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

SECTION 1: Introduction

1.1 Background to the scoping review

• Civilian authorities and service providers have the responsibility for meeting the needs and aspirations of Veterans and their families who currently reside in Scotland.
• 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 within the remit of the Mental Health Division of the Directorate of Primary & Community Care and the Social Inclusion Division.
• In a concerted endeavour to meet this responsibility, the Scottish Government has instigated a variety of initiatives designed to support Veterans in recognition of the fact that Scotland owes a debt to its service personnel and 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 UK Armed Forces, their Families and Veterans" (17 July 2008), set out its commitment to assist Service personnel and Veterans across Scotland. These included the launch of a new dedicated fund, the Scottish Veteran Fund, which marked for the first time direct investment from the Scottish Government in Veteran service provision and was designed to run as a complementary programme to the MoD administered Veteran's Challenge Fund. In addition, NHS priority treatment was extended to all Veterans (CEL 8, 2008), and the Scottish Government invested £930,000 in a pilot scheme dedicated to a community-based, one-stop-shop for Veterans' mental healthcare in an endeavour to provide them with effective support and comprising a partnership involving the NHS, Combat Stress, Veterans' organisations and others to deliver alternative approaches to care.

1.2 Terms of reference

• Following a meeting at St Andrew's House (Scottish Government, Edinburgh) on 11 February 2009, Mr Geoff Huggins (Head of Mental Health, Directorate of Primary & Community Care, Scottish Government) commissioned the Aberdeen Centre for Trauma Research (ACTR, Robert Gordon University) to undertake a 6-week Scoping Review in collaboration with Wing Commander Walter Busuttil (Director of Medical Services, Combat Stress).
• In accordance with the grant conditions set out in Annex A of the Letter of Award from Mr Huggins (dated 24 April 2009), it was agreed that the grant not exceeding the sum of £13,215 for the purpose of a 6-week Scoping Review to examine the issues and possible methodological approaches to conducting a robustly designed population based survey of Scottish Veterans and their families. Based on an estimated start date of 4 May 2009, the expected outcomes were agreed as follows.
  • To use the data derived from the methods and work plan set out in the original proposal to define possible methodological approaches to conducting a robustly designed population based survey; including identification of cost requirements associated with the possible approaches.
  • To present the outcomes within agreed timescales to a core group of Scottish Trauma experts; and the Scottish Government, to inform next steps.
• This report presents the findings of that scoping review, the key aspects of which were presented to the Core Group of Scottish Trauma Experts on 17 June 2009 at St Andrews House (Scottish Government, Edinburgh). In addition, it provides a wide ranging examination of the policy context and how initiatives for meeting the health and wellbeing needs of ex-Service personnel and their families have developed along side key government themes and policy drivers. In acknowledgement of the breadth of the remit, the length of the review has been substantially extended and updated to provide a contemporary evaluation as a basis on which to move the agenda forward.

1.2.1 Aim

• The principal aim of this scoping review was to identify to what extent a population-based survey is required to inform the national commitment to meeting the health and wellbeing^[1] needs of ex-Service personnel and their families in Scotland.

1.2.2 Objectives

• In furtherance of this principal aim, 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.

1.2.3 Parameters of the Scoping Review

• For the purpose of the scoping review, a holistic definition of health was used according to the World Health Organisation (WHO)^[2]:
  "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".
• The most inclusive definition of the term "Veteran" has been used in line with MoD and UK Government policy and strategy. Unless otherwise specified, all references to "Veteran(s)" refers to all military personnel who have served more than one day (together with widows/ widowers and their dependents) in the UK Armed Forces (both Regular and Reserve personnel).
• For the purpose of this report, the term "UK Armed Forces community" includes:
  • Service personnel (i.e. current serving members of the UK Armed Forces - including the UK Reserve Forces);
  • Ex-Service personnel/ Veterans (i.e. former members of the UK Armed Forces), and
  • Families (i.e. the immediate family members of either Service or ex-Service personnel/ Veterans)

1.2.4 Methodological Framework and Analytic Strategy

• The methodological framework for this scoping review derived from that suggested by Arksey & O'Malley (2005). As such, the methods used throughout the different stages were conducted in accordance with the views upheld by proponents of systematic reviews (Mays et al, 2001), although it should be noted that a scoping study is by definition a non-systematic review of the literature (Anderson et al, 2008a). The rationale for choosing this method was 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. The work was subdivided into three inter-related phases based on what was deemed to be achievable within the short time-frame and budgetary constraints of this scoping review. The activities assigned to each phase are described below.
• Phase I: compilation of a database

This involved desk-based research to compile a database comprising the following three elements:

(i) policy mapping - to identify key papers that have shaped the policy context within which the Veteran care initiative has been developed.

(ii) conceptual mapping - to establish how particular terms are used in what context, by whom, and for what purpose given that it is recognised as an important element within broader literature mapping exercises (Anderson et al, 2008a).

(iii) literature mapping - to identify gaps in the emergent evidence base by conducting a selective and critical analysis of seminal studies and relevant reviews, which derive predominantly from the UK.

• Phase II: consultation process

This comprised both telephone and face-to-face interviews^[3] with a range of individuals within policy, practice, and academia. Their views and recommendations were specifically sought in order to provide: (i) valuable insights about key issues that may not be apparent from the literature, (ii) additional references to include in the review, and (iii) additional themes to inform the search process. The importance of consulting with key stakeholders is well recognised (Oliver, 2001) as are the techniques for doing so (Anderson et al, 2008a).

• Phase III: synthesis of data

This was dedicated to synthesising the data derived from Phases I and II in order to address the five specific objectives detailed above.

1.3 Format of the report

• The remainder of this report comprises the following broad outline.
  • Section 2 is dedicated to understanding the context (both historical and contemporary) 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.
  • Section 3 provides an overview of the current status of health and welfare support provision for the UK Armed Forces community in terms of its organisation and delivery.
  • Section 4 summarises the views of those key informants who participated in the consultation process.
  • Section 5 presents the outcome of the desk-based research undertaken in Phase I of the review, which comprises a critical and selective analysis of three main sources of data in order to: (i) 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.
  • Section 6 concludes by summarising the key evidence that has emerged from the scoping review and considers the case for undertaking a methodologically robust needs-based assessment and population-based survey of Veterans and their families in Scotland. In so doing, the extent to which similar studies conducted elsewhere might offer a valid blueprint for such a study is explored and potential models of funding and delivery are also addressed.