Scoping Review: A Needs Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and their Families in Scotland

EXECUTIVE SUMMARY

1. Background

1.1 The deployment of the UK Armed Forces to Iraq and Afghanistan has engendered a broad political imperative and increased the academic interest in the health and wellbeing of both Service and ex-Service personnel.

1.2 Each year in the UK, approximately 25,000 men and women leave the UK Armed Forces (Fletcher, 2007) and return to civilian life for a miscellany of reasons and in a variety of different circumstances including medical discharge (Iversen et al, 2005). Whilst some have completed lengthy terms of service, over 5 million individuals have served at least one day in the Armed Forces (in accordance with the broadest definition of a "Veteran"). Currently, however, the average length of military service is four years.

1.3 Little is known about what happens to ex-Service personnel when they leave the UK Armed Forces, although much has been reported about Veterans from other countries (e.g., US Armed Forces). Currently, within the UK most findings derive from studies conducted by the King's Centre for Military Health Research using existing data from their original military cohort established in 1995 (e.g., Dandeker et al, 2003; Iversen et al, 2005; Iversen et al, 2005, van Staden et al, 2007). These findings confirm that, although the majority who leave the UK Armed Forces benefit from their experiences and are successful in their transition to civilian life, there is a significant minority who fare less well due to a variety of factors including mental health problems and pre-enlistment vulnerabilities.

1.4 Issues relating to Veterans, continue in the main, to be reserved issues to the Westminster Government with responsibility for Veterans falling to the Ministry of Defence (MoD). However, by virtue of the fact that, when men and women leave the UK Armed Forces and return to civilian life, civilian authorities and service providers take on the responsibility for meeting the needs and aspirations of the 600,000 Veterans that currently reside in Scotland.

1.5 The Scottish Government has certain devolved responsibility over a wide range of services that can be accessed by Veterans, such as healthcare, housing, social care, education and skills training, and employability. Responsibility for the co-ordination of Veterans' issues across the Scottish Government falls under the remit of the Social Inclusion Division. In a concerted endeavour to meet this responsibility, the Scottish Government has undertaken various actions to support Veterans in recognition of the fact that Scotland owes a debt to its service personnel and to her Veterans. To complement the Scottish Government's consultation paper on the wellbeing and welfare of the UK Armed Forces and Veterans in Scotland (26 June 2008), the Scottish Government's contribution to the MoD Command Paper "The Nation's Commitment: Cross Government Support to our Armed Forces, their Families and Veterans" (17 July 2008), sets out its commitment to assist Service personnel and Veterans across Scotland.

1.6 This report is based on the outcome of a Scoping Review, the principal aim of which was to identify to what extent a population-based survey is required to inform the national commitment to meeting the health and wellbeing needs of ex-Service personnel and their families in Scotland.

2. Approach

2.1 The methodological framework and analytic strategy for this scoping review derived from that suggested by Arksey & O'Malley (2005) in order to ensure a comprehensive but selective coverage of current knowledge, practice, service provision and the emergent evidence- and eminence-base given the extensive nature of this field of enquiry.

2.2 The work undertaken focussed on fulfilling five specific objectives (project deliverables) to:

• (i) review extant knowledge, practice, and service provision in respect of meeting the health and wellbeing needs of ex-Service personnel and their families;
• (ii) identify existing gaps in the implementation of the Veterans Initiative at the policy, health systems, provider practice and community behaviour levels, which may compromise its effectiveness in fulfilling its strategic outcomes;
• (iii) review relevant research activity to identify outcomes and gaps in the emergent eminence- and evidence-base;
• (iv) identify possible methods for conducting a robustly designed population-based survey in Scotland with particular reference to the implications for comparative analyses, and
• (v) provide indicative costs and timescales associated with the methods identified.

3. Establishing the context

3.1 An overview of the evolution of Veteran-related policy and strategy in the UK (following the launch of the Veterans Initiative in March 2001) was undertaken. Its purpose was to understand the historical and contemporary context in which cross-Government policy on the provision of health and welfare support to the UK Armed Forces community has developed and to identify the key drivers of Veteran-related policy and strategy.

3.2 Subsequent commitments made by UK Government and the Devolved Administrations in respect of providing health and welfare support for the UK Armed Forces community were mapped chronologically based on the publication date of relevant 15 key strategy and policy-related papers and reports.

4. Overview of the current status of health and welfare support

4.1 An overview of the current status of health and welfare support provision for the UK Armed Forces community was considered in terms of its organisation and delivery.

4.2 Key factors that have led to substantive shifts in strategic thinking with regards to the development, organisation, and delivery of health and welfare support services and which have consequently been influential in shaping current service provision were identified.

4.3 Particular consideration was given to those factors associated with the risk of social exclusion in vulnerable subgroups of the ex-Service population given the wider political agenda.

5. Outcome of the consultation process

5.1 The views of a wide range of stakeholders were sought on key issues relating to meeting the health and wellbeing needs of ex-Service personnel and their families in Scotland.

5.2 These included representatives from the statutory and voluntary services, priority groups, and related agencies, military, clinical, and academic experts in the relevant domains, and key political figures informed in Veteran affairs. In addition to engaging with those user groups with established links, the consultation process also included those that have not engaged with formal initiatives in order to identify gaps which need to be addressed.

5.3 Key issues associated with pre-Service factors, Service-related factors, transition-related factors, and post-Service factors were categorised in accordance with the Needs Map generated by the Veterans Agency.

5.4 The issues highlighted were those identified by those consulted as being of particular importance and were grouped according to general themes within each of the categories.

6. Outcome of the desk-based research

6.1 A critical and selective analysis of three main sources of data was undertaken in relation to:
(i) MoD and Government commissioned reviews;
(ii) surveys commissioned by charities and agencies affiliated to the provision of the Veterans Initiative, and
(iii) academic-based research reported in the peer review literature.

6.2 In line with the terms of reference for the scoping study, this review reflected a UK focus with specific reference to data that would inform the national commitment to meeting the health and wellbeing needs of ex-Service personnel and their families in Scotland.

6.3 The objective of the analysis was to establish the current status of knowledge based on evidence and eminence-based practice in meeting the health and wellbeing needs of the Veterans' community, and (ii) identify in-progress research in this domain.

7. Summary of findings, conclusions and recommendations

7.1 The following key issues and suggestions emerged from the interviews conducted with stakeholders and Veterans.

• Pre-enlistment vulnerabilities play a major factor in determining those who fare least well on leaving Service and who are at an increased risk of social exclusion.
• Paradoxically, whilst military life offers a number of positive benefits in terms of providing structure, security, a sense of identity and an esprit de corps, these benefits may exact a penalty on demobilisation and the transition to civilian life including the risk of fostering a "dependency culture".
• Those who enlist in the Army and of a lower rank experience the greatest problems in adjusting to civilian life.
• The prevailing culture/ethos of "machismo" and "toughness" does not readily accommodate the need to report mental health problems and seek help. It also was also suggested as being a major reason why the heavy use of alcohol is a common feature of military life.
• Stigma is a prevailing issue in relation to mental health problems and help seeking.
• Support for partners of Service personnel is lacking, particularly for those of Reservists.
• Significant advances in military prehospital care and trauma management have generated a new major challenge in terms of the long term physical and emotional adjustment for severely injured personnel.
• Efforts by the Services to facilitate the transition from military to civilian life are inadequate, particularly for those who are most vulnerable to transition difficulties such as Early Service Leavers and those discharged on medical grounds.
• Differences in need exist between older and younger Veterans.
• A number of barriers to provision of mental health care for Veterans exist including:
  • attitudes and behaviours of the individual (e.g., fear of stigma, denial, excessive alcohol use);
  • attitudes and behaviour of others (e.g., employers, healthcare professionals, GPs), and
  • delivery of mental health services for Veterans (e.g., lack of specialist trauma services, conflict of interest between voluntary and statutory agencies, lack of integration among agencies).
• For some, the transition from military to civilian life includes a number of social and environmental problems in terms of employment, housing, finance, support for partners, and social exclusion

7.2 The following key findings emerged from the review of eminence- and evidence-based literature.

• Overall, the evidence suggests that military life is beneficial for the majority who serve and that their transition to civilian life is successful. However, there is a significant minority who fare badly, particularly Early Service Leavers (i.e., those who have completed fewer than four years of Service) and those who have served time at the Military Correctional Training Centre (MCTC) prior to discharge. Both of these groups are more likely to have had a previous history of childhood anti-social behaviour than their Serving counterparts.
• Military personnel with mental health problems are more likely to leave Service early and have an increased risk of ongoing social exclusion and ongoing ill-health.
• Pre-enlistment factors known to affect the risk of adverse health and wellbeing outcomes include: childhood traumatic experiences; socio-economic adversity; previous psychiatric history; personality, and coping style.
• Single males, of lower rank, with lower educational status and who have served in the Army are most likely to have experienced these adverse vulnerability factors in childhood. To what extent, however, this association would be significantly different from a similar age-matched group in the general population has yet to be established. Moreover, it is not known to what extent these findings would generalise to women.
• Recent KCMHR studies of Veterans report a prevalence rate of 4% for "probable" PTSD, 19.7% for symptoms of common mental health problems and 13% for alcohol misuse.
• Reports from the charitable sector suggest that presentation with combat-related mental health problems can be as long as 14 years post-discharge. There is however no evidence to suggest that ex-Service personnel are no more or less likely to seek help than people who have never served.
• Compared with their Regular counterparts, Reserve UK Armed Forces personnel (particularly medical reservists) have an increased risk of experiencing mental health problems as a consequence of deployment to Iraq and Afghanistan. However, the evidence suggests that this finding is more likely due to family issues prior to deployment, support to families during deployment, and experiences of home-coming than events in theatre.
• Relative to the general population, both serving and ex-Service personnel report higher levels of alcohol consumption (but only in younger age groups). Alcohol misuse has also been identified as a problem affecting Service women.
• The overall rate of suicide is no greater among UK ex-Service personnel than in the general population. However, for men aged 24 years and less who have left the UK Armed Forces the risk of suicide is approximately two to three times higher than that of the same age group in both the general and serving populations.

7.3 The following key research gaps in the evidence were identified.

• Whilst a considerable body of literature exists on the health and wellbeing outcomes in respect of serving military personnel, few studies are specifically dedicated to those who have left the UK Armed Forces.
• Most of the literature relating to ex-Service personnel in this domain derives from the US. The extent to which the findings from such studies are generalisable to ex-Service personnel in the UK is limited.
• To inform service provision and the development of appropriate interventions it is imperative to establish the extent to which the Veteran population differ from those in the general population. Whilst there have been two studies in the UK that have adopted this approach, one in England (Woodhead et al, 2010), and one in Wales (Wood et al, in press), comparisons between the two are limited due to variations in the design, sampling strategies, and method of diagnostic assessments used.
• There is a paucity of robust epidemiological data about the health and wellbeing, views, expectations, and needs of ex-Service personnel and their families in Scotland, and how these compare with the general population. The current evidence-base is therefore not sufficient to design specific health strategies or develop new services-within or outside the conventional health care system-particularly in order to reach non-treatment seeking ex-Service personnel who suffer from mental health problems and are at risk of social exclusion.
• Although the number of Service women has gradually increased in line with the implementation of equal opportunities policies by the MoD, there is a paucity of research about their specific health and wellbeing needs, particularly post-Service.
• Given the evidence that military service has a positive impact for the majority of UK Armed Forces personnel, it is necessary to understand what factors facilitate and enable those with the same vulnerabilities to fare well by using appropriate comparison groups. Such an approach would enable the UK Armed Forces to identify what could be done to improve the life chances of young people with pre-enlistment vulnerabilities in preparation for leaving military service.
• Although evidence suggests a link between areas of high social deprivation and offending behaviour, it is not known for example whether recruitment into the UK Armed Forces from such areas has a positive or negative impact on the risk of subsequent offending and incarceration of those particular recruits on leaving military service and to what extent there is regional variation.
• Relatively little is known about the health and wellbeing outcomes in the longer term for ex-Service personnel due to the paucity of large prospective longitudinal studies. Well-designed cohort studies offer a number of advantages in respect of identifying the longer term implications of military service.
• Given the increasing numbers of injured combat troops returning from Iraq and Afghanistan with complex trauma injuries there is a particular need for research to understand the longitudinal course of post-traumatic reactions and to assess the factors which may affect psychosocial adjustment. The post-acute clinical management of such cases in rehabilitation and primary care settings has not been adequately addressed in the literature.
• Very little is known about the impact of military and ex-Service life on partners and families.
• An increase in the deployment of reservists in the UK Armed Forces and concerns about poorer health outcomes following deployment highlights the need for a greater understanding of the impact of the additional challenges facing families of Reservists compared to the family members of Regular personnel.
• There remain gaps in the evidence with regards to determining the effectiveness of health and welfare interventions including establishing whether recommended treatments (e.g., for PTSD) are best delivered in specialist Veterans' mental health facilities or in the mainstream NHS (Fossey, 2010).

7.4 The outcome of the review confirmed the need to undertake a population-based survey in order to inform the national commitment to meeting the health and wellbeing needs of ex-Service personnel and their families in Scotland.

8. The following design and funding recommendations were made.

• Possible options for the design of a population based survey to inform policy development in meeting the health and wellbeing needs of ex-Service personnel and their families in Scotland need to take into consideration the following challenges.
  • Identification and tracking of Scottish Veterans and their families to permit a representative sampling frame and strategy.
  • Adequate sample size(s) to ensure sufficient power to detect statistically significant differences thereby maximising the generalisability of findings.
  • Recruitment and retention mechanisms to maximise compliance rates and minimise loss at follow-up thereby enhancing the representativeness of the sample(s).
  • Reliable and valid assessments.
  • Identification of index and comparison groups against which different sub-samples of the Veteran population (e.g., those who are at risk of social exclusion) could be meaningfully contrasted.
  • Data protection and ethical requirements (including identifying mechanisms to ensure the safety of research personnel involved in the recruitment and assessment of participants).
  • Costing requirements associated with possible approaches according to:
    • a realistic and feasible timeframe, and
    • a realistic estimation of the resources required (i.e., research personnel, travel, subsistence, equipment, consumables, consultancy, data entry and analysis).
• The design should be ambitious in terms of sample size to allow for detailed sub-group analysis and to take into account the potential effects of attrition due to the nature of the target population.
• Commitment should be sought for funding for at least 3 years but preferably longer to ensure that the long term value of the resource is fully realised.
• A mixed methods approach should be used to allow for the in-depth understanding of key issues (e.g., barriers to help seeking).
• The design must be founded on the rigorous application of population-based research methods to:
  • assess a broad range of health and wellbeing needs;
  • accurately identify those individuals who require health and social care services;
  • reliably evaluate the use and perceived effectiveness of health and social support and clinical care currently available, and
  • identify factors conducive to recovery, wellbeing, and psychosocial adjustment.
• Given the likely scale of a population-based survey in Scotland and the range of interests it is likely to serve, a form of collaborative funding is recommended.