Organisation submitting example
Local authority/local area:
Nottinghamshire - West Mansfield
The context and rationale
Mothers are at risk of depression during pregnancy and after the birth of their child, with negative impacts for their own health and well-being; the way in which they bond with their new child; and the safe and healthy development of their child (see Bowlby, J.,1951, Maternal Care and Maternal Health, WHO). Both the Frank Field and Graham Allen reviews identified intervention in the early years as key to maximising health and social care interventions into the lives of vulnerable families and children, with the perinatal stage being the earliest possible point for intervention. Postnatal depression (PND) affects 10-15% of mothers, and in rare but extreme cases can result in maternal suicide. Yet according to a recent Patients Association Study, 78% of Primary Care Trusts (PCTs) do not know the incidence of PND in their region and 64% of PCTs do not have a strategy for commissioning perinatal mental health services.
There is an urgent need to deliver joined-up cost-effective interventions at this vital stage in vulnerable children’s development during tough economic times and amidst a changing commissioning landscape that will see local authorities become drivers of public health and GPs responsible for addressing mental health.
Family Action’s perinatal support projects in West Mansfield, Oxford, Swaffham and Hackney are an innovative solution based on scientific evaluation of a Family Action Newpin project in Peckham carried out by Guys and St Thomas between 1999 and 2003. In this study, Dr Tirril Harris conducted a randomised controlled trial to measure improvements in perinatal depression obtained as a result of women at risk being allocated a volunteer befriender, in combination with access to drop-in support. This study found that those who received the befriending were half as likely to experience the onset of perinatal major depression (27 per cent) compared to the control group (54 per cent). (See Chapter Eleven: Putting Newpin to the Test by Dr Tirril Harris in Newpin: Courage to Change Together by Mondy and Mondy, Uniting Care Burnside 2008.)
The ability to impact on mild and moderate perinatal depression via a simple method of tackling social isolation has potential to impact positively on the mother’s ability to relate to her child and the child’s development. Many mothers feel ambivalent towards their babies, are overwhelmed, are unable to manage within difficult economic circumstances or experience an unsupportive emotional climate within the household. All of these factors can impact upon their confidence and can lead to emotional shutdown or withdrawal. The support of a befriender can provide a sympathetic ear, assist in ‘normalising’ fears and provide peer role support, all of which help combat feelings of loneliness and low mood.
Family Action felt that this was a cost-effective early intervention that merited further piloting in a wider range of contexts. In 2009, the charity won funding from the Big Lottery and the Monument Trust to test and evaluate the service further in four locations in West Mansfield, Swaffham, Hackney and Oxford. These project pilots are testing the contexts and the different partner agencies through which this service can be delivered. West Mansfield has been chosen as an example of where the perinatal support project is delivering particularly well in partnership with children’s centres and local health professionals. West Mansfield is an area of high child poverty, unemployment and deprivation where Family Action runs Phase One children’s centres. While good services are usually available in the perinatal period to those women with serious and enduring mental health problems, no other early intervention has previously been available for those women whose mild to moderate depression is a cause for concern.
The Perinatal Support Service (PSS) is based on a model whereby a professional perinatal co-ordinator recruits, trains and supervises a network of volunteers to befriend women at risk of mild to moderate perinatal depression who have been referred to the service; or where risk factors have been identified that may mean a woman is vulnerable and more at risk of developing perinatal mental health problems. The support is available during pregnancy and for up to a year after the birth. (The service is not intended for women with severe and enduring mental health problems or for cases involving child protection issues where specialist services would be more suitable.) The timescale for the completion of the process of a change for an individual service user can therefore be up to 18 months. The timescale for the four pilots demonstrating change is three-years from their start date of 2010.
Family Action appointed a perinatal co-ordinator for all the perinatal pilot areas to recruit, train and supervise the area perinatal co-ordinators; and establish central monitoring systems; and commissioned Warwick Medical School to scope and carry out an evaluation of the service. Family Action’s central office provides support for promotion and marketing of the services.
The perinatal co-ordinator for West Mansfield is based in children’s centres run by Family Action. The post is line managed by the manager of these centres. The post of perinatal co-ordinator was appointed in August 2010. In September and October, she established monitoring systems, recruited volunteers via newspaper advertising and, using the children’s centres established links, networked with a range of children’s and health professionals to publicise the launch of the service and obtain referrals. These professionals included social workers and children’s centre workers, health visitors, community midwives, and delivery midwives, and other voluntary local providers such as Homestart. In February 2011, she established an additional facility, a specialist support group based in the children’s centre with a trained counsellor for those mothers with additional background factors such as childhood trauma. This year she has established a more informal social group, supported by volunteers, for all mothers the service is involved in.
Volunteers come from a range of backgrounds including those who have experienced perinatal depression and wish to use their experience of tackling their personal condition to support other women. Most volunteers are not in fulltime work. Some are seeking work or undertaking training and are using volunteering to gain or refresh skills, for example, a nurse who has been made redundant. In addition to nine half-day training sessions in issues such as perinatal depression and child safeguarding, volunteers get regular six-weekly supervision as well as bi-monthly group supervision.
In West Mansfield the service works closely with the children’s centres, family support providers, social services, community midwives and health visitors, to ensure a joined up integrated approach to the referral and provision for mothers-to-be and new mothers. The main formal referral mechanism is the Nottinghamshire Common Assessment Framework. Once this is completed, families are notified within 14 days and then visited and assessed for the perinatal service. Where families have severe and enduring mental health problems and/or child protection issues, families must be receiving other health and social services for the perinatal service to be offered with the expectation that it will provide emotional support only. All those receiving Family Action’s perinatal support service are logged with their permission with the Integrated Services Team, whether or not they are receiving other social services. Where this is part of multi agency work, regular Team Around the Child meetings are held with the family to agree the work of those involved in supporting the family.
Since the service has been set up there have been 37 referrals, 24 individuals have used or are using the service and there are 10 volunteers in the pool. Nine cases are formally closed with work completed from start to finish, 4 of these include 6-month follow up data.
Achievements so far
The Tirril Harris randomised controlled trial study together with a 2009 evaluation of Family Action’s perinatal service by Lederer (available at www.family-action.org.uk) show the befriending service is moving in the right direction in terms of i) an approach focussed on tackling social isolation as a factor or main cause in perinatal depression and ii) supervised volunteer delivery being an appropriate method of delivery. The current evaluation by Warwick Medical School which will be completed by July 2012 aims to:
• provide preliminary data concerning the impact of the Perinatal Support Service on key outcomes i.e. reducing social isolation, and improvements in maternal mental health and the mother-baby relationship;
• locate and to capture perceptions of the PSS within local perinatal service networks;
• assess stakeholder perceptions about the role of the theory of change underpinning PSS;
• and assess the extent to which PSS improves the social capital of both service providers and recipients.
A Pro Bono Economics team is investigating the question of social return on investment.
The experience of West Mansfield shows that the service can be particularly effective when based in a children’s centre with existing baby groups and linkages to health and social services. This has assisted effective networking and integrated referral and working. Scores from West Mansfield are showing good progress for users along the Modified Scale for Suicide Ideation (MSSI) and Milestone of Recovery Scales (MORS) scales. Referral data shows increasing referrals from community midwives pre-birth compared to health visitors, suggesting that the service is fulfilling its potential to increase capacity to both deliver early intervention and through improved targeting and engagement, facilitate early intervention by other agencies: for example, by engaging mothers in children’s centre services or, where appropriate, more intensive professional family support services.
A local community midwife is convinced the service makes a difference because it tackles a primary factor in perinatal depression: social isolation; She says:
“Family Action’s service is great because it’s saying to mums “you’re not the only one”. It’s destigmatising depression, offering mums the emotional and practical support they need and networking them into parental peer support at a very early stage.”
She recently referred a disabled mother who had experienced a premature birth: “She didn’t have serious mental health issues but she was a candidate for getting over-whelmed and isolated. The emotional support she is getting from a social network has made a big difference to her coping and being able to bond with baby in a way that will be good for baby’s development.”
She believes there’s more room for services like this. “Midwives get good training in the mental health issues affecting new mums, the challenge is finding the resources to support them. Family Action’s solution is a smart way of adding extra value to the essential community health services we provide.”
• An integrated local service referral and service offer approach, with a range of appropriate interventions, is vital if inappropriate referrals are not to threaten safe delivery by volunteers.
• Despite the fact that there is wider-ranging buy-in to the Nottinghamshire CAF, the fact that some agencies do not co-operate or have a separate assessment and referral procedure impacts on the full effectiveness of our referral and assessment processes.
• The three year pilots in four locations together with substantial evaluation and promotion are being made possible by £369,153 funding from the Big Lottery, plus additional grants from Monument and the Henry Smith Charity.
• When the project is replicated most costs will be due to the employment of a perinatal co-ordinator, training, and monitoring and evaluation.
• There is potential for very low unit cost per service user given delivery via volunteers, i.e. below £5k. However this will depend on context specific features, such as pre-existing well-resourced management and supervisory arrangements, appropriate infrastructure including i) IT and monitoring and evaluation systems and buildings, ii) referral networks and integrated local services which reduce time spent on targeting and promotion and ensure a joined up approach to local resources and iii) features which support volunteering such as affordable and accessible public transport.
A Social Return on Investment study will be carried out shortly. Potential savings may include:
• Reduction in the need for more acute forms of intervention by adults and child mental health and social services, for example including the costs of the Care Programme Approach and child protection plans.
• Reduction in uptake of certain services as impact of depression on health at birth and developmental delays is reduced.
• Welfare benefits, as women whose perinatal mental health issues are ameliorated are fit to return to work.
• Social capital generated by volunteers.
Links to C4EO’s ‘golden threads’ are:
• You Can Do It
• Together with children, young people and families
• Prove It
t. 020 7833 6825
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