www.england.nhs.uk veterans’ mental health current response to the mandate & challenges for...
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www.england.nhs.uk
Veterans’ Mental HealthCurrent Response to the Mandate & Challenges for the Future.
Andy Bacon
NHS England
Central Team
Lead for Armed Forces
March 2015
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Cross Government Obligations Armed Forces Covenant/ Mandate
“The NHS need to demonstrating progress against the Government’s priorities of: upholding the Government’s obligations under the Armed Forces Covenant;
The Covenant says:• The Armed Forces Community should enjoy the same standard of, and access to, healthcare
as that received by any other UK citizen in the area they live.
• Personnel injured on operations should be treated in conditions which recognise service needs
• For family members, primary healthcare may be provided by the MOD in some cases (e.g. when accompanying Service personnel posted overseas). And … should retain their relative position on any NHS waiting list, if moved around the UK due to the Service person being posted.
• Veterans … should receive priority treatment where it relates to a condition which relates to .. their service, subject to clinical need
• Those injured in service should be cared for in a way which reflects the Nation’s moral obligation …with professionals who have an understanding of Armed Forces culture
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• Access to services should be governed, as far as practicable, by the principle of equal access for equal clinical need. Individual patients or groups should not be unjustifiably advantaged or disadvantaged on the basis of age, gender, sexuality, race, religion, lifestyle, occupation, social position, financial status, family status (including responsibility for dependants), intellectual / cognitive function or physical functions.
• Developing a better understanding of the unique needs of ex-service personnel and families enables discrimination based on need (and hence treated as a “Minority” with particular health needs).
The Equalities Act
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DIVIDED RESPONSIBILITIESfor Commissioning
Serving Veteran
Operational Care MoD/DMS Not Applicable
Occupational Health MoD/DMS
Public Health (Immz and Screen)(Health Promotion)
NHS England (PH)Local Authorities
Primary Health Care MoD/DMS NHS England (Primary Care)
Community Health Care NHS England (AF)
NHS CCGRehabilitation MoD/DMS
Acute Hospital Care NHS England (AF)
Mental Health MoD/DMS
Social care/Welfare Charities/ Local Authorities
Specialised Health Care NHS England (Spec Comm)
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Armed Forces commissioning responsibilities
Serving Armed Forces in England
Serving Armed Forces overseas
Armed Forces Families registered with DMS med centres in England
Armed Forces Families registered with DMS med centres overseas
Armed Forces Families registered with NHS GP Practices
Reservists while mobilised i
Veterans (inc. reservists when not mobilised)
Primary CareDMS ii DMS DMS DMS NHS England
DMS&NHS England iv
NHS England
Community Mental Health DMS DMS NHS England DMS CCGs DMS CCGs
Secondary acute & community care NHS England
DMS&NHS England iv
NHS EnglandDMS&NHS England iv
CCGsDMS&NHS England iv
CCGs iii
MOD Enhanced pathways DMS DMS N/A N/A N/A DMS N/A
i - Reservists have access to DMS care whilst mobilisedii - Serving personnel can access local GPs on an emergency basis if needing to access care whilst away from the military addressiii - The NHS England will commission specialised services for veterans, e.g. limb prostheses, iv - While overseas, serving personnel and families can access DMS-commissioned healthcare where such provision exists, or may be provided with non-DMS healthcare by local Host Nation or other contracted arrangements, or have right of return for NHS care in England
www.england.nhs.ukHealth and Wellbeing Boards, AFNs, Community Covenant and partnerships
NHS England Board
NHS England Commissioning
Operations
Central & Regional TeamCommunity and Acute Hospital
for those registered in MOD Centres
Armed Forces Commissioning Interface between MOD and Providers
Assurance of CCGs All non-specialised services for Veterans, Families, Reservists
Armed Forces Commissioning
Veterans’ and families commissioning Transition management
Veterans, reservists and families
Reservists, Veterans’ & Families Commissioning
Design Principles :Retain: Knowledge, expertise, capability, continuity, skillsets, credibilityEnsure: Momentum, partnerships, linkages, AFNs, practical configuration and delivery
CLINICAL COMMISSIONING
GROUPS
NHS England - Armed Forces HealthNOT UK WIDE
NATIONAL LOCAL
Limited Range of Services
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Transition – Wounded Injured and Sick; ‘service leavers’, mobilisation and demobilisation
CCGsReservistsVeteransFamilies
DMS Operations
OccupationalPrimaryMentalRehab
NHS EnglandCommunity CareAcute Care, CHCTRANSITION IN
AND OUT OF SERVICE
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System and network complexity
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Armed Forces Networks• Represent all local Stakeholders, including:
• Regional Armed Forces command and health structures• MoD Personnel Recovery Units• Local NHS – commissioners and providers• Local Authorities• Charities• Veterans and families organisations/ individuals –
patient and user voice
• Supporting Transition of service leavers, local learning, national learning, information sharing, commissioning and key patient voice issues
• Meet regularly 3-4 times per annum and ‘virtually’ all the time to resolve cross-system issues
• Currently 9 in England mapped closely to Army regional Brigade structure
• Routine monthly AFN teleconf - to share system leadership and oversight of issues with partners and stakeholders
• Regional models vary to reflect stakeholders and relationships, but based on core principles above
NHSHealth Care
CharitiesArmed Forces
Local Authorities
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• Who are our community?• Age, service history, type of service
• When do they engage?• Delay
• Who do they engage through?• Where do they engage?
• Veterans distribution• What are their issues?
• Co-morbidities• New reports:
• Ashcroft – most do well from service• Stephen Phillips – (Former Members of the Armed Forces and the
Criminal Justice System)
• RBL – (UK Household Survey of the Ex-Service Community)
• KCL – “Myth buster”• Service evaluations (NVMHN, CIE Needs Assessments)• Etc.
What we know?
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OP and Community Veteran Provision(IAPT and NVMHN for NHS)
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OP and Community Veteran Provisionby Region
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• Local Authority JSNAs• Good (but not complete) coverage• Narrow focus of assessments
• CCG provision:• IAPT/ Parity of Esteem/Crisis Concordat/ Closing the Gap• Variable specialist veteran provision:
• Type of services• Availability of services
• Diverse Charity Provision • A few large vs. multiple small; • Quality assurance & navigation issues
• Gaps• National gaps e.g. crisis, young people, etc.• Limited user views• Families• Step 3 • Co-morbidities
Early Impressions from Review of Needs Assessment
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• Direct Commissioning for • Health and Justice settings • Specialised (e.g. Forensic, Tier 4 CAMHs)
• Delivering National Programmes:• 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 like Combat Stress and Help for Heroes, to local community groups
• CCG Assurance …..
NHS England’s General Roles in Mental Health
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Current NHS Roles re Veterans MH
• CCGs (should have) taken over veterans commissioning • IAPT services• Different local models to meet local needs• Veterans are below “critical mass”
• NHS England inherited roles:• £1.5M nationally for Regional (locally decided to deliver
Murrision “Fighting Fit”) - original purpose more professionals
• £3.2M specialised in Patient PTSD• £350k Big White Wall
• Developing the Evidence Base• Domestic Abuse• Needs assessments• Pilot development
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• Providing fora for advocacy and discussions:• Clinical Reference Group• Veterans’ Mental Health Network• Armed Forces Networks• Covenant promotion e.g. contract, royal colleges etc.• Funding
• Response to national reports:• House of Commons Defence Select Committee• Philips on Veterans in Custody
• Improving integration and transition:• Temporary Registration• Summary of care record on discharge
Other Activity in Veterans’ Mental Health
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• Transferred Service personnel from MoD system to NHS System and so single registration (MoD retain own record)
• Maintained continuity of intherited mental health services for Veterans
• Rewrite of Joint Services Publication for joint work with the recovery of the wounded, injured and sick and transition
• Research in Domestic Violence, • Needs assessments for veterans: Mental Health (in
progress)• Gathering of data on activity of 10 regional mental health
services.• DCMH & NHS Provider Pilots• National IAPT data capture and Health and Justice capture
including L&D
Changes in the last 2 years
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Possible Future Roles• Use System Management/ Market Management to
deliver new services to:• Improve Data capture• Define roles more clearly
• CCG• Charities• NHS England (redefined specialist only?)
• Provider assurance• Promote under provided services:
• Complex Trauma with comorbidity• Personality/Adjustment Disorder• Families support
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PREVENTION• Importance of transition out of service work between DMS and NHS• Understanding incidence and causes of:
• Alcohol misuse• Mental ill health• Criminal behaviour (especially violence and sexual)
ACCESS• Who is a veteran?• Attribution a minimal issue in healthcare access• Behavioural aspects of care:
• Accessing care• Non clinical interventions
INTEGRATION• Common Philosophy• Data definitions• Common assessment• Common Pathways• Record sharing• Measuring joint outcomes
Possible Items for Discussion
