Armed Forces Personnel and Veterans Health Joint Group’s Implementation Group minutes: September 2023

Attendees and apologies

Attending

• Jason Leitch (Chair), National Clinical Director, Scottish Government
• Neil Morrison, Health Representative, Veterans Scotland
• Sharon Callaghan, Operations Manager Scotland, Defence Primary Healthcare (Scotland and North)
• Robert Reid, Regional Manager Scotland and Overseas, Defence Medical Welfare Service (DMWS)
• Jo McBain, NHS Highland Armed Forces and Veterans Champion 
• Craig Cunningham, NHS Lanarkshire Armed Forces and Veterans Champion
• Ian Cumming, Third Sector Representative, Erskine
• Mark Fergusson, Senior Policy Manager, Survivor Support and Veterans’ Mental Health, Scottish Government 

Guests

• Professor Murray Leith, School of Education and Social Sciences, University of the West of Scotland  
• Professor Liz Frondigoun, School of Education and Social Sciences, University of West of Scotland

Official support

• Gary Cocker, Person Centred, Participation and Sponsorship Unit, Scottish Government
• Lindsey Restrick, Person Centred, Participation and Sponsorship Unit, Scottish Government 
• Jennifer Donovan, Person Centred, Participation and Sponsorship Unit, Scottish Government

Apologies

• Lesley McDowall, Head of Survivor Support and Veterans’ Mental Health, Scottish Government 
• Mairi McKinley, NHS Fife Armed Forces and Veterans Champion
• Martin Bell, Director Primary Care & Counter Fraud Services, NHS National Services Scotland
• Andrew Carter, NHS Borders Armed Forces and Veterans Champion

Items and actions

Welcome and apologies – Chair

Jason welcomed all to the group and noted the apologies as above. 

Brief roundtable catch up – Chair, all

Jo referred to a discussion from the last meeting, regarding forces families being included in various pieces of veterans' work. NHS Highland has undertaken some research and engagement with Armed Forces Families, The Ripple Pond and Forces Children Scotland which has produced a briefing document. This document includes background information and recommendations which may be of interest and something for this group to consider.    

Craig raised the issue that those returning from military service have had in finding dentists taking on NHS patients. While Craig was able to support an individual to find a dentist, he is conscious that this could be an ongoing issue elsewhere so suggested the group might want to look at this and see if there is a formal, consistent approach which could be taken.

Jo provided a further example where a service family struggled to get continuity of orthodontic care when returning from service and had to access private treatment instead. 

It was acknowledged in discussion that there are problems with accessing dental services in some areas, with dentists only offering NHS services to children. A challenge regarding dentistry that was acknowledged is that they are independent contractors, and they can opt to offer private or NHS services. 

Lindsey highlighted that the issue of dentistry was raised at the UK Department of Health and MOD Partnership Board, so it is a known issue across the UK, particularly for Armed Forces families due to regularly needing to change dentist due to moves with deployment. Sharon noted that service personnel and their families who are posted to Northern Ireland are also affected as they must then travel back to Mainland UK for dental treatment. 

Jason said he will write the Chief Dental Officer to make him aware of the issue.

Action points:

•    Jo to send the briefing to Lindsey to circulate with the minutes; 
•    Jason to highlight comments on dentistry to Chief Dental Officer.

Update on Implementation Group priorities – Gary Cocker

Gary gave a progress update on current priorities. 

The General Practice Armed Forces and Veterans’ Recognition Scheme

The scheme is in its final stages before being launched nationally and will be managed inhouse by Scottish Government colleagues. The training for the scheme is made up of three modules which outlines the Armed Forces covenant, how this applies within General Practice and Clinical case studies. These modules have now all been made available on the TURAS website. 

To be involved in the scheme, practices should complete a registration form and appoint a practice lead. Practices are encouraged to promote to patients that they have completed the training, which in turn may help veteran and Armed Forces families to self-identify to the Practice. 

We are hoping to expand the scheme to cover similar training intent for secondary care. Colleagues from NHS Highland and DMWS in NHS GG&C are currently working together to create content for this. 

Jason praised the effort on the GP scheme, but highlighted that practices need to sign up to make it impactful and asked how we ensure that it is publicised properly. 

Lindsey advised that, following ministerial approval, we will ask the GP subgroup to help us promote this, membership of which includes representatives from Primary Care and NHS Champions. Hopefully IG members and the Scottish Veterans Commissioner can help with this also. 

Jason also suggested that to help publicise the scheme it may be beneficial to arrange a ministerial visit to a participating practice. 

‘Fife’ coding project

In the first stage of the Fife project, it was recognised that not every practice has the resource to complete the recognition scheme training. As a result, the aim is to encourage practices to take simple steps which help identify their veteran patients.  

The Scottish Government is currently gathering information to assess the impact of the letter issued by Jason and whether it has increased the numbers of veterans being identified within primary care records. While the initial aim is to increase the identification of veterans and armed forces families in Primary Care, the intention is that such markers carry through to Secondary Care when required. Some early initial conversations have been had to try and identify a system solution. The group will be kept updated with progress. 

Jo noted that NHS Highland carried out a concentrated piece of work on the Black Isle which tripled the number of people in veterans' community included on their list within 3 weeks, so it is valuable work.

Jason asked if this is through the coding of individuals. Jo replied that a text was sent to patients to ask if they identify as part of the veteran's community, veteran / family member / currently serving, etc. 

Craig highlighted there might be potential to advertise the benefits of this activity to encourage people to take this up and have wider impacts on NHS services.

Female and LGBTQ+

The Implementation Team for Veterans Mental Health have identified female and LGBTQ+ as specific workstreams within the implementation plan. It is also understood that research has been commissioned across the UK into female veterans specifically. It is due to be published shortly. 

Neil commented that he is increasingly concerned that Scotland does not have a female veterans focus. He is keen to make this happen and to have a female focus in Scotland working on similar lines to ‘Fighting with Pride’.
 
Jo agreed and added that we need to be structurally building this into all the pieces of work we are doing to ensure that all veterans are considered.

Neil commented that some veterans have additional challenges due to personal characteristics and this needs to be addressed whilst remaining complimentary to the plan as a whole. 

Lindsey commented that there is possibly work to be done with MOD given that this group is AF and V. There is an opportunity for collaborative working to ensure that personnel are supported both in and out of service.

Scottish Veterans Commissioner (SVC) recommendations

Working with colleagues across Scottish Government to provide the annual update to parliament against the SVC recommendations, there is confidence that the progress that has been made will be recognised. While some of the recommendations are not within Scottish Government’s gift to resolve, we have been engaging with UK Government, Department of Health and Social Care, and Ministry of Defence, which is helping to build positive relationships. Engagement with key stakeholders is also continuing but, as always, if there are gaps, Scottish Government is happy to connect. 

Jason advised that he recently met with the SVC, and he felt that this work was contributing to achieving the recommendations. Neil shared this positive sentiment. 

Lindsey said that the intent behind some of the 2018 recommendations are being adhered to, even if they are being implemented in a slightly different way to the original wording. 

Jason noted that this work has meant that he is not being called upon to answer questions by Ministers, engagement of this kind is often if there are actions required or if there is a cause for concern. 

Scottish Veterans’ Treatment Pathway (SVTP)

Gary gave an overview of the progress to date and highlighted that a part of the design process is how we capture both quantitative and qualitative data so that we can measure the use and the impact of the pathway and ensure that its implementation is effective and accountable. As with any new system or model, it is highly unlikely that we ‘get it right first time.’ 

Lindsey advised the intention is that referrals to the pathway will come into one place so rather than replicating the process in each board, it is centralised and more streamlined. As a result, Scottish Government are currently exploring who may be a ‘host/ ‘hub’ board. This approach supports information governance as any medical history/ records will be sent NHS to NHS, and due to the numbers anticipated to be referred to the pathway, it makes sense to centralise where possible. 

Craig wondered although it is slightly different in approach, whether the national trauma network could provide a way in? 

Jason responded that the model might work but not with the same people. Craig noted that the infrastructure might be helpful. 

Jo sought clarification of what a host board would do as she thought the key principle behind this work was to facilitate a specialist review / second opinion rather than it being convened as an entity. Lindsey clarified that the notion of host/hub board is somewhere for the referrals to come in to and from which the virtual MDT (Multi-Disciplinary Team) can be convened. It would not be responsible for the treatment.

Gary advised that following feedback from the working group, Veterans In Service Injury Review (VISIR) is the working title of the MDT review process as it helps to identify what the function is. Bob explained it is very similar to what they have in England, and it works well. 

Neil stated that regarding a trauma service, anecdotally surgeons who have worked in a military/ combat setting e.g., Afghanistan, are clinically shown to get better results on veteran patients who have suffered an in-service injury. 

Lindsey talked the group through the slide on the proposed referral process, explaining that this work should have a clinical lead. The main criterion for referral is that it must be injury received in service that has already been treated.  It will not support a referral for the primary treatment of an injury. The purpose of the VISIR is to determine if any additional clinical or non-clinical support can be offered to the veteran to help them live well with their injury.   

The outcome of the VISIR discussion will be fed back to the original referrer in Primary Care. It should be noted that the VISIR will only make a recommendation and not a direct referral for a further clinical intervention. Providing recommendations is a conscious decision as a recommendation does not mean acceptance of such treatment.   

Bob advised that DMWS currently provides welfare support to veterans that have been referred to Op Restore (previously the Veterans Trauma Network in NHS England). Bob is happy to help with suggestions or provide support to help ensure that patients can wait well until their case is reviewed by VISIR. 

Neil thinks there is an opportunity to promote this pathway directly to General Practice. 

Veterans Lived Experience Group

This item was not discussed.

Department of Health and MOD Partnership Board

Lindsey advised that SG is part of UK Department of Health and MOD Partnership Board, and that Scotland is hosting the next meeting in November. Jason, as Chair of the IG, will speak to the Board. 

There has been a suggestion that Board members that are travelling to Scotland the day before the meeting may want to visit a project or projects that align with the Board outputs. The meeting is currently scheduled to be in Victoria Quay, Edinburgh on the morning of Wednesday 8 November, meaning the visit would take place on the Tuesday the afternoon.

This is being brought to IG members to help consider what might be of interest and that goes beyond what we are doing as IG and SOG. 
Jason suggested showcasing work that is ongoing. 

Bob suggested that the Lanarkshire Technology Enabled Care (TEC) project could be highlighted for a visit. 

Craig wondered, since the meeting will take place in Edinburgh and there could be two or three different areas in one room, if this means we could bring the TEC project, Veterans First Point, and other work around coding, which may make for a more beneficial visit. 

Neil also suggested going to Erskine Home where there is a Veterans First Point and Combat Stress, which is also an easily accessible location. 

Update on Technology Enabled Care (Presentation slides included)

Bob gave an outline of the project. Murray and Liz provided some additional detail. 

Liz said they want to make sure staff training goes further than just how to use the equipment, and it should also involve details of the outcome and impact of using it. 

Craig is delighted with the work and, although it is early days, feels it is important to help people use technology to support them before they have care needs. Managers of health services could consider how digital technology can be used to support clinical staff and enable patients to help manage their own care such as diabetes and blood pressure. Digital technology is to play a bigger role in supporting health care and it may require challenging discussions and appropriate training to take place with clinicians. If digital technology could be used more effectively it could improve the delivery of healthcare. 

Jo explained that she visited Blantyre after the groups last meeting. Lots of people in remote and rural were really excited at the potential of this, but there is a huge culture piece around the workforce embracing technology more than the service users due to poor bandwidth etc. in rural areas. 

Murray thanked Craig for all his support in this work. 

Any other business – Chair, all

Sharon highlighted that she is looking at re-invigorating the orthopaedic pathway for the rehabilitation unit into NHS Lothian. It is in its initial stages, but she is happy to provide an update at the next meeting. 

Date of next meeting – Chair

The next meeting will be arranged for 3 months’ time. Scottish Government officials will send out a placeholder for the next meeting in due course.

Jason thanked all for their attendance and closed the meeting.