1. Introduction

This framework provides information on how NHS England works with people and communities. in the commissioning of healthcare services for the Armed Forces community. This includes serving personnel, mobilised reservists, veterans and some families of those serving who are registered with Defence Medical Services (DMS).

This framework is designed to be read in conjunction with the following documents:

• NHS England Patient and Public Participation Policy – this sets out our ambition to build and strengthen effective partnerships with people and communities in all of our work, and how we intend to achieve this. Our values are rooted in the NHS Constitution, which states that the NHS belongs to us all.

This policy and associated documents are based on how health services and outcomes are better when people who need, use and care about services, have meaningful opportunities to be involved in them.

• Working in Partnership with People and Communities Statutory guidance (July 2022) – this details the ten principles (set out in diagram 1) that can help organisations adopt good practice and achieve the benefits of effective working with people and communities. Annex B of the guidance includes public involvement legal duties and other relevant legal duties, such as The Equality Act 2020. 

2. National Health Service Act 2006 and Health and Care Act 2022

Under Section 13Q of the National Health Service Act 2006, amended by the Health and Care Act 2022, NHS England has a duty to involve patients and the public. The Act states that integrated care boards (ICBs) (Section 14Z45) and NHS England (Section 13Q) must involve the public in:

• the planning of the commissioning arrangements by the Board/Group
• the development and consideration of proposals by the Board/Group for changes in the commissioning arrangements
• decisions of the Board/Group affecting the operation of the commissioning arrangements.

When designing and commissioning services, NHS England has a duty to ensure that all people are treated fairly and that as an organisation we are meeting the legal duties around equalities and health inequalities under the Equality Act 2010 and the Health and Care Act 2022.

These requirements are reflected in our Patient and public participation policy and supported by this framework, which sets out our commitment to participation at each stage of the commissioning process. It also demonstrates how patient and public oversight is embedded at each layer of the governance for Armed Forces healthcare commissioning.

The policy sets out NHS England will follow the statutory guidance on working with people and communities. It is based around ten principles which we seek to apply to the healthcare we commission for Armed Forces personnel and veterans.

The ten principles for working in partnership with people and communities

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1. Centre decision-making and governance around the voices of people and communities.
2. Involve people and communities at every stage and feed back to them about how it has influenced activities and decisions.
3. Understand your community’s needs, experiences, ideas and aspirations for health and care, using engagement to find out if change is working.
4. Build relationships based on trust, especially with marginalised groups and those affected by health inequalities.
5. Work with Healthwatch and the voluntary, community and social enterprise sector.
6. Provide clear and accessible public information.
7. Use community-centred approaches that empower people and communities, making connections to what works already.
8. Have a range of ways for people and communities to take part in health and care services
9. Tackle system priorities and service reconfiguration in partnership with people and communities.
10. Learn from what works and build on the assets of all health and care partners – networks, relationships and activity in local places.

3. The Armed Forces Covenant

The Armed Forces Covenant reflects the moral obligation that exists between the Armed Forces and society. These principles are enshrined in law under the Armed Forces Act 20221.

The Covenant commitments

• The Armed Forces community should enjoy the same standard of, and access to healthcare as that received by any other UK citizen in the area they live.
• Family members should retain their place on any NHS waiting list, if moved around the UK due to the service person being posted.
• Veterans should receive priority treatment for a condition which relates to their service, subject to clinical need.
• Those injured in service should be cared for in a way that reflects the nation’s moral obligation to them, by healthcare professionals who understand the Armed Forces culture.

The Armed Forces Covenant is reflected in the NHS Constitution.

For further information about the Armed Forces Covenant see www.armedforcescovenant.gov.uk

The Armed Forces Bill will see the Armed Forces Covenant enshrined in law, creating a duty for certain public bodies, health, education, and housing, to have ‘due regard’ to the:

• unique obligations of and sacrifices made by the Armed Forces
• principle that it is desirable to remove the disadvantages arising from being a member of the Armed Forces community
• principle that special provision may be justified.

4. Context

What healthcare does NHS England commission for Armed Forces personnel?

For individuals serving in the Armed Forces (including mobilised reservists and those registered with DMS), NHS England commissions secondary care services (i.e. healthcare provided in hospitals and the community) for those serving in the Armed Forces who are based in England.

ICBs are responsible for commissioning healthcare services for non-mobilised reservists, as well as veterans and their families.

Recognising that most secondary care and specialised services only form part of a patient’s overall care and treatment pathway and that most patients access care from other health and care services, it is vital that their care is joined up to achieve the best possible outcomes.

What specialised healthcare is commissioned for veterans?

In addition, NHS England commissions the following specialised services for veterans:

• Op COURAGE: The Veterans Mental Health and Wellbeing Service
• Veterans prosthetic services

These services are provided in relatively few hospitals and accessed by small numbers of patients.

How are healthcare services commissioned?

Since 2018, NHS England has been working with local commissioners to consider how we can maximise the opportunity for more joined up, high quality and equal care for patients. This has informed new legislation set out in the Health and Care Act 2022 that set up 42 integrated care boards (ICBs) in July 2022. These are statutory bodies bringing together local health and care organisations to improve population health by taking on the responsibility for the design and delivery of health and care services across their geographical footprint.

Under the Health and Care Act 2022, the responsibility for commissioning healthcare for Armed Forces personnel and those registered with DMS, remains with NHS England through the single national Armed Forces Healthcare Commissioning Team. Whilst the commissioning responsibility for Armed Forces health has not changed, it is important for commissioners to work closely with ICBs to inform service provision and realise the benefits of integrated working at local levels. As wider system changes are implemented in support of ICB delegation, we will continue to work with these bodies to ensure the effective delivery of local services for the communities we serve.

Most veterans services are commissioned by ICBs, with the exception of the aforementioned specialised veterans services.

In this context:

• NHS England remains responsible and accountable for all secondary care services commissioned on behalf of Armed Forces personnel and those registered with DMS
• all veteran specialised services continue to be subject to consistent national service specifications and evidence-based policies to ensure patients have the same access to services around the country

How are clinical policies and service specifications developed?

NHS England is responsible for developing clinical policies (these define access to a service, drug or technology for a particular group of patients) and service specifications (these define the core requirements for the delivery of a service and the quality standards expected).

Service development has three phases:

1. Clinical build – New/amended clinical commissioning policies and new/amended services specifications are proposed and developed. This process is overseen by the Armed Forces Clinical Reference Group (CRG), which includes clinicians, commissioners, expert patients and public health representatives.
2. Impact analysis – Identification of financial and operational impacts of what is set out in the policy/specification, which are then subject to stakeholder testing and/or public engagement. In cases where significant changes are proposed to clinical policies and service specifications, it is likely that a consultation is required.
3. Decision – Approval decision is based on clinical benefit if the policy/service specification proposition is cost-neutral or cost-saving. For those that require additional funding, policy propositions are assessed on their likely relative clinical benefit and value for money. Twice a year, NHS England carries out a relative prioritisation process to determine which services will be routinely commissioned service development model.

For more information about the service development process, visit the NHS England website.

Case study

In April 2017, NHS England launched the Veterans’ Mental Health Transition, Intervention and Liaison Service, followed by the Veterans’ Mental Health Complex Treatment Service in April 2018 and the Veterans’ Mental Health High Intensity Service in November 2020. Throughout the commissioning of each of these services, veterans and families have played a key role, from informing the approach to engagement exercises and assisting with their development and delivery, to participating in engagement activity and supporting the procurement, mobilisation and launch of these services.

Following feedback from veterans that the three service names were confusing and causing a barrier to access, a naming convention engagement exercise was held which resulted in veterans and families developing the new overarching name, Op COURAGE: The Veterans Mental Health and Wellbeing Service. This new name, which was launched in March 2021, has been well received by veterans and led to the reprocuremnt of these three services under one Op COURAGE service specification. The new combined service model, which was informed by further engagement activity, launched in April 2023, resulting in the provision of a fully integrated mental health care pathway for veterans, informed by veterans.

Central to all of this activity have been our Armed Forces PPVAG members who have supported this work, along with being part of clinical discussions to ensure the voice of patients is heard and reflected.

5. Patient and public participation within Armed Forces healthcare commissioning governance

NHS England is committed to ensuring that the lived experience of patients and their families is at the centre of shaping our healthcare services. As such, Patient and Public Voice (PPV) Partners play a crucial role in healthcare services commissioned for Armed Forces personnel, those registered with DMS and specialised services for veterans. They are represented throughout our boards, committees and groups to ensure that the views of patients, families, carers and the public are at the heart of all we do and that our decisions are informed by those that use and care about our services.

Patients and the public are now included at almost every level of governance for Armed Forces healthcare commissioning, which is shown in table 1 below.

We have a dedicated team in Armed Forces healthcare commissioning who oversee the recruitment, training and development of PPV partners involved in these boards, groups and committees. A central part of the recruitment process is ensuring the appointment of PPV Partners who represent different protected characteristics and the range of health issues commonly affiliated with the Armed Forces community. As part of their role, PPV Partners can then champion these different areas and ensure their experiences and those of the individuals they represent are reflected in our commissioning arrangements.

The following table sets out the operating model for the Specialised Commissioning Directorate of which the Armed Forces Commissioning Team are part.

Table 1: Roles of board and committees with PPV partners

6. Involving people and communities in the commissioning of services

1. Overview of how we work with people and communities

People and communities have the skills and insight to transform how health and care is designed and delivered. Working with them as equal partners helps them take more control over their health and is an essential part of securing a sustainable NHS. This includes involving people with relevant lived experience as equal partners in the full range of SQG activities.

The Armed Forces PPVAG members work as equal partners with the Armed Forces SMT and the Armed Forces Clinical Reference Group who have dedicated expert advisory groups that inform clinical commissioning policy and service specification development. The inclusion of PPV representation is to ensure that patient insight and experiences relevant to the clinical policy area are represented.

Within Armed Forces healthcare commissioning, PPV Partners can be either from patients/people with lived experience of the condition/treatment, or people (such as a patient advocate or family representative) who can bring a wider patient perspective and help identify relevant stakeholder groups for further patient and public engagement. Examples of how they support our commissioning include the following:

• co-development of engagement and consultation activity and supporting materials
• participation in engagement and consultation activity
• informing the development of clinical policies and service specifications
• participation in the procurement process for services
• supporting the launch and promotion of services
• participation in the review and assurance of services

‘The Armed Forces Patient and Public Voice Group is helping the NHS understand the challenges that the Armed Forces community can face by sharing our lived experiences’ Chair, Armed Forces PPVAG

Case study

In July 2022, NHS England launched an engagement exercise to test and inform a proposed specification for a new service to support veterans pre, during and post prison custody.  Views were captured from veterans and their families with lived experience of the justice system, as well as from people working in this area.

Whilst proposals for the pre and post prison custody service model were welcomed, the in-prison element was deemed insufficient. As a result, procurement progressed for a pre and post support service, with a commitment to undertake further scoping work to inform the service model for in-prison support. Veterans with lived experience were also involved in the procurement and mobilisation of this new service.

Another key outcome of the engagement was the need for this service to have a meaningful name that would resonate with veterans. As a result, a naming convention engagement exercise was undertaken, with views sought from veterans with experience of the justice system and those working in this area. This resulted in the name, ‘Op NOVA: supporting veterans in the justice system,’ which aligns with Op COURAGE, the name for veterans mental health and wellbeing services.

2. Wider work with people and communities

The Armed Forces PPVAG contribution is complemented by engagement with wider stakeholders, such as via CRG members and through the use of the Armed Forces stakeholder list. This list is compiled through the stakeholder registration process that is open to all interested stakeholders so they can be kept informed of relevant news and opportunities to be involved, i.e. notification of engagement and consultation activity and invitations to events. Stakeholders on this list include a broad range of individuals, such as patients, carers, clinicians, the general public and representatives from patient groups, charities, professional bodies, providers and government departments.

The PPVAG and registered stakeholder list is central in the development of clinical policies and service specifications, which are required to undergo a minimum of two weeks of stakeholder testing. Commissioners and working group members identify key stakeholders for engaging as part of policy and service specification development, including any missing stakeholders who are not currently on our list. These individuals and organisations can then be invited to join the registered stakeholder list and give feedback on draft clinical policies and service specifications.

3. Stakeholder testing of clinical policies and service specifications

Stakeholder testing is led by the commissioning managers, with support and guidance from the Armed Forces Healthcare Commissioning Team. Testing draft clinical policies and service specifications with stakeholders is particularly important when there may be contentious issues and differences of opinion, which need to be explored further with a range of stakeholders. This stage is also used to explore whether there are any perceived negative impacts that might not have been considered.

The findings from stakeholder testing are analysed and a report is then shared with the relevant working group and CRG. The next stage will be to decide if any further patient and public engagement is needed. A 13Q assessment will help support this decision.

4. The Armed Forces healthcare commissioning 13Q assessment process

A 13Q assessment helps commissioners identify if there is a need for patient and public participation, and if it is required, helps them to plan a level of participation which is ‘fair and proportionate’ to the circumstances. This helps to ensure that NHS England, as accountable commissioner, is meeting its legal duty to involve patients and the public in service development (section 13Q of the Health and Care Act, 2006).

To do this, commissioners complete a 13Q assessment form, with the support of the Armed Forces Healthcare Commissioning Team. The form requests commissioners to state if a proposal presents a material change in how services could be delivered or accessed (e.g. where and how services are delivered), and how these changes might impact patients. It also requires commissioners to detail any stakeholder engagement that has taken place and how equality issues have/will be addressed.

Depending on the information that is presented, an assessment is made on whether there is a need for further patient and public involvement, including a formal public consultation. For example:

• 30-day public consultation – This occurs if there are significant changes that are broadly supported by stakeholders through prior engagement.
• 60-day public consultation – This occurs if there are significant changes with some contentious aspects.
• 90-day consultation – This occurs if the proposed activity is highly contentious, impacting on several stakeholders, is causing high levels of dissent, has financial implications, has a high media / political profile.

For clinical policies, there are three likely outcomes when considering further need for patient and public involvement:

• No further involvement required – When a proposal offers a clear and positive impact on patient treatment, e.g. making a new treatment available and / or widening the range of treatment without impacting current care/patient choice.
• Further involvement needed – when there are complications or concerns raised about the potential impact on patients, e.g. current care/patient choice.
• Further involvement needed – when there is a proposal to not routinely commission / decommission a current treatment.

For each of these outcomes, assurance is provided by the Armed Forces Healthcare Commissioning Team and the Armed Forces PPVAG.

7. Assurance process for patient and public involvement

The Armed Forces Healthcare Commissioning Communications and Engagement Team lead on strategic communications and engagement within Armed Forces healthcare commissioning and provide support and advice to commissioners on how to involve patients and the public in their work. This includes helping colleagues plan and deliver engagement and consultation activity, developing associated material and promoting and supporting opportunities for stakeholders to get involved and have their say. The Communications and Engagement Team also support the Armed Forces PPVAG whose role it is to provide assurance on the overall approach to engagement and consultation activity.

The PPVAG representation is drawn from PPV Partners who sit on key groups and committees within the Armed Forces healthcare commissioning governance structure. Members represent groups from across the Armed Forces community and the focus of the Armed Forces Forward View programmes. This is supported by 12 independent members recruited via a transparent external recruitment process. These individuals are responsible for supporting a number of workstreams that align with the work of the Armed Forces health team. These are race and faith, trauma, hidden harms / adverse childhood experiences, LGBT+, families and carers, addiction and substance misuse, neuro-diversity, chronic conditions, suicide and bereavement, mental health, female veterans and the justice system.

For clinical polices that offer a clear and positive impact on patient treatment, and where it is considered no further public consultation is required, this decision is approved by the Armed Forces Senior Management Team on the advice of the Communications and Engagement Team lead and Chair of the Armed Forces PPVAG. For clinical policies that need further patient and public involvement, PPVAG members will assure whether plans for this are fair and proportionate, as follows:

• Fully assure – The plan is of a high quality and considers the specific needs of the target group.
• Assure with recommendations – There are suggested areas for improvement or other areas for consideration which should be implemented prior to the work taking place.
• Not assure – The plan is not ‘fit for purpose’ and requires further review and revision before being re-presented at a future Assurance Group for further consideration.

8. Reporting of patient and public involvement

Patient and public involvement is monitored and recorded centrally by NHS England through the 13Q reporting system. Colleagues use this system to record whether the 13Q legal duty to involve applies to their work and how they have involved people and communities in the commissioning of services. The information is used by the national communications and engagement lead to provide a six monthly report on relevant activity which is signed off by the Armed Forces Senior Management Team. These reports are submitted to the central Public Participation Team, which compile them into national reports for each area of commissioning activity. These are then submitted to the relevant commissioning boards or assurance groups. A summary of the national findings is included in a report to the NHS England board each year.

Beyond this and following any engagement undertaken in relation to Armed Forces health, an associated report is produced, setting out information on the engagement, key themes and subsequent actions that have been taken and / or planned. This is shared with individuals who participated in the engagement, along with key stakeholders and partners, including those who have subscribed to the NHS England Armed Forces health brief.

Publication reference: PRN00647