Veterans' health and wellbeing: a distinctive Scottish approach

Chapter 1: A Distinctive Scottish Approach to Veterans’ Health

This chapter covers a range of issues that relate to the delivery of health and social care to veterans and considers how the current system might be strengthened or adapted to improve outcomes for all in this community. It includes discussion about the commitments made in the Armed Forces Covenant (the ‘Covenant’) and the Scottish Government’s Renewing Our Commitments strategy, priority treatment, funding arrangements and the structure of current services.

The fact is that the provision of healthcare for veterans in Scotland has always contrasted with other parts of the UK, just as for the wider population. Different structures, funding arrangements, governance and, in some cases, delivery models have led to a national health service which varies from those found in England, Northern Ireland and Wales. For veterans this also extends to the specialist care that is provided for those with serious and life-changing injuries or illnesses that have resulted from their military service. These bespoke services, some of which were set up in response to a series of reports by Dr Andrew Murrison MP, provide a level of support which goes beyond that typically offered by NHS Scotland ( NHS(S)) and local Councils. They are also recognised by Lord Ashcroft in his various reports about veterans and fulfil a significant part of the promises laid out in the Covenant and in Renewing Our Commitments.

The combination of mainstream and specialist services has established a robust package of support that meets the needs of most veterans. This has been particularly so for the thankfully small number of those whose military careers have left them with the most severe and debilitating conditions. The impressive work at the start of this decade in establishing ‘specialist’ physical and mental health services in Scotland has had a significant impact over subsequent years and has rightly attracted considerable attention and praise. We still see the benefits of this today.

However, despite there still being a significant number of men and women in our communities who struggle with Service-related injuries and conditions, it is obvious that the levels of ambition and innovation which characterised this work have waned in recent years. This may be understandable given the pressures on the health system, but it is also disappointing that the health of veterans no longer attracts the same level of attention it once did. Discussions with senior decision-makers indicate a strong desire to check this trend, rekindle the spark that set up the current structures and invest in future long-term planning. This is encouraging.

Having examined the provision of healthcare over many months, it has become apparent to me that there is merit in now adopting a distinct strategic approach that ensures veterans’ health sits squarely at the heart of current and future models of service provision in Scotland. Furthermore, this approach should aim to present a realistic and practical means of embedding the specific needs of veterans within mainstream services, ensuring current specialist care is protected and improving planning for long-term support.

Of course, veterans’ issues do not sit in isolation within Scotland’s healthcare system. The fast-paced, transformational nature of this landscape can be expected to have a significant impact in the years ahead and it will be crucial that veterans are part of, and benefit from, recent Scottish Government and NHS(S) policies in this field. Of these, I recognise the importance of the integration of health and social care services, an increasing role for allied health professionals within Primary Care settings, the Chief Medical Officer’s proposals for Realistic Medicine and national strategies covering healthcare quality and mental health. Each has had considerable influence on this report and informed many of my recommendations.

In order to maximise the opportunities presented by these initiatives the following sections set out my thinking on what a new approach should seek to achieve and go on to discuss some of the key factors relevant to making it a reality.

Rethinking Priority Treatment

Before exploring some of the ideas behind this approach, I believe it important to address the prominent subject of ‘priority treatment’ for veterans from the outset. This was first introduced in the 1950s, is currently a significant feature of the Covenant and continues to be the most controversial and contested issue in terms of providing healthcare for this community. Its central premise is that veterans should receive early treatment for health problems that have resulted from military service, unless there is an emergency or another case that demands clinical priority. This is laudable, but as stated in my previous paper, the concept is flawed, often misunderstood and occasionally ignored by a number of health professionals and veterans – whether unwittingly or, in some cases, quite deliberately.

These views have been emboldened in recent months by feedback received from many individuals and organisations. This has reinforced the fundamental point that care within the NHS is based on clinical need and not on the background, occupation or category of a patient. As a consequence, the promise of priority treatment for veterans is a largely meaningless concept that rarely has any direct impact on individuals. Like many, I also have a growing conviction that an emphasis on waiting time lists, while never irrelevant, is no longer as important as it used to be. Instead, I sense an increasing demand – certainly in NHS(S) – for greater focus on the principles of excellence, accessibility and sustainable treatment for all veterans.

Frankly, the current confusion about what priority treatment means and its impact serves nobody well, especially if it results in unrealistic expectations which cannot be matched. It is clear to me that the time is right for a fresh and bolder vision, which will be especially important for those with the most severe and enduring injuries and conditions.

But in suggesting any alternative, I recognise there is a great deal of political and public support for these veterans receiving ‘special’ treatment and I am determined there must be no hint of any reduction in the level of support that has been hard-won over many years. Notwithstanding, there is a definite need for greater clarity about what veterans can expect from the health and social care system.

Addressing this aspect of treatment and care is, however, only the start. I am convinced that those in charge of healthcare in Scotland should go even further by taking a refreshed approach to all aspects of veterans’ health. Recent transformational changes in the sector – more on which later – and a growing appetite for adapting to changing needs, offer a unique opportunity to develop a more innovative, focused and relevant approach to veterans’ healthcare. Within this, priority treatment will be just one aspect.

Principles of a Scottish Approach to Veterans’ Health

It is with this in mind – together with the need to refocus efforts within the Scottish Government, NHS(S), Health Boards and local Councils – that I am proposing a distinct Scottish Approach to Veterans’ Health. This needs to provide the impetus and framework that protects and enhances Scotland’s reputation for supporting its veterans while ensuring we place particular emphasis on those coping with the most severe and enduring conditions. It should also seek to promote the wider ex-Service community as a unique cohort whose health and wellbeing can benefit from the changes currently being seen across the health and social care sector in Scotland.

In particular, the unambiguous focus and priority placed on the small group of veterans with the most serious and life-changing conditions will send the strongest possible message of compassion and appreciation from Scotland’s citizens. These are, after all, the people who have made the greatest sacrifices, suffered the most challenging consequences and are, therefore, in need of specialist and sustained support. Even more important than the message it sends, the prioritisation and long-term commitment to this group will provide the clarity and reassurance that their medical and social care needs will be met properly, now and in the future.

As a first step to establishing this fresh approach, it will be important that the Scottish Government, NHS(S) and their partners can agree a set of principles to provide strategic direction and guidance for those individuals and organisations responsible for planning and delivering day-to-day support. Many ideas have emerged during the past few months since the publication of my initial paper. The following set of proposed principles reflect the key priorities of the many health professionals, veterans, charities and officials that I have engaged with over that time.

Guiding Principles

Generally…

• Veterans, like the rest of the Scottish population, have the right to the highest possible standards of health and live longer, healthier lives.

• Veterans never suffer disadvantage and instead benefit from efforts to reduce health inequalities caused or m exacerbated by military service.

• Veterans’ specific characteristics and needs are recognised and well understood, shaping the design and delivery of their health and social care.

Exceptionally…

• Individuals with severe and enduring conditions caused by military service are the most important and deserving group within the veterans community and are the focus of efforts and resources.

• The treatment and care for these veterans is based on the best possible mainstream and specialist services, both in the statutory and third sectors, that is available no matter their circumstances or where they live.

• These veterans can be confident that this support – across the health and social care sector – is available whenever required and for the rest of their lives.

These principles are not intended to be either prescriptive or exhaustive. The Scottish Government and NHS(S) may wish to adapt or add to them now and in the future but I believe that in their current form, they offer a coherent and ambitious framework that will help raise the profile of veterans while ensuring they get the support they need and deserve. They also offer the chance for those in positions of leadership to make a public commitment to support our ex-Service community and satisfy their health needs over the long term.

Recommendation 1 – A Distinctive Scottish Approach to Veterans’ Health

The Scottish Government and NHS(S) should commit to establishing a distinctive Scottish Approach to Veterans’ Health at a strategic level, accept or adapt the guiding principles of this approach and work with their partners to embed it at an operational level.