Chapter 5: Improving Outcomes for All
For much of this report the emphasis has been on veterans who face serious and life-changing injuries or conditions resulting from military service, our obligation to provide them with ‘special’ treatment and care and how this can be guaranteed for as long as it is required. This is only right given their previous sacrifice and the cost which they will bear over many years. As is evident from previous chapters, this has been the main thrust of the proposed Scottish Approach to Veterans’ Health and I make no apology for giving these individuals, and their needs, such prominence.
However, it is also important to consider the wider population of veterans, their health and social care needs, and determine whether the support provided is as good as it could be.
Jane Duncan – Veterans Support Adviser
“When you leave the Armed Forces, you leave a community, and that is very difficult to step away from. Replicating that community sense via social groups and organisations can, for some, help military personnel feel part of a tight knit group and most importantly, valued. The appetite from the three councils [Renfrewshire, East Renfrewshire & Inverclyde] to help veterans integrate into the community has significantly increased since 2014 and they all want to play their part in ensuring that the region is viewed as a place to settle for veterans. They want ex-Service personnel to know that they, and their families, are welcomed to the area and that there is support and help in place at a local level.”
Veterans in Society
The overall number of veterans who live in Scotland is still not known precisely, something that is a continued source of frustration for those who are responsible for planning and allocating resources for their treatment and care. A series of reports from MOD, Royal British Legion and Poppyscotland provide an estimate of the size and socio-demographic characteristics of the population and, although these have proved useful, they have their limitations. I have therefore strongly supported the campaign to include questions about previous military service in the next national census, given its potential to provide clarity and inform future policy and resource decisions.
Despite this lack of absolute certainty, the most recent studies suggest approximately a quarter of a million veterans currently live in Scotland, with the expectation that this figure will decrease over time as the older generation of National Servicemen pass away, and as a consequence of our Armed Forces having reduced in size. Of this community – which comprises about 4% of the nation’s population and includes individuals who range in age from their late teens to over 90 – the majority will have served in the military for less than four years, in many cases up to 50 or 60 years ago, and at least half will be over the age of 75. They are found in every part of society, include increasing numbers of women and have very similar personal aspirations, worries and challenges to their peers who have not served. Many of their health and social care needs are no different to those in the wider population.
For everyone in Scotland, the Scottish Government makes clear they have a fundamental right to the “highest possible standard of health” and a “fairer share of the opportunities, resources and confidence to live longer, healthier lives”. This is enshrined in policy documents such as A Fairer, Healthier Scotland 2017-22 and dictates the approach taken by NHS(S), Integrated Joint Boards, Health and Social Care Partnerships, Health Boards and Councils as they strive to reduce inequalities and improve the overall health of the nation. One of the key aims of my report is to ensure all veterans benefit from this strategic framework.
However, throughout this report I have also attempted to address the fundamental question as to whether veterans face any disadvantage when accessing health and social care provision. The good news is that I have come across very few instances where this is the case and none that suggest it is an endemic problem across the statutory services. That said, the focus on addressing inequalities within the health system has opened my eyes to members of the ex-Service community who may be experiencing what NHS(S) describes as “unjust and avoidable differences in [their] health…that are socially determined by circumstances largely beyond [their] control”.
According to the same source, health inequalities are rooted in the unequal distribution of power, wealth and income, and the associated social determinants of health which include housing, employment, education, family income, social support, communities and childhood experiences.
It has long been recognised in the veterans community how vital many of these determinants are to ensuring ex-Service men and women and their families prosper after a career in the military. Much effort and resource is invested by both government and charities to support those leaving the Armed Forces and veterans on these and other fronts.
As Commissioner, I have previously published reports on aspects of the transition to civilian life, housing, employment, skills and learning. All have been seeking, firstly, to promote veterans as valuable assets to their local communities and Scotland’s wider economy and, secondly, to increase opportunities for them to secure suitable housing, meaningful and sustainable jobs, and college, university and training places. As well as helping to ensure veterans are properly recognised and rewarded for the skills and attributes they have, it is heartening to think that improvements in all of these areas may, in part, also contribute to them living well and being in good health.
As with the wider population, the veterans community stands to benefit from the holistic approach to health which exists in Scotland. There are, though, certain characteristics that distinguish veterans from the general population that mean some may still face health inequalities and are worthy of separate consideration within the system. Research by different academic organisations and my own discussions over the past few years indicate that Early Service Leavers ( ESLs), the elderly and those who served as reservist members of the Armed Forces may be at particular disadvantage.
Early Service Leavers
ESLs are those who leave the military voluntarily before completing the minimum term of four years, have been compulsorily discharged or who have not completed basic training.
There is a growing body of research that shows this group at particular risk of being adversely affected by a range of health conditions. We also know some experience difficulty in securing accommodation and work, and on occasion end up in the criminal justice system after their time in the military. I have examined some of these challenges in previous reports and recognise they all have an effect on the future health and wellbeing of this more vulnerable cohort.
The reasons for ESLs being at higher risk of poor health are varied and complex. It is a subject that is increasingly the focus of investigation and debate amongst the academic, Armed Forces and veterans communities. I won’t, therefore, go into detail here other than to highlight the emerging understanding that their physical and mental health issues can often be a legacy of their lives prior to joining the military. Factors such as social deprivation, lower educational attainment, childhood traumas and poverty all play a part.
A report on mental health in the military by ForcesWatch highlights just some of the challenges faced by these individuals: “The youngest personnel from the most disadvantaged backgrounds are: more vulnerable to trauma; more likely to be in a close-combat role and exposed to traumatic stress when deployed; and then less likely to be able to draw on the social support they need to manage a mental health problem after leaving the forces. This group is therefore disadvantaged before, during and after their military career in terms of the mental health risks they face”
Regardless of the reasons and whether they are attributable to time in the military or beforehand, what is clear is that some ESLs are more likely to suffer adverse health conditions and consequently face inequalities.
Armed Forces Reserves
Whether an individual has served as a regular member of the Armed Forces or a reservist, they have the same status as a veteran afterwards and are rightly regarded no differently by the health system, charities and others. There is, though, evidence to suggest reservists face a number of health challenges which merit separate consideration.
For example, a number of academic reports found that reservists who had been deployed in a combat situation were at higher risk of developing PTSD compared to regular members of the military. The reasons for this are likely to be many, and will include issues such as the stresses of balancing other jobs and family commitments, less well established networks of support and comradeship within the military, and the disruption of transitioning between Service and civilian life.
There are already joint NHS and MOD programmes with a particular focus on mental health, run for reservists who have previously been deployed. This is an important part of addressing the needs of this group. Notwithstanding, it remains a cohort that still faces an increased health risk and about which there appears to be limited understanding. While the numbers affected are relatively small, I still believe there is a clear need to invest time and effort in recognising and addressing the specific health and wellbeing needs of this group in Scotland.
Laura Anderson – Occupational Therapist
“At V1P Lothian we have seen a rise in physical problems, most commonly loss of hearing, general wear and tear, frailty, and occasionally weight management, breathing difficulties and malnourishment…
As with the elderly in the wider population, one of the biggest challenges we face is social isolation and the team facilitates group activities and attendance at drop-in sessions to combat this. Some veterans are fit enough to get themselves to such activities, but for those that aren’t we work with partners to assess carer needs and assist with putting any requirements in place.”
Our population of veterans is aging and declining in number. As I mentioned earlier, almost half of veterans are aged 75 or older, with the majority having spent a relatively short time in the military during National Service. Most encounter similar health challenges to anyone as part of the natural consequences of aging, such as different forms of dementia. They increasingly face a range of illnesses and conditions that have a cumulative and often significant impact on their quality of life. Some of these later-life health conditions can, at least in part, be attributed to or exacerbated by military service.
Veterans charities have traditionally provided invaluable support to older members of the community. However, the challenges faced by this group have gained a higher profile and a greater priority amongst many more organisations in recent years. For example, last year I was pleased to launch a large UK Government funded programme of services to veterans over the age of 65. Called Unforgotten Forces it brings together 15 organisations in a consortium led by Poppyscotland. It includes a number of the traditional military charities but also several others such as Age Scotland and Music in Hospitals Scotland. One of the main concerns the programme is seeking to tackle is loneliness and isolation, something that is particularly acute amongst many in the older veterans community.
There are also veterans whose military career will leave various legacies which can impact their future health and wellbeing. This is especially evident amongst the large number of ex-Service men and women who struggle with pain and mobility issues resulting from musculo-skeletal conditions, the long-term effects of smoking and excessive alcohol consumption, and the consequences of frequent exposure to extreme noise. All are associated, to a greater or lesser extent, with service in the Armed Forces and can have a detrimental impact on an individual’s quality of life, health, employability and, in the most serious circumstances, their life expectancy.
Severe Musculoskeletal Disorders ( MSDs) are highlighted earlier and comprise the most common medical reason and conditions for someone leaving the Armed Forces. However, it is apparent that for a large number of veterans, other MSDs and conditions like arthritis may develop in later life and lead to considerable mobility and other difficulties. This is not surprising when one considers the physical nature of the working life many will have led and the associated risk of injury, stresses and strains to the body.
The most recent Household Survey produced by Poppyscotland highlights mobility, both inside and outside the home, as the most common health problem cited by veterans themselves. This is backed up by a number of other reports and reflects the older and aging profile of the ex-Service community. Mobility problems can often lead to struggles with activities of daily living, such as washing, cooking and dressing. They can also result in isolation and loneliness if, for example, someone struggles to get out of the home, cannot drive or readily use public transport.
Many older veterans completed their military service, including National Service, in an era when the dangers of smoking were not well understood and cigarettes were given out freely as a daily allowance. The consequences have been highlighted by Dr Beverly Bergman in a 2016 report which confirmed veterans in Scotland born before 1955 were at increased risk of smoking-related diseases.
Although overall smoking rates are decreasing in the Armed Forces, it is still the case that serving personnel are more likely to smoke, and more heavily, than their civilian counterparts. The potential future health implications are now well-known and spoken about. It is encouraging that the MOD is taking action to reverse this trend. For example, a Tri-Service Tobacco Control Working Group has been tasked with increasing smoking cessation, including identifying ways of discouraging recruits from taking it up in the first instance.
I am optimistic that smoking levels within the military will continue to fall, as across the wider population, with the consequent positive impacts on future veterans’ health. However, the effects of a historical culture of heavy smoking will still leave some with related health problems that include certain cancers, cardiovascular and respiratory diseases, that will be seen for many years to come.
A previous chapter covered the serious effects of very heavy drinking when linked to mental ill health. However, it is still the case that veterans are more likely than their civilian peers to display problem levels of drinking. Some of this can be explained by aspects of the culture and attitudes within the Armed Forces. The following quote from a 2011 King’s College London report, Alcohol Use and Misuse Within the Military, by Edgar Jones and Nicola Fear neatly encapsulates the nature of the problem and the difficulties the medical profession have in responding to it.
“Of necessity, the Armed Forces recruit risk-taking individuals. It may be that some of the characteristics that make a successful combat soldier also put them at risk of alcohol misuse. Sub-groups within the Armed Forces are particularly predisposed to heavy drinking. In particular those who are young, single and who have been involved in traumatic incidents. Because drinking has been used by UK Armed Forces as an agent to assist cohesion and informal operational debriefing, it requires a powerful cultural shift to modify ingrained habits and traditions….Alcohol has played such a significant part in service culture for so long that any intervention will take the form of a war of attrition.”
Research by The Northern Hub for Veterans and Military Families’ Research at Northumbria University also found barriers to veterans accessing appropriate treatment for alcohol problems. These include the inherent drinking culture within the military, a lack of understanding amongst the medical profession of their unique needs, and the stigma associated with asking for help. As with smoking, there are encouraging signs of problem drinking being tackled and reduced both within military and veterans circles. However, the effects of heavy drinking still leave some facing related health problems which can adversely impact on the individual, their family and the community.
Almost everyone who served in the Armed Forces will have been exposed to a significant amount of noise, which will almost inevitably take a toll on their auditory system. Severe hearing loss has already been covered earlier but it is also important to recognise that many, perhaps most, veterans will experience lesser degrees of impairment following their time in the military. This may entail noise-induced hearing loss from prolonged and repeated exposure to loud noise, or acoustic trauma usually as the result of an explosion or gunshot at close range.
The Royal British Legion report Lost Voices succinctly summarises some of the impacts of this hidden cost of military service when it states, “hearing problems can have a profound effect on an individual’s career prospects, family relationships, social life and mental health”.
Veterans – a distinct group?
All of the above leads me to the conclusion that there are a number of veterans who, despite the many improvements made in recent years, remain susceptible to health inequalities after a Service career. For many, it will have exposed them to combat, harsh physical conditions, stressful situations and a lifestyle that has had a detrimental effect on their long-term health and general wellbeing.
Given NHS(S)’s emphasis on reducing such occurrences of disadvantage, and an increasing body of academic evidence that highlights the long-term health implications of a military career, I believe there is a strong case for considering veterans as a group that deserves closer attention. In most cases, there will be an existing national strategy, framework or plan that dictates the approach and treatment required for specific conditions. However, these sometimes fail to consider the often unique requirements and characteristics of a sizeable veterans population. I am also concerned that they don’t always address the multiple co-morbidities that frequently appear amongst this group.
I should stress at this point that I am not making a direct plea for significant resources to provide exceptional treatment for veterans as a whole. This is only relevant to those with the most severe and life-changing injuries, as I have argued in previous chapters. However, I firmly believe that the Scottish Government, NHS(S) and their partners should identify veterans as a distinct group whose health and wellbeing is influenced by their prior military service which leads, in certain circumstances, to inequalities that need to be addressed. I appreciate this is a complex ask that will involve many different organisations but the approach mirrors that taken for other groups in Scottish society. It has the potential to help build a better understanding of veterans’ needs and characteristics, and develop practical measures that will improve health and wellbeing outcomes for all.
Recommendation 15 – Tackling Health Inequalities
The Scottish Government, NHS(S) and partners should identify veterans as a distinct group in their work to tackle health inequalities. In doing so they should produce proposals for preventing or mitigating inequalities as they apply to this group, with the ultimate aim of improving health outcomes for all.
Process and Administration
Given the size and complexity of the health and social care sector in Scotland it is unsurprising that issues of process and administration are important. This affects veterans just as much as the rest of the population but I have become aware of several factors which can complicate and hamper access to treatment and affect health outcomes for this group. These cover a range of subjects which may, on first inspection, be relatively minor and procedural in nature. However, each has a noticeable impact on how veterans are treated by the system and the quality of care provided.
One of the great frustrations expressed by many health professionals is their inability to identify consistently and accurately those who have served in the military. There is no doubt that the current practice that requires GP surgeries to ask new patients whether they have served is a good starting point but it is also evident that the process has several limitations.
One of the first hurdles to overcome is the reluctance by some veterans to identify themselves as such, typically citing security concerns or personal antipathy for their decision. This is an entirely legitimate and understandable response but the consequences can be far-reaching, both for the individual and his/her access to bespoke care, and the health professionals who may not have a full medical history on which to base decisions. Ultimately, it is a personal choice to declare prior military service but I sense more can be done by the MOD, veterans organisations and NHS(S) to reassure and encourage people along this path. My personal experience is that this is a fundamental building block to enabling health professionals to better understand and consequently treat veterans.
There is also an internal problem with this process in that it misses a large proportion of those who may have been with a practice for many years and have never had the opportunity to formally share information about their previous military careers. Some are ‘caught’ during consultations and when surgeries request an update of personal records but too many are never identified. In the most serious situations this can limit access to the ‘special’ treatment covered in previous chapters but it may also deny health professionals extra background information that can influence diagnoses and decisions about treatment. I am also aware that this lack of basic data and medical statistics makes it more difficult to measure outcomes, shape future policy and address the health inequalities that affect some in our communities.
Recommendation 16 – Identifying Veterans
The Armed Forces and Veterans Joint Health Group should oversee work to increase the number of veterans declaring their previous service to GPs and others in the system. This will likely involve NHS(S), MOD and veterans organisations.
Using the Information
Further shortcomings of the present process concern the consistency of recording a veteran’s military service on primary healthcare IT systems, the low profile this is given on electronic medical records once logged, and the difficulty of sharing it with systems supporting other areas within the NHS. This is partly a technical issue but I am surprised that there is still no contractual requirement, or incentive, for GPs to formally encode data fields about military service. The result is that busy surgeries will often give this work a lower priority despite the requirement to record such information during initial consultations with new patients.
To my mind this is a fundamental breakdown in a process that was first intended to ensure veterans were properly recognised by the health system and it is disappointing that after several years there is still no reliable method of recording, displaying and sharing this vital information. I strongly urge that NHS(S) address this issue as a priority since failure to do so could have an adverse impact on health outcomes for veterans and easily act as a block on other initiatives that rely on good statistical data.
Recommendation 17 – Using Information
The Armed Forces and Veterans Joint Health Group should oversee efforts to improve methods of recording, displaying and sharing information about veterans within the health and social care sector. This will be with a view to providing health professionals with the information needed to better understand and support veterans.
Registering with a GP
The final paragraphs in this section examine the recurring challenge of getting Service personnel to register with civilian medical practices when they leave the military.
I should stress that for the majority, and certainly for those with on-going severe medical conditions, responsibility for providing care is transferred effectively and efficiently from the Defence Medical Services to a local GP and NHS(S). In most routine cases the onus will be on Service leavers to follow instructions provided by MOD during their overall transition process. This is straightforward and rarely presents problems for those who are well-organised and confident of their future plans.
Despite this, there remains a significant number of Service men and women – usually younger and single – who leave and delay enrolling with a local medical practice. In the past I considered this to be a serious problem and disadvantage but am now aware that these individuals join many others in our society who rely on Accident & Emergency units, drop-in clinics and ad hoc visits to surgeries whenever they need treatment. This is not the preferred approach and I would encourage the MOD and NHS(S) – including through its Inform website – to do more to help these Service leavers to organise their healthcare more responsibly.
During the past four years I have had the privilege of meeting many Health Board veterans champions and have seen, at first hand, the positive impact they have in their local areas. Each has the latitude to tackle the role in their own way but there is no doubt that they have raised the profile of veterans amongst their colleagues and provided a valuable point of contact for those with concerns or needing help to access NHS(S) services. I admire and strongly support the work they do.
Warwick Shaw – Veterans Champion at NHS Borders
“By signposting help and resources, such as SSAFA and Veterans Scotland, champions allow GPs to direct veterans towards the right support as soon as they are seeking advice.”
Circumstances have changed since the role was created and there is now a significantly different landscape following the integration of health and social care services across Scotland. Traditionally, champions have been recruited from the senior management or local board levels within NHS(S) but the introduction of Integrated Joint Boards ( IJBs) and Health and Social Care Partnerships ( HSCPs) present a markedly different structure in which they must now operate. With responsibility for delivery of services shared between this partnership of Councils and NHS Boards, champions will need to extend their influence more widely, work closely with a broader range of interested parties and be prepared to assist veterans who may struggle to understand the new set-up. This is likely to be a more complex and time consuming task.
A recent aide memoire issued by the Scottish Government and Veterans Scotland provides a welcome reminder about the role, its purpose and the key characteristics of an effective champion. I am pleased to see this document and believe it offers a good starting point as the role adapts to changing structures. Future work will, I anticipate, need to focus on (1) coordinating the efforts of local Council and NHS champions in supporting the provision of health and social care, (2) harnessing the clear commitment and tenacity of champions so they can influence IJB and HSCP decisions that affect veterans, and (3) empower champions as they support ex-Service personnel in their communities. In many cases this is already being done on an informal basis but there is a role for the Scottish Government, Veterans Scotland and NHS(S) to provide further advice and support as this important resource adjusts to changing demands.
Recommendation 18 – Veterans Champions
The Scottish Government and Veterans Scotland should build on recent work to support the network of NHS and Council champions to develop the role so that it can continue to be effective in supporting the delivery of health and social care to veterans within the new health landscape of Scotland.