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“The first duty of Government is the defence of the realm. Our armed forces fulfil that responsibility on behalf of Government, sacrificing some civilian freedoms, facing danger and, sometimes suffering serious injury or death as a result of their duties. Families also play a vital role in supporting the operational effectiveness of our armed forces. In return, the whole nation has a moral obligation to the members of the Naval service, the Army and the Royal Air Force, together with their families”. (Ref 1)

In whatever capacity they served, for however long, all members of the armed forces gave their willingness to die for their country.

“In return they deserve not only our respect and gratitude but also our constant attention to how they are treated and the impact that service life has on them and on their families.”

“Veterans … should receive priority treatment where it relates to a condition which results from their service in the armed forces, subject to clinical need.”

This means that unless there are people on the waiting list whose condition is more serious and need more pressing, a veteran with a service related problem, mental or physical, must go to the top of the list.

“Those injured in service, whether physically or mentally, should be cared for in a way that reflects the nations’ moral obligation to them whilst respecting the individual’s wishes. For those with concerns about their mental health, where symptoms may not present for some time after leaving service, they should be able to access services with health professionals who have an understanding of armed forces culture.”

One of the most common responses from veterans is “You are a civilian, you won’t understand.” Armed forces culture can act as a barrier to veterans needing help, and through our efforts to understand and appreciate the experience of ex-armed forces we can make it easier for them to accept help when they need it.

Mersey Care wins silver award for support of armed forces community 

For the purposes of the Covenant it means all those to whom the nation has an obligation due to their service in the armed forces including:

  1. The serving armed forces consisting of regulars and reservists:
    • Regulars are employed full time and will have signed up for various lengths of service
    • Reservists are made up of both regular and volunteer reservists. Regular reservists are former full time members of the armed forces and may still be eligible for call up for a number of years after their military service has ended. Volunteer reservists have usually joined directly from the civilian community and have jobs and careers outside the military. They are required to train two to three weekends per year plus 15 continuous training days. They are called up for compulsory operational tours when necessary.
  2. Ex-armed forces
  3. The families of serving and ex-armed forces who have or are supporting their family member and make their service possible.

Here is a table showing the hierarchy of roles across all 4 services. Below this table you will find a presentation giving more information about what the various roles actually involve.

Royal Navy Army Air Force

Royal Marines

Admiral - Admiral of the Fleet FM - Field Marshal MRAF- Marshal of the RAF

Gen - General

Adm - Admiral

Gen - General

Air Chf Mshl - Air Chief Marshal

Lt Gen - Lieutenant General
V Adm - Vice-Admiral

Lt Gen - Lieutenant General

Air Mshl - Air Marshal Maj Gen - Major General
R Adm - Rear Admiral Maj Gen - Major General

AVM - Air Vice Marshal

Brig - Brigadier

Cdre - Commodore Brig - Brigadier Air Cdre - Air Commodore Col - Colonel

Capt - Captain

Col - Colonel

Gp Capt - Group Captain

Lt Col - Lieutenant Colonel
Cdr - Commander Lt Col - Lieutenant Colonel Wng Cdr - Wing Commander Maj - Major
Lt Cdr - Lieutenant Commander Maj - Major Sqn Ldr - Squadron Leader Capt - Captain
Lt - Lieutenant Capt - Captain Flt Lt - Flight Lieutenant

Lt - Lieutenant

S-Lt - Sub Lieutenant Lt - Lieutenant Fg Off - Flying Officer 2nd Lt - Second Lieutenant
WO - Warrant Officer 2nd Lt - Second Lieutenant

Plt Off - Pilot Officer

WO1 - Warrant Officer I
CPO - Chief Petty Officer WO1 - Warrant Officer I WO - Warrant Officer WO2 - Warrant Officer II
PO - Petty Officer WO2 - Warrant Officer II FS - Flight Sergeant CSgt - Colour Sergeant
Ldg Smn - Leading Rate

SSgt - Staff Sergeant

Chf Tech - Chief Technician Sgt - Sergeant
A/B - Able Seaman

Sgt - Sergeant

Sgt - Sergeant Cpl - Corporal
  Cpl - Corporal

Cpl - Corporal

LCpl - Lance Corporal
 

LCpl - Lance Corporal

Jnr Tech - Junior Technician

Mne - Marine
  Pte - Private SAC - Senior Aircraftman  
   

LAC - Leading Aircraftman

 
   

AC – Aircraftman

 

Taking the Army as an example, the presentation below gives information about progression through the ranks and the kind of tasks and responsibilities for each role. Civilians might associate the role of Sergeant Major with a very loud person on the parade ground, but we learn from this presentation that Sergeant Major is a senior management role focussing on the welfare, training and discipline of the company and involving a great deal of project planning and management skills.

British Army Rank structure and roles

The census of 2017 showed that there were 2.4 million ex-armed forces living in households across the UK. In 2018 a further 14,400 trained and untrained men and women left the armed forces followed by a further 15,230 by 31 December 2019. Despite the armed forces being 11% UK population, 20% of recruitment from the North West and 25% of the army infantry who are likely to experience combat. 6000 ex-military personnel return to the North West region every year.

People leaving the regular armed forces can leave under a range of very different circumstances, however, and these can be grouped into three categories:

  1. Normal service leavers who are discharged when they have given notice to leave and have completed their term of service, or when they have been made compulsorily redundant.
  2. Medically discharged leavers who have developed physical or mental health problems caused by, or made worse by, their service to the extent that it has affected their future in the services and a medical board have decided they need to leave. Some will be happy with the decision taken, others will not. Those who are unhappy with the decision may struggle to trust community support agencies when they return to civilian life and can sometimes avoid or delay seeking their help.
  3. Early service leavers who have either:
    • been discharged compulsorily (as a result of alcohol/drug misuse, criminal acts, inefficiency, temperamental unsuitability – not ‘fitting in’) and therefore lose their entitlement to any resettlement provision
    • or leave at their own request, having completed less than four years’ service. Early service leavers leaving at their own request have the same discharge procedures as normal service leavers but often leave at extremely short notice without having the opportunity to plan their transition to civilian life.

Those in the volunteer reserve forces, formerly known as the Territorial Army, (Army Reserves, Royal Naval Reserves, Royal Auxiliary Air Force and Royal Marine Reserves) will have signed up for a set period of time when they joined the forces but can leave voluntarily at any time unless they have been mobilised and are on full time active service.

Support available to service leavers (Ref 10)Normal service leavers can access resettlement support up to two years before the date of discharge and each branch of the armed forces offers this. It usually begins months before their final day and includes advice about housing, education, finances and employment and the armed forces work with a number of agencies who provide advice .For some, however, their appreciation of why they might benefit from this can come too late but these agencies can also be contacted directly after discharge and include:

The Career Transition Partnership (CTP)CTP delivers free resettlement services to all ranks of Her Majesty’s Armed Forces with the aim of easing the transition from military to civilian life. They help service leavers produce a CV, learn interview techniques, research the employment market and apply for jobs. Mersey Care is registered as an employer with CTP and posts non-clinical vacancies on the site.Website: www.ctp.org.uk/ctp or phone: 0207 469 6661.

The Career Transition Partnership Future Horizons ProgrammeFuture Horizons was developed specifically in response to the need to improve resettlement provision to early service leavers. The programme is open across all services, regardless of how long they have served or their reasons for leaving. The programme has been designed and is delivered by the RFEA, The Forces Employment Charity with the support of the CTP. Website: https://www.ctp.org.uk/futurehorizons

All early leavers should be registered with the programme automatically when they are discharged by their military unit discharge staff but can contact their CTP Future Horizons Employment Advisor closest to Merseyside at RRC Catterick. Phone: 01748 872900/01748 872949.

All ESLs should be registered with the programme automatically when they are discharged by their military unit discharge staff but can contact their CTP Future Horizons Employment Advisor closest to Merseyside at RRC Catterick: Tel 01748 872900 / 01748 872949

Jobcentre PlusArmed forces champions provides Jobcentre Plus support to veterans, service leavers, serving personnel within their resettlement period, spouses and civil partners of serving and ex-service personnel and can be accessed via their local job centre. Champions maintain close contact with Jobcentre Plus staff, who make the champion aware of armed forces issues and raise issues with them if requested. Champions are not always based in the jobcentre.

Defence Transition Services (DTS)DTS is run by the MOD’s Veterans UK and provides information and support for those service leavers and their families who are deemed most likely to face challenges as they leave the armed forces and adjust to civilian life. By this is meant with severe physical or psychological disablement or those considered as having an enduring welfare need. DTS liaise with other government departments, local authorities, the NHS or trusted charities until the point of discharge and will continue to provide support into civilian life as needed on a case by case basis.

Ex-armed forces who are diagnosed with diffuse mesothelioma may be eligible to claim a one off lump sum or weekly/monthly war pension along with professional help, guidance and support to veterans and their dependants. Further information at https://www.gov.uk/guidance/help-for-veterans-diagnosed-with-diffuse-mesothelioma#how-to-claim

Veterans Welfare ServiceThe Veterans Welfare Service is run by the Ministry of Defences’ Veterans UK and provides free one-to-one support to veterans or anyone supporting a veteran, their families and dependants and has a network of welfare managers across the UK. They work with the Royal Navy, British Army, Royal Air Force, local authorities, voluntary organisations, service charities and Veterans Advisory and Pensions Committees. See leaflet below for further information.

Veterans Welfare leaflet.pdf

Step into HealthStep into Health provides a dedicated pathway for the Armed Forces community to access the numerous career opportunities available in the NHS. The armed forces community can create a profile on the system giving potential NHS employers information about the careers they are interested in and in what part of the country and they have access to work placements and information days put on by NHS employers. Mersey Care is a registered NHS employer with Step into Health and offers placements and apprenticeships: https://www.militarystepintohealth.nhs.uk/

  • Consider how best to ask a service user if they are a member of the armed forces community. If you don’t ask in the right way you may not get an accurate answer
  • Make sure the information is recorded on your clinical information system so that all staff are aware in future
  • Understand why some ex-armed forces and their families can struggle on leaving the armed forces
  • Understand the challenges for reservists and their families if reservists are called up
  • Be alert to the incidence of physical and mental health problems in ex-armed forces and how this compares with the general public
  • Understand some of the things that can help to engage a veteran despite not being an ex-member of the armed forces yourself
  • Be familiar with sources of specialist support for the ex-armed forces community, both NHS and voluntary sector.

How do you know you are not disadvantaging someone if you haven’t asked the question? Ask: “Have you or any member of your immediate family ever served in the armed forces?”

Don’t ask: “Are you a veteran?” as people often think about older people, heroes and the Invictus Games when they think about veterans and many ex-armed forces, particularly those who are younger or who have served for only a short period of time, won’t identify themselves with that term. Also remember that ex-armed forces can be any age, male or female and we also need to identify the families of ex-armed forces.

Some may be reluctant to acknowledge that they are ex-armed forces. This may be because they have experienced people reacting negatively or making negative assumptions about ex-armed forces. So it can help to explain that being aware of their veteran status can help you to get them the most appropriate care and support for their needs.​

RiO, CareNotes, IAPTus and PACIS usersFor mental health services, the Trust is required to submit the Mental Health Services Dataset, and within this there is a section which specifically looks at which of our service users are ex-armed forces or a family member. To help the Trust improve on this recording, the Business Intelligence Team have created reports which pull this data from the clinical recording systems so that for each clinical team we can see how many service users have been asked if they are part of the armed forces community. Your clinical record system asks you to record whether the service user is:

01 Ex-services member
03  Not an ex-services member or their dependant
05 Dependant of an ex-services member
UU Unknown (person asked and does not know or is not sure)
ZZ Not stated (person asked but declined to provide a response)

 

EMIS usersFor EMIS users the questions about veteran status are part of the Physical Health Data Set. Where the GP has already recorded this information on EMIS it will already be available to you and it is important that you note what has been recorded.

Where the information on veteran status has not yet been recorded, you will need to tick the drop down menu as follows:

Q02 Military veteren
Q03 Active duty military
Q04 Left military service
Q05 Member of military family
Q06 History relating to military service

 

Be aware that their GP may only/also have ticked the following:

Q07 Acute PTSD following military combat
Q08 Delayed PTSD following military combat
Q09 Chronic PTSD following military combat

 

Service life involves frequent deployments both home and abroad, and in 2019, 8 percent of the armed forces were currently deployed abroad in 14 countries including peacekeeping, training, the Falklands etc., and the frequency of deployments and the disruption this causes to family life is the most cited reason given for leaving.

This picture shows the deployments around the world as of November 2019. (Ref 8)

deployments map.png

People often sign up to the armed forces as a career expecting to do 20+ years but in the Army, only 1 percent will serve the full 22 years and the average age of a service leaver is just 29 years. Those service leavers may have been in the armed forces since they were 18 years old, however, and have had no experience of adult life outside the armed forces.

All service leavers face a big adjustment when they return to ‘Civvy Street’ and it can have a huge impact. Most negotiate this with few problems but for others it can be more of a challenge and can contribute to the development of mental health problems.

Why does leaving the services require such a big adjustment?Although frequent deployments affect family life, service life also means that accommodation, medical and dental care are provided, there is free access to fitness and sports facilities, and a job which brings good pay, self esteem and pride in the unit and its achievements.

Service men and women have a clear chain of command and a wide range of support for healthcare, spiritual needs, money concerns and all aspects of life and welfare. Welfare is a leadership responsibility and a chain of command function, so although each service has its own welfare organisations and structure, all commanders at every level are responsible for the welfare and wellbeing of the service personnel they command. They are part of a much bigger team who work together, often in difficult and dangerous situations. They are surrounded by comrades who share a common language and values and who they can always rely on for support and advice, to an extent that can seem incomprehensible to a civilian.

Most will negotiate the adjustment well but for others the return to Civvy Street can mean the loss of role and income which can lead to a loss of self-esteem. They may have had difficulty finding a job, somewhere to live and adapting to the whole process of paying bills, for example, rent, council tax and electricity for the first time. Even when they find a job they may find that they are earning less and are not used to having to budget carefully to pay for services that used to be provided for them without getting into debt. Even negotiating the health care system can be very different and some may not have registered with a GP.

Without their team around them sharing common goals and ways of working, the characteristics that were highly valued when they were in the services such as having a ‘can do’ attitude, not letting your mates down, stoicism and pride, can, for some people, all get in the way of seeking and accepting help, particularly for psychological and mental health problems, and studies have shown that when they do finally find their way to help, it can be many years after they have left the forces.

For some, joining the armed forces was an escape from a difficult and chaotic family life or circumstances and on leaving and losing the structure and support of their armed forces ‘family’, these early challenging experiences can make coping with the transition all the harder.

Circumstances that seem to make an unsuccessful transition more likely are:

  • A difficult or impoverished childhood where joining the armed forces was an opportunity for not only survival, but economic mobility
  • Childhood trauma experiences which can exacerbate a failure to seek help
  • Unplanned or involuntary departure from the armed forces
  • Experiencing leaving the armed forces without support as abandonment
  • Immediate or delayed reactions to service-related mental health problems complicated by a level of avoidance or rejection of symptoms
  • A feeling of loss of identity or self esteem
  • Lack of employment and service skills which have not easily transferred to civilian employment

 

The challenges for families during armed forces serviceAlthough many civilian families experience separation due to work, for example, lorry drivers, oil rig workers, service families can experience unique challenges compared to their civilian counterparts.

Life for families in the armed forces can mean frequent moves and disruption to career, schooling and friendships. Although long periods of time without a family member is not unique, service families have to cope with the added elements of uncertainty and risk that come with service life, as well as the potentially challenging emotional consequences of both their serving member’s departure and return and whatever that brings with it as a consequence of their active service. (Ref 11)

The diagram shows the ‘Emotional Cycle of Deployment’ which was originally developed for naval families and is a helpful tool in understanding some of the common feelings and behaviours that are experienced by family members.

emotional cycle of deloyment.png

 

In practice, however, service family life encompasses a broad spectrum of experience, from families who enjoy the benefits service life has to offer, those who struggle with the challenges of relocation and separation, through to those who have to cope with injury, illness and bereavement. The majority of service families will operate somewhere in the middle of these experiences, depending on the service person’s career or their family’s circumstances.

When the serving family member leaves the armed forcesThis also involves a huge adjustment for their family who may also be leaving support networks behind and have to find their way in Civvy Street, and it is not just the serving member who has to negotiate the unfamiliar territory of renting or buying accommodation, finding work, new schools, finding health care and budgeting.

The stresses and strains of finding their way in the world again means that relationship difficulties and marriage breakdown within former armed forces families is not unusual and is a major cause of veterans becoming homeless. (Ref 4) Many armed forces families, particularly Navy families, now remain in the community and don’t live on base although not being surrounded by other families going through the same experiences has its down side.​

​​

Formerly known as the Territorial Army, the numbers of reservists have grown significantly over the last 10 years and are an important part of armed forces personnel for all the services, but particularly for the army. As of 1 January 2020, the Armed Forces Reserves constitute nearly a fifth of UK service personnel. (Ref 10)

Increasingly reservists may be working alongside us in our everyday jobs one day, and on another day may have abruptly left their families and work colleagues behind to serve in a theatre of war, conflict or national or international emergency.

Reservists are usually given several months notice of call up but in an emergency the notice they are given may be very short. This will be the challenge they trained for and welcome but they may also be joining an already tightly knit team of regular soldiers who may have lost a comrade under difficult circumstances.

Back at home, their families are suddenly left to cope both practically and emotionally. Many will be well prepared and have contact with other reservists and regular forces families, but others may feel cut off from the support of other families who are in the ‘same boat’. Reservist families have to cope with the uncertainty and risk that comes with their family member’s service and the potentially challenging emotional consequences of both their departure and their return and whatever that brings with it.​

Mental health problemsOne in four people can experience mental health problems in their lives and those who have been in the armed forces are no exception to this. Military veterans are not at increased risk of mental ill health but they may find it difficult to ask for help in civilian life.

The armed forces have been trained to work in teams and to rely on each other in their team to solve the problem … in order to survive, complete the project or face the danger. In civilian life some find it difficult to ask for help from others, such as health professionals, because it feels as if they are going outside the team and letting the team down. In some cases, they may not even recognise that they are experiencing difficulties.

Service personnel are exposed to events that others are not and so can be at greater risk of experiencing life threatening incidents.

mental disorders.png

During conflict, service personnel are required to respond rapidly in dangerous situations, to make split second decisions which may save or take a life. But when they are out of danger or out of service, some may question themselves about difficult decisions and actions. (Ref 4)

Research shows that the main problems that armed forces personnel face are common mental health disorders such as anxiety, low mood and problems around adjustment, and the research also tells us that veterans, especially if they have served in combat, are more likely to misuse alcohol. The overall incident rate for post traumatic stress disorder (PTSD) is around 5 percent in the armed forces which is not much different from the general population but this is likely to be higher for those who were in combat roles and the much higher rate of adjustment disorders than the general population may include some whose PTSD has not yet been diagnosed. (Ref 8)

The King’s Centre for Mental Health Research study looked at the incidence of PTSD in armed forces deployed in Iraq in 2003 n= 7700. Of these, 7 percent who had a combat role had probable PTSD and 3 percent of regulars had probable PTSD of which 50 percent were not in a deployed role. Of the reservists in this study, 6 percent had probable PTSD and in the North West as a whole there are approximately 6000 reservists and 6000 cadets.

PTSD does not just come about due to being deployed in combat. Soldiers can struggle with the experience of having a comrade die when they were safely at home or at base. People can be traumatised during peace keeping missions if they are exposed to atrocities and suffering ,or when deployed after environmental disasters, during training, in refugee situations, working in medical field hospitals fighting Ebola or behind the front line, in straightforward accidents or because they have been assaulted or raped. The concept of ‘Moral Injury’ refers to an injury to an individual's moral conscience resulting from an act of moral transgression and has been defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” (Ref 8)

Veterans’ mental health problems can have a major impact on family members and peers, as well as creating difficulties for the individual. Those veterans who suffer from mental health problems can often delay seeking help for many years after they have returned home from active service. They may become socially isolated and therefore harder for services to reach. If they do decide to seek help, they may find navigating civilian health and support services difficult due to the differences between these services and the support available in the military and may also be facing other issues such as problems with housing and finances.

Military Trauma (Ref 8)Military trauma is different. Being traumatised from being in a car crash is different from being traumatised in a situation where you are trained and required to deal with what may happen and the trauma. In the military the trauma tends to be severe and multiple and may involve IUDs, children and Hazmat suits.

When traumatised on peace keeping missions, soldiers may be traumatised associated with feelings of intense disgust, nightmares and flashbacks yet may never have felt their life was at risk. When dealing with the aftermath of a Tsunami soldiers again may never have felt that their life was at risk but were carrying out body recovery work and seeing horrific sights. They were also working outside their job role and expertise which may have made it particularly difficult.

Triggers can be very varied but for example:

  • Fireworks and loud bangs
  • Battenburg cake – smells like Semtex
  • Barbecue smells – smells like burning flesh
  • Screaming and crying from children – very common in war zones and has been used as an interrogation technique.

 

When triggered, soldiers can get ‘antagonised’ so that their body goes into flight, fight, freeze mode, cortosol is pumped into the blood stream and through the body and so heart rate goes up. They will get hot, breathe shallowly and rapidly and feel as if they can’t breathe. The armed forces are trained to eliminate the flight response. The freeze reaction is more likely to be evident if the veteran has also experienced childhood trauma when freezing was most appropriate.

Transition problemsSkills and competencies essential to combat and battle-ready alertness can cause difficulties for ex-armed forces or reservists making the transition home. Below are some of the issues which can arise:

‘Battle Mind’ – Combat skills making the transition home (Ref 9)

Combat skill In combat At home
Buddies Cohesion – nobody understands your experience except your buddies who were there

Withdrawal

Prefer to spend time with buddies

Avoiding speaking about self to family and friends

Accountability

Maintaining control of weapon is necessary for survival

Controlling

Become angry when someone moves or messes with your stuff, even if insignificant. Nobody cares about doing things right except you

Targeted aggression Targeted aggression involves making split second decisions that are lethal in a highly ambiguous environment to keep you and your buddies safe

Inappropriate aggression

Over react to minor insults

Irritability

Assault

Rage

Targeted awareness Survival depends on being aware at all times of your surroundings and reacting immediately to sudden changes

Hypervigilance

Feeling constantly edgy or anxious

In standby mode

Lethally armed Carrying a weapon was mandatory and necessary

Needing to have your weapon on you, in your car/home

Believing you and your family are not safe without this

Emotional control Controlling your emotions is critical for mission success

Anger/detachment

Failing to show emotions, or only showing anger around family and friends will hurt relationships

Mission Operational Security (OPSEC) Talk about mission only with those that need to knowCan only talk about combat experience with unit members

Secretiveness

Avoid sharing deployment experiences with family and significant others

Individual responsibility Your responsibility in combat is to survive and to keep your buddies alive

Guilt

Feeling you failed those who were injured/killed

Distress at memories

Shame

Survivor guilt

Non-defensive (combat) driving Unpredictable, fast, rapid lane changes, straddling the middle line, keeping other vehicles at a distance designed to avoid IEDs

Aggressive driving

Speeding tickets

Accidents

Road rage

Discipline and ordering Survival depends on discipline and following orders

Conflict

Inflexible interactions (ordering and demanding behaviours) with family and friends

 

Addiction problemsDrug use is 17 percent compared with 1 percent in the general population and alcohol abuse is 30 percent compared with 26 percent in the general population. Incidences of problem gambling and risky thrill seeking behaviour are high possible due to the loss of high adrenaline experiences.

Physical health problems

  • Musculoskeletal problems are higher in veterans than in the general population
  • Hearing loss is common due to proximity to ordinance firing in spite of ear protectors
  • Ex-armed forces also have a significantly higher incidence of mesothelioma than the general population
  • Mild traumatic brain injury (mTBI) is common due to soldiers getting blown off their feet and getting concussion and there is a danger that this can go undiagnosed or be misdiagnosed as PTSD as there is no obvious sign of physical trauma. It presents similarly to PTSD as people have problems with sleep, managing emotions, memory, cognitive and functional impairment, so questions about whether they have had a known head injury, ever been knocked unconscious or if they struggle with impulsivity are important to ask.

By asking specific questions about a veteran’s service career, you can find out useful information which may help when providing support –when they joined and why, and where they served.It is also well recognised by veterans themselves, the voluntary sector and specialist services that some people fabricate or embellish a forces history ( a ‘Walt’ or Walter Mitty’ as they say in the armed forces) and for all of these reasons it can be useful to request a veteran’s service record using the request template below.

Template request for service records

So useful general questions to ask a veteran or reservist are:

  • What was/is their service number?
  • What was their reason for discharge?
  • What agencies (veterans and non-veterans) have they engaged with?
  • Do they have a copy of their medical documents?
  • Have they been injured due to service in the armed forces?

 

Some veterans may appear to have very high, or very low expectations of mental health services but their experiences of army health services may mean that they are not as tolerant as some other clients might be of perceived mistakes, lateness to appointments, barriers to treatment or ‘stuck’ points, as they are used to things happening exactly when they are told they will. You may not be able to deliver that but you can adjust their expectations and be careful to let them know if you are going to be late for an appointment, for example. If you can’t do what you said you would, explain this as soon as possible. Trust is likely to be earned and not a given. Be clear about your role and theirs to help manage expectations.

You may be asking them to talk about things that they have ‘pushed away’ for years and to experience difficult emotions which they have avoided at all costs for a long time. Their training supported this and may have been how they were able to continue to function and tackle the next challenge (see ‘BATTLE MIND’ above), not only as a way of coping themselves. Respect this, make sure you can provide the support they will need before they share difficult experiences and take things slowly. Remember that they may also be wary of being judged for things they’ve done or been part of in service and may be judging themselves vary harshly (see ‘Moral Injury’ under ‘Mental Health problems’ above)

As you would with any client, make sure you know your client’s key dates, anniversaries and triggers. Remember that, depending on their experiences whilst serving, your appearance or accent may trigger a trauma reaction. Don’t take it personally.

Don’t pretend to be an expert on everything military. You will be found out or tested further! Be an expert in your field and let them be an expert in theirs. Ask for clarification. Expect military ‘lingo’ (see attachment below). Some knowledge of this may be good but it’s not essential. The first few in particular may be helpful for engaging.

Some armed forces slang

  1. Veterans IAPT Service
  2. Transition,Intervention and Liaison Service
  3. Complex Mental Health Service for Veterans
  4. High Intensity Service
  1. Veterans IAPT ServiceThese services are funded by CCG s and were set up across the country as specialist IAPT services providing psychological support for veterans who were unable to engage successfully with a generic IAPT service due to the nature of their service related difficulties. These veterans tend to be at the upper end of the severity level that an IAPT service would work with and often have multiple difficulties in their living and social situations so that veterans IAPT services also have social workers in their teams .

    Veterans in MindVeterans in Mind is the veterans iapt service for Cheshire and Merseyside apart from Liverpool and is delivered by Greater Manchester Mental Health NHS Foundation Trust (GMMH) in partnership with Combat Stress, Support and Management Solutions (S.A.M.S), the Armed Forces Community Support Hub and Veterans in Sefton.

    Referring to Veterans in Mind

    • You can refer directly to Veterans in Mind if they live in any borough covered by Mersey Care apart from Liverpool. Liverpool CCG opted out of this service when it was last recommissioned. For Liverpool veterans who meet the criteria for IAPT, you should refer to Talk Liverpool and if Talk Liverpool concludes that they definitely need a specialist service they can apply to Liverpool CCG for funding on a case by case basis although this funding is not always granted.
    • Or you can refer via the Transition, Intervention and Liaison Service (TILS) (see below) who will assess and direct your referral to either Veterans in Mind or to the Complex Treatment Service if they think that would be more appropriate.

Veterans in Mind

Tel: 0151 908 0019

Email: military.veterans@gmmh.nhs.uk

Web: www.gmmh.nhs.uk/military-veterans-services

 

If people don't feel they need urgent help but would like support to manage their mental health and wellbeing, there are a range of other options to consider.

If already under the care of one of our services, contact them directly.

If people are experiencing a common mental illness such as anxiety, depression and/or stress, then psychological therapies can support you. Find out more about local services below:

Talk Liverpool Call: 0151 228 2300

Think Wellbeing Halton Call: 0151 292 6954  

Think Wellbeing Knowsley Call: 0151 430 1707

Think Wellbeing St Helens Call: 01744 647 100

 

If you live outside the above areas, you can find your local service on the NHS website.

 

  1. The Transition, Intervention and Liaison Service (TILS)TILS provide a single point of access for existing veterans, as well as those currently serving and within six months of discharge from the military who have identified mental health problems. They will also provide general advice to professionals. TILS will refer on as appropriate to Veterans in Mind (see above) or to the Complex Treatment Service (CTS) which is a service for veterans with very complex needs. Whilst people can refer directly to Veterans in Mind, TILS is the only point of access for CTS.

    Phone for professionals: 0161 253 6638 (8.30am to 5.00pm, Monday to Friday)

         Phone for clients: 0300 323 0707

         Email: the.mvs@nhs.net

         Fax: 0161 761 7083

         Website: www.penninecare.nhs.uk/military-veterans

         Clinical lead: Dr Alan Barrett

         Service manager: Nicola Salsbury

TILS NW covers Cheshire, South-Cumbria, Greater Manchester, Lancashire, Merseyside and this service also Pennine Care also provides the Veterans IAPT service for Greater Manchester and Lancashire.

     2. The Veterans Complex Treatment Service (CTS)

This is an enhanced service for veterans with attributable complex mental health problems as a consequence of their military service, and which has not been resolved earlier in the care/support pathway. Assessment by TILS will have indicated that the veteran has not responded to interventions earlier in the pathway; the veteran needs a more intensive/assertive package of interventions; or the veteran may have been excluded from other primary or secondary mental health services. This means that CTS target those who are hard to engage, exhibit poor coping styles, have poor impulse control and/or have high risk behaviours whose mental health needs and associated level of risk cannot be met by primary care, the IAPT service or other community services. The service includes support for substance misuse.

Access is only via TILS and capacity is very limited. To contact CTS Phone: 0191 441 5974 or email: vwals@nhs.net

      3. High Intensity Service ( HIS)

This is a new NHS service for armed forces veterans experiencing severe mental health problems and in crisis which launched on 2 November 2020 across the North of England.

The Veterans’ Mental Health High Intensity Service (HIS) will provide care and treatment for veterans who are in a mental health crisis and need urgent help. It will do this by working with local mental health services that are already treating a veteran, to improve experience and outcomes for them.

HIS will work with local mental health services to provide:

  • Advice to front line staff in AED Liaison, Crisis Teams and Inpatient teams via a clinical advice line available 24 hours a day, 7 days a week, 365 days a year.
  • Support the veteran and their family, friends and carers engage better with the mental health service and to access wider provision based on individual need e.g. addictions, housing, finances and social support.
  • Training to Increase veteran awareness and skills development

The aim is to provide specialist support to mental health staff, reduce signposting to other services and veterans being passed around the system, buddying support and contact with other veterans for veterans in crisis.

Referrals to the Veterans’ High Intensity Service (North of England)

Via the 24/7 Single Point of Access (SPA) Team at Leeds and York Partnership NHS Foundation Trust on 0300 300 1485.

Clinicians Advice Line

Local mental health professionals have access to an advice line 24 hours a day, seven days a week to provide expert veteran-specific mental health support: 24/7 Clinician Advice Line 0300 300 1493.

From 8am to 6pm (daytime hours) – this will connect directly to the HIS North of England team and from 6pm to 8am (overnight) – this will be answered by Combat Stress.

To understand the service better email at: veteranshis.lypft@nhs.net

Presentations from Training sessions provided to Mersey Care staff.

  1. Creating a Military Veteran aware inpatient ward
  2. The MVS and TILS – working with military veterans

Liverpool Veterans HQ

Mersey Care has a long standing strong relationship with Liverpool Veterans HQ which works closely with a number of Mersey Care teams including Criminal Justice Liaison and Diversion and Morris ward and provides NAAFI breaks for ex-armed forces for both public and staff in conjunction with Mersey Care’s Life Rooms at Walton. They aim to provide a ‘one stop shop’ for veteran’s needs and ex-armed forces, reservists and their families can gain access to employment support, education, training, housing support and health referrals. The team includes a dedicated custody co-ordinator, a families’ officer, housing officer, outreach buddies and a team of case workers who provide a free and confidential support service.Website: www.veteranshq.org.uk

Professionals and veterans should use the referral form below.

Veterans HQ referral form

 

Veterans in Sefton

Veterans in Sefton have a team of over 20 volunteers as well as full time staff. They work at the Brunswick Youth and Community Centre (“the Brunny”) from 9.00am to 5.00pm Monday to Friday and provide ex-service personnel, reservists and their families help and advice with housing, employment, drug and alcohol dependency, financial problems and mental health issues. They also offer volunteering opportunities and ex-armed forces can also to train as a ‘buddy-befriender’ providing support to other veterans and their families.

Veterans in Sefton hold weekly NAAFI breaks at various locations around Sefton:

  • Tuesday, 10.30am to 12.30pm at Southport Community Centre, Norwood Road
  • Wednesday, 10.30am to 12.30pm at Brunswick Youth and Community Centre in Bootle
  • Thursday, all day drop in and holistic care at the “Strand by Me” shop in Bootle Strand Shopping Centre
  • Senior NAAFI break for aged veterans every Friday, 10.30am to 12.30pm at Crescent Court, Litherland.

 

For more information professionals and members of the public can call:Dave Smith or Steve Calderbank on 0151 933 0800Email: dave.smith@veteransinsefton.org.uk

Website: http://www.brunswickycc.co.uk/health-and-wellbeing/veterans-in-sefton/

Address: Brunswick Youth and Community Centre, 104 Marsh Lane, Bootle, Merseyside, L20 4JQ.

 

Tom Harrison House

Mersey Care addiction services in particular has a close relationship with Tom Harrison House which is a specialist facility providing a 12-week addiction recovery programme exclusively to military veterans, reservists, emergency personnel, and their families.

In partnership with other agencies, they provide trauma-informed addiction therapy through a “sensory and wellbeing” model of care, support, therapy and education and deliver a structured programme over seven days each week including personal recovery planning, group work, assignments and reintegration work alongside equine therapy, art, nutrition, physical fitness, yoga and mindfulness.

On completion, a second stage of continued support is available, providing a stepping stone between primary care and a return to independent living.

Website: http://tomharrisonhouse.org.uk/

Email: info@tomharrisonhouse.org.uk or phone: 0151 909 8481

Address: Tom Harrison House, 4 Argyle Road, Anfield, Liverpool, L4 2RS.

 

Project Nova

This is a joint project between the RFEA and ‘Walking With The Wounded’ and first trialed in 2014. There are over 17 police forces operating this service. Project Nova supports vulnerable veterans and veterans who have been arrested and enter Police Custody. Veterans may also be referred by specialist Police teams, or other statutory organisations, because they are at risk of arrest.

This means that Community Nurses and other mental health professionals can refer veterans to this service, especially if they have a forensic background or are displaying behaviours that could lead to arrest.

Project Nova is operated by staff with a blend of experience from the armed forces, Criminal Justice System and charities. The staff are skilled at engaging with veterans to understand their experience of military service, their lives before they joined the armed forces, and their transition back to civilian life. Project Nova undertakes a needs assessment for each individual and puts in place specialist support from a network of military charities and other organisations. They will then keep in touch ensuring that the veterans they support have an ongoing connection, checking in and resolving issues when they occur.

Project Nova may be contacted on:Freephone 0800 917 7299or by email at info.nst@projectnova.org.uk

 

SSAFA

SSAFA Forces Help provides financial, practical and emotional assistance to anyone that is currently serving or who has ever served in the Army, Navy or RAF, and their families. Website: www.ssafa.org.uk Phone: 0207 463 9354.

SSAFA also provides a number of services for retirement-age veterans, helping with both domestic and emotional needs including help with mobility, loss and access to critical domestic goods for families in need. https://www.ssafa.org.uk/get-help/supporting-older-veterans

SSAFA also provides FORCESLINE which is a confidential helpline by phone on 0800 731 4880 (9.00am to 5.00pm, Monday to Friday) which provides access to a team of advisors for veterans and their families who can provide support with isolation, debt-related problems and signposting to specialist services.

 

The Royal British Legion

The ‘Veterans’ Gateway’ supports veterans and their families to find the help they need and a team of advisors can be contacted 24 hours a day, seven days a week and are connected to a network of armed forces organisations. Phone: 0808 802 1212. Website: https://www.britishlegion.org.uk/

They support:

  • Serving personnel
  • Those who have previously served
  • Reserve or auxiliary personnel
  • Those who have served with the Mercantile Marine in hostile waters
  • Current or previous full-time members of Allied Civil Police Forces
  • Anyone entitled to a campaign medal issued to the Royal Navy, Army or Royal Air Force
  • Any member of Voluntary Aid Societies who has served full-time and in uniform in direct support of the United Kingdom Armed Forces
  • Any British subject (by birth or otherwise) who has served at least seven days in the forces of an allied nation during hostilities and received seven days' pay from that nation
  • Any British subject (by birth or otherwise) who served in a resistance organisation of an allied nation during hostilities in which the United Kingdom armed forces were engaged
  • Any person who served in the Home Guard for at least six months, or in a Bomb and Mine Disposal Unit for at least three months
  • Any person who was awarded the Defence Medal in respect of service in the Home Guard
  • Past and present members of the Brigade of Gurkhas and their families

 

RBL also provide care homes for older veterans and support for carers at home.

 

Combat Stress/Rethink

Provides a 24 hour, 365 day helpline on 0800 138 1619. They have 15 pop-in centres around the UK. The area office and Liverpool pop-in is:25 to 31 Williamson Street, Liverpool, L1 1EB. Opening hours are weekdays 10.00am to 4.00pm.

For other outreach centres in the region see: https://www.britishlegion.org.uk/get-support/local-community-connections/the-legion-near-you

 

Big White Wall

Free for all service personnel, veterans and their family members aged 16+ through a partnership with the Ministry of Defence and NHS England.

It provides safe, anonymous 24/7 online support for mental health and wellbeing issues and is available 24/7 at www.bigwhitewall.com It’s easy to join Big White Wall and is completely confidential, go to www.bigwhitewall.comand click ‘Join now’.For more information, visit the website or email theteam@bigwhitewall.com

Big White Wall has been working with the UK armed forces community for several years and is experienced in supporting people with issues like bereavement, PTSD, supporting family members, loneliness, anger and drinking, as well as depression, stress and anxiety.

 

Help for Heroes

Provide a range of services including health and wellbeing courses and financial support. H4H also have recovery centres around the country, the one for the North West is Pheonix House in Catterick: Phoenix House Recovery Centre, Richmond Road, Catterick Garrison, North Yorkshire, DL9 3AW Phone: 07808 789 492 or email: catterick.supporthub@helpforheroes.org.uk

 

All Call Signs

This is a peer support organisation for veterans and serving military personnel. The chat app is supported by over 500 volunteer listeners with experience of life in uniform and digital case workers for users seeking help with mental ill health.

All Call Signs: Camaraderie in the face of adversity, whether in uniform or out.

Go to: https://allcallsigns.org/ and click on the ‘Chat Now’ button.

 

Royal Air Force Benevolent Fund

The Royal Air Force Benevolent Fund supports current and former members of the RAF, their partners and families, providing practical, emotional and financial support and work closely with SAFFA. For former serving RAF and their partners, they offer financial grants to aid day-to-day living, cover one-off unexpected costs like replacing a broken boiler, right through to adapting homes to help independent living based on holistic assessment.

RAF a guide to our service

 

Army Benevolent Fund

Helps very young serving families cope with a sudden bereavement or traumatic loss. Also provides wide-ranging support to wounded soldiers, including financial assistance. Help with housing, education and training for employment for soldiers and veterans of all ages. Support for older veterans and their widows or widowers when they find themselves lonely or isolated.

Pride themselves on acting fast when help is needed and aim to make a relevant grant if appropriate within 48 hours. It is important to contact SSAFA or The Royal British Legion in the first instance to ensure a fast response as they usually provide the background information. Website: https://soldierscharity.org/

Live Well Directory

The Live Well Directory for Liverpool City Region is kept up to date. The document provides links to the information on the directory for services for ex-armed forces and their families in Liverpool. Website: www.thelivewelldirectory

Merseyside Live Well directroy

Sefton DirectoryThe document provides links to the information on the directory for services for ex-armed forces and their families in Sefton. Website: www.seftondirectory.com

Excerpt Sefton

Most service men and women negotiate their transition out of the armed forces well and go onto successful careers in Civvy Street and many have found that the NHS is a good fit for them. Mersey Care is proud to have signed up to the Armed Forces Covenant Employer Recognition Scheme. The Trust was a Bronze award winner in 2019 and became Silver award winner in August 2020. Being an award winner means that the Trust has demonstrated a commitment to supporting the armed forces community and recognises the benefits of the skills, training and experience that ex-armed forces and reservists bring to their work.

The document provides the results of a survey of 59 NHS trusts carried out by NHS Employers on the considerable benefits of employing ex-armed forces in the NHS.

Evidence based infographic

The Trust is registered with and posts vacancies on the Career Transition Partnership website and is registered with Step into Health.

Trac jobs indicates our support of the armed forces community, showing the Armed Forces Covenant, Step into Health and CTP logo beneath job adverts. All adverts include the wording: “We welcome applications from reservists and ex-armed forces as we recognise the benefits of the values, skills, training and experience that they bring to their work with us.”

Mersey Care works closely with the Department for Work and Pensions (DWP) when advertising jobs, apprenticeships and work experience and the DWP armed forces champions receive information about every launch and distribute this to their own contacts such the Royal British Legion. Mersey Care is also committed to supporting its employees who are reservists and cadet trainers. Reservists play an essential and growing role in the armed forces and bring a wealth of skills and experience to NHS organisations.

The document below addresses some common myths around employing reservists and provides information on how managers can understand and effectively support the reservists in their teams.

Reservists Key Facts

Policy HR04 describes the additional support which Mersey Care has committed to providing for its reservist and cadet trainer staff which includes an entitlement to 10 days paid leave (pro-rata) to attend annual armed forces training and the supports and safeguards accorded to reservists during and following periods of mobilisation.

Regular NAFFI breaks at our Life Rooms bring together our armed forces community staff and service users, local veteran voluntary sector organisations and armed forces from local barracks. Managers are encouraged to support ex-armed forces and reservist staff to attend these whenever possible.

Staff who have identified as armed forces community are part of an informal network and receive information about events and opportunities, developments in services for veterans and opportunities to contribute to improving the Trusts’ offer for the armed forces community.

The Trust armed forces lead and the Armed Forces Oversight Group bring together ex-armed forces staff and strive to continuously improve the work we do as a Trust in supporting members of the armed forces community with physical or mental health problems.

Mersey Care has also achieved accreditation with the Veteran Aware Hospitals Alliance which is part of the GIRFT programme and showcases high quality armed forces community healthcare, supporting trusts to learn from each other by sharing best practice.

​​

  1. Armed Forces Covenant
  2. The Armed Forces Covenant, Today and Tomorrow 2011
  3. UK Armed Forces Quarterly Service Personnel Statistics, 1 January 2020, Ministry of Defence, Published 20 February 2020
  4. SAMH (2009) Life Force: A Practical Guide for working with Scotland's Veterans
  5. ‘The Overlooked Casualties of Conflict’ Report, (2009) The Royal Navy and Royal Marines Children’s Fund Ministry of Defence UK Armed Forces Families Strategy 2016 https://nff.org.uk/wp-content/uploads/2017/01/Homeport-pull-out-Making-Sense-of-the-Emotional-Cycle-of-Deployment.pdf
  6. Creating a Military Veteran aware inpatient ward (November 2019) Dr Alan Barrett, Consultant Clinical Psychologist, Clinical Lead for TILS, Pennine Care NHS Foundation Trust
  7. Military Veterans Service: Introduction to the Transition, Intervention and Liaison Service (2018) C Barry, Pennine Care NHS Foundation Trust
  8. Armed Forces Awareness Training 2019
  9. Gov.UK – Jobcentre Plus services for the armed forces and their families.