Welcome to the APPG meeting on the complex needs of Veterans

1. Welcome to the APPG meeting on the complex needs of Veterans Chaired by Lord Victor Adebowale CBE and Baroness Judith Jolly Follow or link to us on Twitter: @appgcomplexneed, @Voa1234 and @DavidBurrowesMP

2. Agenda • 11.30am – Welcome and introduction • 11.40amto 12.05pm– Speakers • 12.05pm - Questions and discussion • 12.50pm– Closing comments • 12.55pm – Next meeting and staying informed • 13.00pm – Meeting ends

3. Today’s Speakers: • Prof. Neil Greenberg – Professor of Defence Mental Health, Help for Heroes • Wing Commander (Rtd) Dr Walter Busuttil - Medical Director and Psychiatric Consultant, Combat Stress • Major General (Rtd) Nick Caplin CB – CEO, Blind Veterans • Kevin Lowe - 1stBtn Royal Regiment of Wales (Served between 1998 -2002) • Bill Nevill - Royal Engineers (Served between 1969 - 1981)

4. COMBAT STRESS Wg Cdr Walter Busuttil MB ChB MPhil MRCGP FRCPsych RAF (Retd) Consultant Psychiatrist & Director of Medical Services walter.busuttil@combatstress.org.uk Combat Stress 24 Hour Helpline 0800 138 1619

5. Combat Stress National Third Sector Charity 6,004Veterans are currently being supported. 2, 328 Total of new referrals in the year. 1,168Number of Veterans discharged. 5 • Established 1919: • UK wide • Largest Third Sector Veterans’ Mental Health Provider • Multi-Disciplinary Clinical Staff • National Specialised Commissioning by NHS • Funding: 33% Statutory, 66% Charity • Turn over: • 2007/8: £4 million; • 2014/5 £19 million.

6. Combat Stress Access & Needs-Led Tiered Clinical Pathways

7. Research and Audit • Formal Link into Kings Centre for Military Health Research (KCMHR) & Academic and International Collaborations • Research aimed at identifying needs of help-seeking veterans and service development • Bio-psycho-social presentation • Stigma and barriers into care • Treatment outcomes • Family and Carers • Brain Injury and PTSD • Help seeking and illness behaviour

8. Demographics • Army 84% • Merchant Navy 0% • Royal Air Force 7% • Royal Marines 3% • Royal Navy 6% • Majority - Army and lower ranks • 97% male and 3% female • In Under 65s - 50% unemployed • Average Age 41.8 years • Average Length of Service 11.1 years • Interval between discharge and first contact 12.3 years

9. Demand • 2014/15 - 5,954 active veterans vs 5,473 end 2013/14 - 9% increase • 2014/15 2,328 new referrals vs 1,854 end 2013/14 - 28% increase • 7% NHS Community Mental health, • 4% GPs, • 3% from the Website • Access • 44% self referral ; 4% Families / friends • 21% other charities/Unknown • 17% from Helpline

10. Theatres of Operation – Active Veterans (n=6004) Northern Ireland 33% Iraq 13% Afghanistan 11% Balkans 10% Gulf 7% Falklands 6% All other conflicts and Wars 13% None 8% Please note, a veteran may appear in both conflicts

11. Help Seekers: Needs Analyses One Independent study and large Combat Stress clinical audit dataset since 2005

12. Evidence Base: • For treatment to be effective the following must be satisfied: • Accessible • Engage • Complete • Efficacious: Improvement of symptoms & function • Maintain improvement long term • Plus: Skilled qualified; professionally registered staff

13. Intensive Six Week Programme - OutcomesBritish Medical Journal (March 2015) • Naturalistic study: Successive patients-246 veterans who accessed Combat Stress between late 2012 and early 2014 for treatment. • Six week and six month follow-up • High engagement and high completion rate (94%) – (US studies drop out rates 22-46%) • Highly significant reductions in symptoms (87%) and improvement in function to six month follow up. • One year FU data - similar findings - about to be submitted for publication. • Optimum outcome predictors paper published.

14. Collaboration NHS • Most Veterans remain unidentified – Stigma; no means to identify veterans. • Majority must access statutory NHS services – 80% of CS veterans have tried to get help from NHS first! • IAPT - data incomplete – similar to general population in terms of treatment completion - around 50%. - No long term FU studies of efficacy • Specialised Services: Veterans’ Mental Health Network: • 10 across England – minority are psychology/therapy led clinical services not truly multidisciplinary – others are signposting services. • No long term FU studies of efficacy. • Many shared patients with CS. • No standardisation of NHS services – difficult to interface with

15. Recommendations • More Joint Working & Collaboration • Simplify accessibility especially Military Charity Sector • Identify veterans within the NHS • Evidence based service planning (remember A,E,C,E,M). • Joined up tiered pathways & programmes – NHS & Third sector

16. References • Andrews, B., Brewin, C.R., Philpott, R., Hejdenberg, J. (2009). Comparison of immediate-onset and delayed-onset posttraumatic stress disorder in military veterans. Journal of Abnormal Psychology, 118, 767-777. • Brooks, E., Novins, D.K., Thomas, D., Jiang, L., Nagamato, H.T., Dailey, N., Bair, B., Shore, J. (2012) Personal characteristics affecting veterans’ use of services for Post Traumatic Stress Disorder. Psychiatric Services 2012; doi: 10.1176/appi.ps.201100444 • Brooks, E., Novins, D. K., Noe, T., Bair, B., Dailey, N., Lowe, J W.J., Richardson B., Hawthorne, K., Shore, J.H. (2013) Reaching Rural Communities with Culturally Appropriate Care: A Model for Adapting Remote Monitoring to American Indian Veterans with Posttraumatic Stress Disorder Telemedicine and e-Health. Apr 2013, Vol. 19, No. 4: 272-277. • Busuttil, W. (2010) Mental Health Problems in British Veterans. In: Managing Trauma In the Work Place: Supporting Workers and Organisations. Ed Noreen Teherani. Routledge Taylor and Frances Group pp33-50. • Busuttil, W. (2011) Post-traumatic stress disorder and substance misuse. In Practice in Mental Health Substance Use 109-124; D C Cooper ed. Radcliffe Publishing Ltd: London. • Busuttil, W (2012) Military Veterans’ Mental Health – the long term post trauma support needs. In: 'International Handbook of Workplace Trauma Support', eds Rick Hughes, Andrew Kinder and Cary L. Cooper. pp458-474. Wiley- Blackwell: Oxford. • Busuttil, W. (2014) Trauma Related Substance Misuse. In Attorney’s Guide to Defending Veterans In Criminal Court. (Brocton Hunter ed) Chapter 7. National Veterans Foundation: Minneapolis USA. • Busuttil, W (2014) The Charity Worker’s Tale. In Battle Against Stigma eds M Neville & J Hacker-Hughes - its Role ed Jamie Hacker-Hughes Bringing War Home. Volume 2, pp 66-79. Wellcome Trust: London. • Creamer, M., Morris, P., Biddle, D., & Elliott, P. (1999). Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: A cause for cautious optimism? Journal of Traumatic Stress, 12, 545–558. • Elhers, A., Gene-Cos, N., Perrin, S. (2009) Low recognition of post traumatic stress disorder in primary care. London Journal of Primary Care. Royal College of General Practitioners, 2, 36-42. • Forbes & Creamer M, (2003) The Treatment of Chronic Post Traumatic Stress Disorder. In: Military Stress and Performance: The Australian Defence Force Experience (eds G E Kearney, M Creamer, R Marshall, A Goyne) pp206-218, Paul & Co Pub Consortium: Defence Science and Technology Organisation. Canberra. • Forbes D., Lewis, V., Parslow, R., Hawthorne, G., Creamer, M. (2008). Naturalistic comparison of models of programmatic interventions for combat-related post-traumatic stress disorder. Australian and New Zealand Journal of Psychiatry 2008; 42:1051-1059 • Foa, E. B., Keane, T. M., Friedman, M. J. (2009) eds. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. 2nd Edition New York: Guilford Press. • Iversen A C, Van Staden L., Hacker Hughes, J Greenberg N Hotopf M., Rona RG Thornicroft J Wessely S, Fear, NT (2011) The Stigma of mental health problems and barriers to care of UK Armed Forces. BMC Health Services Research, 11, 31.

17. References • Klein, S., Alexander, D., & Busuttil, W. (2013) Scoping review: A Needs-Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and their Families in Scotland Robert Gordon University. Aberdeen December 2012 www.scotland.gov.uk/Resource/0041/00417172.pdf • MacManus, D., Dean, K., Al Bakir, M., Iversen, A. C., Hull., L., Fahy, T., Wessely, S., Fear, N.T., (2012) Violent behaviour in UK military personnel returning home after deployment Psychological Medicine 42(8):1663-73. • MacManus, D., Dean, K., Jones, M., Rona, R.J., Greenberg, N., Hull, L., Fahy, T., Wessely, S., Fear, N.T., (2013) Violent offending by UK military personnel deployed to Iraq and Afghanistan: a data linkage cohort study Lancet 2013; 381: 907–17 • Murphy, D.& Busuttil, W. (2014). Reviewing PTSD, stigma and barriers to help-seeking within the UK Armed Forces. Journal of the Royal Army Medical Corps, 0:1–5. doi:10.1136/jramc-2014-000344. • Murphy D, Hodgman G, Spencer-Harper L, Hinton M, Wessely S, Busuttil W. (2015) Mental health and functional impairment outcomes following a six week intensive treatment programme for UK military veterans with post traumatic stress disorder (PTSD): a naturalistic study. BMJOpen. Open 2015;5:e007051. doi:10.1136/bmjopen-2014-007051 • Murphy, D., & Busuttil, W. (2015). Exploring factors that predict treatment outcomes in UK veterans treated for PTSD. Psychology Research, 8(5). • Murphy, D., Weijers, B., Palmer, E., Busuttil, W. (2015) Exploring patterns in referrals to Combat Stress for UK veterans with mental health difficulties between 1994 and 2014. International Journal of Emergency Mental Health, 17, 652-658. • Murphy, D., Palmer, E., Busuttil, W., & Oddy, M. (In press) Exploring the prevalence of traumatic brain injury (TBI) and associations between TBI and mental health difficulties within UK veterans accessing support for mental health difficulties. Psychology Research • Scheiner, N.S. (2008) Not ‘at ease’: UK Veterans’ perceptions of the level of understanding of their psychological difficulties shown by the National Health Service. Doctoral Thesis. City University London: Department of Psychology. • Wood, S., Jones, C., Morrison, S., Kitchner, N., Dustan, F., Fone., Fear, NT., Bisson, J. (2011) Mental health, social adjustment, perception of health and service utilisation of three groups of military veterans living in Wales: a cross-sectional survey. Cardiff University. Unpublished study; synopsis on Welsh Committee Website Wales •  van Hoorn, LA., Jones, N., Busuttil, W., Fear, NT., Wessely, S., Jones, E. Hunt, E.,Greenberg, N. (2013). Iraq and Afghanistan veteran presentations to Combat Stress, since 2003. Occupational Psychiatry. doi: 10.1093/occmed/kqt017

18. Today’s Speakers: • Prof. Neil Greenberg – Professor of Defence Mental Health, Help for Heroes • Wing Commander (Rtd) Dr Walter Busuttil - Medical Director and Psychiatric Consultant, Combat Stress • Major General (Rtd) Nick Caplin CB – CEO, Blind Veterans • Kevin Lowe - 1stBtn Royal Regiment of Wales (Served between 1998 -2002) • Bill Nevill - Royal Engineers (Served between 1969 - 1981)

19. Our next meetings will be on: • Tuesday 2nd February 2016 – on MEAM’s Solutions from the Frontline report • You can find more information on the APPG or contact us via: WEBSITE: www.turning-point.co.uk/whoarewe/appg TWITTER: http://twitter.com/APPGcomplexneed EMAIL: appg@turning-point.co.uk