Veterans’ Mental Health Current Response to the Mandate & Challenges for the Future. Andy Bacon NHS England Central Team Lead for Armed Forces March 2015

Cross Government Obligations Armed Forces Covenant/ Mandate “The NHS need to demonstrating progress against the Government’s priorities of: upholding the Government’s obligations under the Armed Forces Covenant; The Covenant says: The Armed Forces Community should enjoy the same standard of, and access to, healthcare as that received by any other UK citizen in the area they live. Personnel injured on operations should be treated in conditions which recognise service needs For family members, primary healthcare may be provided by the MOD in some cases (e.g. when accompanying Service personnel posted overseas). And … should retain their relative position on any NHS waiting list, if moved around the UK due to the Service person being posted. Veterans … should receive priority treatment where it relates to a condition which relates to .. their service, subject to clinical need Those injured in service should be cared for in a way which reflects the Nation’s moral obligation …with professionals who have an understanding of Armed Forces culture

The Equalities Act Access to services should be governed, as far as practicable, by the principle of equal access for equal clinical need. Individual patients or groups should not be unjustifiably advantaged or disadvantaged on the basis of age, gender, sexuality, race, religion, lifestyle, occupation, social position, financial status, family status (including responsibility for dependants), intellectual / cognitive function or physical functions. Developing a better understanding of the unique needs of ex-service personnel and families enables discrimination based on need (and hence treated as a “Minority” with particular health needs).

DIVIDED RESPONSIBILITIES for Commissioning Serving Veteran Operational Care MoD/DMS Not Applicable Occupational Health Public Health (Immz and Screen) (Health Promotion) NHS England (PH) Local Authorities Primary Health Care NHS England (Primary Care) Community Health Care NHS England (AF) NHS CCG Rehabilitation Acute Hospital Care Mental Health Social care/Welfare Charities/ Local Authorities Specialised Health Care NHS England (Spec Comm)

Armed Forces commissioning responsibilities   Serving Armed Forces in England Serving Armed Forces overseas Armed Forces Families registered with DMS med centres in England Armed Forces Families registered with DMS med centres overseas Armed Forces Families registered with NHS GP Practices Reservists while mobilised i Veterans (inc. reservists when not mobilised) Primary Care DMS ii DMS NHS England & NHS England iv Community Mental Health CCGs Secondary acute & community care CCGs iii MOD Enhanced pathways N/A i - Reservists have access to DMS care whilst mobilised ii - Serving personnel can access local GPs on an emergency basis if needing to access care whilst away from the military address iii - The NHS England will commission specialised services for veterans, e.g. limb prostheses, iv - While overseas, serving personnel and families can access DMS-commissioned healthcare where such provision exists, or may be provided with non-DMS healthcare by local Host Nation or other contracted arrangements, or have right of return for NHS care in England

NHS England - Armed Forces Health NOT UK WIDE NHS England - Armed Forces Health NHS England Board NATIONAL LOCAL NHS England Commissioning Operations CLINICAL COMMISSIONING GROUPS Limited Range of Services Reservists, Veterans’ & Families Commissioning Armed Forces Commissioning Design Principles : Retain: Knowledge, expertise, capability, continuity, skillsets, credibility Ensure: Momentum, partnerships, linkages, AFNs, practical configuration and delivery Central & Regional Team Community and Acute Hospital for those registered in MOD Centres Assurance of CCGs All non-specialised services for Veterans, Families, Reservists Health and Wellbeing Boards, AFNs, Community Covenant and partnerships Armed Forces Commissioning Interface between MOD and Providers Veterans’ and families commissioning Transition management Veterans, reservists and families

TRANSITION IN AND OUT OF SERVICE Transition – Wounded Injured and Sick; ‘service leavers’, mobilisation and demobilisation CCGs Reservists Veterans Families DMS Operations Occupational Primary Mental Rehab NHS England Community Care Acute Care, CHC TRANSITION IN AND OUT OF SERVICE

System and network complexity

Armed Forces Networks NHS Health Care Armed Charities Forces Represent all local Stakeholders, including: Regional Armed Forces command and health structures MoD Personnel Recovery Units Local NHS – commissioners and providers Local Authorities Charities Veterans and families organisations/ individuals – patient and user voice Supporting Transition of service leavers, local learning, national learning, information sharing, commissioning and key patient voice issues Meet regularly 3-4 times per annum and ‘virtually’ all the time to resolve cross-system issues Currently 9 in England mapped closely to Army regional Brigade structure Routine monthly AFN teleconf - to share system leadership and oversight of issues with partners and stakeholders Regional models vary to reflect stakeholders and relationships, but based on core principles above NHS Health Care Armed Forces Charities Local Authorities

What we know? Who are our community? Age, service history, type of service When do they engage? Delay Who do they engage through? Where do they engage? Veterans distribution What are their issues? Co-morbidities New reports: Ashcroft – most do well from service Stephen Phillips – (Former Members of the Armed Forces and the Criminal Justice System) RBL – (UK Household Survey of the Ex-Service Community) KCL – “Myth buster” Service evaluations (NVMHN, CIE Needs Assessments) Etc.

OP and Community Veteran Provision (IAPT and NVMHN for NHS)

OP and Community Veteran Provision by Region

Early Impressions from Review of Needs Assessment Local Authority JSNAs Good (but not complete) coverage Narrow focus of assessments CCG provision: IAPT/ Parity of Esteem/Crisis Concordat/ Closing the Gap Variable specialist veteran provision: Type of services Availability of services Diverse Charity Provision A few large vs. multiple small; Quality assurance & navigation issues Gaps National gaps e.g. crisis, young people, etc. Limited user views Families Step 3 Co-morbidities

NHS England’s General Roles in Mental Health Direct Commissioning for Health and Justice settings Specialised (e.g. Forensic, Tier 4 CAMHs) Delivering National Programmes: The Mental Health Crisis Care Concordat The right quality of treatment and care when in crisis Recovery and staying well, and preventing future crisis Parity of Esteem Better data and information for the public, commissioners and providers Addressing the physical health of people with serious mental illnesses Addressing and improving crisis care Closing the Gap Mental health must have equal priority with Physical Health Involvement of many partners from across the voluntary sector, from national charities like Combat Stress and Help for Heroes, to local community groups CCG Assurance …..

Current NHS Roles re Veterans MH CCGs (should have) taken over veterans commissioning IAPT services Different local models to meet local needs Veterans are below “critical mass” NHS England inherited roles: £1.5M nationally for Regional (locally decided to deliver Murrision “Fighting Fit”) - original purpose more professionals £3.2M specialised in Patient PTSD £350k Big White Wall Developing the Evidence Base Domestic Abuse Needs assessments Pilot development

Other Activity in Veterans’ Mental Health Providing fora for advocacy and discussions: Clinical Reference Group Veterans’ Mental Health Network Armed Forces Networks Covenant promotion e.g. contract, royal colleges etc. Funding Response to national reports: House of Commons Defence Select Committee Philips on Veterans in Custody Improving integration and transition: Temporary Registration Summary of care record on discharge

Changes in the last 2 years Transferred Service personnel from MoD system to NHS System and so single registration (MoD retain own record) Maintained continuity of intherited mental health services for Veterans Rewrite of Joint Services Publication for joint work with the recovery of the wounded, injured and sick and transition Research in Domestic Violence, Needs assessments for veterans: Mental Health (in progress) Gathering of data on activity of 10 regional mental health services. DCMH & NHS Provider Pilots National IAPT data capture and Health and Justice capture including L&D

Possible Future Roles Use System Management/ Market Management to deliver new services to: Improve Data capture Define roles more clearly CCG Charities NHS England (redefined specialist only?) Provider assurance Promote under provided services: Complex Trauma with comorbidity Personality/Adjustment Disorder Families support

Possible Items for Discussion PREVENTION Importance of transition out of service work between DMS and NHS Understanding incidence and causes of: Alcohol misuse Mental ill health Criminal behaviour (especially violence and sexual) ACCESS Who is a veteran? Attribution a minimal issue in healthcare access Behavioural aspects of care: Accessing care Non clinical interventions INTEGRATION Common Philosophy Data definitions Common assessment Common Pathways Record sharing Measuring joint outcomes

Thank you! andy.bacon@nhs.net http://www.england.nhs.uk/resources /resources-armed/