We need each generation of perinatal psychiatrists to lead the development of the next and wider teams to be knowledgeable about the issues, risks and care of all women of childbearing potential, writes Dr Liz McDonald
One of my first experiences as a trainee psychiatrist was a visit to a well known high secure mental hospital. Our group was taken to “the sewing room”. There, seated around a huge square table were 20 or so elderly ladies. All of them stitching. They looked at us cheerfully and told us about their sewing projects.
When we left, I asked why these women were there. I was told that these women had killed their infants in the throes of a post-partum psychosis. They had been admitted to the secure unit, but had never left.
This was my first insight into how severely mentally ill women can become during pregnancy and after childbirth, the extreme impact this can have on their children, and how unforgiving society was at the time. And I wondered why there were no services specifically for these women when there seemed to be such a clear need.
Advances in developing perinatal mental health services in previous decades has almost always been down to the perseverance of local champions or in response to serious untoward incidents in local areas
And so began my career long drive, in association with many other mental health professionals and women with lived experience, to develop perinatal mental health services to support new and expectant mothers and their children.
After a long slog, progress has been made in the past year that I would never have previously dared to dream about. This includes a unique one year programme, developed by the Royal College of Psychiatrists, to train psychiatrists to become perinatal specialists.
This means that hundreds more women and their babies will receive specialist mental health support across England, and it will help to ensure that all women in England can access the right support, at the right time, close to their homes.
Advances in developing perinatal mental health services in previous decades have almost always been down to the perseverance of local champions or in response to serious untoward incidents in local areas. These efforts were insufficient to make serious headway on providing services for women with perinatal mental illness, despite suicide being one of the leading causes of death for pregnant women and women in the first year after giving birth in the UK.
Throughout the life course of children born in one year in England, the cost of perinatal mental health problems is estimated to be £8.1bn to wider society. Of this, 72 per cent relates to negative effects on the child and over a fifth of total costs are borne by the public sector, with the bulk of these falling on the NHS and social services (£1.2bn).
Adequate support has just not been there.
And so the commitment to transform perinatal mental health services, in the Five Year Forward View for Mental Health, and to help at least 30,000 more women by 2021 with £365m of funding, came not a moment too soon.
But the big question was, who would deliver this support to so many more women and their families?
Shortage of workforce
A whole raft of specialist clinicians to provide, lead and develop new perinatal services was needed. And in a timely fashion. Money would be devolved from NHS England to clinical commissioning groups in 2019-20 and the workforce would need to be ready to take action.
The idea was to provide bursaries so that consultant level psychiatrists in areas with no perinatal mental health services could receive a year of training from a “mentor” at an established “host” perinatal mental health service
But, for starters, there is a national shortage of psychiatrists. Full training from medical school to consultant level takes 13 years. Those with specialist perinatal skills are particularly scarce (along with the lack of services is also the lack of training opportunities).
The need to train and develop clinical leaders rapidly to support women and their families in an effective, comprehensive and equitable way in all areas was clear.
So what was to be done?
My idea, worked up with a colleague at NHS England, Andrew Turnbull, was to provide bursaries so that consultant level psychiatrists in areas with no perinatal mental health services could receive a year of training from a “mentor” at an established “host” perinatal mental health service.
After much groundwork, the Royal College of Psychiatrists received £1.6m to develop an innovative programme to grow the perinatal workforce, in partnership with NHS England and Health Education England. This was the birth of the Building Capacity Project.
Mental health trusts lacking in specialist perinatal services but with commitment and interest in developing them were invited to apply to the project and to nominate participating consultant psychiatrists.
Once the bursary holders were in place at their “host” trusts, we delivered a training programme to enable and support them to think about how they would contribute to and lead service development.
It has been incredibly rewarding to watch keen, committed psychiatrists become even more passionate and skilled and develop into the next generation of perinatal psychiatrists.
Perinatal psychiatry is not for softies. The work is challenging – intellectually and emotionally – and requires a capacity to both lead and work within a team and across agencies in a compassionate, humane and effective manner.
We hope that a clearer, simpler, formalised training pathway will be developed for future psychiatrists who chose to train in perinatal psychiatry
I’m delighted that one year on, all nine of the final bursary holders are poised to apply for and take on consultant perinatal psychiatrist roles to deliver specialist perinatal mental health services.
This will have a profound impact on their local areas, but the impact of the Building Capacity project will also go far wider.
Masterclasses, run by leading clinicians and academics in the field, were delivered on subjects ranging from workforce and service planning; maternal mental health; infant mental health; physical and psychological treatments and leadership skills. These masterclasses were attended by 20 psychiatrists with a further 265 psychiatrists from adult and child and adolescent posts being upskilled by attending an intensive course.
The bursary holders themselves took up important audit projects, wrote information leaflets for women and their partners and delivered training to multidisciplinary groups.
Crucially, they engaged with local CCGs to ensure that services would be developed. They contributed to and often led the writing of successful bids for further “Wave 2” funding for developing community perinatal services.
Who would have thought that this could happen? Partnership working between the RCPsych, NHSE and HEE has transformed the decades long dream of many into reality. When the final Five Year Forward View perinatal funding is transferred to CCGs, there will be a highly trained, passionate, committed (small, but much enlarged) battalion of perinatal psychiatrists ready to lead and deliver high quality clinical services and to teach and train colleagues.
The challenge is now to maintain the momentum and build on what we’ve started. We hope that a clearer, simpler, formalised training pathway (known as a “credential”) will be developed for future psychiatrists who chose to train in perinatal psychiatry, whether that is when they are new to their consultant roles or further down the line when they might like to change course in their career.
We need each generation of perinatal psychiatrists to lead the development of the next and importantly for wider teams to be knowledgeable about the issues, risks and care of all women of childbearing potential. This is everyone’s business.
One bursary holder told me “there has been a real shift in the trust from one executive opening a meeting saying ‘I don’t know anything about perinatal mental health’ to… perinatal mental health being talked about and promoted widely across the trust.”
I think we are getting there.