The Greater Manchester and Lancashire Military Veterans’ Service (MVS) grew out of a regional, North West-wide pilot service, established in 2011. We provide a dedicated psychological therapies exclusively for veterans of the British Armed Forces and also working with a range of statutory and third sector organisations to support them when they’re working with veterans with complex needs
What We Did
The Greater Manchester and Lancashire Military Veterans’ Service (MVS) grew out of a regional, North West-wide pilot service, established in 2011. We provide a dedicated psychological therapies exclusively for veterans of the British Armed Forces and also working with a range of statutory and third sector organisations to support them when they’re working with veterans with complex needs. The service offers a range of evidence-based therapies including CBT, EMDR, psychodynamic psychotherapy, and clinical psychology. Most importantly the service provides specialist case management and stabilisation interventions, including for substance misuse, which allows veterans who are not “therapy ready” to eventually access the treatment they need.
We meet the Armed Forces Community Covenant (2011) commitment that: “For those with concerns about their mental health, where symptoms may not present for some time after leaving Service, they should be able to access services with health professionals who have an understanding of Armed Forces culture.”
Feedback from clients indicates that whilst therapists do not need to be veterans in order to help veterans, this client group very much appreciate seeing therapists who are familiar with armed forces culture, as summed up by the following quote from an ex-RAF client:
“I went in with negative thoughts: same old staff with the same old responses, but this wasn’t the case. The experience was good because it was specific – I felt that was the key for me, that was the most important thing – it was specific. The language and terminology showed me she understood……I don’t think the help I got would have been as good coming from standard CBT – that isn’t to knock standard CBT – I just think the service needs to be specific – and for me it’s been an absolute godsend. It’s helped me get my life back on track. I’ve got my confidence back”
For many of our clients the support we provide helps them complete their transition into “civvy street”, sometimes after years of struggling to do so:
“…through the course of my therapy I secured and maintained a four month contract. This is the first time since 1992 that I have been able to hold a job down and not be dumped for “not fitting in” or similar reasons. I have significantly reduced my drinking, addressed my housing situation and moved on from breaking down and grieving on an almost daily basis, to building new friends and interests. I cannot thank you enough for providing me with a service that has fundamentally changed the quality of my life in the here and now, and for the future.”
When clients are discharged from the service, or choose to drop out of therapy, we are always clear with them, their referrer and GP, that they can re-refer themselves. A number have done and the extract below from the blog of one of our ex-clients suggest that they have confidence that we will help when they need it:
Help where it’s needed
“Well I have not had a great few day and then last night “BANG” panorama smash the egg and I felt rough all night things creeping to the surface that have not been about for 18 months or so I had been keeping a lid on it. There is help outside for some of us but the help seems patchy at best luckily for me the NHS are funding a veterans project via the Pennine NHS foundation trust that have been amazing. It shows how things can work.”
“Even with that very specialised help I struggle I have been exited from them now because I was fine. I am pretty sure I could phone them today and they would try to help but this is a battle that only I can win I think having a week off without anything to do has not helped me as I really need to be busy or I really start to struggle. I am going back to the basics of what I have leant from the amazing “***” from Pennine First planning every day something I enjoy even if it’s just for 5 mins plan thing for the months in advance and start my mindful practice again. Today feels a little like day 1 again but it’s better than the 7 years before that so I will just keep plodding on”
Wider Active Support
Our service started out as a two year pilot, funded by the Strategic Health Authority. The new CCGs agreed to roll the pilot forward whilst independent evaluation was published, and, because that supported the excellent client feedback and feedback from partners the CCGs agreed, even in a period of austerity, to mainstream the service. Whilst we provided strong evidence of the effectiveness of what we do we are aware that without some key champions in CCGs and other influential agencies in the North West the service may not have been put on the current 3 year contract footing.
The service has developed innovative partnerships with a range of agencies: the Personnel Recovery Unit (PRU) at 42 Brigade based in Preston with whom the service works jointly during the 3 months preceding a medical discharge to support a seamless transition to NHS service; Walking With the Wounded – whose DIY SOS Veteran Village project was featured on BBC in autumn 2015, who fund an Employment Mentor post embedded in our team; Royal British Legion who kindly provide our service with free rooms in the centre of Manchester. Members of our team have regular contact with RBL caseworkers on individual cases and attend a range of events to advertise our service and provide information on mental health issues in relation to veterans; the Reserve and Cadet Forces Association who support he service through providing discounted room hire so clients who are comfortable doing so can access their treatment in a TA Barracks rather than an NHS setting; We work with a range of other local community organisations some of which are veteran specific e.g. Veterans in Communities www.veteransincommunities.org, and a gardening project based in Preston www.diginnorthwest.org based in Preston whilst others have a focus on health and wellbeing and wish to gain a better understanding of veteran issues e.g. START in Salford with whom we jointly ran some art therapy groups; We have strong working relationships with other statutory organisations e.g. JobCentrePlus though their veteran champions, and Probation Services through their Veterans in Custody Support Officers network.
As a specialist service our focus has been on making psychological therapies accessible to veterans who are unwilling or unable to access generic mental health services. The consultation that took place in the set up phase indicated that some of the main barriers were: Veterans’ lack of confidence that NHS staff could understand their experience; The stigma often associated with mental health in society as a whole is even more powerful in this community; Some veterans’ with mental health needs had little understanding of how to access NHS services e.g. may not be registered with a GP; Veterans with mental health problems are quite likely to misuse alcohol to “self-medicate” and this may result in primary care mental health services not offering interventions until the alcohol use has reduced; Family members often suffered as a result of untreated mental health problems of veterans; For some, joining the Forces as a teenager is a way of escaping difficult family circumstances which can impact on their experience of returning to “civvy street”.
Veterans also told us that they don’t want to be referred to as “patients” or “service users”, they prefer the term “client” and that is what we use. In response to the above we: Appoint staff who had a specific interest in working with veterans – some were veterans or related to serving personnel or veterans; Included psychodynamic psychotherapy and other modalities such as Acceptance and Commitment Therapy (ACT) and appointed a substance misuse/offender caseworker; Accept self-referrals (which can be made on-line or via telephone) as well as referrals from voluntary sector organisations and non-health statutory organisations – these make up 72% of our referrals with only 28% coming from within the NHS; Often see people in non-NHS venues such as community centres or football clubs, as well as TA barracks; Work with clients who are misusing alcohol/drugs – independent evaluation of the service indicates that the clinical outcomes for this group are comparable with those for clients not misusing substances
We were aware that amongst the group of veterans who are most likely to experience mental health issues (Army Infantry) there are some who have difficulty with literacy and more with limited emotional vocabulary, therefore in addition to traditional promotional materials such as posters (using a logo which we undertook consultation on) we produced a short DVD, which we know has been very effective in accessing potential service users. The DVD can be seen on our website www.penninecare.nhs.uk/military-veterans
As an IAPT-compliant service all clients are invited to complete a patient experience questionnaire and we have also held service user consultation events, as well as regularly spending time as a team reflecting on our learning from clients and reviewing our processes and practice in light of that learning. Interviews for clinical staff have always involved client representatives, which is something we have found very useful in making appointments.
Looking Back/Challenges Faced
We are fortunate in that most of the things we would have done differently we have now had the chance to amend/develop. Some practical examples include: we started out with an 0161 (Manchester) number for telephone referrals, which some people in other areas found off putting – we now have an 0300 number; when we were initially appointing staff we didn’t place enough emphasis on the need to enjoy driving and to be content to not spend much face to face time with colleagues; we are now very much clearer with potential new recruits about the “realities” of doing this work which means they have a much better idea about what to expect and we have lower turnover
Thinking about this question has made us realise the extent to which the service has evolved over time from an IAPT service – staffed predominantly by trainee therapists – into a specialist complex care team staffed by well qualified, experienced staff with duty staff available to respond to unexpected contacts from clients in distress.
As a specialist service covering a wide geographical area and delivering therapy as close to home for our clients as possible we faced a number of practical problems in terms of suitable accommodation to see clients in, support staff who work remotely/alone in a challenging role, ensuring the security of client information, obtaining and storing military records for clients, recruiting and retaining staff when only temporary contracts are on offer.
A range of organisations outside the NHS and non- NHS organisations have supported the pilot by providing free accommodation e.g. local primary care mental health services, health centres, community centres, veteran drop-in centres, football clubs and as noted above we have also been able to use TA barracks where this has suited the clients.
The Trust has supported us by making the team one of its mobile working pilots back in 2011 so we’ve always been supported to work remotely and flexibly. We have utilized lone worker support equipment in the form of Skyguard (this includes a GPS tracker as well as providing emergency help via a call centre should it be required). We have arrangements with all 3 branches of the Forces to obtain service records, which are stored securely separately from clinical notes.
We were fortunate that a number of staff were prepared to give up permanent contracts to be part of the initial pilot, and we appreciated when the Trust took something of a risk in making us all permanent before funding was secured from the new CCGs. Challenges in terms of engaging with what had been identified as a “hard to reach” group have been addressed through our flexibility (both in terms of process e.g. we continue to work with clients who DNA/cancel appointments quite regularly provided we believe it is of benefit to them, and in terms of the individual approach of clinicians). The independent evaluation of our service by the Personal Social Service Research Unit based at the University of Manchester indicates that we achieve some of our best clinical outcomes with clients who left the Forces early and have a forensic history, as well as those who are least well socially adjusted.
We have also faced some “political” issues in terms of engaging with individuals and groups who are suspicious of NHS services and in terms of working with a wide range of organisations some of whom have difficult relationships with each other. We have sought to work in a fair and transparent way with all agencies with whom we find common ground in terms of a shared commitment to meeting the needs of veterans with mental health issues.
The management team of the service has remained remarkably stable over the last 5 years with 3 of the original 4 members still in post. The opportunities to innovate and evolve, as well as to take up some other opportunities in the Trust without moving job, have supported this.
There is a strong, client orientated culture in the team and an expectation that all team members contribute to keeping the service at the cutting edge of care for veterans. Moving to a mainstream contract has put some constraints on the freedom previously enjoyed by the pilot service, although in most cases CCG colleagues are open to constructive dialogue view it.
The service enjoys strong support from non-NHS partners e.g. MoD, Local Authority Armed Forces Covenant Groups, criminal justice services and the reputable veteran charities therefore any moves to decommission the service are likely to meet with considerable opposition.
The initial pilot service was evaluated by the Personal Social Services Research Unit and the University of Manchester which concluded: The MV IAPT Service engages a ‘hard to reach’ group, not served by traditional IAPT services; Clinical outcomes are good and statistically significant – comparable to effects seen in trials and greater in impact than antidepressants alone; The clinical outcomes for early service leavers who also have a forensic history, and those with poor social adjustment at referral, were significantly good; The service is cost effective in comparison to regular IAPT when considering improvement in depression; Within the MV IAPT clients who misuse alcohol achieve positive clinical outcomes comparable to those who do not; The above analysis is based on a large and detailed data set comprising 505 patients who had an assessment and one or more treatment sessions it permitted comparisons of standardised measures over time.
When the service was out to tender Pennine Care NHS FT as the existing provider was subjected to a rigorous process to determine whether we were “fit for purpose” and value for money. The presentation stage of the process was to a panel room of 13 people including GPs, the Chief Officer of the lead CCG and the Mental Health Clinical Lead for Greater Manchester.
Recognising that we have a unique clinical data set (no service has provided therapy to more veterans of the British Armed Forces than we have) we are working with colleagues from North West Universities to undertake research into veterans’ experience of mental health care.
The evaluation we value most however comes from our clients:
“The MVS are a group of highly skilled and extremely helpful professionals who clearly care about the services they provide and who they provide that service to. The service I received was, without a doubt, life changing”
One of our objectives as a pilot was to share what we learn and we did this in a variety of ways: – In January and February 2013 we ran two professional update events for mental health practitioners on working with veterans, including the opportunity to bring veteran cases they were working with to group supervision sessions. Feedback from the sessions was very positive e.g. “There are some issues for our service that I will take forward. Joint working , medical records, flexibility for DNAs / CNAs, stepped care”; We have produced a training DVD, featuring some of our clients talking about their experiences, for use by health professionals and distributed to primary care mental health services across the North West; We have hosted many visits from clinicians and managers across the country looking to establish services for veterans or improve their current arrangements –as we were grateful for the support we got from Veteran mental health Services who were in operation before us
Our commitment to sharing continued when we were rolled forward and even now, despite the constraints imposed by being subject to competitive tender and therefore have the need to avoid giving away commercial advantage (we are mindful we will probably be out to tender again in 2017-18) we provide advice, consultation and supervision to other services – both within and outside the NHS.
We intend to publish some of the outcomes of our work and what we have learned to date will inform the training we have been asked to provide by NHS England on veteran awareness in Lancashire and Greater Manchester. Outcomes form the Overcoming Barriers project we undertook for NHS England are available at http://peoplesvoicemedia.co.uk/overcoming-barriers
Perhaps most importantly of all however we disseminate our learning and skills to our clients. As one put it: “Cannot praise it highly enough the help and support I received helped me in so many ways. The professionalism and genuine care and advice has helped me understand more about my condition and hence, better able to avoid or combat the symptoms. Awesome”
We remain actively involved in the National Veterans’ Mental Health Network, have spoken at a number of national events about our experience working with veterans and our Clinical Lead is heading up a working group looking at pathways between different services for veterans experiencing mental health issues (unfunded work!)