This project ensures that the veteran patients that need help from the NHS in the local area get the tailored help by enhancing the normal care pathways to take account of the patient’s military experience to ensure that they get what they need (sometimes on a priority basis linked to the Armed Forces covenant) as well as working in active partnership with charities, local government and third sector providers.
Anyone that has served in and left any of the British Armed Forces is known as a veteran. Most veterans enjoy good mental health although for a variety of reasons a significant minority may develop problems around the transition back to civilian life and/or with their mental health. The Armed Forces has a particular culture which affects both the willingness to seek help and also how s/he is likely to experience mainstream civilian services such as the NHS. This project ensures that the veteran patients that need help from the NHS in the local area get the tailored help by enhancing the normal care pathways to take account of the patient’s military experience to ensure that they get what they need (sometimes on a priority basis linked to the Armed Forces covenant) as well as working in active partnership with charities, local government and third sector providers to ensure that all of the entitlements are brought together and navigated successfully for the veteran in a joined up manner.
The project is fundamentally based on veterans that have been through the service staying part of it through an active forum. The project was to enable people from veterans that needed help to get it as soon as possible and in a manner that engaged them and was sensitive to their particular needs and entitlements.
Some of the outcomes for the project were to enable a mainstream mental health NHS Trust to enhance its services in an affordable, meaningful and systemic manner by:
Ensuring access to priority treatment for veterans by systematic data capture of veteran status at the point of referral; Establishment of an enhanced standard care pathway tailored for veterans referred to IAPT and secondary care services; Identification and co-ordination of a veterans Champion’s Network including training package for staff with veteran-specific knowledge, experience and skills that work within the Trust to work alongside mainstream clinicians/teams to educate about and facilitate the enhanced care pathway; Identification and co-ordination of veteran service-user engagement through establishment of a ‘Veterans Forum’ who contribute to all aspects of service planning including education and training; Develop and formalise active partnerships with key veterans charities (Contact Point, RBL, SSAFA, Walking with the Wounded and others) and establishment of a ‘one- stop shop’ approach for veterans and in time their families.
Working collaboratively with other agencies has enabled the Trust to put veterans at the heart of their own healthcare to drive improvements in their mental well-being and work to try and ensure they are receiving the appropriate support from the local agencies set up to support veterans. The background work in terms of building alliances, presence and relationships across this range of stakeholders has been integral to a successful, sustainable pathway being established. Significant work has been undertaken developing relationships with key partner organisations such as SSAFA, Royal British Legion, NHS England, Local Universities, GPs, Public Health, Local Authorities and the National Positive Practice in Mental Health Collaborative.
The Project Manager and clinical Lead have prioritised development of strong relationships with the Military Service Charities as many of them have the trust of veterans that NHS services may lack, and have developed a weekly drop in morning which is held at a local Veteran charity. This is an excellent example of collaborative working and the one stop shop pilot has brought together or ‘joined-up’ relevant providers (NHS, service charities, third sector) to signpost and provides veterans with the most appropriate care and providing effective support. Many developments have come from this such as new initiatives (such as Warrior programme now starting in Coventry and Warwickshire) veterans breakfast meetings which have been well attended and enabled other access points into mental health services for veterans.
We offer a now well established weekly ‘One Stop Shop’ from a local Veterans Charity whereby we work alongside SSAFA, CAB, Veterans UK, RBL and the Recovery Partnership, which is working well. Veterans find this approach useful and it means that they can access support for a wide range of issues whilst being in one place. This partnership working has recently led to us becoming involved in a successful bid through the Covenant funding, working with these agencies to support Veterans in custody in tandem with Warwickshire and West Mercia Police – which will seek to identify more veterans in criminal justice system and provide veteran-specific liaison and diversion pilot.
The Veterans service user Forum works well and it provides feedback on the services we provide and informs future thinking in relation to service development. Engagement is via meetings or email dependent on how the service user feels they are able to engage. The engagement activity has increased over the last twelve months with thirteen service users actively involved in such things as consultations (e.g. on commissioning intentions and NHS veteran’s mental health consultation, contribution to teaching/training of clinical staff, joint presentations to meetings/conferences, feedback on the website and other ideas and developments).
Veterans are identified via secondary care clinical services, IAPT, GP surgeries, Contact Point or other charities and below are some examples of the active engagement we have developed:-
With both the project lead and manager only working on the project part time it has meant that we have had little time to look at fundraising for the project. Whilst all our efforts have been focused on service user access and care, looking back it may have been useful to have recruited an additional member whose role would have been around fundraising and looking at grant applications. Only two years on we are now beginning to look at this going forward.
Trying to implement a new care pathway for Veterans did pose us with some challenges along the way. One of the initial challenges was that we needed to educate staff around the Military Covenant and why this particular group of society had particular rights around their healthcare. We overcame this with a systematic programme of education including preparation of materials, health promotion and presentations at team meetings.
Another challenge was recruiting staff to become our trust veteran champions. Whilst all our volunteers were extremely keen and willing to support our project, the time restraints and current work loads of clinicians within the NHS often meant that they were unable to be released by their managers to participate in training and veteran work, we have however overcome this by educating management and teams how valuable having a “”champion”” in the team can be, and how it can help reduce care coordinators workloads by linking into other service charities/agencies as well as writing the champion role into job plans in some cases.
In essence the CWPT veterans project has successfully in demonstrated that mainstream secondary care mental health services can be meaningfully adjusted to better meet the needs of veterans. The model has proved to be enormously cost effective in that it is an overlay to normal care pathways that are of course already in existence and so the additional costs are minimised. In discussion with CRCCG it is clear that the pathway is valued and veterans mental health was listed as a Commissioning Intention for 2016/17. As things stand at report writing the commissioning arrangements are such that Veterans Project is likely to be funded going forwards via a third year of CQUIN. This will enable some additional targeted areas of development and will be an excellent opportunity to continue to improve and expand the pathway in active collaboration with the Service User Forum.
Qualitative feedback is collated and has been very positive. The service user forum is testament to this as veteran service users that have been helped to recovery want to help other veterans and expand the project. Service users have represented the project directly to commissioners and senior managers about the imperative to continue the work with veterans that we deliver. The case examples provided later in the application are further examples of qualitative evaluation.
Standardised measures are given to veterans as they enter SCMH and again when they leave as well as at appropriate time points along their pathway, which objectively show good outcomes. This is alongside NHS Friends and Family Tests again administered at beginning, mid points and end of treatment. The current data we have on FFT is encouraging and positive.
The Veteran Project Team were asked to attend a meeting at King’s College in September 2015, which was to present NHS England’s review of military mental health provision undertaken by Forces in Mind Trust, prior to its imminent publication – see link below to the Executive summary.
Forces in Mind Trust & NHS England held up CWPT as an exemplar site and it should be noted that the event was also encouraging as Lord Patel, Kate Davies (Head of Armed Forces Commissioning at NHS England) and Dr Bashford presented a paper which articulated one model in particular as an exemplar, which was our model in Coventry and Warwickshire.
We are in planning stages for a second conference (the first was a highly successful and evaluated as such at regional level) National Conference that we will run in collaboration between National Positive Practice in Mental Health Collaborative and NHS England in Autumn 2016. The theme for this conference is “ENHANCING MENTAL HEALTH SERVICES FOR EX-ARMED FORCES PATIENTS: Achievable ways to develop into a HM Forces Friendlier NHS Trust and better meet their needs and entitlements”. It will be an education and motivating/showcasing event for other Trusts to be able to learn a model and approach about how they can find a pragmatic way forward towards their services becoming better attuned to veterans.
Following the links established with North Essex veteran service CWPT are now invited to the National Armed Forces Network Meetings alongside the specialist, funded NHS England services coordinated by Andy Bacon, under Kate Davies National Head of Public Health, Armed Forces and their Families and Health & Justice for NHS England.
CWPT Project Lead is now also the National Lead on Veterans Mental Health for the National Positive Practice in Mental Health Collaborative and as a result various links are being established, with the aim being to try and begin to join up good practice. We are visiting Military Veterans Service at Pennine Care NHS Foundation Trust in May 2016 to review and learn from practice elsewhere in the country. We have also made links with a nationally active veterans consultant who is pioneering work in UK for young military carers and we will be working together to bring this approach to CWPT.
CWPT Project Lead has attended Westminster by invitation to provide ‘Lobby on veterans mental health’ to ministers from Conservative in power, and those in opposition. In particular a link has been made with MP for Berwick-upon-Tweed, Anne-Marie Trevelyan and they are passionate about the welfare of veterans and a member of the Armed Forces Parliamentary Scheme and keen to work on improving access to metal health services. This link continues and follow up 27/4/16 where CWPT approach was discussed has led to more potential to roll out principles of the approach much more widely nationwide.
The Project Lead alongside a service user were recently invited to give a plenary address to circa 350 people in attendance at the Public Health and Local Authority Mental Health National summit held at Kia Oval, London alongside Paul Farmer Chief Executive of Mind and Professor Kevin Fenton, Head of Public Health England.
This presentation was moving and extremely well received and we will be following up with Professor Fenton for a service visit. Furthermore, a link was established with a commissioner from the North of England who wants to join up over how they might consider their commissioning arrangements. Further, Professor Woody Caan was in attendance and has asked us to send abstract of our research for consideration for publication in Journal of Public Mental Health.
The system set up in the Year 1 to identify service users that are ex-Armed Forces is embedded now and the electronic flagging that has been in place since June 2014 demonstrates that it is working. This system ensures that the Trust continues to identify the number of Veterans (ex-Armed Forces) and you can see from the graph below, the number of service users identified as veterans has continued to increase.
Case Examples After 40-years’ service, the Army ensured I was medically examined, treated and compensated for physical injuries accrued during my career. But the transition to ‘Civvie Street’, although administratively detailed, did not include any psychological welfare. I therefore left the institution that had supported the bulk of my existence, and made my way into a new world with much trepidation. It didn’t take long before the cracks started to appear. My routine had gone; my mates were left behind; and the nightmares began. I started to drink too much; I became jealous, insular and angry. My health suffered and I became deeply depressed. It therefore didn’t surprise me when my girlfriend threw me out. I had reached a very low point and considered suicide.
This was the situation less than a year ago. All changed once I faced my problems and sought help from Combat Stress who, thank God, referred me for treatment to the Coventry and Warwickshire NHS Partnership Trust. I can say without exaggeration, they saved my life.
M.P – Service User – On a personal level I need you to know the difference you have made to our lives. As a spouse of an Army Veteran SSgt who suffers from Post-Traumatic Stress Disorder, without your Veterans Project I would have felt very alone. Although my husband is the person with the illness, you are aware that people close to him are affected too. Luckily I can only surmise about the knock on effect this could have on mine and other members of family’s well-being if they didn’t have support that you have tirelessly provided!
Because the Armed Forces world is so different to civilian life, Veterans have specific needs that do not necessarily translate into ‘civvy street’, leaving some people struggling with the transition. With your advice and support I am gaining the confidence to help my husband deal with his recovery. Without having encountered the Veterans Project I can say with sincerity that I would not have been able to cope. I would not have been in the positive and knowledgeable frame of mind I find myself in now. My family and I certainly would not have had the confidence to offer my husband the daily emotional support he needs alongside the second-to-none therapy he is continuing to receive from Dr Barnard.
I cannot thank you enough for all your hard work. As service users, your support and knowledge has been life changing and life enhancing. I can’t imagine where we would be if we hadn’t have found this service. Your Veterans Project and the specialist expertise within is a credit to the NHS and long may it continue!!
Kind Regards Dawn Caswell Wife of service user
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