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

The Issues

In order to start answering my initial questions, I have considered how Scotland is currently fulfilling the promises made to veterans. Does the concept of priority treatment respond to the specific medical and social care needs of individuals and groups within our ex-Service community?

The 'Promise'

The promises contained in both the Covenant and the Scottish Government's complementary strategies are of huge importance to veterans and their families. I am pleased to say that the dedication and attitude of the health and social care sectors to those who have served very much upholds these commitments.

Here in Scotland, early responses to the Covenant allowed veterans to benefit from access to a number of specialised services over and above what might otherwise have been typically provided by the NHS. Examples include the dedicated prosthetics clinics in Glasgow and Edinburgh, the network of Veterans First Point (V1P) centres across Scotland and the residential mental health treatment at Combat Stress' Hollybush House.

These and other initiatives go a good way to fulfilling our obligations to those veterans with the most severe and enduring illnesses and injuries, allowing them to access specialist and bespoke services. It is reassuring to have heard very few complaints about the quality or timeliness of this support over the past three years.

The Scottish Government has also introduced a number of measures to facilitate the transition into civilian life and to ensure that the long-term clinical needs of Service personnel and veterans are better understood and supported within the NHS. This positive and dynamic response to the Covenant has rightly attracted considerable recognition from across the UK.

Feedback received from all parts of the veterans community has typically been very complimentary about the dedication, resilience and professionalism of a National Health Service that faces considerable challenges. I would reiterate my view that veterans as a whole face no disadvantage when accessing health and social care services in Scotland.

That said, I am beginning to detect one or two concerns, and some criticism, that Scotland may be in danger of damaging its well-deserved reputation for being at the forefront of treating and caring for veterans. Although such views may be a little premature, this is a good time to re-examine our fundamental approach to the way we care for those who have served.

Rethinking Priority Treatment

NHS priority treatment (or care) for veterans, mentioned in the Covenant, dates back to 1953 and was originally restricted to war pensioners. Today, the idea is that veterans should receive priority treatment for health problems resulting from military Service, unless there is an emergency case or another case that demands clinical priority.

This is a particularly tricky concept which elicits some notably divergent and contentious views. For some, it is seen as an important benchmark that demonstrates the Government's commitment to the health of its veterans. At the other end of the spectrum, some regard it as little more than an abstract statement where the requirement to prove 'clinical priority' means veterans are treated no differently from anyone else by the NHS.

What has become apparent, though, is the serious lack of understanding about what it should deliver. This is despite concerted effort by both NHS Scotland and England to clarify the caveat of clinical need.

I am aware of a minority of individuals who understand the notion of priority care as an entitlement that provides veterans with preferential or faster treatment without regard to their individual clinical needs. This, in my view, is neither within the spirit of the Covenant, nor is it supported by the majority of those I meet. I accept there are occasional grumbles about delays in seeing consultants or other health professionals. But, this is not unique to veterans and often appears to be the result of limited capacity within the local health system.

This early work has led me to believe that the concept of priority treatment, as currently set out, is becoming out-dated and is certainly misunderstood or ignored by large sections of the military, veterans and medical professionals - as well as the general public. It may be that it has served its original purpose and the time is right for an honest appraisal of how effective and relevant it is today, especially now that NHS quality standards have tailored waiting times for everyone to their clinical need.

I have come to the conclusion that we could all benefit from a much clearer understanding of the concept, an open debate about its relevance, and an exchange of ideas about how it might be improved.

Supporting Those With Severe And Enduring Conditions

Veterans are a diverse sub-section of society. Those with severe and enduring health issues acquired as a result of their military service – often colloquially known as the 'Wounded, Injured and Sick' – is one group that stands out starkly. Their lives have been permanently affected by injury or illness, sometimes as a result of enemy action but just as often caused by peacetime accidents.

The overall number of men and women who are affected is thankfully small but they have sacrificed the most. In accordance with the Covenant, they deserve the best possible medical and social care – both now and over the long-term.

This group will be the focus of a subsequent report. Amongst other issues, I will review the sustainability of the impressive bespoke care currently available to those with prosthetics, severe mobility issues, and mental health conditions. I am also keen to explore the opportunities offered by the current integration of health and social care, a growing emphasis on a more holistic approach to care, and the greater role that can be played by allied health professionals in improving the overall quality of life and wellbeing.

I do not anticipate that protecting the best of the current specialist services requires a large investment of new resource. I do, though, think it is crucial to ensure that this provision is protected in the medium to long-term and that the evolving needs of this group of veterans is part of a strategic plan.

The good news is that initiatives like these feature heavily in the Scottish Government's Healthcare Quality Strategy and are already being discussed and implemented for the wider population as a result of its consultation on Creating a Healthier Scotland. The trick may be to ensure that the care regime for this very specific group of veterans becomes an integral and enduring, if small, part of the overall health system in Scotland.

Finally, I want to highlight the plight of the families of those affected by Service-related injuries or illnesses as well as the bereaved who have lost loved ones. Caring for someone with a disability, growing up around a parent who cannot work or losing a loved one is a heavy and far-reaching sacrifice, which creates many and often invisible challenges. Here, too, it is important that their personal sacrifices are recognised and that they always have access to support which is tailored to their needs.

I strongly believe that providing these groups with the best possible treatment and support should be the focus of our efforts and our strategic priority.

Improving Outcomes For All

Having rightly focused on those veterans with severe and enduring conditions, I am also determined not to lose sight of the health and social care needs of the wider ex-Service population. In a separate report, I will explore some of the bigger challenges they face but I already sense there is more that can be done to improve their overall health and wellbeing.

While the types of illnesses affecting veterans may vary in severity, very few are likely to be unique to this group and it may be difficult to prove any sort of direct and unambiguous connection with military service. That said, recent studies have gone some way in identifying a number of conditions that are more prevalent amongst veterans than their
non-veteran counterparts. These include:

• hearing loss - from regular exposure to extreme noise,
• musculoskeletal problems, such as arthritis - after a physically demanding career, and
• alcohol and smoking-related diseases - often linked to cultural lifestyle factors such as access to cheap cigarettes and smoking and drinking in the mess decks or barracks.

Such work has significant potential in helping the medical profession identify, prevent and provide early treatment which will, ultimately, be of lasting benefit to veterans and their families. It will also be in keeping with the broader approach of NHS Scotland with its emphasis on patient-centred, holistic care. I am looking forward to exploring this further as part of the next phase of my work.

There are other aspects of treatment and support for the wider veterans community that have been suggested for further study. One example, which has been raised repeatedly by researchers and veterans alike, is the particular challenges faced by certain demographic groups. This includes Early Service Leavers, the older generation of veterans and those who live in remote or rural areas. I believe a better understanding of these groups – and of a life in the Armed Forces – would be of significant benefit to GPs, Practice Nurses and other professionals when managing the overall health of veterans in their communities. This is already recognised in some geographical areas but I sense there is scope to share good practice more widely and to further encourage health professionals to consider veterans as a distinct group with particular vulnerabilities.

Given that there is wide acceptance in Scotland that better education, screening and early intervention will invariably lead to improved health outcomes, it seems entirely logical that this should be applied to our veterans community with its own characteristics and needs.

The next phase of this study will also provide the opportunity to examine whether the right structures and processes are in place to ensure veterans can access health and social care services as easily as possible. An example of this includes the procedure for registering at a GP practice upon leaving the Services. On first examination, this should be a relatively straightforward step but a minority of mostly younger veterans fail to follow it and rely instead on A&E or walk-in clinics with its consequent inefficiencies and costs. Regrettably, those who fail to enrol are often amongst the most vulnerable and this puts them at an obvious and considerable disadvantage.

Similarly, veterans and medical professionals continue to report complications and delays when trying to obtain patient records. This seemingly simple procedure is proving especially hard to resolve despite sustained efforts to give the NHS – and GPs – full and seamless access to veterans' medical records. The introduction of new IT equipment and data sharing issues compound a problem which causes serious frustration for many. A solution needs to be found without further delay and I will be keen to hear ideas as to how this problem might be addressed.

Finally under this section, I intend to examine the governance arrangements within the Scottish Government and NHS Scotland as they relate to veterans, and their ability to work collaboratively with the third sector. Both aspects will be vital for the long-term future of veterans health and wellbeing. The good news is that there is already a national policy framework in Scotland to facilitate much of this; the challenge may be to integrate veterans health as part of the wider NHS without diminishing or overlooking their specific nature and needs.