Perinatal Mental Health Team Ablett Unit, Ysbyty Glan Clwyd, Sir Ddinbych, LL18 5UJ	Perinatal Mental Health Team Ablett Unit, Glan Clwyd Hospital Denbighshire LL18 5UJ
	Gofynnwch am / Ask for			Donnalee Williams
	(		01745 858484 ext 2674
	Ffacs / Fax
	E-bost / Email	Donnalee.williams@wales.nhs.uk
	Dyddiad / Date  18.01.2019

Dear Lynne,

Following the meeting held on the 10^th of January 2019 there are a few comments that have caused some concern to the North Wales Perinatal Mental Health Team, particularly in relation to the development of and perceived need for an MBU in North Wales. I have included narrative from the meeting for clarification on points made. I hope you find this helpful.

Lynne Neagle

“So, you will measure, then, as well, the numbers of women who have had to turn down a hospital bed in an adult psychiatric ward or a mother and baby unit because they didn't have a placement that was appropriate for them.”

Dr Liz Davies11:29:21

“Yes, we do know, and the reason we know is because the community teams are so closely involved with every one of these women. So, they're not plucked from a community mental health team and put in an adult bed—they're being supported by the community team throughout, the placement in the adult bed—that can be for a variety of reasons—and then following that, placing her back into her home in the community. So, there's a really good trail for every woman.”

In response to the above statement

When women are already open to generic CMHTs, then this is possible. However 6 out of our 10 admissions to MBUs were unknown to any psychiatric services prior to the deterioration in their mental health and subsequent admission to an MBU in England. We have had a number of unsafe discharges from MBUs in England where neither the perinatal team, CMHT or local HTT were notified of discharge (despite details being provided) and no follow up arranged by the MBUs. We also continuously have to chase for discharge papers. There is no indication of any perinatal specific interventions that are recommended upon discharge, and information sharing in general is poor. This practice feels very unsafe and lacking in continuity of care for the women of North Wales.

Processes for admission to an MBU also vary depending on which one has a bed available, so procedure for admission to an MBU is not standardised. For example Manchester takes paper referrals, once accepted admission is booked, prior to confirmation of funding and transport arrangements. Brockington takes referrals over the phone; however require funding confirmation in writing before agreeing to accept an admission.

In addition to this it is impossible to look back at numbers (which pre date the implementation of the perinatal mental health team )of women who have required, accepted or turned down an acute or MBU bed as the way in which information has historically been recorded does not allow for perinatal specific disorders to be identified.

MBU Data so far –

May 2017-May 2018

6 admissions to MBUs

3 went to an acute mental health unit without baby 1^st

May 2018 to Jan 2019 (not a full year)

4 admissions to MBUs

3 went to an acute mental health unit 1^st

We have had a total of 12 mothers refuse to go to an MBU even though assessed as needing to go, due to distance

Vaughn Gethin

“Within north Wales, there's been a conversation with NHS England. We're not in a position where we have agreement on a detailed way forward, and the reason is that there has been an assessment of five women who would have needed to be supported within a mother and baby unit to date this year, and that isn't enough to actually create a unit within Wales solely for Wales. There have been active conversations with NHS England, though, about provision together with them—either provision in Wales, where they would actually make use of beds in Wales, or indeed the potential to purchase bed space in England for women from Wales. That hasn't been concluded, because NHS England themselves are in a position where they are not—. They either don't agree to purchase beds in Wales or to create extra capacity closer to north Wales, because they say that they think that they have enough capacity, because they think that with the extra capacity they've created within the system in England, they actually say that they've seen a reduction in assessed demand for those spaces. Now, we're not in the space where NHS England are in understanding why that is—why, despite creating more units, they've actually had less assessed demand. They've also suggested to WHSSC that the option is there to block purchase beds in England. The challenge with that is—and it's not completed—that their expectation would be that you block purchase beds regardless of the use of them. So, the bed space could be vacant, but NHS Wales would still be expected to pay for it. So, that's a conversation that is not concluded. That is where we still are”

“NHS England are planning for the population that they directly serve. We've had a conversation with them, because it is a regular part of healthcare that people transfer geographically, and in north Wales more so than most other parts of the country. People are used to going for hospital-based treatment, in particular, into north-west England. But, actually, their own planning assumptions have changed because they'd invested in perinatal community mental health services across England after we'd started, but they've seen an impact, and I think it's fair to say they themselves don't understand the reduction in demand for mother and baby units because they expanded the number they had, but the demand's reduced. Now, I can't speak for them about why that is. We're interested in having a conversation about that because, obviously, we'd want to understand that not just for cross-border purposes, but it might help to inform our own work here in Wales as well.”

The demand for MBU beds in North Wales has not decreased.  We in North Wales alongside our mental health colleagues in already stretched existing services are struggling to manage women with perinatal psychiatric illness at home. This more often than not is due to not being able to identify a bed and/or women refusing to go because of the distance. Our closest MBU is Manchester (vary rarely have we been able to get a bed there). For a woman living on Anglesey, it would take over two hours to get to the Manchester MBU provided there is no traffic and excluding breaks to feed the baby. This journey would be very difficult for a mentally unwell woman, struggling with her thoughts and feelings, and a baby needing to be cared for. This journey was enough for one woman to take her own discharge as a result of being so far away and her family not being able to visit during the week due to the distance. She subsequently ended up back and forth between HTT, perinatal, CMHT and another admission to an MBU. Another woman who refused an MBU for the same reasons spent 9 months as an acute inpatient between two units within North Wales. She spent 9 months separated from her baby. 

 With around 7086 live births last recorded (2015) and the size of the geographical area we cover, the North Wales Perinatal Mental Health Team is not resourced to educate, detect, prevent, treat and in addition respond to crisis when we cannot access a bed, or the bed is refused due to distance, fear or inability to maintain family support during the admission. To date the North Wales team has seen 10 admissions and in addition 12 refusals. When a woman is admitted to an MBU, vary rarely is it possible for one of our practitioners to attend ward rounds and discharge planning meetings due to workload capacity (clinics are booked in for up to 8 weeks ahead). This has a significant impact on continuity of care for these women.

Michelle Brown

“Okay, thank you. I mean, I appreciate you're working on the MBU issue. In the meantime, we've got women who are being sent out of area for in-patient services. I know there are some women who would prefer to be sent out of area for various reasons, but what support's being provided to patients who are being sent out of area? And those who are refusing the option of being sent out of area—what's happening to them and what support are they getting?” 

Dr Liz Davies

This goes back to the community teams having a very strong step-up, step-down type of model. So, the community teams would be involved from the beginning. They would be involved through the lady's stay in whichever unit she was at, and then be ready to receive and bed her back into her community and her home. So, it's a strong thread there that is followed. 

Again I would disagree. Many women who become mentally unwell in the perinatal period are not open to CMHTs and may have had no previous involvement with psychiatric services. When being stepped up to secondary care, there is frequently a wait to be allocated a care coordinator in an already overstretched CMHT and this can take a number of weeks. In the interim there would not be a community mental health professional to attend ward rounds, discharge planning etc. Women who decline MBU admission, are not always readily accepted into secondary care and it can become a battle to achieve care coordination (as we know the threshold for perinatal women to access secondary care should be lower than it would be outside of the perinatal period).

Lynne Neagle

“And in terms of north Wales, if it's not possible to reach agreement with NHS England, is it an option to simply commission a unit in Wales for north Wales use?”

Vaughn Gethin

“It's always an option, but the challenge comes back to the reason why the previous unit in south Wales didn't continue, about the ability to maintain skills and quality. And it depends on the demand as well. At this point, the demand isn't there to sustain a single unit on its own in north Wales. But we have got to have an answer for how we improve the service, where that service is needed. And that still goes back to linking to the community team, and if the beds that we are going to make use of are in England, we still have to make sure that the current beds that exist are continued between the north Wales community team and wherever that specialist unit is, whether it's in Wales or whether it continues to be that the regular port of call is in England.”

There are many barriers for women in North Wales, not only with women refusing due to distance and family separation, but also we have had situations where the father has refused to allow the baby to go with the mother when she lacks capacity and he has parental responsibility. Again this is usually due to distance, not being able to visit when it is convenient for him and not knowing who is looking after his baby.

There are many things being disregarded when looking at MBU provision for North Wales, in particular the additional 12 mothers from North Wales who refused an MBU admission last year. If we had had a local MBU then these women would have been admitted with their babies. There are also instances where women with a history of serious mental illness would benefit from a short stay with their babies for example to regulate sleep or adjust medication to prevent deterioration into more severe mental illness.

Yours sincerely

Donnalee Williams

Perinatal Mental Health Team Manager

North Wales