Recommendations from Veterans Health and Wellbeing - A Distinctive Scottish Approach, 2018

Scottish Government update, 2019

We are working with stakeholders, NHS Armed Forces and Veterans Champions and through the refreshed Armed Forces Personnel and Veterans Health Joint Group to ensure we create the conditions for and drive forward progress towards the ‘Distinctive Scottish Approach to Veterans Health’. Our progress towards the remaining recommendations shows how we are working to achieve this.

Scottish Government update, 2020

The Armed Forces Personnel and Veterans Health Joint Group will continue to keep the recommendations from this document central to its work going forward, as a directive and impetus for improvement. The SVCN via the proposed governance structures and delivery mechanisms will bring a distinctive Scottish Approach to Veterans’ Health at both a strategic and operational level.

Scottish Government update, 2021

The Scottish Veterans Care Network (SVCN) has brought a distinctive Scottish Approach to Veterans’ Health. The SVCN structure provides fora, on a range of areas, for cross-system collaboration and veterans and Armed Forces family input. The SVCN has undertaken a range of mapping and consultative exercises, which will be key to fully understanding and developing the Scottish healthcare context for veterans.

The Armed Forces & Veterans Health Implementation Group (IG) continues to regularly meet to drive forward progress on priorities set by the Strategic Oversight Group (SOG). The IG provided an update to the SOG in May 2021, and priorities were set. The 2021/22 priorities are a continuation of the priorities set in October 2020 – Mental Health, employability of veterans in the NHS, and Priority Treatment – plus the addition of Veteran GP Accreditation and exploring the setup of a veterans trauma network within the Scottish health landscape.

Scottish Government update, 2019

We actively participate in cross-border networks through the MOD/DH Partnership Board and a number of sub-groups. A meeting of the MOD/DH Partnership Board will be held in Scotland in November 2019.

Scottish Government update, 2020

We have established mutually beneficial relationships and networks with organisations in England and the devolved nations. During this reporting period we have utilised these to take a central role in sharing best practice on priority treatment messaging at four-nation level; with Welsh counterparts on messaging around veterans identifying their status. In November 2019, Scotland hosted the MOD / DHSC / Devolved Nations Partnership Board where we took the opportunity for the National Clinical Director and the Scottish Veterans Commissioner to address this group to highlight the Scottish landscape in terms of health, veterans and what we have achieved. This was well received and further strengthened links.

Scottish Government update, 2021

We continue to reinforce mutually beneficial relationships and networks with organisations in England and the devolved nations. We continue to participate in the MOD/DHSC/Devolved Administrations Partnership Board, including continued input into the four nation Priority Treatment Working Group. Recognising the value of collaboration, we provide frequent updates to the Partnership Board and have brought papers for cross-nation agreement. We have also established quarterly meetings with the Office for Veterans Affairs and take part in cross-nation meetings centred on health IT alignment between NHS Scotland and the MOD Defence Medical Service. Scottish representatives also take part in a UK Armed Forces Clinical Forum.

Scottish Government update, 2019

The Armed Forces Personnel & Veterans Health Joint Group (AFPVH JG) brings together NHS Champions, representatives of the serving community, veterans organisations, Scottish Government officials and other stakeholders. Refreshing the structure, role and remit of the Joint Group has been a priority, as it is central to delivering a number of recommendations. In December 2018, DG Health and Social Care and Chief Executive of the NHS approved a new structure for the Joint Group, which consists of a Strategic Oversight Group and an Implementation Group. The Strategic Oversight Group will meet for the first time on 16 May 2019 and the Implementation Group’s inaugural meeting will be on 10 June 2019.

Scottish Government update, 2020

Work has continued throughout 2020 and recommendation has now been assessed as fully met.

Scottish Government update, 2019

NHS National Services Division are exploring a Managed Clinical Network as a potential longer-term solution to ensuring equitable and sustainable health services for veterans. The proposal has moved to stage two of their planning process, meaning a full application and a detailed work plan will now be developed before putting the proposal to NHS Chief Executives then Scottish Ministers.

Scottish Government update, 2020

The Scottish Veterans Care Network has been established and will be formally launched in November 2020. Engagement with a broad range of stakeholders has enabled the Network to create a delivery strategy, setting out immediate priorities and a strategy for implementation of these. The SVCN strategy document was accepted and approved by the NHS Chief Executives Group on 4th August. This document will go to the Chief Officers Group shortly.

Scottish Government update, 2019

Scotland’s 10-year mental health strategy, launched in 2017, reinforces our commitment to the Armed Forces Covenant and includes a range of actions to improve care, services and support for people with a mental health problem, including veterans and their families.

In addition, we continue to work with NHS(S) in order to progress with establishing a Managed Clinical Network (MCN) for veterans healthcare. We would expect, should the network be approved through the formal NHS(S) process, that its initial priority would be to lead on the development of a Veterans Mental Health Action Plan which would complement our Mental Health Strategy.

Scottish Government update, 2020

This is an immediate priority for the Scottish Veterans Care Network. Early engagement with stakeholders to inform that work is now underway. However, due to the impact of the pandemic response on capacity within the Network, and also the availability of stakeholders to engage in this work, timescales for publication may be slightly delayed until later in 2021. A mapping of stakeholders and the services provided is in progress. An integral part of this work will be involvement in the development with partners, of clear and integrated pathways for/to care for our veterans, in relation to mental health. One of the SVCN first consultations was with Scottish Government, Combat stress and Veterans First Point (V1P) as the key mental health providers in Scotland.

Scottish Government update, 2021

The Scottish Veterans Care Network is continuing to work on the Mental Health Action Plan. Extensive mapping and consultation has been undertaken to gain the views of veterans, their families, third sector providers, and the NHS. The comprehensive plan was submitted in draft on 10 September 2021, with a final version expected in December 2021. It will contain recommendations for the Scottish Government and NHS Scotland.

Scottish Government update, 2022

The Veteran Mental Health and Wellbeing Action Plan was published in December 2021. Dr Charles Winstanley has been appointed to lead the Implementation Board.

Scottish Government update, 2019

The new Drug and Alcohol Information System (DAISy) will be introduced no later than December 2019. DAISy will gather key demographic and outcome data on people who engage in drug and alcohol treatment services and a field identifier for veterans has been included. This will provide useful data on the nature and scale of drug misuse among veterans across Scotland. Alongside this is potential to link this dataset to other health and social care datasets, providing a more detailed picture of service demand.

Scottish Government update, 2020

The DAISy system will record details of individuals receiving treatment for alcohol and drug problems and will have the facility to highlight veteran status, so that the scale and nature of those receiving treatment can be measured. Timeframes for DAISy have been reviewed externally and an implementation date has been set for before the end of the current calendar year Once implemented, we will use the first quarter of data collection to construct metrics around alcohol and drug treatment in the veterans population. The Scottish Government has established a Short Life Working Group (SLWG) on Prescription Medicine Dependence and Withdrawal. Its remit is to consider, in a Scottish context, the recommendations made in the Public Health England Prescribed Medicines review (of the evidence for the dependence on, and withdrawal from, prescribed medicines). The group has met virtually during the COVID period and will report its finding (in the form of draft recommendations) to the Cabinet Secretary for Health and Sport by the end of October. It is envisaged that a public consultation will then follow.

Scottish Government update, 2021

The Drug and Alcohol Information System (DAISy) was implemented on 1 December 2020 and went live across Scotland on 1 April 2021. Public Health Scotland are developing a series of reports for use at local and national level to better understand the issues related to alcohol and drug harms. This will include issues for veterans.

The Short Life Working Group on Prescription Medicine Dependence and Withdrawal presented its draft recommendations to the Cabinet Secretary for Health and Sport at the end of 2020. These recommendations were then published as a consultation in spring 2021. The consultation has now closed and Scottish Government is considering the responses together with the Short Life Working Group prior to making finalised recommendations to the Cabinet Secretary. The Veteran’s Mental Health Action Plan will include recommendations to improve the mental health and wellbeing of all Veterans, including where problematic alcohol or drug use is causing damage to their lives or the lives of their families.

Scottish Government update, 2022

Since the Drug and Alcohol Information System (DAISy) was implemented, Scottish Government and Public Health Scotland (PHS) have worked together alongside local areas to ensure the data it gathers is robust and useful. We have devised a set of research questions to understand how many veterans are presenting to treatment services, the nature of their drug use and what outcomes they are experiencing. This data will help us to better understand the impact of alcohol and drug use on veterans and how we might better support veterans who have an alcohol or drug problem.

Scottish Government update, 2023

In June 2023 Public Health Scotland published a report using data from the Drugs and Alcohol Information System (DAISy) which, for the first time, included data describing what proportion of people seeking treatment for drugs and/or alcohol are veterans. This reported that in 2021-22, 3% of people starting treatment were veterans with a further 3% not wishing to answer. We will continue to monitor this data to understand changing trends and identify if veterans differ from the general population. 

Notes

Commissioner’s comment – SVC will re-assess this recommendation in early 2023, to ensure it is still appropriate.

Scottish Government update, 2019

The Managed Clinical Network referred to under Recommendation 4 will provide the oversight that this recommendation requires. In addition, the Scottish Trauma Network, now in its second year of phased implementation, aims to meet the needs of the population of Scotland, working across traditional specialities and geographic boundaries to deliver better outcomes for patients, improving outcomes at every stage of the patient journey, from pre-admission to rehabilitation.

Scottish Government update, 2020

We would expect this to be explored within the remit of the Scottish Veterans Care Network. SVCN has undertaken a stakeholder mapping exercise to ensure that all appropriate bodies and organisations across the landscape of health and social care (and other stakeholders) have representation on the SVCN Governance groups (Oversight Board and Core Steering Group) to ensure engagement in collectively working towards access to life-long services. This includes a Health and Social Care Partnerships (HSCP) Chief Officer representative who will link to the overall Chief Officers Group, as well as NHS Veterans Champions (working regionally) to disseminate and collate intelligence from NHS boards/ HSCPs. This recommendation will interlink with Recommendation 7.

The SVCN has begun work to map the range of existing health and care services available for veterans across Scotland, this will include services provided by NHS Boards, Health and Social Care Partnerships (HSCPs), Integrated Joint Boards (IJB’s), Third Sector and Councils and Charities. This will be compiled along with existing published data on veterans’ health, in order to develop a Mental Health Action Plan which will inform the planning of services for the future. The SVCN has started collaborative work with Public Health Scotland (PHS) and MoD on sources of data regarding veterans in Scotland. A working group within the SVCN on data and information is in the development stages and this group is intended to drive forward work on this. The proforma to gather intelligence around the Mental Health Action Plan will also go out to HSCPs and IJB’s to gather intelligence around strategic planning for veteran’s services and will thus link to this recommendation and is envisaged will inform planning of services for the future.

Scottish Government update, 2021

As detailed in our 2020 update, the SVCN has undertaken a wide range of consultation, mapping exercises, and a literature review on services and support for veterans in Scotland. Upon publication of the Mental Health Action Plan, we will work closely with the SVCN and other partners to deliver on its recommendations.

Delivery of priority treatment is an important mechanism in ensuring veterans have life-long access to the appropriate treatment for Service-related injuries. As noted in A Distinctive Scottish Approach, the concept of priority treatment is contested and often misinterpreted. We participate in a four nations Priority Treatment Working Group, which is re-examining the term “priority treatment” and its related definition to ensure veterans receive the appropriate Service-related care they are entitled to. The overarching aim of this work is to ensure that the terminology is appropriate and therefore consistently applied so that Service-related injuries are provided with the care and consideration they are due.

Once the four-nation work has concluded, we will work on Scottish messaging and communications with Health Boards, Primary Care, and other partners to ensure awareness of any new developments/ outcomes.

Scottish Government update, 2022

We regularly engage with our stakeholders with regard to upholding the principles of the Covenant and the concept of priority treatment. We engaged in the recent consultation on the guidance to support the Armed Forces Bill, to ensure that the principle of due regard is recognised and can be applied to the Scottish context. Our Joint Group priorities provide a focus to assist in improving health outcomes for the Armed Forces and Veteran community and establish an understanding of their health and social care needs. For example, our project which applies a consistent marker on primary health care records will go some way to identify our veteran community. This data, on who and where our veterans are, can assist us to identify the support that is needed and the annual review of these priorities enables us to drive progress forward.

Scottish Government update, 2023

The Armed Forces Act 2021 saw the Armed Forces Covenant enshrined in law and this places a legal obligation on specified public bodies, including health boards and local authorities to consider the principles of the Covenant when delivering relevant functions, which include NHS Primary Care, NHS Secondary Care and local authority-delivered healthcare services. Statutory guidance has been issued to health boards and local authorities on how best to meet the duty of due regard to the principles of the Covenant for the Armed Forces community, including veterans.

Scottish Government update, 2019

The National Advisory Committee on Chronic Pain (NACCP) is taking forward work to inform policy development and support NHS Boards and Health and Social Care Partnerships (HSCPs) to improve the provision of pain services across Scotland. This includes a project to develop a core dataset and a set of Quality Performance Indicators (QPIs) to measure service outcomes and improvements for people living with chronic pain, including veterans. The Director of Pain Association Scotland (PAS), sits on NACCP and has been in discussion with the MOD Clinical Adviser for Veterans about the need to recognise veterans as a vulnerable group that would benefit from tailored support for chronic pain. The Pain Association has identified a gap in the quality of support services received on leaving the forces, in comparison to those received whilst serving. We are actively engaging with stakeholders to better understand experiences of veterans. PAS are piloting a programme in Scotland after securing funding from the Veterans Association. The programme offers veterans one-to-one self-management sessions via phone or skype to discuss personal needs and outcomes. This alleviates the need for the individual to attend clinics in person, recognising attendance may be difficult due to the nature of their pain. PAS will evaluate the project after 18 months and NACCP, chaired by the Deputy Chief Medical Officer, will consider outcomes and findings of the pilot.

Scottish Government update, 2020

The Pain Association Scotland (PAS) ran a very successful pilot from 2018 to 2019 on chronic pain self-management for 41 veterans. This was in the format of group meetings at Erskine House and through 1:1 sessions with 11 veterans. The pilot received excellent feedback from participants, with some describing the course as “informative, educational and interesting”, and commenting that the course has “taught me to accept, manage and deal with” pain. PAS has secured a further 18 months of funding as of March 2020, and will put the pilot findings before the National Advisory Committee for Chronic Pain with the aim of embedding the services provided.

Scottish Government update, 2021

Pain Association Scotland (PAS) state that as the challenges of COVID-19 have continued, more and more people have been suffering from increased anxiety and fear, the curtailment of their usual socialising, as well as the difficulties that long-COVID now presents. PAS support for veterans has been mainly by phone on a one-to-one basis and they have a regular cohort of 36 veterans whom they provide support for their chronic pain. They are delighted to have been able to offer continued help and re-assurance during difficult times. Initially, PAS had planned that the project would involve short-term self-management training for up to 5 sessions, but during this last year they have found that some people accessing the service have very complex needs that reach beyond the pain. This cohort, often with adjustment issues and trauma, have required a different approach in which PAS have continued to work longer term looking to improve life in general, often focussing on helping them to cope better with day-to-day life.

Following feedback from some veterans and those who support them, PAS have been delighted to offer an online 5 week self-management group programme. The first course started in July 2021 and they had 12 people sign up and complete the course. Due to the success of this group based programme, they have launched another 5 week course starting on 18th October 2021. Sign-up is available online.

Scottish Government update, 2019

Patients’ needs are assessed by an audiologist, taking account of product specification, flexibility and cosmetic appearance, leading to a recommendation of a specific hearing aid. Typically, a like for like replacement is provided. For example if a patient – veteran or otherwise – has previously worn “in the ear” (ITE) hearing aids, and provided it is still technically appropriate, they should receive replacement ITEs. Custom ITE hearing aids are defined as “specialist” and offer a mainly cosmetic difference rather than significant technical advantage over “behind the ear” (BTE) hearing aids. ITEs are not routinely provided by NHS Audiology Services, mainly due to cost (often several times the price of BTEs) and being seen as less reliable and requiring more maintenance. ITEs may be prescribed where there is a physical fit issue or where personal protective equipment or other head wear may make the wearing of a BTE difficult. In the past, ITEs have been prescribed due to BTEs not meeting the acoustic performance required to overcome hearing loss. However, most hearing loss can now be resolved to the same standard with a BTE.

Scottish Government update, 2020

Hearing Aid provision has been a priority for the Strategic Oversight Group and Implementation Group (SOG / IG). The National Clinical Director wrote to the Head of Audiology in all NHS Boards to request support to ensure that where a serving member of the Armed Forces or a veteran, presents with a previously issued hearing aid, that every effort will be made to maintain and support their use of that device or, where that is not possible, any change is sympathetic, even where this means that in some cases there is a small additional cost.

Scottish Government update, 2021

Engagement through surveys – one for veterans using services and another for audiology departments – provided a basis to assess the impact of the 2019 joint letter from the National Clinical Director and Adrian Carragher, Head of Audiology at Ayr University Hospital, which went to the heads of audiology departments across Scotland. While presentations to NHS audiology services may have been curtailed by COVID-19, the survey results highlighted that there were a very small number of presentations since August 2019, the requests in the letter were being carried out, and there were no issues. The situation will continue to be monitored. The survey can be repeated if considered necessary at any stage.

Scottish Government update, 2022

With regards audiology, as per the update provided, a letter was sent in 2019 from the National Clinical Director and Head of Audiology at Ayr University Hospital was sent to the heads of audiology departments across Scotland and while presentations to NHS audiology services may have been curtailed by COVID-19, the survey results highlighted that there were a very small number of presentations since August 2019, the requests in the letter were being carried out, and there were no issues.

Scottish Government update, 2023

NHS Audiology Heads of Service have confirmed that veterans are given priority appointments for initial assessments and hearing aid fitting appointments. They have advised that they are also given the hearing aid that is needed. As services seek to recover from the pandemic, backlogs and staffing issues, there may be some waiting time issues with some services at present however, veterans who have been identified as such, should still be given priority access.

A joint letter was issued to Board audiology services by the National Clinical Director and Adrian Carragher Head of Audiology, University Hospital Ayr in 2019 which requested that ‘where a change of device is needed either due to deterioration in hearing or that the existing device is no longer serviceable, that any change in device is “sympathetic” i.e. if clinically and technically appropriate that replacement is made on a “like for like” basis, particularly where in-the-ear styles of product have been used’.

Scottish Government update, 2019

The refreshed Joint Group on Armed Forces & Veterans Health will be considering ways to encourage more veterans to identify themselves to health professionals. We have worked with Veterans Scotland to update online information about veterans on NHS Inform. This was initiated from an awareness raising campaign for the duration of June 2018 to coincide with Armed Forces Day. A Toolkit to compliment the updated information has been produced for organisations who support veterans, and will be sent out early May 2019. NHS Inform has conducted an evaluation of the content on the pages to ensure that the information is as helpful as possible to veterans and a report on this will be published in May 2019.

Scottish Government update, 2020

The Implementation Group has initiated work between NHS Fife IT department and Scottish Government eHealth policy leads to overcome challenges with the Trakcare system, with the aim of veterans’ status being highlighted on medical referral documents between primary and secondary care. It was necessary to pause this work in February 2020 and we are hopeful that it can be resumed soon. Statisticians from NHS National Services Scotland have been working with MOD to use data on veterans and service leavers to better understand the trends and messages that can be drawn from this. Going forward, we will add another layer to this work by working with a Scottish Government Improvement Adviser to establish i) where the data indicates good practice, and share this and ii) where the data indicates a gap or need, we can provide targeted support. The SVCN has started collaborative work with Public Health Scotland (PHS) and MoD on sources of data regarding Veterans in Scotland. A working group within the Network on data and information in the development stages and this group is intended to drive forward work on this.

Scottish Government update, 2021

The Armed Forces & Veterans Health Implementation Group assigned a project team to work on a pilot project within NHS Fife. The pilot centres on working with a cluster of GP practices, using Quality Improvement methodology, to identify and trial improved methods of identifying and registering veterans with appropriate clinical coding on IT systems. The project will include retrospective coding of veterans already registered with practices. It is hoped that learning from this pilot will be expanded further across NHS Fife and then other Health Boards. Clinical coding is a key method of identifying veterans within and across health services and, in turn, providing a basis for delivering person-centred care.

In preparing for the Fife Pilot, there have been challenges in gaining clarity on the appropriate clinical code, with competing advice between nations and from different organisations. Recognising the need for a collaborative solution, we have raised this at the four nation DHSC/MOD Partnership Board by bringing a paper requesting cross-nation clarity and agreement. A four-nation group is being set-up to review coding advice and related documentation/processes. Clarity on this will allow progression of the NHS Fife Pilot Project.

Scottish Government update, 2022

The General Practice Armed Forces and Veterans’ Recognition Scheme is currently being developed and it will be rolled out us a pilot scheme at the end of 2022. The purpose of the scheme will be to increase awareness in General Practices around the unique challenges that veterans and Armed Forces families are facing as a patient group, and establish consistent best practices across the nation. This work is further supported by the work that is currently ongoing on the Fife Coding Project. These projects are working in tandem, since by identifying who the veteran population is, and understanding the specific issues that veterans might experience, a proper course of action can be taken. Additional data may be obtained from the Scottish Health Survey and the Census, with the potential of providing an additional locus of service improvements.

Scottish Government update, 2023

The work of the Armed Forces and Veterans Health Joint Group continues to raise the profile of the Armed Forces Community within health and social care. The Joint Group takes forward priorities that can have an impact on the Armed forces Community across Scotland. Membership of the Group has matured and along with the NHS Champions Network, information, not only in relation to current Joint Group priorities, is shared and exchanged regularly and partners can implement any relevant changes locally with a view to improving health outcomes for veterans in a meaningful way. A recent and practical example of this is the development of the Armed Forces and Veterans General Practice Recognition Scheme and the letter issued by the National Clinical Director, both of which have helped to raise awareness of the health issues that can occur while in Service and what colleagues in General Practice, often the gatekeeper to health services, can do to identify their veteran patients.

Scottish Government update, 2019

NHS Champions are in place in every NHS Board, acting as a veterans’ advocate to meet the intent of the Armed Forces Covenant and the Scottish Government’s “Renewing Our Commitments” document. We recently sought feedback from Champions on the role and are working with them to consider how best to use this network going forward. Updated materials to raise awareness of veterans healthcare needs have been shared with NHS Board Champions and healthcare practitioners. This includes guidance for GPs on how veterans can share their full service medical record.

Scottish Government update, 2020

Work has continued throughout 2020 and recommendation has now been assessed as fully met.