Gate to Gate

Gate to Gate: Improving the mental health and criminal justice care pathways for veterans and family members is a CIE publication on a programme of work undertaken on behalf of NHS England, to explore the effectiveness of health and criminal justice care pathways for veterans with complex mental health needs.

“It is becoming increasingly recognised by commissioners and service providers that veterans with complex mental and related health needs, including Post Traumatic Stress Disorder (PTSD) and dual diagnosis, require appropriate assessment and treatment. Without the correct support, this patient group is possibly at risk of offending, often more serious offences and there are consequential impacts on the whole family, including partners and children and for society in general.

The needs of these veterans and their family members extend along a continuum from inside the military gate while still serving, through transition and resettlement into civilian life, in the community and for some, up to and including contact with the criminal justice system, entry to prison and on leaving the prison gate.

However, progression along this continuum should not and need not be inevitable. There are a number of key points along mental health and criminal justice care pathways where more effective, integrated and higher quality interventions should take place and there is a need to develop these further”.

The programme took place in two stages between February and June 2016:

Stage one: Scenarios were developed using real case studies that formed the basis for two workshops with a range of expert stakeholders including clinicians, commissioners, managers and service planners from across the spectrum of health and criminal justice services. The case scenarios involved veterans who had experienced complex mental health problems including PTSD, which resulted in contact with both health services and the criminal justice system, either through arrest by police or being sentenced to a prison term.

The first workshop explored the critical points along the care pathway in each case scenario and how this might have been made more effective. The second workshop identified the key implications for policy, commissioning and planning of services.

Stage two: Family members and veterans were consulted on the key findings and conclusions from the case scenarios and implications for policy, commissioning and planning. Although some veterans took part, the primary focus was on the experience of family members as it was recognised that their needs are often overlooked. It was important to ensure that the views of families and their experiences of mental health and criminal justice care pathways could inform this report.

The report, which provides the key outcomes and conclusions from the workshops notes that despite some significant improvements in mental health and criminal justice care pathways these do not always best meet the needs of veterans with complex mental health problems.

Risks for the individual, the family and the wider community take place along a continuum from neglect, substance misuse and self-harm, through to aggression, assault and violence in the family home or community. Along this continuum, there are key points for intervention where care gaps become more salient:

  • as a result of exposure to trauma and the failure to appropriately assess, diagnose and treat within the military gate;
  • prior to and during transition to community from the armed services;
  • registration with primary care;
  • entry to a care pathway in the community;
  • at the point of first dis-engagement with services;
  • contact with blue lights services, including attendance at A&E; at the point of arrest;
  • at Court;
  • reception to prison;
  • during a custodial sentence;
  • on release from prison – at the gate;
  • support and management in the community post release.

The recommendations include the following:

Recommendation One: Assessment NHS England and the MOD should work collaboratively with criminal justice partners to improve the assessment of trauma related conditions for serving personnel including reservists and veterans. In particular, there is a need to increase the competency and skills of medical staff including GPs and CMPs in trauma related mental health assessments.
Recommendation Two: Using and sharing data NHS England and NHS Improvement should work with the MOD and criminal justice partners to ensure that appropriate and effective protocols and standards are in place for sharing of information about veterans and mental health problems across relevant agencies. Also, the Department of Health should ensure that HSCIC can provide timely and accurate reports on veteran status.
Recommendation Three: Crisis intervention There is a need to ensure an effective response including assessment and interventions at points of crisis for veterans with complex mental health problems. NHS England and the LGA should work collaboratively with CCGs and criminal justice partners to ensure that local area crisis Concordat Action Plans take account of the needs of veterans with complex mental health problems.
Recommendation Four: Integrated mental health and criminal justice care pathways There is a need to review the current service models for mental health and criminal justice interventions under a joint governance arrangement involving health, criminal justice and the MOD. This could be taken forward through an integrated action group, led by NHS England, that considers the findings from this report and seeks to develop pilot service developments, building on areas of best practice that can meet the identified needs for veterans with complex mental health problems who are at risk of offending.
Recommendation Five: Strategic leadership and governance The strategic lead and governance for an integrated mental health and criminal justice system for veterans should sit within NHS England.
Recommendation Six: Parity of esteem for veterans who are TIS In line with the previous recommendations there should be greater parity of esteem between veterans who are Wounded, Injured and Sick (WIS) and veterans who are Trauma, Injured and Sick (TIS)

Some particular recommendations are made regarding the feedback from the family member consultation:

Recommendation Seven: Earlier intervention and support for family members There is a need to improve the welfare response and services for families within the military gate. This should include ensuring an appropriate and professional service that recognises the mental health needs of family members.
Recommendation Eight: Employment and housing support for veterans during transition to civilian life NHS England, PHE and the LGA in collaboration with the MOD should explore the development of service pathways, alongside social sector partners to promote greater access and support into employment and/or housing for veterans during transition to civilian life.
Recommendation Nine: Perinatal mental health care NHS England should include women who are partners of armed forces personnel or veterans in access targets and reinvestment plans for perinatal mental health care.
Recommendation Ten: Participation and involvement of service users, families and carers NHS England should continue to engage veterans and family members including carers and children and young people in order to ensure that their voices and the lived experience of those who need and use services continues to be at the heart of service commissioning, planning and delivery.

The full report can be downloaded here: Gate to Gate