Statement 1

The Committee is keen to hear how services link together under the umbrella of Perinatal Mental Health, including specialised perinatal mental health services, maternity services, general adult mental health services, inpatient mother and baby units, parent and infant mental health services, health visiting, clinical psychology, and midwifery services, GPs and the extended primary care team, role of the third sector and local support groups, and private providers of services


It is specifically seeking evidence on:


The Welsh Government’s approach to perinatal mental health, with a specific focus on accountability and the funding of perinatal mental health services covering prevention, detection and management of perinatal mental health problems. This will include whether resources are used to the best effect.




Perinatal mental illnesses are common and affect at least 10% and up to 20% of women. Providing good perinatal mental health services saves lives, but also prevents long term harm to women, their families and children.


The Health Board (HB) is committed to working in partnership to improve outcomes for children and families and is currently prioritising work on the first 1000 days of life pathway and the prevention and mitigation of Adverse Childhood Experiences ACES. These are explicit priorities within our planning and strategy work. The HB is part of the Cymru Well Wales 1000 days collaborative, with a pathfinder project ongoing in Wrexham. As part of this strong focus on the early years, perinatal mental health is a priority with clear actions within the Health Board’s Operational plan for 2017-2018.


Following additional funding from Welsh Government, the Health Board is currently setting up a new perinatal mental health team. Links between services are being strengthened under the leadership of the BCUHB Perinatal Mental Health Steering Group. The group has representation from the all the relevant key stakeholders including primary care, Women’s services, children’s services, adult mental health services, CAMHS and public health. Guidance and referral processes for the new service are being developed


The new specialist team  will ensure: :


·         Clear clinical pathways in place and improved access to services

·         Universal promotion of mental wellbeing by all services involved in the care of pregnant women and their families

·         Support and training for frontline staff

·         Co-ordinated care for expectant mothers and their families and integrated working with social services under the Social Services & Wellbeing Act (2014)

·         Co-ordinated third sector commissioning for community-based interventions

The new Perinatal Mental Health Service is establishing links with specialist CAMHS services across North Wales to explore opportunities for joint working with infants where significant need is identified. Targeting infants of parents with mental health problems, in particular where there are identified attachment problems, is a priority for prevention of later mental health difficulties.



The pattern of inpatient care for mothers with severe mental illness who require admission to hospital across both specialist mother and baby units (designated mother and baby units in England) and other inpatient settings in Wales. (Since 2013, there has not been a mother and baby unit in Wales).




A referral to a mother and baby unit a long distance from home brings considerable family stresses from the travel required which can only add to distress at an already extremely difficult time. There are also other considerations for Welsh families accessing services in units outside Wales such as language for Welsh speaking patients.


Consideration should be given to establishing Specialist Clinical Networks for Perinatal Mental Health in the same way they are provided for other aspects of maternity care such as cardiac, liver, feto maternal unit (FMU) and neurology. The Health Board feel it would be timely to review the provision of tertiary level care and the existing perinatal mental health clinical networks for Welsh families in relation to volume, outcome, demand and need for this service currently.


Statement 3

The level of specialist community perinatal mental health provision that exists in each Health Board in Wales and whether services meet national standards.




The new perinatal mental health service is being set up in line with national standards and guidance. Some of the current standards may be challenging for the new service to meet such as the RCOG recommendation of rapid access to psychological care within 4 weeks of referral, given current levels of demand and wide geography of NW. The service will be audited on an ongoing basis to assess performance against national standards and highlight areas for improvement


The majority of perinatal mental health issues experienced by mothers are classed as mild to moderate. There will also be a need to be a focus on women and families who don’t meet thresholds for referral to the new service but who are experiencing perinatal mental health issues or struggling with low mood following the birth of a child. The current work within the Health Board is looking at this as part of the first 1000 days pathway to ensure optimum outcomes for all children and families and there is a strong awareness within the HB of the impact of ACE’s. Working in partnership with the third sector and looking at their role in supporting families is also a key aspect of this.


Statement 4

The current clinical care pathway and whether current primary care services respond in a timely manner to meet the emotional well-being and mental health needs? Of mothers, fathers and the wider family during pregnancy and the first year of a baby’s life.




Primary care teams have a key role in identifying and supporting women with perinatal mental health issues. The majority of mental health issues before, during and after pregnancy will be managed within primary care and not by specialist mental health teams. They have a key role is supporting the development of care plans for women with existing mental health issues and advising on appropriate prescribing in pregnancy and breastfeeding. They also have a key role in identifying issues and offering support to women attending for routine preconception, antenatal and postnatal checks in primary care and in working as part of the multi disciplinary team supporting women and families.


The link between the new perinatal mental health team and primary care teams will be key. Current and new clinical pathways being developed need to reflect this important interface. Good communication between GP’s and the wider primary care team such as health visitors, community midwives and community mental health teams is also key part of any perinatal mental health strategy and pathway. Reviews of maternal deaths have shown repeatedly the vital importance of effective and timely communication between health professionals


It would be helpful to have a platform for engagement with GPs at national, regional and local levels on perinatal mental health. The Royal College of General Practitioners (RCGP) has  developed an excellent toolkit for perinatal mental health (see appendix1)


The implementation of the Healthy Child Wales Programme increases the universal contacts offered to parents from Health Visiting Services. Assessment of mental health and providing support to families will be an important part of the HCP programme. 


Embedding pathways for routine  pregnancy testing carried out by GPs (and/or community pharmacists) could provide an opportunity to screen for mental ill-health risk and provide appropriate care from the very start of the pregnancy (as well as timely access to other pregnancy care).


Statement 5

Consideration of how well perinatal mental healthcare is integrated, covering antenatal education and preconception advice, training for health professionals, equitable and timely access to psychological help for mild to moderate depression and anxiety disorders, and access to third sector and bereavement support.




All health visiting teams have been provided with one day training from MIND Cymru. In addition to this training, some Health Visitors have undertaken additional training in Maternal Infant Mental Health, with these staff providing additional support to colleagues.


The new perinatal mental health team will also have an important role to support training for key staff groups and act as an expert resource.


The Families Together Perinatal Support Service has been established in North Wales, delivered by Family Action, a third sector organisation. This project aims to provide families with personalised support to overcome challenges. This service is linked in with Health Visiting services and families are being routinely referred in.


The Health Board feel that the following are potential areas for further investment and development:


·         Maximising opportunities pre-conceptually during planned and opportunistic contacts.

·         Training is needed for wider professional groups to raise the profile of perinatal mental health, it’s prevalence, implications and how to recognise it and signpost

·         The third sector have a key role and often support women with post-natal depression and anxiety, Post Traumatic Stress Disorder (PTSD) and those who have suffered bereavement. These groups are valuable sources of support and can be an important part of the care pathway for families.

·         Campaigns to raise awareness at the population level may have value and could link to much of the current and high profile work ongoing to reduce stigma of mental health issues and to encourage more openness and communication within families and communities. Women with perinatal mental health issues often feel particularly vulnerable about disclosing how they are feeling in case there is judgment in relation to parenting. Diagnosis is often delayed for these reasons.


Statement 6

Whether services reflect the importance of supporting mothers to bond and develop healthy attachment with her baby during and after pregnancy, including breastfeeding support.



There has been a strong focus on infant and early years mental health work across North Wales: significant progress was made following a piece of joint work between specialist CAMHS and the Public Health Directorate in North Wales. Eleven recommendations were prioritised and ratified in February 2016 for implementation.  (Appendix 2)


It would be useful if recent evidence on the prevalence and effects of Adverse Childhood Experiences (ACEs) could help to bring more prominence to the importance of preventing and mitigating perinatal mental ill-health, and also mental ill-health in the wider family. Mental ill-health in the household is one of the recognised ACEs and maternal depression is the biggest risk to early attachment and all aspects of child development especially speech and language.


The Health Board is working to UNICEF BFI guidelines, which support immediate undisturbed skin-to-skin contact after birth to strengthen bonding and promote breastfeeding initiation. UNICEF accreditation has been achieved at the highest level and work is ongoing to ensure continuous quality improvement in relation to key aspects such as skin to skin audits. An infant feeding strategy is also under development which will have a strong focus on nurturing, attachment and early brain development through skin to skin contact and supporting early responsive parenting for all parents. The strategy is intended to link breastfeeding support, early attachment and positive mental health and well being.   


Wales like the rest of the UK, has some of the lowest breastfeeding rates in the world and these have not changed significantly in more than a decade despite our best efforts. Women who want to breastfeed and who do not end up breastfeeding have approximately double the risk of Perinatal Mental Health Problems. In North Wales, we consistently see a high drop off in Breastfeeding in the first 10 days. There is a link with this pattern and Perinatal Mental Health  - both in terms of the negative impacts on the continuation of breastfeeding for women experiencing mental health issues and the increased risk in mental health issues arising for women who want to continue breastfeeding but aren’t able to through lack of early support or other reasons. (Appendix 3 – article on link between breastfeeding and mental health/well being)


There is a general need to address prescribing in lactation within primary care as mothers experiencing Perinatal Mental Health issues regularly report that they have been told to stop breastfeeding in order to take medication.


Statement 7

The extent to which health inequalities can be addressed in developing future services.




Poor mental health is strongly linked to inequality both as a cause and consequence.

Loving, secure and reliable relationships with parents, foster a child’s emotional and mental wellbeing, capacity to form and maintain positive relationships with others, language and brain development, and ability to learn. Providing universal services is key to tackling inequalities with an understanding that enhanced provision is required to support populations in greater need.

The full Implementation of the Healthy Child Wales programme will enable a universal offer of services with additional service provision if required following assessment of need. There are challenges in relation to recruitment of health visiting staff but the HB is committed to full implementation of the HCP. Health services which routinely engage with families are well placed to identify emerging issues and coordinate care. Identification and early intervention is key.


In addition to the implementation of the Healthy Child Programme in North Wales the following is planned:

·         Access to ongoing training for Health Visiting services

·         Specialist CAMHS teams  to promote the Five Ways to Wellbeing, working in partnership with Local Authorities and Third Sector colleagues

·         Promotion of the same and consistent messages across all service areas – universal health visiting, perinatal mental health services, adult mental health services and specialist CAMHS.


The public health directorate have recently led on the development of a successful social media campaign targeting young girls. Dream Big aims to raise aspiration and provide advice on well being and emotional health for young girls. Equipping young people to be emotionally resilient and prepared for parenthood will help to improve mental health and well being and improve outcomes in the long term


Responses in person to the panel


Names of staff members identified as willing to provide evidence in person


Please contact us if this is required and staff will be identified




Appendix 1

RCPG toolkit for Perinatal Mental Health

Tools to Promote Well Being

The charity Pause specifically looks at improving the lives of women subject to serial high risk pregnancy & serial child removal proceedings to break the cycle.





Appendix 2

Infant and early years mental health work is in development across North Wales. Significant progress was made following a piece of joint work between specialist CAMHS and the Public Health Team in North Wales. Eleven recommendations were prioritised and ratified in February 2016 for implementation.

Approved at Emotional Health and Well-being Service Board February 2016 

Specialist CAMHS and the Early Years (children aged 0 – 7 years)


Current provision remains highly variable across North Wales for children in the early years. Public Health Wales led a working group in 2014 which completed an emotional health and wellbeing needs assessment focused on the early years. These findings led to the recommendations below. A draft summary report was presented to Service Board December 2014, final report available August 2015. Eight themes in total were identified, these are collapsed into three broad themes for the purpose of developing next steps in specialist CAMHS



That the Emotional Health and Wellbeing Service Board considers and supports the following recommendations for implementation in specialist CAMHS – further details are outlined in table 1 below and in the attached final needs assessment document:


  1. Identify specialist CAMHS practitioner capacity in all teams to focus on early years and ensure that assessment and intervention in primary and secondary care is routinely available to children age 0-7 years who meet criteria and threshold via SPoA
  2. Deliver information and skills training for the early years workforce and support implementation fidelity through professional consultation and supervision 
  3. Ensure skills are in place to deliver evidence based interventions to children age 0-7 years with more severe difficulties
    1. Behavioural analysis skills
    2. Incredible Years basic programme and baby and toddler programme add on days (group programmes covering 0-7 ages)
    3. EPaS-2 (2014) (individual behavioural programme)
    4. Video Interaction Guidance (VIG)
    5. Fun Friends and Adult Resilience programmes from the Friends suite of interventions to prevent anxiety


  1. Identify a minimum of 2-3 specialist CAMHS practitioners per area who will train to supervisor and mentor/coach/trainer levels and maintain this capacity over time in each of the above modalities - behaviour analysis, Incredible Years, EPaS-2, VIG, Friends
  2. Define clear pathways from universal services into specialist CAMHS for behavioural, feeding, toileting and sleep problems and equip specialist CAMHS practitioners with skills to deliver directly to those with moderate to severe level difficulties
  3. Ensure that clinical leads in each area lead the implementation of emotional and mental health interventions for children looked after
  4. Progress integration of child health psychology services across North Wales teams
  5. Recruit a Child Psychotherapist and define a work plan
  6. Identify age appropriate books and information for young children and parents and ensure available through website and local teams
  7. Ensure that the emotional and mental health priorities for key universal services – health visiting, school nursing and midwifery are agreed and implemented and clinical leadership links to multi-agency steering groups in Education are in place
  8. Ensure all early years developments are closely linked to the North Wales peri-natal mental health pathway and adult mental health 



Table 1: Specialist CAMHS and the Early Years 



Key findings by Theme


What is needed? (Public Health Wales led working group)


What needs doing in Specialist CAMHS?



Supporting parental mental health and wellbeing


Supporting parent-child interaction and attachment

a) adopting 5 ways to wellbeing as means of engaging staff and parents in discussion about helpful ways to look after own mental health and wellbeing recognising that detecting and intervening with early stage emotional health difficulties is important

  1. Adopt and maintain 5 ways with specialist CAMHS staff, universal health professionals including GPs and especially Midwives and Health Visitors and with staff teaching the foundation phase in education settings
  2. Teach parents about the 5 ways during pregnancy
  3. Agree the universal mental health promotion role and priorities for Midwives, Health Visitors and School Nurses





b) Ensuring that AMH service providers recognise that many of the people they support are parents and may need specific support for their parenting role in addition to treatment for their mental health


  1. Engage in discussion and planning of new perinatal mental health services for North Wales
  2. Ensure early years and perinatal pathways and interventions are joined up and integrated
  3. Build close working relationships with colleagues in adult mental health services to promote joint working with parents
  4. Consider targeting specific groups of parents for early help e.g. parents known to have mental health problems, disability, social isolation and parents who are young




c) Providing consistent advice to all parents on the importance of positive interaction, play, talking and reading with infants and toddlers

  1. Identify practitioners in each specialist CAMHS team to work with children age 0-7 years
  2. Train identified specialist CAMHS staff in EPaS-2 (2014) – a targeted behavioural programme for parents delivered on an individual basis via home visiting. Based on social learning theory and the Incredible Years programmes EPaS-2 follows a series of structured evidence based sessions
  3. Train a minimum of two specialist CAMHS staff per area to be EPaS-2 trainers to train and support others – the programme can be delivered by trained and supervised Health Visitors and Family Workers
  4. Train all Health Visitors in EPaS-2
  5. Identify and train additional multi-agency professionals in roles suitable for delivery of EPaS-2
  6. Support implementation fidelity through professional consultation and supervision






d) Ensuring that all parenting programmes

·         Have robust evidence base

·         Are implemented appropriately with support and supervision for staff delivering them

·         Use valid and consistent measures to demonstrate outcomes

  1. Work with local universal services and Local Authority multi-agency parenting strategies to agree clear pathways for parenting
  2. Joint delivery and supervision of agreed multi-agency evidence based programmes (home visiting and group)
  3. Support use of consistent evidence based outcome measures across partnerships – where relevant and appropriate support partnership in delivering training in outcomes and evaluation
  4. Support implementation fidelity through professional consultation and supervision




e) Develop the capacity of universal services to identify vulnerable infants children and parents

  1. Consider adopting a useable observation based screening tool in universal services to more objectively measure parent-child relationships
  2. Support universal services through Specialist CAMHS SPoA and professional consultation
  3. Ensure criteria and thresholds for assessment of children 0-7 years are consistently applied in all teams
  4. Contribute to multi-agency training on emotional health and well being in the early years





e) Intervene where appropriate to promote secure attachment and positive care giving

  1. Advise on/deliver basic training in normal development and secure attachment
  2. Deliver EPaS-2 to targeted professionals who will have capacity to deliver the programme
  3. Support universal services to promote secure attachment and positive care giving for all parents




e) Refer to specialist services to support the development of parent child relationship when necessary

  1. Using video interaction guidance as main one to one clinical intervention, develop a stepped pathway into specialist CAMHS for working with parent-child relationship
  2. Develop clear pathways for 0-7 years into specialist CAMHS SPoA – what to do, what to look for and when to refer in
  3. Develop clear pathway for 0-7 years from SPoA into specific interventions
  4. Ensure all levels of intervention are available in team/area



Prevention and early intervention


Recognising and responding to circumstances that increase vulnerability

f) Ensuring that parental mental ill health does not adversely affect parent-child relationship and attachment

  1. Develop close working relationships with local AMH teams as well as with universal services – carry out shared SPoA activities to develop relationships and identify parents who are vulnerable
  2. Agree clear protocol for joint working across adult and child mental health services (see maternal mental health guideline 2014)
  3. Recruit Child Psychotherapist and agree programme of work




g) Health Visitors, School Nurses and the Early Years workforce are able to support parents ability to attend to emotional health needs of young children and identify and respond effectively to factors that may pose a risk to child’s emotional health and wellbeing

1.   Support implementation through Specialist CAMHS SPoA, and individual and group based consultation

2.   Deliver targeted and clinical interventions as required





h) Provide effective interventions for behavioural, feeding, toileting and sleep problems in very young children through Tier 1 services with input from specialist CAMHS and other practitioners where appropriate

  1. Develop clear pathways for 0-7 years into specialist CAMHS SPoA – what to do and what to look for in behavioural, feeding, toileting and sleep and when to refer in
  2. Develop clear pathway for 0-7 years from SPoA into specific targeted and clinical interventions
  3. Ensure interventions are available in team/area





i) Access to specialist CAMHS practitioners for children and young people with chronic and/or life limiting conditions (cancer, Type 1 diabetes, cystic fibrosis, epilepsy) as part of on-going care

  1. Progress the integration of CHP into specialist CAMHS across all teams
  2. Clear protocol and pathway for  wards/out patients
  3. Define criteria and thresholds of non-specialist CAMHS elements of child health psychology work and roll out




j) Offering classroom based emotional learning and problem solving programmes to children aged 3-7years where classroom populations have a high proportion of children identified as at risk of developing CD or ODD – develop clear protocols to identify classes at high risk and multi-agency care pathways 

  1. Ensure the right people are on local multi-agency strategic groups with Education in each Local Authority area
  2. Ensure all are clear on recommended evidence based programmes
  3. Link recommendations to Together for Children and Young People work streams




k) Use video interaction guidance where appropriate to improve maternal sensitivity and mother-infant attachment

  1. Train all specialist CAMHS early years practitioners in VIG in each team
  2. Establish supervision requirements in each area 
  3. Train 2-3 to supervisor level VIG in each area




l) Use parental self help interventions (books/audio/TV/web) to improve child behaviour

  1. Roll out new Better with Books scheme across all areas
  2. Develop Mental Health Matters website/recommend others
  3. Ensure evidence based materials are on the site with links to local and national information




Provision of specialist CAMHS interventions


Advice and support to staff working in Tier 1 services

m) Timely access to address attachment difficulties developmental trauma and provision of emotional support/mental health services for children looked after

  1. Launch maintain and develop specialist CAMHS SPoA in each team
  2. Agree and roll out consistent model for children looked after – foundation training, professional consultation, mental health assessment and intervention for parent/carer group work
  3. Agree whether to introduce mental health screening at annual health check for all CLA – increase early detection and targeting




m) If no specialist CAMHS practitioner CAMHS teams should identify a lead professional (i.e. Clinical Lead) to help responsible authorities to carry out duties in addressing emotional and mental health needs of children looked after

  1. Establish clear lead role in Clinical Leads in each area




n) Alerting health and social care professionals in primary care, education and community settings to possible anxiety disorders in children

  1. Develop and deliver training for front line professionals in recognising anxiety in young children – early detection and role appropriate interventions focus of training
  2. Develop clear pathway into specialist CAMHS SPoA for 0-7 years with early signs of anxiety – what to do, what to look for and when to refer in
  3. Develop clear pathway from SPoA into specific targeted and clinical interventions
  4. Build local capacity for the delivery of ‘Fun Friends’ prevention of anxiety intervention and maintain minimum 2 trainers per area
  5. Define annual programme of ‘Friends’ training and programme delivery including on-going support to Tier 1 staff





n) Specialist CAMHS should contribute to the assessment of children and their parents and deliver effective interventions directed at both parent and child

  1. Specialist CAMHS routine assessment and primary and secondary care intervention for 0-7 years in all teams





o) Children with depression should have diagnosis confirmed and recorded

  1. Local specialist CAMHS teams – training and implementation of NICE guideline




o) If depression is moderate or severe specialist CAMHS staff should manage the intervention

  1. Specialist CAMHS SpoA in all areas with implementation of clear access and eligibility criteria in each team
  2. Routine use of standardised tools [MFQ] in all teams to determine level of depression
  3. Manage in primary care if mild to moderate, specialist team if moderate to severe
  4. Ensure training and professional consultation adheres to these principles in practice




o) Children should be given age appropriate information about their condition

  1. Implementation of NICE clinical guideline
  2. Ensure information tailored to 0-7 years is easily available in all teams




p) sleep difficulties in children with a learning disability and/or autism should be actively screened for and evidence based sleep programmes should be implemented

  1. Sleep work stream recommendations for specialist CAMHS and neuro-developmental service to be adopted





q) following a diagnosis of ADHD in their child all parents should be provided with relevant information evidence based self instruction manuals and other materials based on positive parenting and behavioural techniques

  1. Local specialist CAMHS teams and neuro-developmental service implement NICE guideline
  2. Ensure all specialist practitioners are trained in Incredible Years toddler and basic programmes and deliver rolling group programme
  3. Ensure all specialist practitioners working in ADHD intervention are trained in New Forest Parenting programme
  4. Ensure supervision arrangements are in place for both programmes




p) For children with more severe behavioural problems / conduct disorders the provision of group programmes to support parents and carers is recommended. Only when parents are unable to participate in groups should one to one parenting support be offered 

  1. Fully adopt toddler and basic Incredible Years programmes in specialist CAMHS and deliver rolling programmes for 0-7 years
  2. Ensure and define links to local Incredible Years Programmes
  3. Ensure all specialist practitioners working with 0-7 years are trained in Incredible Years and deliver rolling programmes and work towards accreditation
  4. Ensure minimum 2/3 per area are trained to supervisor level and implement supervision across multi-agency network to increase programme fidelity 







r) Increasing specialist CAMHS involvement in multi-disciplinary teams including community child health and paediatric services that provide services for children with behaviour problems, conduct disorder, ADHD, learning disability or autism to  provide assessment and treatment of possible psychiatric co-morbidities and to ensure evidence-based interventions. Where indicated parents/carers should also be assessed

  1. Ensure communication about specialist CAMHS SPoA in all areas
  2. Job plans to ensure regular links in place with specific service areas where specialist input is indicated




Appendix 3 Breastfeeding

Link to a recent article by Kathleen Kendall-Tackett (acknowledged expert in this field) regarding the protective effect that Breast Feeding has on Mental Health both in mothers & their children