Mental Health Service

It is an initiative designed to prove a model of community-based mental health recommended by the Health and Social Care Advisory Service (an independent expert charity) and advised by a panel of appropriate experts. It recognises that in some areas of the country, the NHS can no longer access easily the expertise in military mental health required to meet the needs of some mentally ill veterans. It addresses this by establishing on a regional basis networks of expertise in military mental health to provide specialist assessment and treatment in a culturally sensitive setting. There will be 6 sites across the UK as well as some associated projects. The pilots will last 2 years, with evaluation before consideration is given to wider rollout.

What was the background to this initiative?

The Government is committed to good mental health and well-being for its personnel, both in service and after they leave. For veterans, healthcare is primarily the responsibility of the NHS. With the cooperation of Combat Stress, MOD funded an independent review of the Society’s programmes by the specialist independent Health and Social Care Advisory Service (HASCAS) to ensure that the treatment offered and its place in the wider NHS was appropriate.

In response to this review, officials from the MOD, the UK Health departments and Combat Stress, advised by national clinical experts, have been working together to develop and implement a new community-based model to address the special circumstances that may affect the treatment of veterans mental health problems.

Does that mean there were no treatment services in England providing specialist help for veterans with mental health problems?

There is little evidence that veterans generally suffer different mental health disorders from the rest of the community nor that these require different treatments when seen in veterans. What is different is that in order to be useful services must be accessible and acceptable and the evidence is at this date that some veterans are reluctant to seek help from civilian health professionals. They feel that they lack understanding of military life or the context of their injuries. This delay in help seeking means that successful treatment may be more difficult. From 1996 when it began as a pilot project Humber Mental Health Teaching NHS Trust has run a PTSD service for ex-military personnel in the area of Hull and the east Riding. This area has a catchment of about 600000 people and is a high area of recruitment to the armed forces. It is also the home of the National Gulf Veterans and Families Association. At present the service is led by Dr Jennie Ormerod, clinical psychologist. There are a further two clinical psychologists and a senior occupational therapist all working part time for the service. It aims to provide a direct access priority service for ex-regular and reservist members of the armed forces. Support is also provided to partners and families. Clients are seen within one month of referral and therapeutic input is evidence based.

How will this new service differ from the current arrangements?

There are currently no networks of expertise in military mental health across the UK; historically, the NHS has been able to rely on the significant numbers of its health professionals who had military service; However, with the declining size of the Armed Forces over the years, many of these have now retired, with expertise more thinly spread.

The new model reflects current NHS evidence-based best practice with regional clinical networks, made up of NHS primary care and community mental health facilities linked variously to centres of military expertise, academic centres with an interest and Combat Stress provisions. At its heart will be a facility with a Community Veterans Mental Health Therapist. Following initial triage clients will be directed to relevant treatment and support. Some will have social needs; others can be dealt with by the GP or community mental health services with or without the support of the community therapist or others with relevant military expertise/experience. Some with complex and severe needs may require specialist assessment and treatment. This may be provided by the community veterans’ mental health specialist or elsewhere including in some cases, in-patient referral to a Combat Stress home

The new model is firmly based on a holistic coherent approach to mental health well being. It is multidisciplinary with links to local social services, ex-service charities especially the regional welfare officers of Combat Stress and the Veterans Welfare Service. The aim is to provide help with social integration, financial issues, relationships, housing, job seeking, training education physical fitness, sports and recreation.

Where are the pilot sites?

The sites participating in the new pilot scheme are: Stafford, Camden & Islington, Cardiff, Newcastle, St Austell and Scotland

What are the catchment areas?

The Pilot sites are situated within the catchment area of a Mental Health Provider Trust or equivalent (Care Trust or a PCT) for example; Stafford will cover Shropshire and Staffordshire.

The Combat Stress Treatment Centres are situated in the catchment areas of the following Mental Health Trusts or providers: Tyrwhitt House Leatherhead is in Surrey and Borders Partnership NHS Trust (South East Coast SHA), Audley Court is in South Staffordshire and Shropshire Healthcare Foundation Trust, and Hollybush House, Ayrshire is in Ayrshire & Arran NHS Trust.

Why have these specific sites been selected?

They cover a cross-section of the UK that will test the model in a range of social and geographical situations. A large number of service personnel have been recruited from these areas and the sites are located within a reasonable distance of one of the Combat Stress treatment centres. Stafford has been traditionally known for its high levels of recruitment into the Army and its experience in delivering specialised services more widely. Camden and Islington will implement a service for veterans across London, (the Traumatic Stress Clinic hosted the NHS trauma response to the mental health needs of those affected by the London bombings).

What are the individual pilot start dates?

Stafford started its (Pilot) Community Veterans Mental Health service in September. Camden and Islington will launch in January 2008. We hope to launch in succession; Cardiff, Newcastle upon Tyne, Cornwall and Scotland.

What services will the pilots provide?

The Pilots will provide a mental health assessment and treatment service that can be easily and quickly accessed by military veterans. The community-based clinics will be open to all ex-service personnel and will be able to help with the diagnosis and treatment of veterans suffering from anxiety, depression, alcohol and drug misuse and PTSD. The focus will be on those veterans whose severe/complex, service-related mental health needs are not met currently by their local mental health services.

How do individuals access the programme?

An important feature of the pilots is that veterans can access the service by a variety of routes including self referral and via social service departments, the charitable sector, notably via the ex-service organisations and the Veterans Welfare Service. An important route into the programme will be via an individual’s GP. Partners or family members contacting the programme will be advised to encourage the patient to contact their GP. Or in some cases to register with a GP. Referrals from civilian psychiatric services (such as Combat Stress) are also accepted. Where possible the intention will be to involve the GP and to keep him informed. Details for accessing the service and on the areas covered are available at: www.veterans-uk.info

What about personnel with disabling psychological trauma?

They will be a key potential beneficiary of the pilots; psychological trauma can have several clinical presentations including most commonly anxiety and depression. PTSD is an uncommon diagnosis in serving personnel and veterans. The MOD recognises PTSD as a serious and disabling condition, but one that can be treated. We attach a high priority to increasing awareness of stress-related disorders, and to their diagnosis and treatment. For those areas not covered by the pilots, referral to the MAP for veterans having operational service on or after 1982 should ensure that previous undiagnosed cases of PTSD will be picked up until the pilot model is rolled out more widely. A key challenge in setting up a new mental health service for veterans is the lack of hard data on likely demand. To avoid overwhelming the system a cut –off date of 1982 has been applied. On present evidence it seems likely that most veterans with problems caused before that date will already be receiving help via some route.

What is the MOD doing about trauma related problems?

The Armed Forces recognise the risk of psychological injury resulting from service especially operational deployed service and have over recent years taken major steps to address it. We have put measures in place to increase awareness at all levels and to mitigate the development of PTSD and other stress-related disorders occurring among Service personnel. These include pre-and post-deployment briefing and the availability of support, assessment and (if required) treatment, both during and after deployments. This is available to all personnel, whether Regular or mobilised Reservist.

Do GPs know about the new pilots?

Through the MoD partnership with the Department of Health and arrangements within the individual pilot areas, information will be passed to UK Health Authorities for wider dissemination to GPs. In addition, we are developing project information for service leavers, veterans, ex-service organisations and health professionals. It is also intended to host a series of seminars and educational events in the various pilot areas

Who will pay for the New scheme?

The MoD will provide start up costs to the six pilot sites that will participate in the scheme. The remainder of costs will then be the responsibility of the local NHS trusts.

Combat Stress

What will be the role of Combat Stress?
How does the MOD fund Combat Stress?
How much is the fees increase for 2007/2008?

What will be the role of Combat Stress?

The current NHS approach to delivery of health care uses a model with quality assured services delivered by a mixture of public, private and third sector agencies. The new arrangements will allow Combat Stress to take up a mainstream provider role in delivery of mental health services to veterans. Combat Stress provides short stay remedial treatment at three specialist short-stay treatment centres in Shropshire, Surrey and Ayrshire. These provide a range of treatments including psychiatric support and occupational therapy to help veterans rebuild their lives. This will be a two-way process, as Combat Stress will also be able to refer patients to the appropriate pilots for specific assessment and treatment.

How does the MOD fund Combat Stress?

The MOD provides funding under the War Pensions Scheme for war pensioners who receive treatment related to their accepted disablements at the Combat Stress homes. MOD is committed to helping Combat Stress in working towards the new mental health arrangements by increasing fees paid under the War Pensions Scheme to reflect full costs of providing treatment and improvements to it. This amounted to some £2.5M for 2006/2007.

How much is the fees increase for 2007/2008?

The increase will be phased. There will be a 28 per cent increase from April 2007, rising to 35 per cent on 1 October 2007 with a further increase to 45 per cent from 1 January 2008. In cash terms, this sees the daily fee paid by the MOD to Combat Stress for the treatment of each eligible war pensioner increase from around £180 to around £260 a day.

In-Service/Reserves Healthcare

What services do you offer in the UK?
What processes do you have in place to monitor and treat the mental health of reservists?

What services do you offer in the UK?

Our mental health services are configured to provide community-based mental health care in line with national best practice, providing assessment and treatment in line with the guidelines and standards set by the National Institute for Health and Clinical Excellence and the National Service Frameworks. We do this primarily through our 15 military Departments of Community Mental Health (DCMH) across the UK (plus satellite centres overseas), which provide out-patient mental healthcare.

The DCMH mental health teams comprise psychiatrists and mental health nurses, with access to clinical psychologists and mental health social workers. The aim is to see referred individuals at their unit medical centre and, with the patient’s permission, to engage with general practitioners and their chain of command to help manage mental health problems identified in personnel. A wide range of psychiatric and psychological treatments are available, including medication, psychological therapies, and environmental adjustment where appropriate. The Defence Mental Health Services have extensive experience in psychological treatments for mental health problems in general and psychological injury in particular.

In-patient care, when necessary, is provided in dedicated psychiatric units through a central contract MOD has with the Priory Group. Close liaison is maintained between local DCMHs and the Priory units to ensure that all Service elements relating to an inpatient care and management are addressed. The arrangements with the Priory Group mean that the majority of our patients can be treated much closer to their parent units than was the case when we maintained the last of our own psychiatric hospitals.

What processes do you have in place to monitor and treat the mental health of reservists?

Whilst mobilised, Reservists are treated exactly the same as Regulars. Once demobilised, it is a long established tradition that reserve forces’ medical care becomes the responsibility of their own local NHS primary care trust and the majority of Veterans’ physical and mental health needs are met by these provisions. However, the MOD recognises that it has an expertise to offer in certain specific circumstances, and in November 2006, it launched a new initiative - the Reserves Mental Health Programme (RMHP).

The RMHP is open to any current or former member of the UK Volunteer and Regular Reserves who has been demobilised since 1 January 2003 following an overseas operational deployment as a reservist, and who believes that the deployment may have adversely affected their mental health.

Under the RMHP, we liaise with the individual’s GP and offer a mental health assessment at the Reserves Training and Mobilisation Centre in Chilwell, Nottinghamshire. If diagnosed to have a combat-related mental health condition, we then offer out-patient treatment via one of the MOD’s 15 DCMHs. If more acute cases present, the DMS will assist access to NHS in-patient treatment.

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