Perinatal Mental Illness

(Limited Text - Ministerial Extracts only)

Thursday 19th July 2018 Westminster Hall

[The Parliamentary Under-Secretary of State for Health and Social Care (Jackie Doyle-Price)]

It is good to see you in the Chair, Mr Rosindell. The debate has been excellent. I have enjoyed listening to all the speeches, which, without exception, have been thoughtful, constructive, and, in the case of people who have been through motherhood, very honest and gritty about the reality of the situation that we face. I pay tribute to the hon. Member for Stockton South (Dr Williams) for making as articulate a speech as possible on the issue. It covered the whole breadth of subjects that we need to consider. It was a real pleasure to listen to him. I will say the same about my hon. Friend the Member for South West Bedfordshire (Andrew Selous). I am pleased to see two men leading the charge on this subject. It is an important message that this is not a woman’s problem; it is a problem for society and for families. Ultimately, if we do not tackle it, society picks up the tab. It is great that two male Members of the House are leading the charge.

Many themes have come up in the debate, and I will try to address them all. I will begin by tackling the issue of the first 1,001 days. A number of hon. Members present are members of the all-party parliamentary group for the prevention of adverse childhood experiences. We recognise that the period from conception to age two is vital for every child’s development, and that is why we are prioritising and focusing on ensuring that there is sufficient perinatal mental health support at that stage. On the wider issue of adverse childhood experiences, the hon. Member for Stockton South mentioned that having four of them makes someone more likely to end up in prison. This is about the best kind of early intervention—for me, that is a no-brainer. We can identify those young people or children who are most at risk of falling out of society. Therefore, we should look at how best we can intervene early to support them.

[Luciana Berger]

I am delighted to hear the points the Minister has made about the importance of the first 1,001 days and the nought-to-two agenda. On that basis, might we expect the Government to respond to their Green Paper consultation on young people’s mental health by putting in place measures to support and help under-fives?

--- Later in debate ---

[Jackie Doyle-Price]

As I have often said, the real focus of the Green Paper is on schools and measures that we are taking with the Department for Education. However, the hon. Lady and others will be aware that we have committed to extra funding for the NHS and we are working with NHS England on what we can all expect with that extra funding. I am open to representations as we develop that 10-year plan as to what else we can do in this space. As we are in discussions with NHS England, I cannot make any commitments but this is exactly the time when we should rigorously be testing policy suggestions and interventions that we might be able to deliver.

[Dr Paul Williams]

It was reported in the Health Service Journal two days ago that the chief executive of the NHS, Simon Stevens, has outlined five priorities for the 10-year plan and that one is reducing health inequalities. Does the Minister think that a serious focus on reducing health inequalities—particularly those that are embedded from the beginning of life—should be a focus for the 10-year plan?

[Jackie Doyle-Price]

The hon. Gentleman earlier used the phrase “spend to save”, so the answer is yes, because obviously if we make interventions earlier and they help people to help themselves, there is a long-term saving to the NHS. That is the exact spirit in which we are entering the 10-year plan for the NHS. I look forward to hearing suggestions from the APPG—get in touch with us soon.

I thank everyone who has contributed to the debate and hope that we can go forward with the shared objective of doing the best we can for new mothers. By that I mean not only improving services, but giving support in general to women who are going through the experience of motherhood. As many Members have said, we are offered a fairy tale fantasy about how everything is perfect and wonderful, when actually there is a lot of associated vomit, pain and misery—joyful as the experience is overall. We need to tackle the taboo, because the fact that we think that everything is a perfect fairy tale means that the pressure on those women who are struggling makes them feel like failures. They are not: it is all entirely normal.

I am always struck by the fact that one in three women suffers from incontinence. People do not know about it, because everyone suffers in silence and just gets on with it. I often ask, “How would it be if one in three men suffered from incontinence?” We would hear about that a lot more. We need to be generally more open and give women the message: “Do you know what? It is normal to feel you are struggling, and feel miserable, because you have gone through a life-changing experience and a physical trauma. It is inevitable that it will affect your mental health.” Giving them the message that it is normal is half the battle, because they will realise that they are not a failure but just need to manage and work through the situation. We need the right services in place to help them.

[Andrew Selous]

Is the Minister aware of the Best Beginnings “Baby Buddy” app, which has videos of parents sharing their experiences to help reduce the isolation some parents feel? It encourages women to take the time to look after themselves and their relationships, if they are with a partner. Does she agree that that is practical? It is free and lottery funded. It is not making a profit, as far as I am aware. I think it is run by a charity. Things like that can be helpful to mothers who might otherwise be quite isolated.

[Jackie Doyle-Price]

That sounds like a good resource, not least because it means women can get access to help in a more anonymous, less threatening way. We need sufficient tools to be available for women—and families, for that matter.

We have heard constantly throughout the debate that women are not always asked about their mental health in GP health checks. For that matter, they are not always asked about their physical health either; it is all about the baby. One of the challenges we have in improving the way in which we deliver health comes from the fact that an NHS practitioner faced with a patient will focus on the immediate problem and not the patient’s holistic needs. There is a need to consider mother and baby together. A baby cannot be looked at in isolation. The role of the mother, and the relationship with the mother, is part of the child’s welfare. We need to spread better practice in that regard.

[Andrew Selous]

I agree very much about looking at the mother as well as the baby, but does the Minister agree that, where there is a relationship with a partner, dad must not be left out, and that working on the couple’s relationship is a key matter, given that mums probably look to their children’s parent more than anyone else for emotional and practical support?

[Jackie Doyle-Price]

I thank my hon. Friend for being my conscience—we absolutely must not forget dad or partner, or for that matter the wider family. Members have expressed concern about the declining number of health visitors, and the beauty of having a health visitor is exactly the fact that they develop a relationship with the family and can talk to dad as well. Quite often, dad feels excluded from the process.

[Wera Hobhouse]

Valuable and important as that exchange is, the point about the #HiddenHalf campaign is that often attention is diverted away, because the baby and the dad are there. #HiddenHalf is looking for quality time for the mother in particular. I want that space to be preserved, however much is done by the GP. It is important that a woman who has gone through the trauma that the Minister described is able to feel, “Someone is just looking after me.” It is important to recognise that.

[Jackie Doyle-Price]

I agree and do not think the two points are in conflict. We need both—we need the wider package of support.

The theme we have been considering—of women not always being asked about themselves, and its being all about the baby—is not confined to the issue of perinatal mental health. Women face that across the board with respect to their health. The hon. Member for Worsley and Eccles South (Barbara Keeley) spoke about a women’s health strategy and women’s mental health. I co-chair a women’s mental health taskforce with the chair of Agenda, and in the coming weeks we will present our report on a year-long piece of work. It will have information about tools to enable the health service in general better to support women’s mental health. I am also doing more to raise the whole issue of women’s mental health, because I feel strongly that women are often disempowered in health settings. We need to give them the tools to take control of their own care and to feel empowered to engage in good conversations with medical professionals, to benefit their health.

We have heard anecdotal accounts of women’s experiences, and what has come across is the arrogant behaviour of some medical professionals. They see a large number of patients and they are not always sensitive to how best to communicate with certain individuals. We need that practitioner-patient relationship to work a lot better, particularly in the case of women. I am open to representations from everybody about what tool we can use.

The hon. Member for West Ham (Lyn Brown) is no longer in her place, but I have been impressed by her work on hysteroscopies with women. We are developing tools on that. I reassure all Members that women’s health and the way in which the national health service can better serve women are high on my agenda. I am not going to stand here and say that the world is perfect, but we have made perinatal mental health a priority in the five year forward view. We are midway through that review, so I should give Members an account of how far we have got and what more needs to be done.

To go back to 2010, the situation was really quite poor. Only 15% of localities had fully fledged specialist services in the community, and 40% of communities provided absolutely no service at all. People talked about a postcode lottery; clearly, we could not allow that to continue. We need to work towards universal provision. We are implementing the recommendations of the five year forward view for mental health taskforce, which reported in 2016. From 2015 to 2021, we are investing £365 million into perinatal mental health services. NHS England is leading a transformation programme to ensure that, by 2021, at least 30,000 more women each year are able to access specialist mental healthcare during the perinatal period. In May, NHS England confirmed that, by April next year, new and expectant mums will be able to access specialist perinatal mental health community services in every part of the country. We are making progress. The key to that is community provision.

[Barbara Keeley]

I asked the Minister a specific question: we are halfway towards the deadline for the 30,000 target—does she know how that target is going? Has there been an improvement of 15,000?

[Jackie Doyle-Price]

I will write to the hon. Lady with some detail on the figures, but the point is that the access is there. Obviously, it will take time to become embedded. We have a good direction of travel to deliver against that commitment and we will continue with that. Community-based provision is key, but we also need to ensure that there are sufficient specialist perinatal mental health beds in mother and baby units for particularly severe cases. NHS England has taken a more strategic approach to commissioning, so that there is a level of access that does not involve wide-scale moving out of area.

As ever with transformation programmes, change takes time, but we are on track to meet our commitments. We are investing £63.5 million this financial year to support the development of those specialist perinatal mental health community services across England. Our pace of change is to enable 2,000 more women to access specialist care. Last year that was exceeded, so we should maintain the pace that we planned in the five-year forward view.

I have visited one of the new in-patient mother and baby units in Chelmsford, where there are four new beds. That centre is expanding its capacity. As well as opening new centres, we are expanding the capacity of existing ones to give more support. In Devon, the trust opened a four-bed mother and baby unit in a reused space in April this year while the new unit is being built, so we still have that provision even though there is not the physical space. By the end of this financial year, we will have expanded the capacity of those beds by 49% since 2015 and there should be more than 150 beds available for mothers and babies in those units.

We are also expanding psychological therapy services, which successfully treat many women who experience common mental health conditions such as depression and anxiety disorders during the perinatal period. We have set an ambition for at least 25% of people with common mental health conditions to access services each year by 2020-21, including extending provision to ensure swifter access for new and expectant mothers. However, as we have heard today, getting perinatal mental healthcare right is not just about expanding specialist services in isolation. Many professionals in different parts of the health and care system are well placed to support women in the perinatal period. NHS England is working with partners to ensure that care for women is integrated and joined up effectively. More than £1 million was provided in 2017 to enable the training of primary care, maternity and mental health staff, to increase perinatal mental health awareness and skills.

NHS England has also invested in multidisciplinary perinatal mental health clinical networks, which will include GPs across the country to support that strategic planning, working across services to ensure that those wider services are in place. The role of GPs is central in identifying when someone is suffering from perinatal mental illness, and to ensure that those women are directed towards treatment. The role includes monitoring early-onset conditions, including pre-conception counselling, referring women to specialist mental health services, including access to psychological therapies, and specialist perinatal community teams where necessary.

I am aware of the NCT’s #HiddenHalf campaign; I am grateful for its campaigning on this important issue. The National Institute for Health and Care Excellence recommends post-natal checks for mothers and new-born babies. NHS England expects commissioners and providers of maternity care to pay due regard to the NICE guidelines. My hon. Friend the Member for South West Bedfordshire raised this issue and said that, since this was part of what we should expect from GPs, it seemed anomalous that so many mothers and babies were not getting such checks. We make clear to GPs what we expect of them, as part of their contract, but ultimately we rely on clinical commissioning groups to ensure that GPs deliver against the obligations that we expect of them. This is not the only case where this happens—many GPs are not delivering learning disability health checks either. We need to be clear with NHS England that we expect that obligation to be delivered.

[Dr Paul Williams]

The hon. Member for South West Bedfordshire referred to a maternity additional service that only four general practices have opted out of. Is the Minister aware of what period of time that additional service covers?

[Jackie Doyle-Price]

I will come back to the hon. Gentleman, but this area requires further exploration because we need to be clear about how we deliver on those things.

[Dr Williams]

I will gladly tell the Minister: the period of time covers pregnancy but ends 14 days after birth. Whereas it may be very appropriate for a GP to provide care during that time, the additional service that the hon. Member for South West Bedfordshire referred to ends 14 days after birth. We are talking about a different issue: the opportunity to do a check six weeks after birth. There is no commissioning of that check at the moment. It is helpful that the Minister says that she expects commissioners to commission that check, but is that a commitment from the Government to ensure that commissioners are funded to be able to commission that six-week check?

[Jackie Doyle-Price]

I was coming to that—I was just dealing with the point made by my hon. Friend the Member for South West Bedfordshire.

Moving on from the NICE guidelines, we clearly expect GPs to do their part in identifying and supporting women. We are aware of the campaign, but any changes to GP contracting arrangements to specifically include the six-week check-up would need to be negotiated with the GP committee of the British Medical Association. Those negotiations are taking place and will be completed by September. I cannot give any firmer commitment than that, other than to say that we obviously want to see GPs make their contribution.

[Barbara Keeley]

I just want to reiterate what I said earlier: the Opposition support that campaign and would look at implementing it in government. I outlined that the NCT put a cost of £20 million on it. Clearly, the Minister could have that figure checked out, but it is balanced against the £1.2 billion extra cost to the NHS and social care of perinatal mental health problems in every one-year birth cohort. There really is a point here about investing to save further down the road.

[Jackie Doyle-Price]

I thank the hon. Lady for that. As she says, if we are talking about £20 million in a broader settlement, that clearly should be under consideration given the outcomes that could be achieved on the basis of the evidence we have seen. I am not negotiating the contract, but we will have the outcome of those negotiations in the not-too-distant future. Members on both sides of the Chamber expressed very clearly the view that they want GPs to be able to do more to support new mothers. That message has been well noted, and I thank Members for making it. They said they wished to give me as much as assistance as they could in my battles on these things, and they certainly made a very strong case.

I want to come back to health visitors. I am a firm believer that health visitors are uniquely placed to identify mothers who are at risk of suffering, or are suffering, perinatal mental health problems and to ensure they get the early support they need. In fact, I visited the Institute of Health Visiting only a couple of weeks ago and heard a moving story from a new mum who had gone through a mental health crisis. It is striking that she had experienced all the feelings we have talked about—she felt there was something wrong with her, she could not bond with her baby, and she got more and more depressed and withdrawn about it. The other interesting thing about that case was that it was dad who felt utterly powerless to do anything. Only their relationship with their health visitor enabled them both to reach out for help.

I am under no illusions about the importance of health visitors. I was privileged to meet so many fantastic advocates for them as part of the NHS’s 70th birthday. They are our eyes and ears in so many ways, and they are our intelligence network in tackling adverse childhood events. I am full of praise for the important job they do in supporting new parents and families through a child’s early years. I am really pleased about the success of the Institute of Health Visiting perinatal and infant mental health champions training programme. Those 570 champions play a crucial role in spreading good practice and early identification of mental health problems.

Some hon. Members raised concerns about the decline in the number of health visitors. There was a substantial increase in the run-up to 2015, and there has been a fall since. I am bothered about that, so I will look at how we can encourage local authorities to alter that situation, recognising that in some areas local leaders have realised that health visitors can do so much more to deliver better outcomes for their communities. Blackpool, for example, has substantially increased the number of visits. I am really looking forward to seeing the outcome of that work, so that we can encourage that good practice in other local authorities.

I reiterate my thanks to all Members for their thoughtful comments and questions, but I especially thank the hon. Member for Stockton South and my hon. Friend the Member for South West Bedfordshire for securing the debate. I am very proud of our direction of travel in delivering and transforming perinatal mental health services so that we ensure that more expectant and new mothers are able to access high-quality mental health support, but we should never be complacent about that. I look forward to continuing the transformation programme.