Perinatal Mental Illness

Baroness Keeley Excerpts

Thursday 19th July 2018 Westminster Hall

[Barbara Keeley (Worsley and Eccles South) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Rosindell. I congratulate my hon. Friend the Member for Stockton South (Dr Williams) and the hon. Member for South West Bedfordshire (Andrew Selous) on securing this important debate and on how they opened it. We have heard contributions from the hon. Member for Strangford (Jim Shannon), my hon. Friend the Member for Canterbury (Rosie Duffield), the hon. Member for Bath (Wera Hobhouse) and the Scottish National party spokesperson, the hon. Member for Glasgow Central (Alison Thewliss). We also heard interventions from the hon. Member for Thirsk and Malton (Kevin Hollinrake), my hon. Friend the Member for West Ham (Lyn Brown) and, just a moment ago, my hon. Friend the Member for Liverpool, Wavertree (Luciana Berger).

Pregnancy, birth and becoming a parent can be a special and rewarding time for many people. As we have heard, it is a time to celebrate new life and the start of the exciting journey into parenthood. However, for others, the stress and upheaval of pregnancy and becoming a parent can trigger existing mental health problems or spark new ones. Perinatal mental health issues can include severe mental health disorders that require severe immediate hospital treatment, such as postpartum psychosis. It may affect only two cases in 1,000, but it is a very serious condition and can put new mothers at risk of harming themselves and their baby. The issues can also include most common mental health conditions, such as depression, anxiety, post-traumatic stress disorder, obsessive compulsive disorder and panic attacks. My hon. Friend the Member for Stockton South spoke very well about the impact of those mental health conditions on the child’s development.

Given the expectation that pregnancy and becoming a parent should be a joyful time, women who experience those conditions can feel even more stressed and unhappy, and often that they are somehow to blame for their condition. A study by the Boots Family Trust in 2013 described some of those experiences. One mother said:

“I avoided friends at all costs as I lost the ability to communicate and became very isolated”.

Another said:

“I’m currently into my second pregnancy and think I am suffering from depression…I feel scared and feel like I have trouble bonding with this pregnancy…I don’t know what is wrong with me.”

We know that one in five women will experience mental health problems during pregnancy. Given the high prevalence of mental health issues in new and expectant mothers, the woman I just quoted should not have had to feel like something was wrong with her. We have heard many excellent examples in the same vein in this debate. One way to prevent women from feeling isolated or somehow to blame is by identifying those mental health issues and ensuring the proper support is put in place. Unfortunately, as hon. Members said, too often that does not happen.

Hon. Members rightly highlighted that identification is a major barrier to accessing support for mental health issues. I join them in congratulating the National Childbirth Trust on its #HiddenHalf campaign. The research underpinning that campaign shows that nearly half of all the mental health problems that new mothers experience are not picked up by health professionals.

As we have heard, early intervention is key. The sooner issues are identified, the quicker people can access appropriate support, and that surely drives better outcomes. It is simply not good enough that only half of perinatal mental health issues are picked up. As my hon. Friend the Member for Stockton South detailed, GPs should offer a post-natal check about six weeks after the baby’s birth. We have heard that a properly delivered check-up can have a transformative effect on new mothers who are experiencing mental health problems. Research by the National Childbirth Trust found that women directly questioned by a GP about their mental health were almost seven times more likely to disclose a mental health problem. If mental health problems are left untreated, they can escalate into much more severe mental illness.

The National Childbirth Trust also found that 95% of women who had experienced a mental health problem felt it affected their ability to cope or look after their children or family relationships. As we have heard, the six-week post-natal baby check is mandatory, but the maternal check was left out of the GP contract. As a result, the maternal check is often not done at all or becomes a rushed conversation at the end of the baby check. In one third of cases, the maternal check was estimated to last three minutes or less.

The National Childbirth Trust recommends that the Government fund the six-week maternal post-natal check so that GPs have the time to give every new mother a full appointment for the maternal check. As we have heard, the National Childbirth Trust also recommends an improvement in the guidelines for best practice around maternal mental health, including a separate appointment for that maternal six-week check, and they recommend better methods of encouraging disclosure of maternal mental health problems.

I have looked at the NHS England guidance, which states:

“There are no set guidelines for what a postnatal check for mothers should involve.”

It also states:

“The following is usually offered, though this may vary according to where you live...You will be asked how you are feeling as part of a general discussion about your mental health and wellbeing.”

We can and must do better than that.

I have already mentioned the pressure on women to feel happy after the birth of a child and how mental health issues can lead to their feeling that there is something wrong with them. It can often lead to women putting on a brave face. One woman, responding to the Boots Family Trust survey, said:

“I was terrified to admit to any health professional as I was scared they would take my son away.”

That is exactly the point made by the hon. Member for Glasgow Central and it demonstrates the challenges that GPs face in identifying mental health issues. Merely asking how a new mother is feeling is no substitute for a properly trained staff member identifying mental health issues and knowing how to encourage disclosure.

The National Childbirth Trust recommends that NHS bodies should support and invest in initiatives to facilitate and further develop GP education on maternal mental health. Earlier, my hon. Friend the Member for West Ham touched on the fact that investment in perinatal mental health would result in savings. It is worth thinking about how much that might be.

The statement from the Royal College of General Practitioners about perinatal mental health said that post-natal depression, anxiety and psychosis carry an estimated total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK, and 72% of the cost relates to adverse impacts on the child. That reinforces the very important points that my hon. Friend the Member for Stockton South made earlier. More than a fifth of those total costs—£1.7 billion—are borne by the public sector: mainly NHS and social care. I hope that that all helps to give the Minister ammunition. Sadly, the average cost to society of one case of perinatal depression is estimated to be £74,000: £23,000 relates to the mother and £51,000 to the impact on the child. There is every reason to try to make the case being made in the debate today.

We must make sure that, where a diagnosis has been made, appropriate treatment and support is made available. According to the Maternal Mental Health Alliance, a quarter of pregnant women and new mothers cannot access specialist perinatal mental health services that meet the full National Institute for Health and Care Excellence guidelines. Only 7% of the women who reported experiencing a maternal mental health condition were referred to specialist care. It took more than four weeks for the 38% of the women who were referred to be seen. Shockingly—we have heard several examples—some women waited up to a year for treatment. My hon. Friend the Member for Canterbury talked about such an example. In fact, it was recently revealed that there were only 131 specialist perinatal beds in the whole of the UK, with none in Northern Ireland or Wales.

We know that pressure on mental health trusts comes from money earmarked for mental health services being used to pay for other areas of the NHS. The Labour party would ring-fence mental health spending so that funding for mental health services is not siphoned off to pay for other priorities. In this debate we have heard much detail of the #HiddenHalf campaign. The Opposition support that important campaign and we would look at implementing it in government. We call on the Government now to make resources available so that every mother is given the perinatal support that she deserves. It is important that we also include that commitment to ring-fence mental health spending so that the funding that is meant to be for mental health services does not go to other priorities in the NHS.

The Government have made some commitments on perinatal mental health, and I am keen to hear from the Minister, if we have time, what progress has been made. The five-year forward view for mental health set a target to ensure that by 2021 at least 30,000 more women each year would be able to access specialist mental health care during the perinatal period. Given that we are now halfway through that phase of the five-year forward view for mental health, can the Minister tell the House what progress has been made towards that target and whether NHS England is on track to meet it?

In autumn 2017, at the maternal mental health ministerial roundtable, a number of commitments were made to improve perinatal mental health services. They included a commitment that the Department of Health would work with health system partners and other Government Departments to deliver improvements in perinatal mental health services, and a commitment that NHS England would expand specialist mental health services by 2021 to meet the needs of women in all areas. We have heard, as we hear in so many debates on health and social care, about very unfortunate postcode lotteries, so how is NHS England doing in expanding those specialist services to meet the needs of all women?

[Luciana Berger]

My hon. Friend is making a strong case, as have other colleagues, about the inconsistency of the availability of perinatal mental health services. Although there has been some investment, there are still many areas where there is no sufficient, adequate or indeed any immediate access, and mothers still have to travel too far across the country to access a bed if they need one in a mother and baby unit. Does she share the concern expressed by the British Medical Association that there is a 20% difference in referral rates in some areas, which illustrates the inconsistency of care? When the issue is so critical not only for the mother but for the child in its lifetime, that is something that the Government should urgently address.

[Barbara Keeley]

I absolutely agree with my hon. Friend. It is very important that the Minister tells us now or after the debate what is happening to expand the services so that we do not have what are almost deserts, where women have to travel either to get a bed or to get the service that they need.

Finally, there was a commitment in autumn 2017 that NHS Health Education England would support the roll-out of GP perinatal mental health champions across England. I am sure it would help if there was in every area a perinatal mental health champion speaking up for their own area. Will the Minister tell the House what progress has been made on these important commitments?

I want to conclude on a wider point about women’s mental health. Women are more likely to suffer from mental ill health than men, and yet too often women’s specific mental health needs remain a blind spot. Research by Agenda, the women’s mental health charity, has shown that mental health trusts are too often failing to consider women’s specific needs. Only one of the 35 trusts that responded to a freedom of information request by Agenda had a strategy on gender-specific mental health services.

Fourteen years ago, the Labour Government launched a comprehensive women’s mental health strategy to address the specific mental health needs of women. Sadly, that strategy was ditched by the coalition Government, and women’s mental health has since slipped down the policy agenda. The Mental Health Foundation has described it as being “almost invisible” in Government policy.

We have had an excellent debate today in which many useful examples have been given and many good points made. There is a strong feeling that we want to help the Minister do something about this issue. Will she in future match Labour’s commitment to have a national women’s health strategy that would work to deliver the targeted support that women and girls need?

--- Later in debate ---

[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.

--- Later in debate ---

[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.