Call to Mind
A review of veterans and family members
mental and related health needs
2nd July 2015
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
Amanda Fisk
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
Ray Lock
13:16
Lunch
14:00
Close
} NHS
} England
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
Who is here today?
•
•
•
•
•
•
•
NHS Commissioners and Providers
Local Authorities
Other Government departments (MOD)
Service charities
Non-Service charities
Academic researchers
Service users
Call to Mind
A review of veterans and family members
mental and related health needs
Chair, Ray Lock
Chief Executive
Forces in Mind Trust
‘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’
Call to Mind
A review of veterans and family members
mental and related health needs
Lord Patel of Bradford
Director, CIE
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
www.england.nhs.uk
9
• 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
www.england.nhs.uk
10
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
www.england.nhs.uk
Organisation of
armed forces in NHS England
Overview of armed forces
services provision
Looking to the future
11
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
Organisation of
www.england.nhs.uk
services
armed forces in NHS England
Overview of armed forces
services provision
Looking to the future
12
Putting Patients First: Objectives
1
2
Services for the armed forces are
commissioned to achieve the best
health outcomes, in line with the
commitments of the Armed Forces
Covenant
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
Scope of armed forces
Organisation of
www.england.nhs.uk
services
armed forces in NHS England
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.
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
Overview of armed forces
services provision
Looking to the future
13
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
DMS
DMS
DMS
NHS England
DMS and
NHS England
NHS England
Community
Mental
Health
DMS
DMS
NHS England
DMS
CCGs
DMS
CCGs
Secondary
Acute
Community
Care
NHS England
DMS and
NHS England
NHS England
DMS and
NHS England
CCGs
DMS and
NHS England
CCGs
Scope of armed forces
Organisation of
www.england.nhs.uk
services
armed forces in NHS England
Overview of armed forces
services provision
Looking to the future
14
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.
Scopewww.england.nhs.uk
of armed forces
Organisation of
services
armed forces in NHS England
Overview of armed forces
services provision
Looking to the future
15
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.
Scopewww.england.nhs.uk
of armed forces
Organisation of
services
armed forces in NHS England
Overview of armed forces
services provision
Looking to the future
16
Armed Forces
South Region Leads with locality support



Scopewww.england.nhs.uk
of armed forces
Organisation of
services
armed forces in NHS England
Overview of armed forces
services provision
Looking to the future
17
Comparative Figures for Veteran Distribution
Greater London
South East
South West
East of England
East Midlands
West Midlands
Yorkshire &
Humber
North East
North West
www.england.nhs.uk
England
population
Royal British
Armed Forces
Legion Household Compensation
2014 Adult ex(AFCS and
GP
Service community WP)
Registration
%
%
%
%
16%
17%
10%
11%
8%
11%
4%
15%
15%
12%
10%
11%
4%
19%
19%
9%
9%
8%
4%
19%
19%
8%
12%
9%
10%
5%
13%
14%
7%
12%
10%
8%
14%
10%
7%
12%
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
www.england.nhs.uk
19
What people are telling us
• Prevention is a priority
• Access is a priority
• Integrated support is a priority
• Attitudes & experience is a priority
www.england.nhs.uk
20
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
www.england.nhs.uk
21
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
Organisation of
www.england.nhs.uk
services
armed forces in NHS England
Overview of armed forces
services provision
Looking to the future
22
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.
www.england.nhs.uk
23
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
jon@ciellp.com
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.
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
Outcome
A proposed framework for action: Three
building blocks:
1. Targeted and intelligent use of data and
information
2. Appropriate and sensitive evidence based
services
3. Involvement and participation of veterans
and family members
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.
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.
Coverage of veterans in JSNAs in England by region
35
30
No JSNAs
No ref veterans
25
20
15
10
5
0
Eastern
East Midlands
West Midlands Yorks & Humber
Data in main report - page 19
South East
South West
London
North West
North East
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.
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.
Comparative data - numbers and location of veterans
20
Eng Pop
18
RBL 2014
16
AFCS
14
GP Reg
12
10
8
6
4
2
0
Eastern
East Midlands West Midlands
Yorks &
Humber
South East
South West
London
North West
North East
GP registration of veterans compared with population
20
Eng Pop
GP Reg
18
16
14
12
10
8
6
4
2
0
Eastern
East Midlands West Midlands
Yorks &
Humber
Data in main report - page 24
South East
South West
London
North West
North East
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)
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.
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)
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)
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.”
(Consultation respondent, statutory service)
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)
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)
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)
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)
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)
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.
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).
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.
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.
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
Break-out group discussions
After coffee
By 11.30 am please be at your discussion group
Call to Mind
A review of veterans and family members
mental and related health needs
Next steps/Closing remarks
Amanda Fisk
and
Ray Lock
Next steps/Closing remarks
• Slides from today will be posted on our website later
today http://www.fim-trust.org/reports/
• Feedback from today will be summarised and
circulated in a short note to all participants
• Send more thoughts on today to Jon@ciellp.com
• 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?
Call to Mind
A review of veterans and family members
mental and related health needs
Thank you for your
engagement and enjoy lunch!