- 26 Jan 2021
Attendees and apologies
- Gregor Smith, Interim Chief Medical Officer (chair)
- Jason Leitch, Scottish Government Clinical Director of Healthcare Quality and Improvement, and Chair of Implementation Group
- Roddy Neilson, Medical Military Liaison Officer
- Jim Wilson and Neil Morrison, Veterans Scotland, Deputising for Chris Hughes
- Surg Capt Mark Henry, Regional Clinical Director for the MoD
- Ian Cumming , Erskine, representing Third Sector interests
- Mairi McKinley, NHS Fife Armed Forces and Veterans Champion
- Craig Cunningham, NHS Lanarkshire Armed Forces and Veterans Champion
- Karen Ross, Army Families Federation (also representing RAF and Navy Families Federations)
- Cllr Rod Cavanagh, Local Authority Champion, Fife
- Katie Hislop, Armed Forces and Veterans Healthcare policy team, Scottish Government (Secretariat)
- Ruth Jays, Unit Head, Person Centred Healthcare and Participation Unit, Scottish Government
- Annalena Winslow, Team Leader, Person Centred Healthcare, Scottish Government
- Lorimer Mackenzie, Head of Trauma and Survivor Support, Scottish Government
- Lucy Abraham, Scottish Veterans Care Network
- John Mooney, Unit Head, Veterans and Armed Forces Personnel Unit
- Alison Howard, Scottish Veterans Commissioner’s support team
- Sharon Callaghan, Operations Manager to Mary Henry, Regional Clinical Director (attending in support of RCD)
- Amanda Cronin, Scottish Government Improvement Adviser (attending in listening capacity)
- Colonel Sandy Fitzpatrick, Deputy Commander of 51 Brigade
- Chris Hughes, Executive Chair, Veterans Scotland - Health Representative
- Claire Wood, NHS Highlands Armed Forces and Veterans Champion
- Charlie Wallace, Scottish Veterans Commissioner
Items and actions
1. Welcome and Apologies
1.1 Gregor Smith, interim Chief Medical Officer (CMO), welcomed the group to the 2020 meeting of the Armed Forces Personnel and Veterans Health Joint Group’s Strategic Oversight Group, his first as Chair. He listed apologies (noted above) and asked members to observe standard virtual meeting behaviours.
2. COVID-19 Impact on AFV Health landscape
2.1 CMO invited members to share reflections, observations or challenges from their perspective of the last few months, and the impact on the organisations members represent.
2.2 Neil Morrison, Veterans Scotland (VS), described a recent engagement exercise with third sector organisations who are members of the VS Health Pillar Group. Generally, responses were rated green or amber, with only one red from those providing services to veterans with hearing loss, indicating that this has been a particularly challenging time for those individuals. This also indicated an increase in all aspects of mental health and, as a result, increased pressure on services. In relation to funding, Neil fed back that all of the sector organisations are finding it extremely difficult to raise funds and referred to a recent article (hyperlink attached) predicting a 30-40% reduction in funding for veterans’ charities for the foreseeable future which could see the capability of organisations dropping or closing as a consequence of a reduction in funding, and this would cause pressure on public services. Neil asked that the group were alert to this risk. CMO thanked Neil for his contribution and asked whether the findings of the third sector engagement exercise could be shared.
Action: Secretariat to share findings with SOG members
2.3 Ian Cumming of Erskine echoed some of the points made by Neil. He alluded to Erskine having been at the centre of some media activity recently. Ian said Erskine will be interested in feeding into the review of social care. In relation to funding, Ian reported that Erskine spends £10 million more per year that it receives from local authority funding and contributions from self-funders, and they anticipate an approx. 30% drop in funding in the next year and in years to come. In response, Erskine is currently going through a strategic review to work out future delivery. Ian also reflected that the contribution made by volunteers could not be underestimated.
2.4 Lucy Abraham of V1P Lothian and the Scottish Veterans Care Network reported that V1P Lothian has been open throughout the pandemic and since March has seen an increase in rates of veterans coming to them with suicidal ideation and mental health issues, particularly in those reporting feelings of terror and unwanted imagery. For many, they may have become unemployed and be feeling isolated, may lack a meaningful role or may have become homeless, which has caused a decline in mental health and an increase in symptoms. Lucy said that V1P are receiving far more referrals from the intensive home treatment teams and from hospital in-patient facilities. Throughout lockdown they have continued to accept referrals as normal. During lockdown, they have adapted their services to meet the change in demand e.g. to conduct daily support phone calls and via online means. They have provided support online but for those who do not use the internet or do not have internet access, many have arrived at the door of the Hub - the team have supported these individuals, so having the Hub in place has been very important in terms of supporting the most vulnerable veterans.
2.5 Rod Cavanagh, Local Authority Armed Forces and Veterans Champion for Fife, reflected that his volume of work has slowed this year. He informed the group of a flagship project which is being delivered, which will possibly be located in Lochore – this project has progressed and the council is hopeful that the facility can be shared with a number of partners, including Fife V1P, who will engage with the community. This project should be completed in March 2021.
2.6 Craig Cunningham, Armed Forces and Veterans (AFV) Champion for NHS Lanarkshire, agreed with points made by Lucy and Neil in relation to mental health and reported that there has been a notable increased in individuals seeking support. This would be for a number of reasons but predominantly may be due to people being more isolated. The range of support groups – including veteran specific groups – are not there in the way that they once were. Craig acknowledged that these groups continue to do a phenomenal job and the use of technology to adapt has been very helpful but this cannot replace human contact and the benefits that brings. From a more formal NHS perspective, Craig reported seeing an increase in people accessing services in distress, and colleagues from A&E have observed a similar trend. NHS Lanarkshire are trying to capture and quantify this. Craig highlighted that this is a growing issue and, in a recovery context, sees that there is a need to ensure face to face mental health services are prioritised. From an NHS AFV Champion perspective, mental health and substance misuse are among the most common issues they are contacted about. Often, drug use relates to management of chronic pain and the use of over the counter or prescribed medication, which evolves into addiction or withdrawal. Again, these individuals are unable to access services in the way that they once would have been able to.
2.7 Mark Henry, MOD Regional Clinical Director, briefly explained his role to the group and his responsibilities for serving personnel in respect of primary care, mental health and rehabilitation. They have experienced an incredible pace of activity, particularly in March – May. This has accelerated a lot of change that had already been anticipated, for example video consultation models which are now in use and, without the urgency of recent months, it could have taken much longer to embed these practices. Because of these additions, they are currently in a better position than nine months ago. Mark reported that primary care consultations dropped significantly in the initial lockdown period, mirroring the NHS, but are now close to normal again. In contrast to contributions from others, mental health consultations have dropped by 20-30%. A bow wave is anticipated, as personnel realise that the services are still in operation, but this has not yet been seen.
2.8 Jim Wilson of Veterans Scotland began by thanking the CMO and others, on behalf of veterans and also the schools and sports clubs he volunteers with, for Scottish Government advice which he has found to be good and, where it has been observed, has worked well. In coming years, he anticipates funding challenges for all charities, which will cause difficulties in the delivery of the support these organisations provide to statutory services. Some of this is inevitable –a general downwards trend in funding and a greater need for co-operation and collaboration across the charitable sector had already been observed – and the current situation is focussing many charities on what they need to do to continue to deliver for veterans, serving populations and families. In relation to mental health, feedback from most organisations is that they want to keep engaging but this is difficult when they don’t know where the need is, so organisations are working on how that can be done and can be continued. Jim also observed that in order to be visible to users, the importance of having the equivalent of a presence on the high street must not be under estimated, and is of equal importance to the general population as it is to veterans and the serving community.
2.9 CMO thanked all who had contributed. He reflected that the issues flagged were ones that he had heard from other stakeholders and these would be important in terms of how the Group organises priorities going forward. He acknowledged the strong sense of challenges around mental health and the use of the phrase “bow wave” because there may be individuals who are experiencing difficulties but have not yet sought help. He also referred to remarks made about the sustainability of the third sector and how they might work together to maintain services - this will be important when planning future priorities. Lastly, CMO raised the issue of contact – across the country, everyone has felt the effects of change in contact, for example, virtual meetings rather than face-to-face. For those who do not conduct their day to day business in this way, for example veterans who may be experiencing isolation and have had reduced contact over the last few months, this would be felt even more keenly. CMO said that the SOG should do what it can to encourage better forms of contact and support for those who need it.
3. 2019-20 Priority Areas – Implementation Group Annual Report
3.1 Jason Leitch’s letter to CMO of 17 September refers. CMO invited Jason to talk through the highlights and to indicate where more work is needed, so that this can inform the identification of new priority areas for 2020-21, bearing in mind some of the challenges which have been raised and the potential impact of these on delivery.
3.2 Jason explained that in 2018, it was decided to review all elements of armed forces and veteran’s health and wellbeing. This was done in parallel with the Scottish Veterans Commissioner’s report of 2018 on the subject. It was decided to create two layers of governance: one is this Group (SOG) to provide strategic direction and the second is the Implementation Group (IG), which Jason chairs, to work in partnership with NHS Champions and other stakeholders to implement improvement on priorities, as directed by the SOG. The IG has been working on 2019-20 priorities since May 2019, albeit the last six months have been buffeted by Covid and progress has been impacted. In terms of 2020-21 priorities, Jason suggested that these should also take into account comments made by the Scottish Veterans Commissioner in relation to priorities post-covid, as he has a broader lens than those working specifically in health.
3.3 Jason spoke to the achievements and next steps set out in the letter and invited questions. He said that mental health should be the number one priority for the SOG and IG and he is pleased that a veterans mental health action plan is an immediate priority for the Scottish Veterans Care Network. Jason also highlighted other work that the IG has undertaken, aside from SOG priorities, such as veterans aware accreditation for hospitals and primary care and orthopaedics, which has been paused and can be revisited when it is practical to do so. In terms of employability, it was suggested that employment of veterans within NHSScotland should be a priority. He ended by highlighting the work that is necessary in identifying veterans, which will be progressed, led by Mairi McKinley, and the work of the Scottish Veterans Care Network on identification and use of data.
3.4 On this basis, Jason suggests that the IG progresses work that is already in train, and suggested the key priority areas for 2020-21 are Mental Health, Employability of veterans within the NHS and Priority Treatment. The basis for this suggestion is that:
- Mental Health is of increasing importance within the post-covid veterans’ health landscape, and members’ views and experiences expressed at the meeting further supports that. Mental Health has been highlighted by the Scottish Veterans Commissioner (SVC) as a key priority and 2021 will see the Scottish Veterans Care Network producing it’s Veterans Mental Health Action Plan.
- Employability of veterans has also been highlighted by the SVC as a key priority going forward and, as NHSScotland is Scotland’s largest public sector employer, the SOG can have influence in this area.
- A small number of Scottish representatives have been involved in a pan-UK working group on Priority Treatment over the last 12 months. This group has recently concluded, with a recommendation that administrations should work on messaging to meet their own needs, in order to i) encourage veterans to identify themselves and know their rights, ii) ensure that healthcare providers are clear on the priority treatment context to their work. Priority Treatment will also be of importance because of the new Armed Forces Covenant legislation (see agenda item 5) and because of the issue raised by Craig Cunningham on veterans’ access to services (para 3.12 refers).
3.5 CMO thanked Jason and IG members for their contribution in pushing forward this work, said that we should continue to strive for more, and invited questions or remarks.
3.6 Neil Morrison fed back positively on the SOG / IG structure which he considers is working well. He appreciates that everyone on these groups is invested and is pushing in the same direction. Secondly, he agreed with Jason’s point around difficulties in identifying veterans and considers that gaining access to MOD medical records is key to this. Lastly, Neil reflected concerns around V1P – specifically that, at present V1P is not funded after April next year. Neil recalled a similar situation two years ago which resulted in V1P being co-funded between SG and NHS Boards. As a direct consequence of that, 25% of V1P services in Scotland were lost when Highland and Grampian withdrew. In the longer term, Neil is aware that the Network will consider, along with Combat Stress and V1P, how best these services can be delivered, but he expressed concern that this review could not be conducted in time to have a solution in place before April 2021. He asked that consideration be given to funding V1P as it stands for another year which could allow a seamless transition to any new model, with minimal impact on clients. In addition, Neil is aware of considerable concern expressed in relation to V1P staff job security.
3.7 Ian Cumming echoed Neil’s sentiments and referred to the pressure that Combat Stress are currently under, saying that both of these mental health services need to be closely looked at.
3.8 Lucy Abraham of V1P Lothian and the Scottish Veterans Health Network agreed with Neil and Ian. She said that Lothian have a firm staff team who are working incredibly hard but this is being impacted due to uncertainty over future funding. Lucy clarified that whilst the Network will be writing a veterans mental health action plan which will suggest ways of working, celebrate successes and suggest new ideas. It will inform views on funding models and pathways, but will not make decisions on funding of specific services. Currently both V1P and Combat Stress have significant funding from Scottish Government Mental health division that ends at the end of the 2020/21 financial year. This Veterans Mental Health Action plan will be produced by Autumn 2021 and Lucy considered that one additional year’s funding to V1P/combat stress would allow time for this SVCN document to make recommendations that may inform decisions around funding models. She added that all six NHS boards have confirmed that they will provide 50% funding, therefore continuing the co-funding arrangement that was set up at the last funding round.
3.9 Rod Cavanagh agreed and referred to V1P in Fife who are looking to increase capacity.
3.10 Craig Cunningham referred to colleagues in mainstream services who recognise that they do not have the particular understanding of veterans’ needs nor the network that V1P has built. Craig said that he would support the suggestion of one additional year’s funding, as suggested by Neil and Lucy, and considered that this would be a very realistic and worthwhile way forward. Craig informed the group that NHS Champions are often contacted by organisations such as the Citizens Advice Bureau seeking support for veterans, often in very difficult circumstances. Craig spoke of the importance of accessibility of bespoke services for these individuals and how this may fit into a landscape where there is general pressure on access to services. Typically, in such situations, Champions would request that V1P work with the individual until the service they need can be accessed.
3.11 Jason invited Lorimer Mackenzie from Mental Health division to provide input from a policy perspective. Lorimer confirmed that mental health division continue to be in discussion with V1P about funding and that he understands the pressures and the considerable risk of losing expertise. Through the Scottish Veterans Care Network they are also discussing future models of funding for veterans’ mental health services. Lorimer has seen similar circumstances with other sectors and with colleagues he is doing his best to minimise risk and put measures in place to assist the situation. Lorimer asked that members and their contacts keep him in touch on the type of challenges, pressures and sensitivities that are being experienced so that these can be taken into account as discussions progress.
3.12 Jason thanked everyone for these suggestions and reflections and confirmed that the situation with V1P would be looked at as a matter of urgency. In relation to Craig’s point about veterans’ access to services, he acknowledged that access and waiting times will be a global issue going forward and suggested that the Implementation Group looks closely at what this will mean for veterans’ right to priority treatment. He suggested that this issue could be part of another discussion, possibly with NHS Board Medical Directors.
Action: Access to Services for veterans to be revisited at future Implementation Group meeting to construct a specific ask – secretariat to note
3.13 CMO thanked all who had contributed and said that the issue around V1P should be progressed quickly. He requested a targeted approach on this, ahead of other priorities of the Implementation Group.
Action: Secretariat to liaise with relevant officials to provide an update on V1P and feed back to the group.
3.14 In respect of veterans’ access to services, CMO reflected that this could be dealt with very closely with the work on identification of veterans, and suggested that the Implementation Group might usefully involve Jonathan Cameron from the Scottish Government’s e-health directorate in discussions around how we encourage veterans to identify their status. He reflected that unless a patient is clearly identified as a veteran, it can be very difficult to put in place appropriate arrangements relating to their care, so identification is at the foundation of the priority treatment issue.
Action: Secretariat to make linkages between identification, access and priority treatment for the Implementation Group members’ progression of these issues.
3.15 Towards the end of Jason’s letter of 17/09, he suggests potential priority areas for 2020-21 – mental health; employability of veterans within NHSScotland and priority treatment. A narrative around the basis for these suggestions is set out at para 3.4. CMO drew attention to these suggested areas and invited views. The group were in agreement with these being the priority areas going forward and Jason suggested that around priority treatment, this should be expanded to include work on veterans’ access to services, as set out at paras 3.10 and 3.12. CMO agreed and asked that identification of veterans is taken within this area also. This was agreed by members.
3.16 At this point, CMO was required to leave the meeting. Jason assumed the role of Chair. Before he left, CMO expressed gratitude to all members for their contributions and said that he looks forward to engaging with the group in future discussions.
4. Scottish Veterans Care Network Presentation
4.1 Lucy Abraham of the Scottish Veterans Care Network (the Network) gave a presentation on progress of the Network and intended next steps.
4.2 Before she began her presentation, further to the discussion at item 3, Lucy enquired about Scottish Government guidance relating to face to face groups e.g. drop in sessions. Previous guidance had indicated that these could still operate in small numbers, and Jason confirmed that this was the case and said that numbers should be regulated in terms of the size of group. He confirmed that this is the case for all types of therapy groups and included those groups to reduce isolation in vulnerable populations as long as sufficient measures are in place.
4.3 Lucy referred to a full presentation which has been given at other similar interest groups, for example, the last Implementation Group on 1 September 2020, where a number of SOG members were present, so she intended to discuss only the most recent progress.
4.4 Lucy explained that the vision of the Network is to be a “collaborative national strategic network with a cross section of stakeholders facilitating best practice, care and outcomes for veterans health and wellbeing so that all veterans will enjoy a positive state of health and wellbeing and will feel empowered to identify their needs and co-produce services”. Over the past months, the Network has been producing strategic documents and having them ratified, and has confirmed membership of their governance groups and working groups – some SOG members are on these groups.
4.5 Other key points:
- Veterans Mental Health Action Plan will be produced in the Autumn of 2021
- In terms of gathering data, the Network is issuing a proforma on what services are available, going out soon
- Deliverables will be sound, measurable and attainable. Early objectives have been identified as: the mental health action plan; the mapping of current stakeholders and services over Scotland; to reduce barriers to veterans accessing mental health services; to lead on education in terms of awareness of veterans’ needs, to look at data and information, and to conduct a systematic review of literature to ensure the work of the Network is evidence based, and to enhance relationships via engagement with stakeholders.
- The Veterans Mental Health Action Plan (the Action Plan) can encompass a lot and will provide a plan which is informed, developed and based on evidence. It will celebrate good practice and will plan to redesign systems and pathways and will plan new approaches to the care of veterans. It will also develop a supportive network of veterans’ services and will make a range of recommendations to inform decisions on funding priorities going forward. What it will not do is refer to physical health, welfare or substance misuse at this initial stage. It will not critique specific providers and will not give direction on what to fund, more to comment on the best way to deliver. Development of the Action Plan has begun, although engagement with veterans with severe needs is difficult at the moment, as is engaging with services who have other priorities.
- As discussed earlier, the production of the Action Plan in Autumn 2021 would support the suggestion of funding V1P for one more year, then using the Action Plan as a basis for decision making.
4.6 Lucy invited questions or observations:
4.7 Neil Morrison asked whether the mapping of stakeholders would include third sector members of Veterans Scotland with an interest in mental health services, and how they may be able to support the provision of core services – Lucy confirmed that all of these vital services are involved; secondly, Neil asked for confirmation of the Network’s approach to services which are working well – again, Lucy confirmed that efforts will be focused towards areas that may be improved, not those that are currently performing well.
4.8 Jason thanked Lucy for her contribution and said that he looks forward to regular updates within the Implementation Group.
Action: Secretariat to circulate Lucy’s presentation to members
5. Presentation from MOD, followed by discussion on new UK Armed Forces Covenant Legislation
5.1 John Shivas of the MOD Covenant Team gave a presentation on the work his team are leading to develop new legislation on the Armed Forces Covenant which will create a legal duty of due regard to the principles of the Covenant on Health, Education and Housing public services, as they relate to the Armed Forces Community. The intention is that this will cover the four nations of the UK so John’s team are conducting comprehensive consultation of stakeholders in order that the context of services at national level, and the impact of the legislation, are fully appreciated and accounted for. John expressed gratitude to the group for their engagement on the subject, and described the intention and rationale for the legislation, the duty of due regard that the legislation will place on public service providers and the benefit of raising awareness of the Covenant. There will be continued consultation and guidance on how this duty will be subsumed into good practice. In addition, the MOD are working with the Armed Forces Covenant Fund Trust who are preparing a digital learning package to accompany the new legislation. John then invited questions.
5.2 Jason thanked John for his contribution and asked John Mooney of the Veterans and Armed Forces Personnel Unit to explain the Scottish Government level work that is being undertaken on the planned new legislation. John and his team have been working with MOD on the supporting policy document which is currently in an English context, but the intention is to create a Scottish version which we can come to agreement on. For the legislation to come into force in Scotland, a Legislative Consent Motion will need to proceed through various stages before being voted on by the Scottish Parliament,. John described the stakeholder focus sessions that have taken place and his close work with policy areas e.g. health to ensure a comprehensive, collaborative approach.
5.3 Mark Henry asked John Mooney whether engagement with stakeholders has included those who are currently serving in the forces, from a medical perspective. John Mooney confirmed that Major Laura Cox from 51 Brigade, Army HQ Scotland led on organising the stakeholder events and John Shivas said that it is their intention to consult with such colleagues but had placed a priority on engaging with those who provide public services and who the new legislative duty would be placed upon. However, he said that they would be looking for input more widely when constructing the guidance. In addition, they have been working closely with regional points of contact within Army brigades throughout the process. Mark thanked John Mooney and John Shivas for this clarification and said that he would feed specific points through the Surgeon General’s team.
5.4 Lastly, John Shivas flagged a zoom event which will take place on 14 October on the Armed Forces Covenant in the Community, and encouraged all interested colleagues to join.
Action: Secretariat to share details of this event
5.5 Jason thanked John Shivas and acknowledged the different health infrastructure in Scotland, in comparison to England. If passed in Scotland, it will be important for this group to know how this applies for health services in Scotland and Jason said that they will be keen to stay engaged as this work progresses.
5.6 Latterly, John Mooney confirmed that a priority for this work is to ensure that it is fit for purpose in Scotland, in order to progress through the Scottish Parliament. Jason added that it will be important to ensure the legislation is set around the context of the work that is being done in Scotland for the armed forces and veterans community, for example the work of this group, in order for the legislation to function. Ruth highlighted the challenges around the Scottish Parliamentary timetable and the need for full engagement with stakeholders. Mark Henry added that he would be happy to feed in to this process to ensure it is fit for purpose.
6. 2020-21 Priority Areas
6.1 Further to the discussion at para 3.15, Jason invited additional suggestions on 2020-21 priority areas. It was agreed that the priority areas for 2020-21 will be:
- Mental Health
- Employability of veterans within NHSScotland
- Priority Treatment – messaging, veterans’ access to services and identification of veterans
6.2 The Implementation Group will progress these areas, as well as continuing some of the work in train from 2019-20 priorities. The work that Jason described under item two which is not related to a priority area will be resumed when it is practical to do so.
6.3 Jason said that he would like to engage with the Scottish Veterans Commissioner on these priority areas.
Action: Secretariat to arrange a discussion between Jason and the Scottish Veterans Commissioner.
7.1 Jason invited any other business from members:
7.2 Mark Henry raised the issue of antibody testing for MOD divers, particularly those involved with bomb disposal (population of 80) – Action: Mark to send details to Ruth Jays so that this can be progressed with policy colleagues.
7.3 Karen Ross, Army Families Federation raised two points on behalf of the Naval Families Federation:
- Difficulties experienced by forces families when registering a newborn baby at a local GP practice. Action: Katie Hislop to liaise with Primary Care colleagues and share advice with Karen.
- Issue of quicker transferring of medical records when serving personnel or spouse is pregnant and the family relocate. Action: Katie Hislop to investigate
7.4 Lastly, Karen made members aware of the newly launched NHS England forces families engagement project. Action: Secretariat to circulate a link to members
7.5 Neil commented upon individuals who are awaiting medical appointments, due to the pause on services earlier in the pandemic, and connected to the mental health impacts of this time of uncertainty. Neil was aware that this would be a Board issue but suggested that Board Medical Directors may be prompted to issue some form of follow up communication to reassure and inform people on waiting lists.
Action: Secretariat to pick this up with Performance Management colleagues
8. Date of Next Meeting
8.1 Jason reminded members that this Group has traditionally met annually in May, albeit May 2020 was not possible. He suggested two options:
- Resume the May timing and meet in May 2021. This will mean the IG have 7 months to deliver priorities.
- Keep the 12 month recurrence and meet again in October 2021
8.2 The majority of members expressed a preference for resuming the May timing.
Action: Secretariat to canvass members May 2021 dates.
8.3 Jason thanked members for their time and contributions, and closed the meeting.