Chapter 2: ‘Making It Happen’
Over the course of the many visits and discussions undertaken in preparing this report, I was struck by the evident dedication and determination of professionals and others to ensure veterans in Scotland are given the best possible treatment, care and support. It was equally impressive that so many in the sector, from those in positions of leadership and practitioners through to volunteers, expressed a desire to do even more to improve health outcomes. In these times of stretched public finances and constantly competing demands, this commitment is not one to be underestimated.
Allied to this powerful sense of goodwill and resolve is a strong track record of providing impressive specialist and mainstream health services to veterans. This is something which is important to acknowledge. That said, we cannot afford to allow complacency to compromise that record nor see veterans’ health take lower priority. To do so would put Scotland’s hard earned and deserved reputation for supporting and valuing its veterans community at a degree of risk. Now is, therefore, an opportune time to protect the best practice that already exists, build on it with improvements wherever possible – in terms of practice, policy and governance – and prepare for the future. It is intended that the distinctive Scottish Approach to Veterans’ Health should provide the strategic framework to drive that ambitious agenda.
The next sections set out the key issues that need to be addressed if this approach is to transition from a worthy set of high-level principles into day-to-day practical measures that will impact positively on the lives of our veterans now and for years to come.
Protecting Specialist Services
Over the past decade or so, veterans in Scotland have been able to access a number of key specialist services that include dedicated prosthetics clinics, a network of Veterans First Point (V1P) teams and Combat Stress’ Hollybush House. I have seen for myself during visits to these establishments, and heard first-hand just how vital and valued they are.
This specialist provision is an important and well-established feature of how healthcare is delivered for veterans in Scotland today, especially those with severe and enduring conditions. It complements mainstream services very well, provides additional support and is seen as a model of care that deserves to be protected for current and future generations. As part of the Scottish Approach to Veterans’ Health I believe the Scottish Government and NHS(S) should reaffirm their commitment to protecting this level of specialism.
That said, a responsible and responsive health system must adapt to changing needs and demands over time; just because a service has been provided or structured in a particular way does not mean it should always continue in the same form. In the case of the specialist services mentioned above, I anticipate these having to evolve and this should not be seen as a backward step or reduction in the levels of support. Indeed, in the case of Hollybush House, Combat Stress has recently proposed adjusting its delivery model from an exclusively residential course to one that includes community based modules that ﬁt around a veteran’s work and family life. This reflects changes across the wider health sector and it will be important to monitor its impact given the organisation’s prominent role in supporting veterans with severe mental health issues.
In other words, we should never lose sight of making sure our veterans are cared for and supported in the best possible way – whatever that ‘way’ may be. The ultimate aim should be to ensure Scotland is a place where treatment – both in the mainstream and specialist sectors – is dynamic and responsive to the needs of the ex-Service community.
Specialist physical and mental health services are a vital and valued part of supporting our veterans with the most severe and enduring injuries and conditions. While their exact make-up and models of delivery will inevitably change and adapt over time, it is imperative that the availability of specialist services – and the outcomes they support – are protected for current and future generations.
Improving Collaboration and Partnership
While the proposed Scottish Approach to Veterans’ Health will see distinct planning, resourcing and delivery in Scotland, there remains much to be gained from engaging regularly with health and defence colleagues from other parts of the United Kingdom and beyond. By doing so there will be an opportunity to share our expertise and experience of supporting veterans while also improving our awareness of good practice, and increasing involvement in new health initiatives elsewhere.
Over the past few months, my team and I have had a number of informative meetings with colleagues in the MOD and NHS England, including the Director of Veterans Commissioning. These have alerted us to several projects that encompass new mental health services, a complex trauma service, and the Veterans Covenant Hospital Alliance scheme that accredits ‘Veteran Aware’ hospitals across the UK. The ‘Step into Health’ initiative is also interesting given its potential for seeing more veterans employed within the NHS.
I am aware there used to be active networks and dialogue linking health officials from across the United Kingdom but some of that has been lost in recent times. This is relatively easy to correct and should be done with some urgency. It has also been apparent that the Military Medical Liaison Officer ( MMLO) to the Scottish Government has fewer opportunities to engage and influence the Government on its relationship with the MOD. This is largely because the role is now part-time and an additional responsibility for an already busy NHS(S) senior consultant and Reservist. As a result we are missing opportunities to benefit our veterans community and the health system in Scotland.
I would particularly advocate regular participation in the MOD’s high-level Partnership Board, chaired by the Surgeon General and DG Health, and attendance at the relevant Clinical Reference Groups run by NHS England which tackle practical issues affecting Service personnel, veterans and their families.
Recommendation 2 – Improving Collaboration and Partnership
The Scottish Government should reinvigorate senior participation in cross-border networks with a view to improved information sharing and increased involvement in collaborative working and initiatives.
Finally in this section, it is important to highlight the key role that charities play in supporting veterans’ health. The expertise and variety of treatments and projects that they offer complement and, in many instances, enhance those provided by the statutory sector. The partnership between these sectors is a vital feature of veterans’ healthcare and must be nurtured and protected over the long-term.
In my initial paper I state that, “ 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 [with severe and enduring injuries and conditions] is part of a strategic plan”. Key to this will be a review of the way parts of these specialist services are funded.
I have been careful to recognise the good levels of specialist health provision for veterans throughout this report. There is, though, a remaining concern about the consistency and longer-term sustainability in some instances.
Current funding arrangements, in part, lack cohesion and can appear ad hoc. For example, the prosthetics clinics are commissioned, performance managed and, crucially, funded by a specialist part of NHS(S) called the National Services Division ( NSD). The NSD receives top-sliced, ring-fenced funding directly from the Scottish Government, which means that the services it funds enjoy a degree of security and certainty that doesn’t necessarily apply elsewhere.
The V1P services, on the other hand, were established and have been sustained using a combination of Scottish Government and Armed Forces Covenant ( LIBOR) Fund money. The former directly funded the first V1P service in the Lothians in 2009 and thanks to on-going LIBOR money it was later expanded to eight locations across Scotland. However, last year when the Fund closed, V1P had to resort to a combination of funding directly from Government, individual NHS Boards and other partners. Matched funds from the Scottish Government will allow most of those services to continue to 2020, at which point Boards and partners will become fully liable. This process has caused an element of turmoil and posed serious questions about the long-term future of services in certain areas.
However, I do not believe that specialist services need to be delivered in exactly the same way forever without close review. For example, NHS Grampian and NHS Highland have decided to discontinue the V1P service in its current form and made alternative arrangements for providing mental health treatment and support to their veterans communities. I am aware that NHS Highland was awarded an additional LIBOR grant in 2017 to continue mental health support in partnership with Poppyscotland. Notwithstanding that welcome development, the recent experience of sustaining V1P has demonstrated that funding from time-limited, non-core sources can lead to uncertainty and insecurity, which will undoubtedly worry those who rely on such support.
Funding for specialist mental and physical health services for veterans is disjointed and in some cases ad hoc. This results in a degree of uncertainty and raised questions about the sustainability of some of these services, which is a worry for those who rely on and value them so much. It is an issue that needs addressed as a priority.
Integrating health and social care
I have made much of a widely held desire to see the health and social care needs of veterans properly planned and co-ordinated over the longer-term. This is central to providing holistic and co-ordinated support as they age and their needs change, especially for those with severe and enduring conditions. In Scotland we are fortunate to already have an advanced and progressive approach to the integration of these services across the entire population; one which ought to lend itself to fulfilling this ambition for the ex-Service community.
Health and Social Care Partnerships ( HSCP) were launched in 2016, bringing together local health and social care services. Partnerships are overseen by 31 Integrated Joint Boards ( IJBs), also known as Integration Authorities, who are responsible – and carry the budget – for planning, innovating and working with professionals, communities and the third sector to deliver a range of services locally.
The creation of these partnerships and IJBs marks a fundamental shift in the way in which health and social care is delivered. It also changes the levers of control and accountability. As the budgets and responsibility for delivery are delegated to an increasingly more localised level then so must the focus of those interested in veterans’ health. The idea of a centralised system of command and control is now outdated and will have little impact in this new environment.
The HSCPs provide the vehicle for ensuring that long-term planning of veterans’ health and social care services is embedded in mainstream structures and budgets. Although they are still in their infancy and will no doubt evolve as they become a more established part of the system, it is still striking that only one IJB mentions veterans within their current strategic plans. I would anticipate this changing over time.
Their existence also offers an opportunity to plan and co-ordinate services across a wider range of areas, extending beyond the fields of health and social care. For example, I heard from Glasgow’s Chief Officer about how his HSCP also has responsibility for children and families, homelessness and criminal justice services. All of which can be relevant to the veterans community.
The integration of health and social care services in Scotland provides a unique opportunity to ensure the longer-term needs of veterans are properly planned and met. The new structure of IJBs and HSCPs is the vehicle for delivering this ambition. They must play a central role in decision-making about veterans’ health and wellbeing and the delivery of both mainstream and specialist services.
Leadership, Planning & Governance
Strong and visible leadership will be critical in delivering the high standards envisaged throughout this report. It will also be required to make the most of the opportunities offered by a changing landscape and to maximise the evident desire to do the best by our veterans. Most will naturally look to the Scottish Government and NHS(S) but in order for veterans services to be consistently at their best over the long-term, leadership and ambition will be required from many others at different levels.
The obvious means for bringing together senior decision-makers and providing national leadership is via the Armed Forces and Veterans Health Joint Group. It was formed back in 2009 and includes representatives from, amongst others, NHS(S), Scottish Government, Armed Forces, veterans’ organisations, charities and academia. It is chaired by Director-General Health and Social Care/Chief Executive NHS(S) and sits annually.
In the past this group has been responsible for overseeing the delivery of innovative support, that has included several successful pieces of work. For example, in 2012 a Sub-Working Group implemented recommendations from Dr Andrew Murrison’s report A Better Deal for Military Amputees in Scotland, which led directly to the formation of the national prosthetics clinics. This was an impressive achievement but my strong sense is that the group has now become unwieldy in number, lost much of its original purpose and has, as a result, been far less impactful than it was in its earlier days.
In recent times, much of that loss of purpose can be attributed to the changing landscape across health and social care, which means that the group no longer sufficiently reflects current models of delivery. A new structure of oversight and governance of veterans’ health that accords with the current system of greater local responsibility and accountability is, therefore, overdue.
That said, there is still a need for a national group that can provide high-level leadership across the health, social care and veterans sectors. The Joint Group should still fulfil that role but will undoubtedly require a refresh – both of membership and remit. It would need to ‘own’ the Scottish Approach to Veterans’ Health at a national level and in doing so provide strategic direction and ideas to those tackling the issues set out in this report on a day-to-day basis. Its membership also needs to reflect the new environment of integrated environment and draw on a smaller senior cohort who can drive the veterans health and wellbeing agenda. It would also benefit from meeting more regularly.
Recommendation 3 – Leadership and Governance
The Armed Forces and Veterans Health Joint Group should refresh its membership and remit in order to provide the vital strategic leadership that will deliver the Scottish Approach to Veterans’ Health
Alongside this, there is a need to introduce a mechanism at an operational level to develop further national thinking, tackle the issues highlighted in this report, and oversee the delivery of veterans’ health. This is a challenging remit that demands a dynamic, innovative and effective body, under strong leadership that can influence and instigate change within a complex structure.
With this in mind, I heard recently from the CEO of the Mental Welfare Commission about a structure which provides an interesting example of how veterans’ health issues could be considered. Its work on perinatal mental health of mothers and infants culminated in the establishment of a National Managed Clinical Network ( NMCN).
There are a number of different National Managed Clinical Networks ( NMCNs) in operation in Scotland. They are funded by the NHS(S) National Services Division and bring together those involved in providing specialist care for particular groups of patients with the most complex healthcare needs – health and other professionals, patients, carers, families and voluntary groups. Each network designs pathways of care that ensure patients and their families have equal access to the highest standards, regardless of where they live in Scotland. Networks focus on issues such as service planning and delivery, education, collating data to measure and improve quality of care, and engaging key stakeholders.
A new NMCN, or similar group, focussed on veterans’ health would have responsibility for considering the issues highlighted in this report and others it regards as relevant. It would need to draw on a wide range of stakeholders with an interest in the health and wellbeing of veterans; including representatives from statutory services, charities, academia, carers organisations and, of course, veterans themselves. I would also anticipate the network drawing on the experience and knowledge of individuals like the MMLO and organisations like the Health and Social Care Alliance. The network’s key responsibilities would be:
Network on Veterans’ Health
- Advise, influence and monitor the planning and delivery of mainstream and specialist services for veterans based on the principles of the Scottish Approach to Veterans’ Health.
- Lead on improving awareness, knowledge and understanding of veterans’ needs and characteristics.
- Produce a Mental Health Action Plan and influence its delivery at a national and local level. (See Chapter 3)
- Identify and address health inequalities for veterans, using those set out in this report as a starting point. (See Chapter 5)
While issues of planning and governance may not seem particularly exciting, or directly relevant to the day-to-day lives of veterans, they are in fact crucial to ensuring that the Scottish Approach to Veterans’ Health underpins the delivery of services and support. Those in positions of leadership have an opportunity – perhaps even a duty – to ‘make it happen’ and play their part in improving the health and wellbeing of our veterans community.
Recommendation 4 – National Managed Clinical Network
The Scottish Government and NHS(S) should establish a network on veterans’ health. The network will have oversight of delivering the Scottish Approach to Veterans’ Health, and will consider the key issues raised in this report and others it deems relevant. It should reflect current structures in the health and social care sector in its membership and approach.