1.1Aims and Objectives of the Review

Public Health Wales / General document template
A Review of the Veterans’ NHS Wales Service
Author: Phill Chick, Mental Health Development Lead for Wales
Date:7th November 2014 / Version:1b
Publication/ Distribution: Welsh Government
Purpose and Summary of Document: To provide Ministers with a detailed review of the VNHSW service and recommendations to improve the service within existing resources.
Work Plan reference: The review forms a part of the Public Health Wales PLA with Welsh Government.
Date: / Version: / Page: 1 of 62

CONTENTS

Executive summary

1.0Background to the review

1.1Aims and objectives of the review

1.2Review objectives

1.3Review methodology

1.4Needs assessment

1.4.1Capacity and need

1.4.2The veteran population in Wales

1.4.3Current and future need

2.0Veterans’ NHS Wales service aims and objectives

2.1A description of the hub and spoke service model

2.2Staff turnover and vacancies

2.3Access to the VNHSW

2.4Service eligibility

2.5Service provision

2.6Service limitations

3.0The features of a successful service

4.0Service issues explored within the review

4.1The scale of the service

4.2The service structure

4.2.1The importance of being locally embedded within the wider service system

4.2.2Ensuring access to crisis support

4.2.3Governance issues and the impact of a complex system

4.2.4The hub and spoke model

4.3The current service specification and service outcomes

4.4The common referral pathway

4.5Access and waiting times

4.6The assessment of qualitative outcomes

4.7The balance of therapy and non-therapy time

4.8The use of network arrangements

4.9Networking the spokes

5.0The potential value of clinical champions

5.1The role of the Director

5.2The delivery of therapeutic interventions

6.0Clinical outcomes and patient satisfaction

7.0Potential unmet need

7.1Provision to Health Boards

7.2Issues of rurality

8.0Conclusion and summary

9.0Acknowledgements

10.0Task and Finish Group membership

11.0Data sources

12.0Supporting / extra data

13.0References

14.0Background reading

LIST OF FIGURES

Figure 1Veteran population projections in Wales 2005-2020 using Royal British Legion prevalence estimates

Figure 2Veteran population projections in Wales 2005-2027 using Office for National Statistics prevalence estimates

Figure 3Service user satisfaction questionnaire Version 1 treatment satisfaction n=48

Figure 4Service user satisfaction questionnaire Version 2 treatment satisfaction n=22

Figure 5Service user satisfaction questionnaire Version 1 satisfaction with therapist n=48

Figure 6Service user satisfaction questionnaire Version 2 satisfaction with therapist n=22

Figure 7Service user satisfaction questionnaire Version 1 satisfaction with waiting time to first appointment n=48

Figure 8Service user satisfaction questionnaire Version 2 satisfaction with waiting time to first appointment n=22

Figure 9Service user satisfaction with first appointment being conducted by telephone

LIST OF TABLES

Table 1Veterans’ NHS Wales referrals 2013-14

Table 2Estimated veteran population, all persons aged 16 and over, Wales Health Boards, 2015

Table 3Referrals to the Veterans’ NHS Wales service 2010-2014

Table 4Average number of days waiting time from referral to assessment and assessment to treatment 2013-14 Veterans’ NHS Wales Service

LIST OF APPENDICES

Appendix 1Veterans NHS Wales Common Referral Pathway

Appendix 2Terms of reference for a review of the Veterans’ NHS Wales Service

Appendix 3Review of the Veterans’ NHS Wales Service – Veterans’ Therapy Service Semi Structured Interview.

Appendix 4Stakeholder organisations contacted as part of the review

Appendix 5 Veterans' NHS Wales Review - Questions to address within Veterans' Focus Groups 57

Appendix 6 Service user questionnaire Version 1 sample size n=48 respondents 58

Appendix 7 Service user questionnaire Version 2 sample size n=25 respondents 59

Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to Public Health Wales NHS Trust to be stated.

A review of the Veterans’ NHS Wales Service

Executive summary

This report outlines findings from a review of the All Wales Veterans’ Health and Wellbeing Service (AWVHWS). This service has recently been re-launched as Veterans NHS Wales (VNHSW). The primaryaim of the VNHSW is to improve the mental health and wellbeing of veterans in Wales, with the secondary aimof developing sustainable, accessible and effective services that meet the needs of those with mental health and wellbeing difficulties who live in Wales.(All Wales Veterans Health and Wellbeing Service (2009).

The study was undertaken by Public Health Wales from April to June 2014.

Background and study aims

Each year over 25,000 men and women from the British Armed Forces leave and enter civilian life. For the majority, the transition into civilian life holds few problems, but for some, the adjustment to living life outside the armed forces can trigger mental health and social problems.

In recent years, the health and well being needs of military ex-Service personnel has beenwidely recognised by theMinistry of Defence and civilian society, especially the needs of those veterans experiencing mental health problems as a result of their experiences serving on the front line and in other military settings.The mental health issues most commonly presented resulting from military service are post traumatic stress disorder (PTSD), depression, anxiety and alcohol dependence syndrome. These may be accompanied by more severe mental illnesses such as bipolar disorder or schizophrenia.

In October 2011, the VNHSW was fully established following successful pilots run in Cardiff and the Vale and Cwm Taf.The service operates on a hub and spoke model with Cardiff and Vale University Health Board operating as the hub and five other Health Boards operating local spokes. Powys’ service is provided by three neighbouring Health Boards; Aneurin Bevan University Health Board, BetsiCadwaladrUniversity Health Board and Abertawe Bro Morgannwg University Health Board.

Following questions received by Welsh Government Ministers from key stakeholders in relation to the capacity of the service to meet current and future demands, the Minister for Health and Social Services requested Public Health Wales to conduct a review of the service.

The review sought to:

•Analyse reports on the operation of the service including activity and access data

•Analyse service entry and exit flows

•Consult with providers and users of the VNHSW on the operation of the service and the potential to improve it

•Consult with key stakeholders

•Produce a high quality report containing recommendations toMinisters.

Review methodology

In order to effectively address the review aims, a multi-stage mixed methods approach was undertaken which included:

Desk top review of relevant literature including the VNHSW operational policy, Public Health Wales needs assessment, Healthcare Inspectorate Wales Review
Review lead meeting with VNHSW’s Principal Clinician to agree scope of the review and draft Terms of Reference
Statistical analysis of routinely collected data already held by various organisations including VNHSW, the Office for National Statistics (ONS), the Royal British Legion (RBL) and Public Health Wales Observatory
Structured interviews with Veterans’ Therapists and key stakeholders
Analysis of VNHSW service user questionnaires
Service user focus groups (n=2). One in South Wales and one in North Wales.

As part of the review, it has also been necessary to consider the role of VNHSW in the context of it forming part of the wider mental health service system, and the broad range of veterans’ services available within Wales.

Capacity and need

The catalyst for the review was a concern from stakeholders of the capacity of the service to meet current and future demand. Currently, the exact number of veterans residing in Wales is unknown. Public Health WalesObservatory projections, based on Office for National Statistic (ONS)estimates,do suggest that the veteran population in Wales will have grown to 159,000by 2017, up from 157,000 in 2007, and may reach 170,000 by 2027.(Woodhead C et al for the Office of National Statistics 2009)

In addition, the rapid demobilisation by 2017, of 33,000 Armed Forces personnel as a consequence of the UK Defence and Security Review Ministry of Defence (2010) will lead to a significant number of people becoming veterans in the coming years, many of whom will have experienced combat, and as a result, may require specialist veteran services.

Since its inception, the all Wales service has received 1,115 referrals, an average of 278 per year. In 2013-14 the service received 395 referrals.(Veterans’ NHS Wales 2014).

It is anticipated that due to a number of factors including HM armed forces deployment in recent conflicts and the demobilisation following the strategic defence review that demand for VNHSW services is likely to increase in future.

Access to VNHSW

VNHSW is a primary care service with an open access policy accepting referrals from veterans themselves and referrals made on their behalf from family members and statutory and non-statutory services.It is available to any veteran of HM Armed forces that has, or is suspected of having, a mental health problem related to military service.A veteran being defined as somebody who has served at least one day with HM Armed Forces as either a regular serving member or as a reservist.(All-Wales Veterans’ Health and Wellbeing Service 2009).

The VNHSW service is not a crisis service and is not suitable for treating people with complex mental health problems that are not resolvable by time limited psychological interventions.

The service has developed a common referral pathway for use by other agencies wishing to consider referral to the service (see Appendix 1). This pathway has been agreed with Welsh Government and the VNHSW National Steering Group.

v.Service issues explored within the review

VNHSW is a small-scale national service, with between 1 and 1.5 WTE Veteran Therapists plus 0.5 WTE admin support per Health Board (except for Powys whose services are provided by three of its neighbouring HBs).It is the scale of this service that poses a risk in terms of continuity of service within HBs. Staff absences and vacant posts have a major impact on the delivery of the service especially in relation to waiting times for assessment and treatment.

The current all-Wales service specification contains 13 outcomes which address the following areas; access to services, assessment, signposting, onward referral, developing management plans with veterans and their families, establishing local and national networks to improve multi agency working, links to the military, promotion of recovery, provision of therapy, provision of local expert advice, awareness raising, the removal of barriers to services experienced by veterans and data gathering. Veteran Therapists strongly advocated for the service to continue this ‘holistic’ approach to service provision as opposed to reducing the number of service outcomes.The review supports this position.

vi.The hub and spoke model

A considerable amount of time was spent within the review considering the fitness for purpose of the existing hub and spoke model being used in the delivery of the VNHSW.

The hub and spoke model was largely seen as a positive arrangement for the delivery of the service, as it provides the ability for the service to be locally embedded whilst providing a national approach. There was a consistent sense from the service that now that the local services have been established and have matured, that a greater emphasis should be placed on the hub for financial and managerial issues whilst retaining the benefits of the locally hosted spokes.

vii.Access and waiting times

Access to the VNHSW and the existence of, or potential for, waiting times was an important component of the review.Throughout the review the issue of waiting times was raised by the service itself, by stakeholders and by veterans within the focus groups. Avoiding waits was universally recognised as favourable and enforced waits were seen as detrimental to the quality of the service provided.For the various Health Board VNHSW services, the average waiting time ranged from 15 to 80 days for referral to assessment and 15 to 140 days for assessment to treatment.(Veterans’ NHS Wales 2014). Reducing these waiting times is and will need to continue to be, a priority for the service.

viii.The use of network arrangements

The development and nurturing of networks in the delivery of services to veterans was considered crucially important.However, networks were found to be better established in some spokes than in others.

ix.Clinical outcomes and patient satisfaction

The VNHSW service screens patients pre therapy and tests again post therapy for measurement of improvement. The service reports statistically significant improvement against all of the scales used comparing symptoms at initial screening and post therapy.

The service also uses service user satisfaction questionnaires, which consistently show high satisfaction rates with the nature and quality of the therapy provided but score less well on satisfaction with waiting times to be assessed and treated.

x.Potential unmet need

The service is available to any veteran that chooses to use the service, subject to an assessment of clinical need and suitability.However, female veterans, early leavers and prisonerveterans were identified as particular groups currentlyunder-represented in service use.

xii.Review recommendations

Recommendation 1

The recently announced £100,000 provided by Welsh Government for 2014-15 should be targeted at reducing current waiting times.

Recommendation 2

The method of assessing referral to treatment times (RTT) for the VNHSW should be reviewed. Greater emphasis should be placed upon reducing the referral to assessment time.

Where a delay in assessment is unavoidable the veteran should be given a provisional date for assessment. Where a delay in commencement of treatment occurs a provisional date for commencement should be given and the veteran kept informed of progress. The RTT should be sufficiently sophisticated to reflect the use of time accessing complementaryservices following assessmentwhich prepare veterans for the commencement of therapy.

Recommendation 3

A standard system should be introduced ensuring that at assessment,veterans are consistently provided with clear information about the manner in which the VNHSW operates; appraising them of what will happen at each step in the treatment pathway.

Recommendation 4

The service should continue to work with stakeholders at a national and local level to ensure service visibility is improved, particularly in the Powys area and among vulnerable and under-represented groups most notably prisoners and female veterans.

Recommendation 5

The function of the VNHSW hub should be strengthened, the budget for the VNHSW should be held at the hub, reducing delays in accessing resources and speeding up recruitment processes. The responsibility for the operational management of the spokes should be drawn back into the hub improving the streamlining of the management and accountability of Veterans’ Therapists. The governance arrangements necessary to achieve this should be set out in formal memoranda of understanding with Health Boards hosting the service. The existing leads should continue to ensure that the VNHSW service is locallyowned and embedded within local service provision.

Recommendation 6

Health Boards should consider identifying veterans’ clinical experts in Community Mental Health Teams, Crisis Resolution and Home Treatment services and Local Primary Mental Health Support Services. This should include a consultant psychiatrist capable of providing second opinions.

Recommendation 7

The VNHSW service specification should be reviewed and updated as necessary.

Recommendation 8

Local services should take steps to ensure that veterans receive timely crisis care.

Recommendation 9

The VNHSW should continue to play a role in informing the commissioning of any additional services to veterans both nationally and locally. This should include advice on the suitability and efficacy of proposals.

Recommendation 10

Local clinical networks should be in place in all of the service spokes including ensuring close integration with other statutory and third sector veterans’ and mental health services.

Recommendation 11

Service spokes should work together allowing one spoke to support another enabling the service to flex and reduce variability of the service arising from a local increase in demand or reduction in capacity. Such an arrangement would need to be carefully managed with appropriate clinical and governance arrangements in place between spokes.

Recommendation 12

The approach used in the Aneurin BevanUniversity HB service spoke, for balancing clinical and non-clinical time during peaks in demand, should be shared with the rest of the service as a means of sustaining good RTTs.

Recommendation 13

The role of the Director should be reviewed, with consideration being given to removing the requirement for the post to be clinical in nature.

Recommendation 14

The evidence base supporting the use of self-management education programmes for use in veteran mental health services as part of a stepped care approach either as a precursor to therapy or as a post therapy maintenance modelshould be reviewed.

Recommendation 15

Local veteran network arrangements should be reviewed and streamlined to avoid duplication and the potential for confusion.

1.0Background to the review

The VNHSW(formerly the All Wales Veterans Health and Wellbeing Service) was established in April 2010 following a successful pilot in Cardiff and Vale and Cwm Taf. During the first two years of the operation of the service, Ministers receivedquestions from stakeholders on the capacity of the service to meet current demand and potentially increasing demand in the future. The Minister for Health and Social Services requested Public Health Wales conduct a review of the service.