www.england.nhs.uk

VeteransMental Health Pathways

Wayne Kirkham

National Lead

National Veterans Mental Health Network

NHS England

March 2015

www.england.nhs.uk

Armed Forces Network – How it Looks

www.england.nhs.uk

Ex - Armed Forces Community

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The size of the Adult ex-Service community is estimated to be 4.9m

(Veterans & Dependents)

www.england.nhs.uk 4

The size of the UK veterans community is estimated to be 2.8m

(88.9% male / 11.2% female)

The size of the veterans community in England is estimated to be 2.3m

• Transition from serving to veteran is key to good health

• CCG is lead commissioner

NHS England has inherited £5M for 3 Veteran Mental Health commissioning roles:

• Online national support (the Big White Wall)

• Regional bespoke veteran services (NVMHN x 10 Regions – 12 providers )

• Residential PTSD services (specialised commissioning) (Combat Stress 6wk

programme)

Ex - Armed Forces Community – cond

Veterans Engagement – 2013/15

Total = 23,342 (NHS)

www.england.nhs.uk

“The Challenge"

• Mental Health is Everybody’s Business - It’s Time to Change. • Together we can make a difference, but to make the most difference to the most people, we

need to look beyond mental health services into wider public services; then beyond public services into our society as a whole.

• 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 to

local community groups.

Wayne Kirkham, National Lead, National Veterans Mental Health Network, NHS England - waynekirkham@nhs.net - 07918368472

North West Helen Lambert Helen.lambert1@nhs.net 0161 7783991 - 0161 2536638 www.penninecare.nhs.uk/military-veterans Greater Manchester, Cheshire, Wirral & Warrington, Merseyside, Lancashire & Cumbria

North East Symon Day Symon.day@nhs.net 01388 646800 www.tewv.nhs.uk/veterans County Durham, Darlington, Teesside, Hartlepool, North East Yorkshire

Yorkshire & the Humber

Jennie Ormerod Jenny.ormerod@humber.nhs.uk

01482 617771 / 594 veteransoutreachservice@humber.nhs.uk

Hull, East Riding & North Lincolnshire (formerly Humberside) South West & North Yorkshire

East Midlands

Paula Jelly paula.jelly@lpft.nhs.uk

01522 526827 – 07500984890

Derbyshire, Lincolnshire, Leicestershire, Milton Keynes & Rutland, Nottinghamshire, Northamptonshire

South of England (South Central)

Dr Deborah Lee Deborah.lee@berkshire.nhs.uk 0118 9296426 sc.veterans@nhs.net Berkshire, Buckinghamshire, Hampshire, Oxfordshire, Southampton, Isle of Wight, Portsmouth

East of England (North Essex)

Diane Palmer diane.palmer@nepft.nhs.uk

01206 228759 www.nevmhn.org.uk

North Essex, East Essex, Mid Essex, West Essex, Bedfordshire, Cambridgeshire, South Essex,

Hertfordshire, Norfolk & Suffolk

West Midlands Jeremy Newell Jeremy.newell@dwmh.nhs.uk 07887 823010 Birmingham & the Black Country, Coventry & Warwickshire, Dudley & Walsall, Herefordshire & North Gloucestershire, Staffordshire, Shropshire, Worcestershire

South West David Wilcox dwilcox1@nhs.net 0300 5550112 www.swveterans.org.uk Bath & NE Somerset, Bristol, Cornwall, Devon, Dorset, Gloucestershire, South Gloucestershire, Somerset, Wiltshire, Swindon

London Dr Nick Hawkes Nicholas.Hawkes@Candi.nhs.uk 020 3317 6826 www.candi.nhs.uk/veterans Camden, Islington, Maudsley, South London

South East Coast

Sussex

Kate Parkin kate.parkin@nhs.net

07770864394

Surrey Vacant

Kent & Medway

Belinda Simpson

www.armedforcesnetwork.org 07976 563 338

Helpline 01303 856 499

Innovative & Collaborative Working in Veterans Mental

Health

Our Armed Forces carry out many different roles

Then they come home

Some with Physical injuries

Some with Invisible wounds

‘Veterans First Service’Our Story

In the beginning…• Concerns were raised by the MOD about the

local provision of mental health services for Veterans in Essex and the need to ensure that the Armed Forces Covenant is upheld.

• The Armed Forces Covenant states that Military Veterans, anyone who has served 1 day or more in HM Armed Forces, should:

• Not be disadvantaged by their Military Service• Should receive Priority Treatment for Service

Related Conditions.

The concerns…

• Veterans rarely fit neatly into secondary care criteria due to nature of their MH Condition.

• Often excluded by IAPT as considered to be too high risk

• Long waiting lists for Psychology services• Lack of understanding of MOD culture and

language

• Lack of shared medical records• Stigma- Difficulty to engage• Prevalence of alcohol and substance misuse• Contact with criminal justice

Action taken…• They formed the NORTH ESSEX VETERANS

MENTAL HEALTH NETWORK, an alliance between the MOD + NHS + COMBAT STRESS

• The Network promoted collaborative working, shared learning, held 2 conferences and set up a website for Veterans and Professionals.

• The Network won the ‘Care of Veterans’ category in the Military and Civilian Health Partnership Awards 2013.

Funding• The NEVMHN put in a bid for DH Funding• £130 K received for first year. £150k allocated

for further 3 years until March 2016.• Money paid via NHS England to the NEP.• Veterans First was created as a ‘Specialist

Secondary Care CMHT’ for those in transition and Veterans in North Essex and became operational in May 2012

Staffing

• Area Team Manager• Clinical Nurse Specialist• 1 x Band 4 (1 day a week)• 1 x Band 3 (1 day a week)• Full time Administrator• 2 Honorary Therapists• 1 Psychiatrist on interest placement

Process• Accept self referrals• All professionals can refer• Triaged• Urgent cases prioritised• All patients receive extensive information pack

and invited to support groups• Care co-ordinated if service related.• Give specialist advice to other staff if needs

best met by another team IE. Eating Disorder, Dementia or Psychosis.

Assessment & Support• Diagnosis• Medication- Prescribe, monitor, review• Psychological therapy• Physical Health and Mobility • Substance misuse• Safeguarding• Offending behaviours• Domestic abuse

ImmigrationHousingDebtsFinancesBenefitsCompensationResettlement, education and trainingEmployment

• Wider family needs• Social inclusion• Carers Assessments

and anything else that is causing the Veteran to be distressed or impairing their functioning personally, socially and occupationally.

• Assessed and treated 300+ Veterans• Majority have PTSD/Depression/Anxiety• Offer specialist care co-ordination (CPA)• Multi-agency approach to support those with

anger management issues, violent and sexual offending, domestic abuse, child protection issues, substance misuse and co-morbid physical injuries and conditions.

• We work in partnership with a multitude of agencies, using the CPA as a framework.

• We work closely with Military Units, including the Departments of Community Mental Health, Personnel Recovery Units, Personnel Recovery Centres, Occupational Health and Unit and Specialist Welfare services in the MOD.

• We obtain military records and military medical notes.

• We work with many Military Charities, including Combat Stress, Help for Heroes and the Royal British Legion.

• We work with specialist resettlement and employment advisors, housing officers, social care, the Police, Probation, the Courts, Prisons, Immigration and generic mental health and substance misuse services, including DUTY, crisis resolution home treatment and in-patient services.

Support Groups• We run 3 Multi-agency Veterans support

Groups and a carers group each month.• These are run in partnership with Combat

Stress and the RBL, with attendance from up to 10 professionals per group. These include staff from Veterans UK, Healing Hands, the Warrior Programme, Invicta Foundation, IAPT, Social Care, Help for Heroes and The Soldiers Charity.

Advice Clinic

• We are currently in the Process of setting up a multi-agency clinic one day a month with H4H

• Veterans First and Combat Stress clinicians will make up half the staff running the clinic.

• Offering set appt times for assistance with a specific matter that could be resolved in up to 1 hour. For example, medication query, advice about housing or debts, to look over a CV, request financial help.

Crisis• All patients are risk assessed and have a risk

management plan.• In working hours patient are seen by the

Veterans Team. Veterans Team staff often stay late to facilitate crisis support.

• Out of hours- Have access to the wider trust Crisis Team

• Combat Stress 24hr Helpline• A+E Psych liaison- run by NEP• Big White Wall

• If picked up by the Police they may end up in the 136 suite at NEP

• Any Veteran accessing crisis care within our Trust will be told about the Veterans Team and offered a service.

• We also work closely with in-patient services to facilitate a timely discharge and arrange appropraite post discharge support.

• We facilitate student placements.• Have produced an E learning package• Delivered over 200 training sessions• Presented at local, regional and national

conferences.• Raised awareness through media (appeared in

BBC East ‘Afghanistan- the Homecoming’) and multiple radio interviews, newsletters, posters and leaflets.

• Chair of the Armed Forces Clinical Reference Group (Mental Health Sub Group) for NHS England.

• Member of the Armed Forces CRG• Member of the National Veterans Mental

Health Network• Chair of the NEVMHN• Specialist Clinical Working Groups

• Member of Crisis care concordat• Honorary Fellow of Anglia Ruskin University

Veterans and Families Institute.• Member of East of England Clinical Senate• Developing PREVENT WRAP training case

studies for Armed Forces and Veterans.• Developing Veterans Universal Passport

• Proud of our 100% patient satisfaction on friends and family test.

• Supported other mental health trusts, councils and charities to develop services.

• Attracted National recognition from MP’s, Ministers, the Deputy Prime Minister, HRH Prince Charles and the Shadow Defence Team.

Shadow Defence Team Visit

Awards• 3rd Place in Trust Positive Practice

Achievement Awards 2012• Winner-Military and Civilian Health

Partnership Awards 2013 for Care of Veterans• Great British Care Awards- Winner of ‘Care

Innovator Award 2013 for EoE and 2nd Place for ‘Outstanding Contribution to Social Care.

• Finalist for the Nursing Times Mental Health Award 2013 and Team of the Year 2014.

• Winner-Nursing Standard, Mental Health Award 2014

• Finalist in Military and Civilian Health Partnership Awards 2014

• Finalist in the National Social Work Award for Innovation.

COMBAT STRESS

John Marham RNMHCommunity Psychiatric Nurse

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Combat Stress 24 Hour Helpline

0800 138 1619

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Focusing on Veterans

We are:• Accessible through our 24-hour Helpline,

We Provide:• Individually-tailored ‘recovery pathways’• Substance Misuse Case Management Service• Outpatient services• Community and Outreach Teams• Three residential treatment centres• Recovery & Social Reintegration Breaks

Our services are enhanced by:• Working in Partnership

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Our work 5,954Veterans are

currently being supported.

2,193Total of new

referrals in the year.

1,168

Number of Veterans

discharged.

• We are working to combat the stigma that so often prevents Veterans from seeking help.

• Many Veterans have reported their perception that the NHS and other providers lack the understanding, knowledge and expertise to treat them.

• Over 93% of Veterans who responded to a Combat Stress survey revealed they are ashamed or embarrassed about their mental health problems.

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Stigma

Partnerships That Work

• The Royal British LegionBreak Centres ‘Pop-in’ Centres

• Poppy Scotland• Help for Heroes• The Armed Forces Health

Partnership Working Group• The Warrior Programme• The Department of Health/

National Health Service/Public Health England

• Kings Centre for Military Health Research (KCMHR)• Rethink Mental Health (Helpline)

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Demographics• Army 84%• Merchant Navy 0%• Royal Air Force 7%• Royal Marines 3%• Royal Navy 6%

• Majority - lower ranks

• 97% male and 3% female

• Average time from leaving Military Service to seeking help from Combat Stress is 13.1 years

• The average time is 2.2 years for those who have served in Afghanistan and 3.9 years for Iraq.

CS Recovery Model

Engagement

Resource Building

Implementing Change

ReintegrationSelf

Maintained Recovery

RelapseManagement

Builds on the Veterans resilience to effectively engage in more intensive in-patient or out-patient treatment options.

Builds on the capabilities of Veterans to change, to strengthen skills and to improve psychological resilience through active and intensive treatment.

Consolidates the skills acquired through treatment enabling these Veterans to improve social re-integration into families and their communities.

Empowers the Veterans to continue to live their lives independently.

Acknowledges the potential for relapse and focuses on the obstacles that are still preventing recovery.

Working with the Veterans to stimulate their self-belief and develop their commitment to recovery.

Assisting Veterans in their Journey of Recovery

Combat Stress Treatment Centres and facilities

Audley Court is in Newport, Shropshire. It has 27 beds, including a small number of rooms for carers. Total upgrade completes Easter 2014.

Hollybush House is in Ayrshire, Scotland. It has 25 beds and can accommodate a small number of accompanying carers.

Tyrwhitt House is in Leatherhead, Surrey. It has 33 beds – 4 of which can also accommodate a partner or carer.

Residential Programmes Currently Delivered

• Transdiagnostic• Stabilisation • Anger Management• PTSD Intensive Treatment Programme• Bespoke individual treatment

The Recovery and Social ReintegrationProgramme

• A stepped care approach to rehabilitation• Structured Occupational Therapy timetable including :

- Behavioural activation exercises - Skills training- Relapse management

• Self esteem• Identity• Peer support• Taking personal responsibility• Family and carers support groups

Our Community Services• RWOs are first contact for Veterans• In addition the RWOs provide follow up welfare visits.• Our Community Clinicians provide support group sessions and individual

therapy sessions.

First Visit; 378Follow up; 1041

Veterans in Support Group;

178 Client Liaison; 196 Service Liaison; 133Individual

Therapy Ses-sion; 60

Outreach Team Activities

• Client Liaison includes communication with the veteran e.g. Triage, war pension, housing support etc.

• Service Liaisons include, communication on behalf of the veteran with external organisation such as Social services, GP’s, funding Bodies etc.

The First Rule of War...There are many challenges involved whilst working with survivors of traumaand there may be a potential for vicarious trauma to the staff or even destabilising the individual by reliving past incidents. The National Institute for Health and Clinical Excellence (NIHCE) guidelines highlights the need for experienced and appropriately trained and competent staff to work with individuals who may have trauma-related issues, including military veterans.

Clinicians should be supervised by those with the appropriate knowledge and experience of working with Veterans.

Outreach Team Activities