Armed Forces Personnel and Veterans Health Joint Group’s Strategic Oversight Group minutes: May 2023

Attendees and apologies

Attendees

• Jason Leitch, National Clinical Director, Scottish Government (SG)

• Neil Morrison, Health and Wellbeing Representative, Veterans Scotland

• Col. Sharon Findlay, Regional Clinical Director, Defence Primary Healthcare (DPHC) Scotland and Northern Ireland

• Ian Cumming, CEO, Erskine

• Mairi McKinley, NHS Fife Armed Forces and Veterans Champion

• Jo McBain, NHS Highland Armed Forces and Veterans Champion

• Craig Cunningham, NHS Lanarkshire Armed Forces and Veterans Champion

• Karen Ross, Health and Additional Needs Specialist, Army Families Federation (AFF)

• Susie Hamilton, Scottish Veterans Commissioner (SVC)

Guests

• Charles Winstanley, Chair, Implementation Board, Veterans Mental Health and Wellbeing Scotland 

Official support

• Lindsey Restrick, Armed Forces and Veterans Healthcare policy team, SG

• Laura-Isabella Muresanu, Armed Forces and Veterans Healthcare policy team, SG

Observing

• Lesley McDowall, Head of Survivor Support and Veterans' Mental Health, SG

• Mark Fergusson, Senior Policy Manager, Survivor Support and Veterans’ Mental Health, SG

• Suzi Macpherson, Interim Unit Head, Trauma, Adverse Childhood Experiences and Resilience Unit, SG

• Paul Hood, Deputy Head of Veterans Unit, SG

Apologies

• Gregor Smith, Chief Medical Officer, SG

• Sharon Callaghan, Operations Manager, DPHC Scotland and Northern Ireland

• Andrew Carter, NHS Borders Armed Forces and Veterans Champion

• Roddy Neilson, Medical Military Liaison Officer

• Cllr Derek Noble, Local Authority Champion Fife

Items and actions

Welcome and Apologies

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

Brief roundtable introductions and catch-up

Jason invited members of the group to reflect on the challenges and achievements of 2021-2022 and draw on any lessons learned.

Ian reflected on the increase in social care demand during the past year but also noted a shortage in staff and volunteers. The sector faces further challenges due to financial constraints, with many organisations reporting difficulties in planning for the future. Erskine specifically are looking at greater collaboration and the sharing of resources to help mitigate the impact on services. 

Jason acknowledged the difficulties faced by the social care sector and recognised that some of the turnover will need to be allocated to continuity of care. 

Craig gave an overview of the activity in Lanarkshire, noting that the firm base arrangement in place can provide support for veterans with issues that are beyond those immediately health related.

Craig also noted that NHS Lanarkshire supported a successful bid by Defence Medical Welfare Services (DMWS) to the Health Innovation Fund (HIF). The project is looking at using technology in the provision of healthcare, and the findings may have application for the non-veteran population.

Craig drew on two cases to illustrate the extensive veterans’ support network that is available across Lanarkshire, with both cases being resolved efficiently and favourably for the member of the Armed Forces Community, and echoed Ian’s comments about the health and social care landscape being difficult to navigate.

Sharon reflected on what has been a period of transformation within Defence Medical Services (DMS) in the past year. Sharon highlighted that the mental and occupational health services within Defence Primary Healthcare (DPHC) are now the responsibility of Col. Sharon Beatty.

Sharon thanked the Scottish Government, Public Health Scotland, and the NHS Armed Forces and Veterans Champions for the collaboration that has been facilitated to date. Sharon noted her enthusiasm for being involved in future discussions and strengthening the links formed. 

Karen thanked Craig for the particularly good support provided to the cases previously illustrated. Karen mentioned that from a service families’ perspective, there are some issues with service children not having adequate access to speech and language therapy. There are continued challenges with dental provision, where some families have to opt for private treatment if they can afford it. Overall, waiting lists for treatment can be long.

Jason reflected that the links formed have now matured. Jason asked Craig about his impression of whether the Strategic Oversight Group, Implementation Group, and NHS Champions Network are working well, and more generally, his view of the wider veterans’ network.

Craig agreed that things have matured and commented that the relationships with the third sector have proven invaluable. 

Sharon observed that from a serving Armed Forces personnel perspective within DPHC, they have relied upon the Armed Forces Champions Network to help them with the IT connectivity challenges.

Neil commented that the change in the structure of the Joint Group, from being a much larger group to the current arrangement, is reaping rewards. 

There was a general feeling that connectivity is better through a range of agencies.

Implementation Group (IG) report to Strategic Oversight Group (SOG)

Lindsey offered a summary of the current priorities and the progress recorded.

Development of the General Practice Armed Forces and Veterans’ Recognition Scheme 

• a pilot version of the scheme was launched in December 2022. This was trialled in 18 General Practices across nine health board areas. The pilot includes a learning programme hosted on Turas, aimed at both clinical and non-clinical staff working in primary care, and a registration form that gives some insight into current levels of awareness

• initial analysis of feedback from the practices involved in the pilot indicates that they are aware of how the Armed Forces Covenant applies to ex-service personnel but not Armed Forces families

Next Steps: 

• the IG proposes continuing to develop this priority to its national launch and moving it into a second phase. This involves extending the learning programme to colleagues in secondary care, as well as exploring how to raise awareness to healthcare providers in the criminal justice system

Progression of the Fife Coding Project 

• observations from the Fife practice, verified by other practices, indicated that the process to code and re-code patients with ‘13Ji’ is straightforward

• a letter outlining some simple steps that practices can introduce to help identify their veteran population has been issued to Practice Leads, and NHS Armed Forces Champions have supported its distribution within their Board area

Next Steps:

• the IG will consider what more can be done to ensure that the work to identify veterans within a primary care setting follows through to secondary care referrals

Understanding the experience of female and LGBT veterans

• the General Practice Armed Forces and Veterans’ Recognition Scheme contains content regarding these cohorts. This content has been shared with specific third sector organisations to ensure that it is accurate and most helpful

• the IG’s understanding is that the implementation plan for veterans' mental health includes a workstream on female and LGBTQ+ veterans

Next Steps: 

• there is still more work on female and LGBTQ+ veterans to be done. The IG therefore proposes to continue this area as a priority, embedding this within existing workstreams. However, Lord Etherton’s review into LGBTQ+ veterans is due to be published, as is some research into the female veterans' experience. The group considers it prudent to evaluate the outputs from this research to help optimise the outcomes of this priority

Development of Scotland-wide Veterans Mental Health Provision

An update on progress will be given by the Chair of the Implementation Board and the IG will continue to observe its development in 2023 –2024.

Establishment of the Scottish Veterans treatment Pathway (SVTP)

• the working group established to consider how the pathway could be developed has agreed the vision, process, and governance structure

• the group has been paused until August 2023, to enable work to be completed on engaging with clinicians and determining the Multi-Disciplinary Team (MDT) membership, as well as its operational pattern

Next Steps:

• the reconvening of the working group will give an opportunity to assess what structures have been put in place and understand what further work is required to embed this process to provide a holistic health pathway

• this work is moving into the implementation phase; the IG proposes to continue this work as a priority

With reference to the Scottish Veterans’ Treatment Pathway (SVTP), Karen asked if there is anything interim for Scotland where referrals could be sent. Mairi answered that any such referrals should go through the relevant NHS Armed Forces Champion for escalation.

Neil noted that he felt that the role of the Armed Forces Champion could be enhanced, and consideration should be given to what more could be done. Neil proposed establishing a short-life working group to further assess this. Neil further observed that outside of the health space, initiatives such as buddy cafés could be especially useful. 

Jo mentioned that NHS Highland would be entirely in agreement with this approach, recognising that NHS Armed Forces Champions are short on resources. In NHS Highland, a generic Armed Forces Champions’ mailbox was set up, which her team manages. Jo noted that she will only have the support of the second team member until March 2024, when their contract ends. 

As an additional priority for consideration, Jo asked to look more broadly to service children and families of serving personnel. 

Jason agreed with both Neil’s and Jo’s proposals and invited further discussions to take place around these.

Craig highlighted the need to proceed cautiously, accepting that these are good things to take forward, but the NHS may not always be the most appropriate party to do so. Craig noted that there are already veterans’ cafes and a gardening project in NHS Lanarkshire that is working very well for veterans. Craig inquired how veterans could be more aware of the available local services that are not labelled ‘veteran.’

Craig observed that at this point, he would not be able to justify any additional budget requests for extra resources. He also reflected that the closer the volunteer resources are to statutory services, the less nimble they can be, and overall, this is outside the scope of the health service.

Jason proposed to have a further conversation about the NHS Armed Forces Champions during the IG. He also noted that the topic of signposting to services is a discussion more suitable for the IG or the NHS Champions Network.

Mairi noted her agreement with Craig on this topic. NHS Fife is currently looking at how this work aligns with the NHS board being an anchor institution as per the health foundation work and not necessarily purely the responsibility of the NHS Armed Forces Champion.

Jason acknowledged all these points and thanked the members of the IG for their continued enthusiasm in carrying forward this work. Jason suggested that the next IG be an in-person meeting.

Scottish Veterans Commissioner (SVC)

Jason welcomed Susie, SVC, who has been in post since August 2022.

Susie highlighted that she has just launched the 3-year strategic plan and updated the website accordingly. The 3-year strategic plan is aligned with UK Government and Scottish Government themes. Over the next 3 years, the focus will be on the following themes: ‘Community and Relationships’ for 2023, ‘Veterans and the Law’ for 2024, and ‘Veterans and Finance’ for 2025. The SVC commented that hearing the veterans’ voices is key, and not just from those accessing support. Several focus groups have been set up, and these groups include family members. Digital tools will be used to support a brief survey.

Susie noted that from her stakeholder engagement, loneliness and the interface between social care and healthcare have emerged as an issue, with veterans and service families unable to participate in the community due to declining health. 

Susie mentioned that mental health is an issue and a priority, particularly for areas of the country that do not have a Veterans First Point (V1P) service. There is also a poor understanding of priority treatment from the veterans’ perspective. Moreover, current public perception particularly affects women, who are often not asked whether they are veterans.

Susie added that another part of the SVC role consists in monitoring progress against previous recommendations, with the current focus being homelessness and mental health provision. The latter has been raised at every engagement that they have had so far. 

Ian mentioned that they have apartments for veterans and families in transition. People in such circumstances often tend to present a modicum of mental health and substance abuse issues. Ian also noted that Erskine is looking at getting a mental health counsellor on their team. Susie observed that this is true of the homeless population. She also referred to service-related injury, and the fact that the outcome of treatment becomes a lottery depending on the consultant that sees the person.

Susie noted the negative impact on the community, particularly the elderly, following the closure of day cafés and other facilities, and the fact that there is a continued struggle to resume some services. Ian mentioned that the Erskine Reid Macewen Activities Centre (ERMAC) has been described as life-changing by veterans. ERMAC currently requires half a million per year to run it. Ian added that if their Care at Home programme is successful, he will be looking at registering those as a Care at Home Hub.

Mental Health and Wellbeing Action Plan (MHWAP)

Jason invited Charles, Chair of the Veterans Mental Health and Wellbeing Scotland Implementation Board, to provide an update on the progress to date.

Charles provided a high-level overview of Veterans Mental Health and Wellbeing Scotland and mentioned that it will link organisations, many of which are already existing, rather than replacing services. The Veterans Mental Health and Wellbeing Scotland Implementation Plan is a continuation of the Veterans Mental Health and Wellbeing Action Plan. The essential points from the MHWAP that are currently being developed are the provision of a single point of entry to a hub and the deployment of veteran navigators. The rest of the points are of procedural nature, and they will be considered in relationship to these two features. 

The Implementation Plan is currently in draft, pending approval from the Implementation Board and ministers, and it will be updated to reflect comments received, particularly regarding risks, costs, governance, and data management. It is anticipated that this will be ready for the next Implementation Board meeting on the 15th of June. 

Charles noted that 30 veteran navigators have been identified to date, most of them from the third sector. Charles mentioned that the third sector organisations are willing to fund the salary of the navigators in the short term, although funds will still be needed to train the navigators. Charles added that training for navigators is currently prepared, but this has not yet been deployed. 

Charles observed that the levels of demand for Mental Health and Wellbeing Scotland are not yet certain, and this is something that is currently being assessed. A clinical pathways group has been set up, and the existing local clinical pathways are presently being mapped under the leadership of Dr Michelle Ramage. This group has not been set up to establish a new clinical pathway, as there are no funds for the implications associated with that.

Charles mentioned that the initial staffing for the Mental Health and Wellbeing Scotland Hub will consist of two people taking the inquiries. This process will use the Combat Stress helpline in the first instance. Charles also noted that a website is required to establish the hub’s virtual presence, but this remains to be developed.

Charles stated that the Implementation Board and Implementation Team are keen to integrate the mental health pathway with the physical health pathway. They are looking at ways to use the same front door for both pathways, and the navigators would be shared.

Charles added that the Board will be putting forward a recommendation to the minister in September 2023 for the post-March 2024 veterans' mental health budget. The Implementation Board and Implementation Team will need a further nine months to do the planning, liaison, and training. Charles stressed the importance of ensuring that all navigators will be comfortable with their role and what is expected of them. Charles further added that based on information from Combat Stress, it is anticipated that 80% of interventions will be non-clinical, with 20% of activities constituting clinical treatment.

Charles invited comments from other Implementation Board members present on the call.

Neil stressed that Veterans Mental Health and Wellbeing Scotland will remove any regional disadvantage. There is the potential to get the veteran to the right service first time around, which in many cases will not be part of the public sector. The hub that will be developed as part of the service will integrate third sector and public sector resources. 

Jo asked whether for the physical health pathway, the single front door approach would be an escalation beyond current treatment.

Charles noted that there will be more triage within Mental Health and Wellbeing Scotland than currently undertaken in V1Ps. Charles added that the referral into the physical pathway will will come in small numbers from primary care (not self-referrals).

Jason asked Charles about the timelines for launching Veterans Mental Health and Wellbeing Scotland. Charles mentioned that he is due to meet both ministers Ms Todd and Mr Dey. Charles will make a request of both ministers to get the approval to commence the navigator training. The estimated launch date is April 2024.

Craig asked if the funding envelope will include a recurring funding provision for V1P services that are already there. Charles advised that the Implementation Board will make recommendations regarding securing longer term funding. Jason observed that enabling such a shift in funding arrangements would be an achievement. Jo and Susie echoed this. 

Sharon noted her support for the work of the Implementation Board, particularly in terms of navigating the regional differences.

Agreement of 2023/2024 priorities

Jason drew on Ian’s comment regarding the resource implications for the provision of care that is not just Armed Forces and veterans related, such as hospices, and noted that this is something that he will investigate.

Jo recalled the need to consider the service families and children piece more closely. Karen reinforced the importance of looking at this from an Armed Forces Covenant perspective and what that means. Susie added that it is important to understand what 'due regard' means.

All other priorities will be continued as previously agreed.

Date of Next Meeting (DONM)

The next Strategic Oversight Group will take place in May 2024. Officials will be in contact with a proposed date.