal Mental Health Worker, carried out in the home. Following this assessment women may be offered a range of services or treatments. These include access to voluntary sector services (e.g. Relate), postnatal depression support groups, community services and a range of psychological therapies delivered by clinical psychologists or a counsellor within the project team. � The Perinatal Project in Salford is currently funded by Sure Start money, but current funding ends on June 30th 2007. There is the possibility of funding until March 2008 from Sure Start monies, but after this time funding switches to the 15 Children�s Centres being established across Salford. As yet budgets for these Children�s Centres are unknown, but Jane Middleton has asked us to provide a plan for delivering the service across Salford. However it seems unlikely that any funding granted for this will be an increase on the current funding. We would therefore potentially be receiving more than twice the number of referrals with no increase in resources to deal with them if delivering the service across Salford. The aim of SureStart funding has always been to provide money for projects to be set up which would then be mainstreamed if successful. � Funding received by the Sure Start Midwifery lead from Sure Start currently stands at �102,000 per annum which covers the cost of running the Perinatal Project plus funding for two Postnatal Depression Support Groups run by a counsellor from outside the Trust, and associated costs for a cr�che etc. IAPT draft commissioning Guidance: FNP piloted Slough, Somerset, Tower Hamlets, IAPT Notes Case Study- Hertfordshire IAPT Pathfinder. Perinatal mental health was identified by a joint commissioning needs assessment as an area the local PCT wanted to develop further. Stevenage and Letchworth Enhanced Primary Care Mental Health Services (EPCMHS) were commissioned �to develop a pilot service for �mild to moderate anxiety and depression in the perinatal period within the overall IAPT service. � In the first 8 months of setting up the IAPT service, 11% of the referrals to Stevenage Enhanced Primary Mental Health Services and 5% of referrals to the Letchworth EPCMHS were perinatal. This represents a significant percentage of overall referrals to the IAPT service and suggests that commissioners need to develop services that are effective for those individuals with perinatal mental health problems and essentially to provide an unmet need that has major implications for the future health of parents and their children. A major concern was that many of the perinatal referrals were at step 3 (complex) and were only referred after other health professionals (such as health visitors) had �gone as far as they could� within existing services. IAPT pilot Salford The Perinatal Mental Health Project � Project Summary � The Perinatal Mental Health Project is a partnership between Salford Primary Care Psychology Service (Bolton, Salford & Trafford Mental Health Trust), Midwifery Services (Salford Royal Hospitals Trust) and Sure Start Salford. � The Perinatal Project was set up in November 2004 to address the higher than average rates of postnatal depression in the five relatively deprived Sure Start areas of Salford. Referrals are taken from midwives, health visitors and GP�s who have identified women as suffering from, or at risk of developing depression antenatally or up to one year postnatally. The project currently comprises a full time Perinatal Mental Health Worker, 0.5wte Clinical Psychologist and 0.2wte Counsellor. The team provides rapid access to a range of psychological therapies, signposting to support groups and other services, and consultancy to health care professionals, as well as providing training to Health Visitors and Midwives on the recognition and management of perinatal depression. � Following referral women receive a psychosocial assessment by the Perinatal Mental Health Worker, carried out in the home. Following this assessment women may be offered a range of services or treatments. These include access to voluntary sector services (e.g. Relate), postnatal depression support groups, community services and a range of psychological therapies delivered by clinical psychologists or a counsellor within the project team. � The Perinatal Project in Salford is currently funded by Sure Start money, but current funding ends on June 30th 2007. There is the possibility of funding until March 2008 from Sure Start monies, but after this time funding switches to the 15 Children�s Centres being established across Salford. As yet budgets for these Children�s Centres are unknown, but Jane Middleton has asked us to provide a plan for delivering the service across Salford. However it seems unlikely that any funding granted for this will be an increase on the current funding. We would therefore potentially be receiving more than twice the number of referrals with no increase in resources to deal with them if delivering the service across Salford. The aim of SureStart funding has always been to provide money for projects to be set up which would then be mainstreamed if successful. � Funding received by the Sure Start Midwifery lead from Sure Start currently stands at �102,000 per annum which covers the cost of running the Perinatal Project plus funding for two Postnatal Depression Support Groups run by a counsellor from outside the Trust, and associated costs for a cr�che etc. IAPT draft commissioning Guidance: FNP piloted Slough, Somerset, Tower Hamlets,

11. Further work being planned by NCSS � PIMH a priority for next year�s business plan � plans include: 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 Where we are now in terms of delivery, our major strengths and weaknesses Promote the network in relation to the Child Health Strategy and IAPT commissioning guidelines particularly in relation to the development of local level perinatal and infant mental health commissioning and practice delivery , comparing it with May 2007 figures Audit range and accessibility of provision through mother and baby units Identify across the network if there is general agreement about the need for an additional NICE guideline in relation to Infant Mental Health Contribute to development of workforce planning in this sector by providing information and specific exemplars Identify the potential for developing the network by-products which will continue to fund the network such as events action learning sets training materials research contracts � Deliver a national conference for network members Use network members to work with NCSS, developing a specific e-learning module to add to the suite of planned NCSS e-learning modules, which will support training for universal services in PIMH Identify current PIMH training at HEI�s and post on website Promote the network in relation to the Child Health Strategy and IAPT commissioning guidelines particularly in relation to the development of local level perinatal and infant mental health commissioning and practice delivery , comparing it with May 2007 figures Audit range and accessibility of provision through mother and baby units Identify across the network if there is general agreement about the need for an additional NICE guideline in relation to Infant Mental Health Contribute to development of workforce planning in this sector by providing information and specific exemplars Identify the potential for developing the network by-products which will continue to fund the network such as events action learning sets training materials research contracts � Deliver a national conference for network members Use network members to work with NCSS, developing a specific e-learning module to add to the suite of planned NCSS e-learning modules, which will support training for universal services in PIMH Identify current PIMH training at HEI�s and post on website

12. 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 - 28%of 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 provided." Sir Ian Kennedy 10.7.08 12 Turf wars between Obstretricians and Midwives are reflected inTurf wars between Obstretricians and Midwives are reflected in

13. 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 need? Challenges Leadership � people argue about who has it but sometimes there is nothing very much to lead. Leadership � people argue about who has it but sometimes there is nothing very much to lead.

14. Challenges 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 areas Workforce � lack of accredited training for universal, targeted and specialist workforces about maternal and infant mental health and ill health Outcome measures, Balbernie uses the Ages and Stages Questionnaire (Squires, Bricker, Twombly et al 2002: Paul H Brookes Publishing) as does the Family Nurse Partnership � USA, validated scoring measure � 6 month intervals to age 3 starting at 3 months, parent completed. Issues for me about the use of parent completed questionnaires in terms of reliability where there are child welfare concerns and the child is unable to express a view. Outcome measures, Balbernie uses the Ages and Stages Questionnaire (Squires, Bricker, Twombly et al 2002: Paul H Brookes Publishing) as does the Family Nurse Partnership � USA, validated scoring measure � 6 month intervals to age 3 starting at 3 months, parent completed. Issues for me about the use of parent completed questionnaires in terms of reliability where there are child welfare concerns and the child is unable to express a view.

15. 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 requirement

16. Where we need to be National, regional and local leadership of effective and coherent programme which ensures that 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 Margaret Oates points out the very sudden movement from health to death in many of the Sx cases: need perinatal psychiatry to be on the case. ?There may be implications for care and risks of home treatment in such cases. Margaret Oates points out the very sudden movement from health to death in many of the Sx cases: need perinatal psychiatry to be on the case. ?There may be implications for care and risks of home treatment in such cases.

17. 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 Leadership

18. Commissioning 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

19. 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 PCT�s PEC commissioners will listen to such coalitions - should include AMHS, CAMHS and LA CSIP in a state of transition from a national to a regional development organisation and the CSIP label will go � but in most places most of the development resources will remainCSIP in a state of transition from a national to a regional development organisation and the CSIP label will go � but in most places most of the development resources will remain

20. The National Perinatal and Infant Mental Health Network David Goodban � PIMH lead, CAMHS RDW (SW) CSIPdavid.goodban@csip.org.uk

21. Initiated by/Objectives Sheila Shribman (DH National Clinical Director for CYP&F) 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, Marc� etc in England Informed by Facing the Future, Child Health Promotion Programme, DH Fill gap in thinking about 0-5�s and DCSF policies especially linking with Family Intervention Projects, Parenting Support programmes, early years programmes and Children�s Centres

22. 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 Summary of Findings Regional Variation: Of the 143 services which responded the majority appear to be situated in the South West and the South East. What type of services and who provides them: Local CAMHS (40%), primary care services (20%), and Sure Start/Children�s Centres (16%). 11% of responding services had adult/perinatal involvement. Professions involved: About 1/3rd of the workforce were Health Visitors. Psychologists and Psychotherapists were the next most frequent providers. There was also significant Primary Mental Health Worker involvement. Who are the services for: About 50% of the services reported that they provided a service for infants (0-2), nearly 40% provided a service for mothers, and 36% provided a service for the parent/carer. Referrers and referral criteria: A majority of professional referrals were made by health visitors (61%), followed by GPs (38%). A majority of referrals to primary care, voluntary or Sure Start were self referrals. 80% of responding specialist services had referral criteria. Parental mental health was the commonest single criterion. Interventions: a very wide range of interventions were offered by the services; some expert evaluation of the evidence for specific interventions and in measuring outcomes may be helpful for commissioners and providers of services. Training offered: More than half of the services reported that they had received some form of specialised training. Duration of treatment: Respondents generally offered relatively short-term interventions of less than 10 sessions. Assessment tools and measures: Just over 60% of services reported using measures but consistency of use and reporting of outcomes seemed very variable from the responses. A very wide range of tools were used. Outcomes: Improving the parent/child relationship or attachment issues was the most commonly (37%) reported outcome aimed for. Numbers of clients seen: CAMHS services tended to see around 40 cases a year; universal services saw many more � 500-2000 being examples. Audit and evaluation: Up to 70% `of respondent services said they either had, or intended to carry out audit of their services. Only one service reported commissioning an RCT Services commenced when: Just over 70% of respondent services had commenced since 2000 and the majority of specialist infant mental health services had started within the past 2 years Future developments: The majority of services would like to develop further, but some 15% of respondents report concerns about funding � the future of Sure Starts is also raised as a concern. Summary of Findings Regional Variation: Of the 143 services which responded the majority appear to be situated in the South West and the South East. What type of services and who provides them: Local CAMHS (40%), primary care services (20%), and Sure Start/Children�s Centres (16%). 11% of responding services had adult/perinatal involvement. Professions involved: About 1/3rd of the workforce were Health Visitors. Psychologists and Psychotherapists were the next most frequent providers. There was also significant Primary Mental Health Worker involvement. Who are the services for: About 50% of the services reported that they provided a service for infants (0-2), nearly 40% provided a service for mothers, and 36% provided a service for the parent/carer. Referrers and referral criteria: A majority of professional referrals were made by health visitors (61%), followed by GPs (38%). A majority of referrals to primary care, voluntary or Sure Start were self referrals. 80% of responding specialist services had referral criteria. Parental mental health was the commonest single criterion. Interventions: a very wide range of interventions were offered by the services; some expert evaluation of the evidence for specific interventions and in measuring outcomes may be helpful for commissioners and providers of services. Training offered: More than half of the services reported that they had received some form of specialised training. Duration of treatment: Respondents generally offered relatively short-term interventions of less than 10 sessions. Assessment tools and measures: Just over 60% of services reported using measures but consistency of use and reporting of outcomes seemed very variable from the responses. A very wide range of tools were used. Outcomes: Improving the parent/child relationship or attachment issues was the most commonly (37%) reported outcome aimed for. Numbers of clients seen: CAMHS services tended to see around 40 cases a year; universal services saw many more � 500-2000 being examples. Audit and evaluation: Up to 70% `of respondent services said they either had, or intended to carry out audit of their services. Only one service reported commissioning an RCT Services commenced when: Just over 70% of respondent services had commenced since 2000 and the majority of specialist infant mental health services had started within the past 2 years Future developments: The majority of services would like to develop further, but some 15% of respondents report concerns about funding � the future of Sure Starts is also raised as a concern.

23. Story so far/Process June � Dec 07 Engagement of stakeholders (ongoing) 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 website Launch June 08 Current membership 815 (Sept 1st) and rising steadily >500 hits on website since July Link with national Gender Equality and Mental Health group in CSIP Link with Maternity Matters

24. Governance National Steering Group comprising range of stakeholders from 3rd Sector (PCWN/FPI/AIMH/Marc�/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

25. Membership as at Aug 08 = 758

26. The future Support clinical staff and commissioners to share emerging practice and raise issues Act as a reference point for policy makers if needed 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

27. How to join Go to www.pimh.org.uk Or email Janet Cobb at janet@jan-net.co.uk But also see our website www.cypf.csip.org.uk/camhs