Veterans' health and wellbeing: a distinctive Scottish approach

Chapter 4: Physical Health

“After the guns have fallen silent, and the din of battle quietened, the real fight begins” – Prince Harry

The image of a wounded veteran is the most stark reminder possible that the men and women of the UK Armed Forces, both regulars and reserves, are often called on to put themselves in harm’s way on our behalf. Some end up paying a heavy price and it is only right that our health and social care system provides the best possible treatment and support for these individuals for the rest of their lives. More widely, it should be recognised that a career in the Armed Forces is nearly always physically demanding, often dangerous and can put a severe strain on the human body.

Combat operations obviously expose individuals to a significant risk of death or being seriously wounded. There are, however, those who suffer life-changing injuries and chronic conditions due to the physical nature of their job or as the result of training or other accidents experienced in military service. All will have to live with severe and enduring conditions for many years, and may need – and deserve – specialist treatment and care over and above that typically provided by NHS(S) and local Councils.

In this chapter I explore some of the most challenging physical conditions that veterans may experience. Most injuries will be obvious and demand immediate treatment although some may not present for many years. Others will change over time as physical demands and age take their toll.

I should stress that what follows is by no means an exhaustive list. Rather, it reflects the priorities and concerns expressed by veterans, their families and members of the health and social care professions. My aim is to highlight some of the good practices already in place and to identify improvements that will help protect and enhance the care Scotland provides to its veterans community. Ultimately we want all veterans, especially the most seriously injured, to have the care that allows them to look forward to enjoyable and productive lives after time spent in the Armed Forces.

Protect and Prepare – The Challenges To Be Faced

Two of the principles of the Scottish Approach to Veterans’ Health are, firstly, to protect vital specialist services currently required by veterans with severe and enduring conditions, and secondly, to plan for their long term care. In my time as Commissioner, I have consistently heard concerns expressed by veterans, charities and other organisations that the first-rate medical treatment provided will not always continue for the long-term. This is a fear of many coping with life-changing injuries who worry that their needs will not be properly met as they get older and struggle with a number of related conditions.

The good news is that Scotland’s overall approach to looking after our veterans, the broad support provided across all sectors and recent changes in healthcare – especially the integration of health and social care services – provide a solid foundation on which to address many of these concerns.

However, in order to make a real difference and provide reassurance to veterans, effective planning and a sustained commitment of public resources will be critically important as their needs change over time. The entire health and social care system will require to be well informed, co-ordinated and responsive if these individuals are to be properly supported. I cannot stress too highly that as the impact of the injuries sustained will be with them for the rest of their lives, so must the care and support.

An example of needs changing over time comes from Andy McIntosh, who served as an Army Corporal for 15 years in Bosnia, Northern Ireland and the Falklands. Whilst at work in 2008, a persistent kidney pain worsened and he collapsed. He was taken to hospital and it was discovered that he had very serious vascular problems stemming from his time in uniform.

Andy McIntosh – SSAFA Lanarkshire Branch Secretary

“I had been in excruciating pain but had just put it down to a chronic kidney infection. It was difficult to believe that I’d been suffering such serious injury. The medics traced it back to the trauma of an explosion in Northern Ireland. Even though I had walked away relatively fine at the time, I was now experiencing the aftermath.”

I am encouraged that the Scottish Government already recognises the need for this longer-term planning. Its 2016 strategy Renewing Our Commitments states, “looking ahead, we want to ensure that long-term clinical needs of Service personnel and veterans are better understood and supported…”. This is an important statement and an ambition that I hope this report can help deliver.

Recommendation 8 – Access to Life-long Services

The Scottish Government, NHS(S), Health Boards and local Councils should make a commitment to veterans with the most severe and enduring physical (and mental) conditions that they can access the highest quality health and social care services for life and as their needs change. Health and Social Care Partnerships and Integrated Joint Boards will be instrumental in planning the delivery of these services and the national network recommended in chapter 2 should assume responsibility for oversight of this work as an early priority.

Severe Physical Conditions

What now follows is a consideration of some of the most severe physical conditions and illnesses faced by our veterans, and suggestions for how we can continue to provide the best care and support in the future.

Multiple and complex injuries

It is a fact of modern warfare that survival rates of those who sustain multiple injuries on the battlefield have increased significantly over the past 20 years or so. Better personal protection, rapid transfer to advanced hospitals and enormous improvements in medical treatment now mean that many more men and women make remarkable recoveries from the most horrific wounds. The initial treatment, in theatre and later back home, is the start of a very long recovery pathway that involves Defence Medical Services, NHS and charities. This is often a painful, complex and difficult process for all – including the families of those affected. It is also one that demands the wholehearted and co-ordinated support of many different organisations.

The most common cause of these multiple, severe injuries – typically labeled polytrauma – are the blast effects from Improvised Explosive Devices or Rocket Propelled Grenades. The impact can be devastating on the human body and can result in Traumatic Brain Injury, amputations, burns, internal injuries, hearing/sight loss and spinal cord injuries. Some victims also subsequently suffer from PTSD and other mental illnesses.

Care for the most severely injured puts clinical and financial pressures on statutory services but it is reassuring that these veterans, probably fewer than 150 individuals in Scotland, are typically looked after extremely well. This starts with specialist support at Queen Elizabeth Hospital in Birmingham or the Defence Medical Rehabilitation Centre at Headley Court and eventually involves local Personnel Recovery Centres/Units, NHS specialists and GPs. I have little doubt that this system provides a level of care that is only right and proper.

Edinburgh House Personnel Recovery Centre

Personnel Recovery Centres ( PRCs) are MOD-run facilities for injured Service personnel and veterans undergoing recovery. They provide a range of medical, rehabilitation, welfare and education services that support either a return to duty or a good transition to civilian life.

Edinburgh House is an Army led PRC which is funded by the Royal British Legion and hosted in Erskine’s Edinburgh Home. It was the first PRC to open in 2009 and was originally funded by Help for Heroes before RBL took over in 2011. During a recent visit I saw first-hand the excellent support given to injured Service personnel and veterans.

That said, I am aware that issues over the funding for this support come to the fore fairly regularly. Treatment can be expensive and there have been public disagreements about where costs should fall – whether between NHS Boards in Scotland or with their counterparts in the rest of the UK. This is worrying, but I am hopeful that instructions soon to be issued by NHS(S) will clarify which organisations should pay in disputed cases.

I have already addressed the general topic of funding in chapter two, but I also have a specific concern about how we pay for the complex needs of those affected by polytrauma. It has been suggested that their long-term care could be funded centrally through NHS(S)’s National Services Division as is done for other discrete groups who need expensive, specialist treatment. By doing so it would reduce the financial risk to individual Boards by spreading the costs between them, and would also minimise inequalities for those in need of such support. I believe this idea warrants further investigation.

Recommendation 9 – Funding for Multiple Injuries

The Scottish Government and NHS(S) should give consideration to whether the costs of specialist care for veterans who have suffered polytrauma should be funded through the National Services Division ( NSD).

Finally in this section, I want to highlight current Scottish Government plans to establish a national Trauma Network that aims to deliver “the highest quality of integrated, multi-speciality care” to all severely injured patients. This project is still in its infancy but discussions with several medical professionals and officials point to its potential role in improving the quality of support to our most seriously injured veterans. This will be especially beneficial as they progress through the rehabilitation process.

I should mention that this proposed network is different from the Veterans Trauma Network, recently launched by NHS England, which is intended as an additional layer of support for trauma-recovering veterans and those transitioning from the Services. It is built around 10 trauma centres that bring together veterans and NHS doctors with military experience to offer bespoke care. Given our number of seriously injured veterans, I do not believe there would be sufficient demand for a similarly dedicated network here.

I sense that the intention of a national network to operate across geographical boundaries and clinical specialities fits well with the needs of veterans. It could promote best practice and contribute towards improving outcomes for all who have suffered the most devastating injuries. By taking specific account of these veterans’ needs in the trauma network, there would also be the opportunity to provide an effective means of tracking them along their recovery pathway and into later life.

Recommendation 10 – The National Trauma Network

NHS(S) should include the specific needs of veterans who have suffered polytrauma as part of its work in setting up a national Trauma Network.

Amputees

Loss of a limb, whether or not as part of polytrauma, has a devastating impact on anyone, including those men and women who have previously led very active lives in the Armed Forces. For those affected, and in response to the Murrison reports mentioned earlier, the Scottish Government set up a dedicated national prosthetic service which provides specialist treatment and care. It operates using a single multidisciplinary team across two centres in Glasgow and Edinburgh, runs alongside the wider NHS(S) prosthetics service and charities such as BLESMA, and is funded by the National Services Division. The establishment and sustainment of this service can rightly be regarded as a key and impressive part of Scotland’s commitment to those veterans who have suffered the most obvious and life changing injuries.

Notwithstanding the excellent care offered by the specialist centres, military amputees and their families have particular concerns about the provision of long-term care, and whether this will continue to adapt to their emerging needs. I heard this directly from Jay Hare, a former Corporal in 45 Commando Royal Marines, who sustained life-changing injuries from an explosion in Helmand Province in 2008. He lost his left leg below the knee, several fingers and had injuries to his right arm, right leg and face which required multiple reconstructive surgeries over a number of years.

Now aged 36, Jay already feels twinges from his prosthetic leg, his other injured knee and back. He questions whether the excellent care and support he has received to date, from both the national and his local clinic in Aberdeen, will be available in the future. He worries about breaking his prosthetics and having access to replacements and updated models. Jay’s concerns are best summed up in his own words…

Jay Hare – Former Royal Marine

“The Armed Forces Covenant made a promise to the veterans community that we would be treated fairly. Are enough future resources in place to really deliver this promise? As ‘Operational’, we were told that we were going to be looked after – that was the deal that was on the table and I hope this is still the case”

Providing answers to these concerns and reassurances to veterans like Jay, whose full story can be read at Annex 2, lie at the heart of my proposal for the Scottish Approach to Veterans’ Health.

Mobility

During a recent visit to one of the specialist centres, Southeast Mobility and Rehabilitation Technology ( SMART) in Edinburgh, I was impressed by the wide range of facilities and the quality of support. These services include prosthetics, orthotics and bioengineering (artificial limbs and special equipment); mobility and posture; a disabled living centre; gait analysis; and the national driving assessment centre. This prosthetic service is evidently well resourced, with clinicians and technical staff being confident of providing first-rate support to veterans.

However, these specialists expressed concern about being able to offer the most appropriate wheelchairs to veterans they treat. As with prosthetics, the provision of mobility aids should meet both clinical need, and current and future lifestyles. It was concerning to learn that this is not always the case.

Many veterans have had very specialised and generally light-weight wheelchairs from DMRC at Hedley Court. When these need replaced, SMART can only provide chairs through NHS(S) contracts, thereby leaving veterans with reduced functionality. Furthermore, when it comes to maintaining these specialised chairs, I was told that the parts can be very difficult and costly to source due to current contract and procurement procedures.

Those I spoke to felt it would be hugely beneficial if they were able to access more specialised wheelchairs, in much the same way they do for specialist prosthetics. I now understand just how important a wheelchair is to an amputee – as important as their prosthetic in many ways – and this will become increasingly so when they become more reliant on them as they age.

This issue puts the provision and funding of wheelchairs in sharp contrast to that of the excellent prosthetics service and seems illogical to me. It may require some additional resourcing or it may simply be that more flexibility around current arrangements is all that is required. In either case, this is a problem which ought to be rectified and one I would like to see addressed as a priority.

Recommendation 11 – Wheelchairs for Amputees

NHS(S) should adapt current arrangements to ensure an appropriate level of funding is available to guarantee that wheelchairs provided by the MOD for veterans with severe amputations can be serviced, maintained and replaced with the best possible equipment commensurate with that individual’s needs.

Musculoskeletal Disorders and Injuries

Musculoskeletal disorders ( MSDs) and injuries are consistently the main cause of medical discharge across all three Services. In basic terms they are described as damage to the muscles, bones or connective tissue that support someone’s limbs, neck and back. They almost always cause an individual to suffer pain – meaning that MSDs and long-term chronic pain are intrinsically linked – and can be resistant to some treatments.

Given the often physical nature of many jobs within the military, and the prevalence of related medical discharge, it is apparent that a significant proportion of veterans are likely to be affected by MSDs of varying severity. As with the general population, they receive treatment and care predominantly within the NHS, with GPs likely to be the first point of contact. Where ex-Service men and women can differ from their civilian counterparts is that their MSDs are more likely to be just one aspect of a complex picture of acute post-combat and/or training injuries. In the case of such injuries, which are likely to involve high levels of pain, a range of treatments and support will be required.

In an ideal world, GPs will be aware if a patient presenting with MSDs is a veteran and will be able to assess if these are linked to other severe and enduring injuries. In such cases, the GP can refer onwards to a number of specialist services, including rehabilitation treatments provided by physio and occupational therapists. However, I am also aware that these are in high demand and veterans can sometimes face long delays in gaining access. Given the long term benefits of proper rehabilitation – both to the individual and wider society – this is an area that clearly needs attention. I suggest there may also be an opportunity here for charities to play an increased role.

Finding 5:

Rehabilitation services, such as those provided by physio and occupational therapists, can be of huge benefit to those suffering from MSDs. Given the high demand for such services, veterans suffering from severe MSDs as a result of their military service should be given early access as part of their special treatment.

Chronic Pain and Pain Management

Chronic pain is often defined as a condition that causes disabling and severely limiting pain which lasts for more than three months. It can become progressively worse and reoccur intermittently.

“Chronic pain is not simply a physical problem. It is often associated with severe and extensive psychological, social and economic factors…The impact of chronic pain on patients’ lives varies from minor restrictions to complete loss of independence” – Dr Colin Tidy, GP and author on chronic pain.

The above quote also demonstrates starkly the complexity and often multiple issues faced by sufferers. Given the links to MSDs, polytrauma and other severe physical injuries, many ex-Service men and women are consequently living with pain. This has been highlighted in my conversations with health professionals in both the statutory and charity sectors.

Pain Concern is an Edinburgh based charity whose goals are to produce information, provide support and raise awareness for those with pain. They have a dedicated veterans section on their website and in collaboration with Forces in Mind Trust and the MacRobert Trust, they provide information and support to veterans in pain and to those who care for them. They have produced three interesting radio programmes featuring ex-Service men and women sharing their experiences of managing pain and interviews with the healthcare professionals who treat them.

Most veterans will be treated firstly by GPs, who may prescribe analgesics and other painkillers. For more serious cases they can refer patients to NHS(S) run clinics that deliver a variety of pain management programmes. It has also been interesting to hear about alternative approaches, such as self-management, mindfulness and regular exercise. These approaches would appear to suit many in the veterans community.

Of note was the recent establishment by the Scottish Government of the National Advisory Committee for Chronic Pain ( NACCP). The group has a remit to guide improvement of chronic pain management at all levels of health and social care, and to inform national policy. Given the relatively high proportion of veterans who are likely to suffer chronic pain, the work of this group will be highly relevant. There is obvious merit in it considering veterans as a distinct cohort.

Recommendation 12 – Chronic Pain Management

The National Advisory Committee for Chronic Pain ( NACCP) should consider veterans specifically as part of their work to improve chronic pain management in Scotland.

Severe Sensory Impairment

Serious instances of hearing and sight loss impact significantly on an individual’s life, both physically and psychologically. Severe sensory impairment may occur as a result of combat injuries from gunfire or explosions, or from other major accidents, and may be every bit as traumatic as some of the other physical conditions discussed earlier.

During conversations with several veterans and organisations I have become increasingly aware of the extent of hearing loss amongst the ex-Service community. One of the starkest figures I have come across is that veterans under the age of 75 are approximately three and a half times more likely than the general population to suffer some sort of hearing impairment. This is a staggering statistic that indicates a serious problem amongst the veterans population. On a positive note, it is clear that the MOD is now investing heavily in training and protective equipment to prevent such high instances in the future. This will, of course, do nothing for those who have been previously exposed to the sounds of artillery, explosions or been in close proximity to jet engines and heavy machinery without proper hearing protection.

For a number of these individuals their disability will have a severe and enduring impact for the remainder of their lives. As well as profound hearing loss, some may also experience tinnitus – a constant ringing, buzzing or whistling sound which can be so overwhelming that around a third of sufferers say they are driven to despair.

The first point of contact for veterans with hearing difficulties is likely to be, yet again, their GP and many will find their needs largely met by the statutory sector. However, for those with severe or profound hearing loss acquired as a result of their military service, they may find NHS(S) is limited in the types of specialist hearing aids that can be provided. In accordance with the commitment to ‘special’ care for these veterans and the principles of the Scottish Approach, resources should be found to provide them with the best possible aids and support in keeping with their needs and lifestyle.

Medical professionals and veterans dealing with hearing loss of whatever severity, should be aware of the substantial additional support available from the charity sector. Some of this has been funded by Government via LIBOR and the Aged Veterans Fund, with those providing support including the Royal British Legion, Action on Hearing Loss, and UK Veterans. They can provide access to some of the best hearing aids available.

Recommendation 13 – Funding Hearing Aids

The Scottish Government and NHS(S) should make funding available so that veterans with the most severe hearing loss as a result of their military service can have access to the best possible hearing aids and support.

Sight impairment is fortunately not as widespread in the veterans community as hearing loss, but for those affected it is significant and life changing. Partial or complete loss of sight may be the result of a combat injury or occur in later life, not necessarily because of military service. The charity Scottish War Blinded runs two centres providing support with independent living, sport and other activities, social events, financial assistance, and rehabilitation for veterans with sight loss.

During a visit to its Linburn Centre in West Lothian, I heard that the majority of those who are supported have lost their sight due to old age and illnesses such as glaucoma and macular degeneration. There are, though, still a proportion of veterans who are blind or partially sighted as a direct result of their military service and clearly the support of charities like this is invaluable.

One such individual, Robert Reid, was a 25 year old Lance-Corporal in the Royal Regiment of Scotland on duty in Iraq when a roadside bomb exploded. He was gravely injured, losing the sight in his right eye. He spent time at DMRC Headley Court and Selly Oak Hospital receiving treatment for his injuries, and while there was put in touch with Scottish War Blinded who have since helped him to adjust to his new circumstances. Such support, over and above that provided by NHS(S), has been a key feature of care for wounded service personnel in Scotland for many years. You can read Roberts’ full story on the Scottish War Blinded website.

The treatment and support available to all veterans with severe sensory loss, both from the statutory and charity sectors, is largely very good, but we must never take it for granted or allow complacency to compromise that situation. Only by properly protecting current services and effectively planning for the future can we ensure that those severely affected can continue to be well supported and cared for. These often ‘hidden’ injuries can be devastating and I strongly encourage Health and Social Care Partnerships, in particular, to take account of these when designing support for veterans.

The Invictus Games

Sports and fitness programmes and events are amongst the most recognisable and popular non-clinical pursuits for veterans with severe injuries. Perhaps the most iconic and high-profile in terms of competitive sport are the Invictus Games.

First held in London in 2014, they are now an established international, multi-sport fixture. Following the last gathering in Toronto in 2017, an evaluation was undertaken which concluded that it was ‘a gift for competitors in their recovery’ – something most of us instinctively knew and observed. Interestingly, the research also highlighted that Canadians’ perceptions of, and support for, injured veterans shifted dramatically for the better in their aftermath. The next will be held in Sydney later this year.

It would be exciting to think of a future Games coming to Scotland. Both Edinburgh and Glasgow, of course, have a proud history of staging successful international sporting occasions and the idea of the Invictus Games being held here would be an enormous boon to our veterans community and fans of sport alike.

Recommendation 14 – The Invictus Games

The Scottish Government should work with partners, charities and others to scope a proposal to host a future Invictus Games in Scotland.

Conclusion

In this chapter I have highlighted some of the most severe physical conditions that can affect veterans following a career in the military. This is not an exhaustive list and I recognise that I haven’t covered issues such as the impact of various cancers, Gulf War Illnesses, non-freezing cold injuries, or exposure to nuclear weapon testing. These often have very serious repercussions but I am confident that veterans have access to effective and compassionate care from NHS(S) in these and similar circumstances.

In concluding this chapter it is worth re-emphasising that the overall numbers of veterans struggling with severe and enduring physical conditions in Scotland is relatively small, and that the vast majority receive very good treatment and care. Mainstream and specialist NHS(S) services – complemented by the work done by a number of charities – are well-placed to provide this. At present, very few ‘fall between the cracks’ and fail to get the level of support they need.

That said, the concern amongst many veterans is that statutory services will struggle to provide this level of care in the long term, and that it will be unable to adapt to their needs as they age. This causes significant worry and I believe the Government can do much to allay such concerns by reinforcing its commitment to providing the best possible ‘special’ life-long care. Integrated Joint Boards, Health and Social Care Partnerships, NHS(S) and local Councils will be required to plan and deliver this. By doing so, I believe this vulnerable group will get the reassurance they seek and the care they deserve.