How Clinical Research, Service Innovation, and Multi-Stakeholder Collaboration Shaped UK Veterans' Mental Health Policy

"Conflict can quickly overload healthcare systems and create challenges where traditional solutions and care pathways are simply not fit for purpose. In Ukraine and Gaza we have seen trauma on a scale that has not been witnessed for a generation. Yet even when conventional pathways can serve only a few, there is often reluctance to step away from tried and trusted approaches. What are the barriers to change? What does it take to re-imagine better solutions? How can we best navigate innovation and systems change? What can we learn from past successes?

These questions are at the heart of LSN's work in re-imagining amputee care. We have been convening a series of events at the Frontline Club to examine different elements of this challenge. The first event focused on prosthetics for children; the second on scaling mental health services—a challenge particularly relevant in conflict and post-conflict settings.

Following on from that event, I am grateful for the collaboration with Professor Walter Busuttil in producing this briefing on 'How Clinical Research, Service Innovation, and Multi-Stakeholder Collaboration Shaped UK Veterans' Mental Health Policy'. The UK's experience in developing specialist mental health services for veterans offers valuable lessons for those seeking to transform healthcare systems in response to large-scale trauma."

This briefing examines the development of NHS England's Op COURAGE veterans' mental health service as a case study in how complex healthcare policy emerges from multiple research streams, stakeholder collaboration, political will, and sustained advocacy.

It demonstrates how Combat Stress, under the clinical leadership of Professor Walter Busuttil, contributed to the broader evidence ecosystem through service innovation, treatment outcome research, and strategic partnership with the King's Centre for Military Health Research (KCMHR) at King's College London.

The briefing acknowledges that Op COURAGE's development was primarily informed by KCMHR's longitudinal cohort study (the largest of its kind, running since 2003), alongside contributions from Combat Stress, Royal British Legion, Forces in Mind Trust, Walking With The Wounded, multiple NHS trusts, government ministries, and international collaboration through the Five Eyes military health network.

The Challenge: When Policy Precedes Evidence

Initial Context (2007)

When Professor Walter Busuttil joined Combat Stress as Director of Medical Services in 2007, during the height of the Afghanistan War, senior NHS staff maintained that veterans did not require bespoke clinical mental health services. This represented a significant policy barrier: the prevailing view was that mainstream NHS services were sufficient for veterans' mental health needs.

At that time, referral audits showed only 3% of veterans were referred to Combat Stress by the NHS, with 56% self-referring or being referred by partners, and 34% coming through other charities. The average time from leaving military service to seeking help was 14.3 years.

Building the Evidence Ecosystem: Multiple Research Streams

The Primary Research Driver: KCMHR

The King's Centre for Military Health Research (KCMHR)

at King's College London has been the leading source of independent, high-quality research on UK Armed Forces mental health since its establishment. Beginning in 2003, KCMHR launched a longitudinal cohort study of more than 25,000 UK military personnel, including those who left service, tracking their health and wellbeing over two decades.

This research programme became the foundation for UK Government policy on veterans' mental health. The Government's Defence People Mental Health and Wellbeing Strategy 2017-2022 was underpinned by 31 peer-reviewed academic papers, and 27 of those (87%) were produced by KCMHR.

KCMHR's work directly contributed to multiple policy developments:

•       Mental Health Services for Veterans in England Consultation and Action Plan 2016

•       Influencing the formulation of NHS TILS (Transition, Intervention and Liaison Service) 2017

•       NHS Complex Treatment Services 2017

•       The Veterans Strategy 2018

•       International policy through Five Eyes collaboration

Combat Stress's Complementary Contributions

Step 1: Establishing Clinical Infrastructure

Despite institutional resistance, Busuttil led the development of bespoke Combat Stress clinical services across the country, transforming the organisation from three respite care homes and fourteen untrained welfare officers into a comprehensive clinical service. This service development provided practical demonstration that specialist veteran services could work in the UK context.

Step 2: Embedding Research in Clinical Practice

In 2013, Busuttil established the Combat Stress Research Department through collaboration with KCMHR. This partnership enabled Combat Stress to publish high quality peer reviewed needs studies of those seeking help. This then led to the establishment of evidence based treatment programmes which were evaluated leading to treatment outcome peer reviewed publications. Together with the epidemiological studies conducted by KCMHR, a broader picture related to the mental health needs and treatment efficacy emerged leading to better evidence which was then used for strategic planning of NHS clinical services nationally.  

The Combat Stress Research department is internationally recognised as a world leader in the veteran mental health field and has produced over 100 peer reviewed publications and reports. Prof Busuttil and Prof Dominic Murphy who was later appointed Head of the Research department have delivered over 400 invited national and international conference presentations. Prof Murphy is currently the President of the European Society for Traumatic Stress Studies. Both professors form part of the prestigious Mental Health Research Intentional Collaborative which advises veteran and defence ministries across the Five Eyes Nations on issues concerning Armed forces and Veteran Mental Health.

Step 3: Generating Peer-Reviewed Evidence

Combat Stress evaluated the clinical needs of the help-seeking veteran population, developed evidence-based interventions, and measured their efficacy with findings published in peer-reviewed journals. This treatment outcome research provided complementary evidence to KCMHR's population-level findings.

The Translation Pathway: Multiple Streams to Policy

Phase 1: NHS Commissioning and Service Partnership (2013)

NHS England commissioned Combat Stress services from 2011 onwards, with formal service specifications recognising Combat Stress's phasic treatment interventions based on sound theoretical principles with an evidence base for treating veterans exposed to trauma. This represented the first formal recognition that specialist services were needed and established Combat Stress as a trusted NHS delivery partner.

Phase 2: Strategic Influence and Advisory Participation (2015-2016)

Busuttil sat on the mental health subcommittee for the Armed Forces Clinical Reference Group from 2015, giving him input into policy discussions. In 2016, when the NHS began developing bespoke veteran services, Busuttil advised on their setup as a member of the NHS England Clinical Advisory Group (formally joining in 2021).

During this period, multiple stakeholders contributed to policy development through the 2016 consultation process, including detailed submissions from the Royal British Legion and other veteran organisations.

Phase 3: Research-Informed Policy Development

Ongoing research from KCMHR, which highlighted the mental health, social, and welfare needs of the veteran population and their families, continued to influence and inform the development and funding of NHS veterans' mental health and wellbeing services.

As noted above, the Government's Defence People Mental Health and Wellbeing Strategy 2017-2022 drew primarily on KCMHR research, establishing it as the most trusted source of data on health and wellbeing of veterans from the Iraq and Afghanistan conflicts.

Combat Stress's treatment outcome research and clinical expertise contributed additional evidence to this broader research ecosystem, particularly regarding effective interventions for complex PTSD and trauma-related conditions.

Phase 4: National Service Implementation (2021)

Op COURAGE was launched in March 2021 by NHS England chief executive Sir Simon Stevens at the King's Centre for Military Health Research Veterans' Mental Health Conference, bringing together three specialist mental health services under one umbrella to make it easier for the 2.4 million veterans in England to access care.

The service was described as having been developed in collaboration with veterans and represents a partnership model involving NHS trusts and multiple charities including Combat Stress, Walking With The Wounded, and others.

The Critical Success Factors: An Ecosystem Approach

The development of Op COURAGE demonstrates that major healthcare policy change emerges from the convergence of multiple factors:

1. Foundational Research Evidence

KCMHR's two-decade longitudinal study provided the primary evidence base, demonstrating prevalence rates, risk factors, barriers to care, and the specific needs of the veteran population. This research was supplemented by treatment outcome studies from Combat Stress and other clinical providers, creating a comprehensive evidence ecosystem.

2. Service Innovation and Proof of Concept

Combat Stress's development of comprehensive clinical services from 2007 onwards demonstrated that specialist veteran mental health services could work effectively in the UK context. This practical proof of concept was essential alongside the research evidence.

3. Political Will and Ministerial Leadership

The Armed Forces Covenant created a policy framework for veteran support, whilst ministerial leadership from figures including Tobias Ellwood and Johnny Mercer provided political momentum for change. The NHS Long Term Plan's investment in mental health services (2019-2021) created the funding environment for Op COURAGE.

4. Multi-Stakeholder Advocacy

Multiple organisations advocated for improved veteran mental health services, including Royal British Legion, Forces in Mind Trust (as a major research funder), Help for Heroes, and numerous smaller veteran charities. This collective advocacy built political and public support for change.

5. NHS Commissioning Evolution

NHS England's progressive commissioning of veteran services from 2013, followed by the development of TILS, Complex Treatment Services, and the High Intensity Service, created the infrastructure that culminated in Op COURAGE.

6. International Best Practice

Collaboration through the Five Eyes military health network (USA, Canada, Australia, New Zealand, UK) enabled sharing of best practice and validated the approach to specialist veteran mental health services as internationally recognised.

7. Strategic Advisory Positioning

Clinical expertise was integrated into policy development through advisory groups. Busuttil's positions on NHS England committees, alongside KCMHR leadership's roles (including Professor Sir Simon Wessely on the first Veterans' Board and Professor Nicola Fear on the Academic Advisory Board for the Office for Veterans' Affairs), created direct channels to influence policy development.

The Outcome: A Coordinated National System

Op COURAGE Service Model

Op COURAGE is an NHS mental health specialist service providing care and support for serving personnel due to leave the military, reservists, Armed Forces veterans, and their families, delivered by trained professionals who are from or have experience of working with the Armed Forces community.

The service brings together three components: Transition, Intervention and Liaison Service (TILS), Complex Treatment Service (CTS), and High Intensity Service (HIS), creating a complete care pathway.

Integration with Wider Services

Op COURAGE works alongside Op RESTORE (the renamed Veterans Trauma Network for physical health), Op NOVA (justice system support), and Op COMMUNITY, creating a recognisable suite of Armed Forces healthcare services.

Partnership Delivery Model

Op COURAGE operates through partnerships between NHS trusts (which serve as lead providers in different regions) and charities including Combat Stress, Walking With The Wounded, and Mental Health Matters, embedding third-sector clinical expertise into the national service delivery.

Key Principles: How Research and Collaboration Drive Policy Change

1. Recognise You Are Part of an Ecosystem

Major policy change rarely emerges from a single organisation. Combat Stress's influence came through collaboration with KCMHR, partnership with NHS England, participation in advisory structures, and working alongside a broader community of veteran advocacy organisations and research institutions.

2. Build Complementary Evidence Streams

Population-level epidemiology (KCMHR's cohort study) and clinical treatment research (Combat Stress's outcome studies) addressed different but complementary questions, creating a more comprehensive evidence base than either could provide alone.

3. Demonstrate Feasibility Through Service Delivery

Build clinical services even when policy makers are resistant, creating practical proof of concept through actual practice. Combat Stress's service development from 2007-2020 demonstrated that specialist veteran mental health services could work effectively in the UK.

4. Publish in Peer-Reviewed Literature

Create rigorous evidence that policy makers cannot ignore. The 350+ research papers from KCMHR's cohort study, alongside Combat Stress's 90+ publications, provided credibility and scientific authority.

5. Secure Strategic Advisory Positions

Participation in NHS England committees, academic advisory boards, and international networks creates direct channels to influence policy development whilst ensuring clinical expertise informs decision-making.

6. Build International Credibility

Position your work within international networks to demonstrate that your approach represents best practice globally, not just local innovation. Collaboration through Five Eyes and international conferences validated the UK approach.

7. Create Commissioning Relationships Early

NHS England's commissioning of Combat Stress services from 2013 created a financial relationship that gave the NHS a stake in Combat Stress's success and established trust in the organisation's clinical capability.

8. Address Service Gaps with Evidence

By demonstrating that 97% of referrals came from outside the NHS and that veterans waited an average of 14.3 years to seek help, Combat Stress (alongside KCMHR's research on barriers to care) provided evidence of system failure that demanded response.

Lessons for Clinical Research Translation

The Timeline Matters

This was not rapid translation. KCMHR's cohort study ran for 18 years (2003-2021) before Op COURAGE launched. Combat Stress's service development took 14 years (2007-2021). Sustained commitment over many years is essential.

Evidence Alone Is Insufficient

Effective policy change required multiple elements working together:

•       Research evidence (primarily from KCMHR, supplemented by Combat Stress and others)

•       Clinical service delivery (proving feasibility)

•       Strategic advisory roles (direct policy influence)

•       International collaboration (external validation)

•       NHS commissioning relationships (financial interdependence)

•       Political will (ministerial leadership)

•       Multi-stakeholder advocacy (collective voice)

Challenge the Status Quo with Data

When told veterans didn't need specialist services, researchers and clinicians proceeded to evaluate actual clinical needs and published findings that demonstrated otherwise. The combination of KCMHR's population data and Combat Stress's clinical data made the case undeniable.

Integrate Charity and Public Sector Expertise

Op COURAGE's partnership model embeds Combat Stress's century of veterans' mental health expertise, alongside expertise from Walking With The Wounded and other charities, directly into NHS service delivery. This shows how third-sector innovation can enhance public services.

Conclusion

The development of Op COURAGE demonstrates that major healthcare policy emerges from the convergence of multiple factors working together over sustained periods:

•       Primary research evidence from KCMHR's longitudinal cohort study, which provided 87% of the peer-reviewed papers underpinning the Government's Defence Strategy 2017-2022

•       Complementary clinical research from Combat Stress and other clinical providers on treatment outcomes and interventions

•       Service innovation demonstrating that specialist veteran services could work effectively in the UK

•       Strategic advisory participation ensuring clinical and research expertise informed policy development

•       Political will and funding through the Armed Forces Covenant, ministerial leadership, and NHS Long Term Plan

•       Multi-stakeholder advocacy from Royal British Legion, Forces in Mind Trust, and numerous veteran organisations

•       International collaboration validating the approach through Five Eyes military health networks

•       NHS commissioning evolution building service infrastructure progressively from 2013 onwards

Combat Stress played an important role within this broader ecosystem:

•       Developing comprehensive clinical services that demonstrated feasibility

•       Generating treatment outcome research through collaboration with KCMHR

•       Contributing clinical expertise through advisory group participation

•       Becoming a trusted NHS delivery partner through commissioning relationships

•       Raising awareness of veteran mental health needs through sustained advocacy

Policy makers often resist change until the evidence base becomes overwhelming, clinical models prove their effectiveness, political conditions align, and multiple stakeholders create momentum for change.

The Op COURAGE story shows that researchers and clinical innovators must be prepared to build evidence across multiple streams, demonstrate practical feasibility, engage strategically with policy structures, collaborate with diverse stakeholders, and sustain effort over many years to achieve systemic change. Success comes not from any single organisation's efforts, but from the convergence of multiple contributions within a supportive policy environment.