1. Call to Mind A review of veterans and family members mental and related health needs 2nd July 2015
Welcome
My role as Lead Facilitator – oversee the agenda, make sure we stick to time and finish as agreed at 1:15pm
Housekeeping – toilets, refreshments, fire alarms and mobiles.
Introduce the team of colleagues who will be speaking – RL (FiMT), Lord Patel, Kate Davies (NHS England) and Jon Bradford

2. Timing
Activity
Speakers
10.00
Introduction to the day
Brian Parry BPA
10:05
Welcome from Chair
Ray Lock FiMT
10:15
Opening remarks
Lord Patel of Bradford
10:25
Commissioning and NHS England context
Kate Davies } NHS
Amanda Fisk } England
10:40
Summary of the HNA report
Jon Bashford CIE LLP
11:00
Plenary discussion/Q&A
11:15
Coffee
11:30 to
12:30
Break-out groups
12:35
Plenary review
Ray Lock
13:10
Next steps
Senior NHS England rep
13:15
Closing remarks
13:16
Lunch
14:00
Close

3. Meeting objectives
Early presentation of report findings for selected stakeholders and service users
To discuss emerging priority areas and consider how we can take these forward to bring real change
Opportunity to meet others working in the area of Veterans mental and related health
Purpose of today

4. Who is here today? NHS Commissioners and Providers Local Authorities
Other Government departments (MOD)
Service charities
Non-Service charities
Academic researchers
Service users
Who do we have here in the meeting
Good mix across the spectrum of commissioners and providers, as well as other interested parties, and most importantly some service users

5. Chief Executive Forces in Mind Trust
Call to Mind A review of veterans and family members mental and related health needs Chair, Ray Lock
Welcome
My role as Lead Facilitator – oversee the agenda, make sure we stick to time and finish as agreed at 1:15pm
Housekeeping – toilets, refreshments, fire alarms and mobiles.
Introduce the team of colleagues who will be speaking – RL (FiMT), Lord Patel, Kate Davies (NHS England) and Jon Bradford
Chief Executive
Forces in Mind Trust

7. ‘The aim of Forces in Mind Trust is to provide an evidence base that will influence and underpin policy making and service delivery in order to enable ex-Service personnel and their families to lead successful civilian lives’

8. Call to Mind A review of veterans and family members mental and related health needs Lord Patel of Bradford
Welcome
My role as Lead Facilitator – oversee the agenda, make sure we stick to time and finish as agreed at 1:15pm
Housekeeping – toilets, refreshments, fire alarms and mobiles.
Introduce the team of colleagues who will be speaking – RL (FiMT), Lord Patel, Kate Davies (NHS England) and Jon Bradford
Director, CIE

9. The Commissioning Architecture
Kate Davies
Head of Public Health, Armed Forces and their Families and Health & Justice &
Amanda Fisk
Director of Commissioning Health and Justice (South) and Armed Forces (England)
NHS England

10. NHS England welcomes review and the partnership approach and work with Forces in Mind and Community Innovation Enterprise (CIE)
NHS England will support the collaborative and partnership approach to improve :
commissioning for armed forces and their families
the transition and needs of veterans and their families

11. Armed Forces and their Families Commissioning Context
‘Armed Forces Covenant’, the Mandate / NHS Constitution
135,000 persons £43 million direct commissioning budget for the registered with Ministry of Defence (MoD) GPs (including mobilised reservists and some families). One team responsible for direct commissioning for this population – mainly Male, young and army other ranks
2.5 million Veterans in England
- Transition from serving to veteran is key to good health
- Clinical Commissioning Group (CCG) is lead commissioner
- Mainly old
- Clinical Needs different from general population
2 Times the reported issues of Musculoskeletal (MSK)
3 times the hearing loss
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

12. What We Commission
NHS England is responsible for planning and commissioning for:
- serving personnel
- mobilised reservists
- families registered with MoD medical centres
Ministry of Defence commission: for serving personnel
- Operational care
- Occupational health
- Primary care
- Rehabilitation
- Mental health services
Commissioning of services for other members of the armed forces community (i.e. most families, non-mobilised reservists and veterans) is the responsibility of CCGs
NHS England manages transition between MoD and NHS led care
Additional Funding is possible e.g. mental health services, prosthetics, wheelchairs and hearing aids (the last two will be funded by Royal British Legion).
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

13. Putting Patients First: Objectives1 2
Services for the armed forces are commissioned to achieve the best health outcomes, in line with the commitments of the Armed Forces Covenant
We work in partnership with the MoD to commissioning healthcare in line with the partnership agreement and in support of DMS’s objective to promote, protect and restore the health of the defence population in order to maximise fitness for role. 3 4
We will work with the MoD and CCGs to improve the model of integrated care that service leavers with mental health or complex physical health needs receive
We will collaborate with CCGs and Health and Wellbeing Boards to develop and embed strong armed forces networks to ensure that the armed forces community receives appropriate care regardless of commissioner
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

14. Commissioning Responsibilities
Complex set of commissioning responsibilities with Clinical Commissioning Groups and Defence Medical Services
Serving Armed Forces in England
Serving Armed Forces overseas
Armed Forces Families registered with DMS in England
Armed Forces Families registered with DMS overseas
Armed Forces Families registered with NHS GP
Reservists while mobilised
Veterans
Primary Care
DMS
NHS England
DMS and NHS England
Community Mental Health
CCGs
Secondary Acute Community Care
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

15. Commissioning Armed Forces Services
The National Team sets the requirements
Service specification, policies and annual commissioning intentions.
Creates a climate for success, through effective relationships with national partners.
Supports regional team.
Undertakes selected national service reviews.
The Region
Accountable for the budget
Operational management of armed forces commissioning,
Working in 1 national team in 3 locations.
Develop collaborative commissioning with Partners: CCGs, Local Authorities, Public Health England and across MoD
Promote improved health outcomes and health & wellbeing.
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

16. Armed Forces Clinical Reference Group
AFCRG has been established to cover services that are directly commissioned by NHS England and advise on other issues
Leads in developing the products required for the effective commissioning of armed forces services, including research
Aim to ensure clinical and patient led development and in particular the commissioning policies for serving personnel
They will have 5 areas of focus:
Pathway redesign
Musculoskeletal care
Mental health
Stakeholder engagement ( 3rd Sector and armed forces charities)
Improving Information sharing and making use of the digital revolution
Dr Jonathan Leach chairs the AFCRG with oversight from Professor Keith Willet in the Medical Directorate.
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

17. South Region Leads with locality support
Armed Forces   
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

18. Comparative Figures for Veteran Distribution
England population
Royal British Legion Household 2014 Adult ex-Service community
Armed Forces Compensation (AFCS and WP)
GP Registration %
Greater London
16% 4%
South East
17%
15%
19%
South West
10%
East of England
11%
12% 9% 8%
East Midlands
West Midlands
Yorkshire & Humber
14%
North East 5% 7%
North West
13%

19. Mental Health Taskforce: A Five Year Strategy for Mental Health
Purpose and Approach:
Asked by Simon Stevens to address:-
- Health and wellbeing gap
- Care and quality gap
- Finance and efficiency gap
Bringing together lived experience, professionals and system
Co-production of approach
Not reinventing the wheel – plenty of evidence
Under Mental Health Parity of Esteem

20. What people are telling us
Prevention is a priority
Access is a priority
Integrated support is a priority
Attitudes & experience is a priority

21. Access is a priority
People want to quickly access effective care and treatment, when they need it
Several aspects of access are coming through, including:
A focus on effective, high-quality treatment and greater choice of treatment;
A wide range of talking therapies, including for complex needs and access within community/primary care;
Reduced variation across the country;
Reduced waiting times; and
Reduced inequalities

22. Putting patients first: key deliverables
Deliver the Armed Forces Covenant and the best health outcomes,
Work closely and collaboratively with Clinical Commissioning Groups to ensure that services, are locally integrated improve care that the wounded, injured or sick service leavers (especially those with mental health or complex physical health needs) receive
Work in partnership with the Ministry of Defence to commission healthcare in line with a partnership agreement and in support of Defence Medical Services objectives to maximise fitness for role
Develop new commissioning policies with strong patient and public involvement
Develop common service specification for the improvement of mental health services in line with national policies
Revise our operational plans
Improve data collection
Scope of armed forces services
Organisation of armed forces in NHS England
Overview of armed forces
services provision
Looking to the future

23. Next Steps
To improve local commissioning and the findings of this report to influence innovation and development across England.
To ensure NHS England's 5 year forward view continues to support the Armed Forces Covenant through mainstream commissioning and provision.

24. Call to mind: A framework for action
Findings from the review of veterans and family members mental and related health needs assessments
Dr Jon Bashford

25. Project aims
Review of the extent to which the mental and related health needs of veterans and family members are being assessed.
Identify priority areas for action to ensure that local services are commissioned appropriately and delivered effectively.

26. Methods
1. Desktop review - all Joint Strategic Needs Assessments (JSNAs) across England:
150 JSNAs
2. Focused consultation - involving 71 individuals:
23 individuals from statutory health services e.g. veterans’ mental health services, CCGs, NHS Trusts and Universities;
20 individuals from the armed forces charities;
28 veterans and family members.
3. Analysis – key themes and priorities for action

27. Outcome A proposed framework for action: Three building blocks:
Targeted and intelligent use of data and information
Appropriate and sensitive evidence based services
Involvement and participation of veterans and family members

28. Targeted and intelligent use of data and information
The purpose of JSNAs is to provide analysis of the health needs of populations in order to inform and guide commissioning of health, wellbeing and social care services within local authority areas.
The need for JSNAs to adequately include and address the health and social care needs of veterans is supported by the commitments on health in the Armed Forces Covenant and the Health and Social Care Act 2012.

29. Targeted and intelligent use of data and information
Fewer than half (40%) of JSNAs across England include a reference to the health needs of veterans;
Variations in geographical coverage and content e.g. less than half of the above (18%) have more than word ‘veteran’;
Only a handful cover the full range of health needs including mental health needs.

30. Coverage of veterans in JSNAs in England by region
Data in main report - page 19

31. Targeted and intelligent use of data and information
The significant gaps in coverage of veterans’ health needs in the JSNAs for England have implications for local area commissioning and whether veterans’ health needs will be adequately addressed in Health and Wellbeing Strategies. This may have an impact on local authorities meeting their statutory duties for public health in line with the Health and Social Care Act 2012.
It is also possible that if veterans and family members are not included in JSNAs then CCG commissioning plans may be affected if they are unable to more fully address this population’s health needs.

32. Targeted and intelligent use of data and information
Priority areas for change and improvement:
primary and secondary care data collection and analysis of veterans and family members;
training and awareness of GPs and wider primary care staff;
adopting a population based approach to health inequalities for veterans and family members.

33. Comparative data - numbers and location of veterans

34. GP registration of veterans compared with population
Data in main report - page 24

35. The care pathway and presenting health needs
Prevention and early intervention
“The GP couldn’t understand what I was trying to explain, my emotional state, physical health, I was also drinking too much, I was just given pills, no referral.”
(Consultation respondent, veteran and family members)
”There are problems getting GPs to understand the issues and feel confident in this area…GPs have very little understanding about veterans...”
(Consultation respondent, statutory service)

36. The care pathway and presenting health needs
Veterans themselves often:
feel reluctant to admit to perceived weakness or being in a position of having to ask for help;
have unrealistic expectations about waiting times and service responses and perceptions that civilians can’t or don’t understand military culture;
Lack awareness and understanding about the options for help and which services are provided either in the armed forces charities or statutory services in the NHS and local authorities.

37. The care pathway and presenting health needs
Access criteria:
“Sometimes people are referred to services but they don't fit the access criteria for either a community mental health team or primary care, they may have personality issues, not coping, problems with adaptation.”
(Consultation respondent, statutory service)
“It’s trial and error to find a good thing.”
(Consultation respondent, veteran and family members)

38. The care pathway and presenting health needs
Complex needs:
“It’s never just a mental health issue, alcohol, debt, employment someone needs to be addressing these needs while the person has therapy for mental health problems.”
(Consultation respondent, armed forces charity)
“If there is any trauma the IAPT reject the case, if they are too angry or too drunk IAPT won’t see them, and they won’t own the referral it just goes back to GP or nowhere.”
(Consultation respondent, statutory service)

39. The care pathway and presenting health needs
Alcohol and drugs
“All the mental health programmes need to have an effective alcohol pathway built in.”
(Consultation respondent, armed forces charity)
“The big gap is in alcohol services, there needs to be a pathway for alcohol.”
(Consultation respondent, statutory service)
“Drug problems definitely exist, I’ve seen it clinically but it doesn’t feature in the research.”

40. The care pathway and presenting health needs
Families and children
“The families don’t know where to get help, they are often isolated with the problems.” (Consultation respondent, armed forces charity)
“Families go through a lot, they need to be involved more.” (Consultation respondent, veteran and family members)
“CAMHS responses for children of veterans are poorly developed, there needs to be greater awareness about this area.” (Consultation respondent, statutory service)

41. The care pathway and presenting health needs
Social care needs
“It works well when you don’t just look at mental health in isolation but include wrap around services, helping people with housing, social care, employment as well as mental health”. (Consultation respondent, statutory service)
“The whole pathway is problematic, there shouldn’t be services in silos, we need more integration not just with mental health but broader welfare.” (Consultation respondent, statutory service)

42. The care pathway and presenting health needs
Physical and related needs
“Once you say you have a mental health problem they won’t treat anything else.” (Consultation respondent, veteran and family members)
“People don’t physically improve if their mental health doesn’t improve, the two are linked.”
(Consultation respondent, statutory service)
“A lot have both physical and mental health problems, but is hard to get this recognised or dealt with together,” (Consultation respondent, armed forces charity)

43. The care pathway and presenting health needs
Armed forces charities
“A lot of the charities are only signposting but if this doesn’t result in people accessing and staying in treatment then it's a waste of money.”
(Consultation respondent, armed forces charity)
“There are too many charities, you don’t where which ones to go to.” (Consultation respondent, veteran and family members)
“There needs to be a kite marking system for the charities but one with teeth…” (Consultation respondent, armed forces charity)

44. The care pathway and presenting health needs
Armed forces charities
“The charities bring additional benefits for engagement with veterans, our branding brings credibility and mainstream services could benefit from this in creating improved access.” (Consultation respondent, armed forces charity)
“Working with a good military charity gives credibility to the NHS service and helps the charity work better with us, it all helps the veterans engage better.” (Consultation respondent, statutory service)

45. Appropriate and sensitive evidence based services
Prevention and early intervention involving the full range of primary and social care professionals;
less restrictive access criteria that can enable services to better respond to complex needs;
clear referral routes for alcohol services as part of an integrated care pathway;
recognition of the needs of family members including children and parents of veterans that takes account of the wider determinants of health such as access to employment, and adequate housing;
greater integration in service responses for meeting both physical and mental health needs and social care needs;
clarity on liaison and partnership working between statutory services and the armed forces charities.

46. Appropriate and sensitive evidence based services
A variety of factors are thought to influence the successful service models including:
a lead clinician with dedicated time and responsibilities for veterans;
champions within departmental service areas across Trusts – often though not exclusively these are clinicians and managers who are themselves veterans;
specific veteran and family member service user forums;
partnership agreements with local armed forces charities where these form part of an integrated pathway;
training and awareness programmes;
formal recognition of the service development with local commissioners either through contracting and procurement or CQUINs (Commissioning for Quality and Innovation).

47. Involvement and participation of veterans and family members
Effective involvement and participation of veterans and their family members is essential for improving data collection and the successful development of appropriate and sensitive evidence based services. There is a need to further strengthen the involvement of veterans and family members in local area service developments to ensure that there is a strong service user voice.

48. Involvement and participation of veterans and family members
Raising awareness – when this is undertaken directly by veterans and family members in a supported way it can greatly enhance credibility and validity of the core messages;
Reducing stigma – overcoming this can be challenging and it is essential that veterans and family members are directly involved;
Assessing and articulating needs –their active involvement also helps ensure that changing needs are picked up at an earlier point and that potential service gaps are avoided;
Co-designing commissioning and service provision – appropriate and sensitive evidence based services are more likely to be developed with the full and active participation of veterans and family members.

49. Conclusion The three building blocks are interdependent and will:
improve the assessment of needs;
inform commissioning;
enhance the delivery of appropriate and sensitive local services that are evidence based;
require collaboration and partnership working across the full range of stakeholders;
promote the involvement veterans and family members

50. Break-out group discussions After coffee
By am please be at your discussion group
BP introduces what happens after coffee
Please identify which room you are in – from the ticket given when you registered. Make sure you are in your room by 11:30 prompt

51. Amanda Fisk and Ray Lock
Call to Mind A review of veterans and family members mental and related health needs Next steps/Closing remarks
Welcome
My role as Lead Facilitator – oversee the agenda, make sure we stick to time and finish as agreed at 1:15pm
Housekeeping – toilets, refreshments, fire alarms and mobiles.
Introduce the team of colleagues who will be speaking – RL (FiMT), Lord Patel, Kate Davies (NHS England) and Jon Bradford
Amanda Fisk
and
Ray Lock

52. Next steps/Closing remarks
Slides from today will be posted on our website later today
Feedback from today will be summarised and circulated in a short note to all participants
Send more thoughts on today to
Report might include annex with key ideas emerging from discussions
Report published by Forces in Mind Trust later this Summer
Come back next year and see how we’re doing?

53. Thank you for your engagement and enjoy lunch!
Call to Mind A review of veterans and family members mental and related health needs
Welcome
My role as Lead Facilitator – oversee the agenda, make sure we stick to time and finish as agreed at 1:15pm
Housekeeping – toilets, refreshments, fire alarms and mobiles.
Introduce the team of colleagues who will be speaking – RL (FiMT), Lord Patel, Kate Davies (NHS England) and Jon Bradford
Thank you for your engagement and enjoy lunch!