Veterans' health and wellbeing: are we getting it right?

Background

The four fundamental questions outlined in the introduction (and repeated below) are largely drawn from a commitment already made to the armed forces community in the Armed Forces Covenant.

• Are the needs of our veterans population properly understood and considered by those who work in health and social care?
• Do veterans face any disadvantages when accessing health and social care provision?
• Does the health system properly fulfil our obligations to those veterans with the most severe and enduring illnesses and injuries acquired as a result of their military service?
• Are the health outcomes of our veterans population as good as they can be?

My hope is that these questions will help me assess whether we are successfully fulfilling the promises that have been made, as well as how we might better improve health outcomes for a community that makes up nearly 5% of Scotland's population.

The Covenant and its Commitments

What is the Armed Forces Covenant?

At the height of the war in Afghanistan the UK Government published the Armed Forces Covenant – a promise from the nation and the government to its Service personnel, veterans and their families that they will be treated fairly and with respect. At its heart is the principle that the armed forces community should experience no disadvantage when accessing public and commercial services. The Covenant highlights that special consideration is appropriate in a minority of cases, quoting the injured and the bereaved as examples of this. It also makes provision for 'priority NHS treatment' for both serving personnel and veterans.

How is it implemented in Scotland?

The Scottish Government subsequently published a complementary strategy called 'Our Commitments' (2012) – recently updated in 'Renewing Our Commitments' (2016). Both documents set out the Government's priorities and pledges to ensure that the armed forces and veterans community is properly supported and their contributions recognised. This includes commitments about meeting the community's specific health and social care needs, including a commitment to 'priority NHS treatment'.

What does it mean?

Our armed forces personnel defend our nation on behalf of government and its citizens, sacrificing civilian freedoms and putting themselves in danger to do so. The Covenant and Renewing Our Commitments, and the promises contained within, are significant expressions of both the UK and Scottish governments' recognition of the sacrifices made by service personnel and the sometimes high levels of risk they have to counter. This is exactly as it should be.

A Changing Landscape

A lot has changed in Scotland since the Covenant and Our Commitments were published. In the areas of health and wellbeing, the most significant impact is the start of transformational change in NHS Scotland, namely the integration of health and social care and the establishment of local Integrated Joint Boards.

We have also seen the publication of several key strategies, such as the Healthcare Quality ^[2] and Mental Health ^[3] strategies that will have a direct and lasting impact on the way the veterans community is treated and cared for. These recent changes offer a timely opportunity to rethink and renew our commitments to veterans regarding their health and social care provision.

In many ways, the most important change in Scotland has come about as a result of the end of combat operations in Iraq and Afghanistan. As with previous conflicts, the public and media interest in the plight of those who made personal sacrifices has faded with the memories of war. This may be understandable. It is also frustrating to those with enduring physical, mental and social care needs whose suffering can be directly attributed to these wars.

For some time now I have sensed the need for a review of how we fulfil the pledges of the Covenant made to the men and women who defend our nation, sacrificing civilian freedoms and regularly putting themselves in danger to do so. The promises made must never be allowed to be forgotten, ignored or diluted.

The Ex-forces Community

There are approximately 230,000 veterans in Scotland today, living in our largest cities, areas close to military bases and in the most rural and remote parts of our country. They range in age from 17 to 90+ and come from all social backgrounds, with those over 75 more than likely to have completed mandatory National Service.

Some will have served for up to forty years. Many more will have spent only a few years in uniform before returning to civilian life, while others will have even shorter service of only a few weeks or months. Very few of these veterans will be that different from the rest of the population. However, their experiences, attitudes and the consequences of their service often set them apart and may have a marked influence in later life.

Despite the public misconceptions on the topic ^[4] , veterans' health is largely comparable to that of the general public. Even with regards to mental health, the assumption often made that veterans are disproportionately at risk of ill mental health is not supported by the evidence.

However, it is also important to understand that for those experiencing health issues, their needs can be different from those of the general population or they can be more at risk of certain issues as a result of their service history. In particular, there are a number of distinct groups within the veteran community who have specific requirements or are at higher risk of ill health.

Health and Social Care Needs of Veterans

The Covenant makes explicit mention of those severely injured in Service and the moral duty to meet their often complex and unique needs. This also applies to veterans who suffer from severe mental health conditions which have been caused, triggered or exacerbated by their service experience. In addition, some carers and the bereaved can face mental health issues, social isolation or loneliness as a result of the sacrifices made by their loved ones. The treatment, care and support of all these individuals should always be our top priority.

That being said, there are two groups within the community as a whole who are particularly at risk of poorer health outcomes.

Early Service Leavers are those who leave the armed services within four years of signing up, sometimes before completing training. It is generally well documented that they are the most vulnerable to ill health. ^[5]

The older generation of veterans, which includes many who did National Service, accounts for nearly half of Scotland's veterans population. They are at increased risk of a number of health issues, when compared to non-veterans of the same age and background. Due to age, this is a group where common health concerns like hearing-loss, musculoskeletal issues, and diseases related to lifestyle factors, like smoking and alcohol consumption, can become more severe. ^[5]

This group is also at risk of greater social isolation and loneliness. I have spoken to many older veterans and have become increasingly aware of just how challenging some of these social issues can be.

Although at no higher risk, veterans settled in remote or rural parts of Scotland will often face challenges in accessing health and social care services. This issue has yet to be sufficiently addressed.

Protect What We Have and Prepare for the Future

The strong sense I get as a result of my engagement is that the overwhelming majority of veterans lead healthy, happy and productive lives. They are able to access the services they need and rarely report examples of coming up against disadvantage.

On the whole, they accept that health resources are finite and that tough decisions have to be made by politicians and officials alike. But I am also aware that many feel frustrated by a lack of clarity regarding the levels of treatment and support they can expect. This view is shared by many within the health sector.

There are a small number of veterans who are known to suffer from severe and enduring physical and psychological conditions that are attributable to their military service. Many – especially those wounded in recent wars – report good care and general treatment but they worry about its sustainability over a lifetime of need. There is also growing concern about the long-term provision of specialist services, especially in view of the diminishing public and media interest since the end of recent conflicts. This is particularly acute for those with mental health conditions which emerge many years after military service.

It is already clear to me that we need to acknowledge the quality of the services we have, protect them and prepare for future challenges in order to live up to the promises made by the Scottish Government.