Support for Veterans and the Armed Forces community: report 2018

Annex

Scottish Government response to: Veterans Health and Wellbeing:

A Distinctive Scottish Approach

Recommendation 1 – A Distinctive Scottish Approach to Veterans’ Health

The Scottish Government and NHS(S) should commit to establishing a distinctive Scottish Approach to Veterans’ Health at a strategic level, accept or adapt the guiding principles of this approach and work with their partners to embed it at an operational level.

We are committed to the general principles of establishing a distinctive approach to veterans’ health and are working with the Joint Group on Armed Forces and Veterans Healthcare and with stakeholders to consider how best to establish this in practice, to ensure their healthcare and support is of the highest standard.

The guiding principles set out in the report are entirely consistent with our ambition for safe, effective and person-centred healthcare as set out in the healthcare quality strategy for NHS Scotland. The integration of health and social care in recent years has changed the delivery landscape for healthcare in Scotland, so we need to ensure that the mechanisms that are in place to support veterans’ healthcare are still fit for purpose.

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.

In relation to cross-border networks, Scottish Government officials actively participate in the Ministry of Defence /Department for Health Partnership Board and their various sub-groups.

We will look to strengthen this participation going forward and will share information on our progress towards these recommendations and other work to improve healthcare for veterans in Scotland on an ongoing basis.

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.

The Director General for Health and Social Care chairs an annual Joint Group on Armed Forces and Veterans Healthcare. This includes representatives from the serving community and veterans’ organisations, Scottish Government officials and other stakeholders.

We are considering how best to refresh the structure, membership and remit of the group to take forward the recommendations of the Scottish Veterans Commissioner’s report and will submit proposals shortly. It is likely that this will consist of a smaller, operational delivery group which will take forward actions agreed at the Joint Group and report back to them.

We aim to have a refreshed structure in place by the end of the year.

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.

We are discussing the option of establishing a Managed Clinical Network ( MCN) for veterans with NHS National Services Division who lead on MCNs. NHS National Services Division are providing advice on the necessary next steps, time-frame and funding required. We would envisage a range of stakeholders and interests being involved in discussions around this option.

Networks are a well-established way of driving improvement in the quality of care through a co-ordinated approach to: service mapping; improving care pathways; tackling inequalities; developing standards; training; awareness raising; data support.

Recommendation 5 – Mental Health Action Plan

The Scottish Government and NHS(S), through the network on veterans health (see recommendation 4), should produce a Mental Health Action Plan for the long-term delivery of services and support. Systemic issues of funding, collaboration, leadership, planning, governance and training of staff will be key.

As outlined above, we are developing a proposal around an MCN for veterans which would enhance care and support for veterans’ physical and mental health.

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.

We also continue to invest in mental health services. Last year the Scottish Government provided £825,000 to support the Veterans First Point services network and will provide a further £1.6 million over the next two years to 2020. Funding for the provision of specialist and community outreach mental health services by Combat Stress for veterans resident in Scotland through commissioned service arrangements with NHS Scotland totals £4.272 million over the next three years, to 2020/21.

The Scottish Government’s suicide prevention plan has as its overarching aim continuing the long-term downward trend in the suicide rate in the general population, including people who have served in the Armed Forces.

Recommendation 6 – Drugs Misuse

The Scottish Government and NHS(S) should assess the scale and nature of drugs misuse – especially prescription and non-prescription painkillers – amongst the veterans’ community in Scotland and introduce remedial measures. This should be taken forward by the Joint Group and network, and included as part of the Mental Health Action Plan.

The SVC highlights the lack of basic data and medical statistics on veterans which makes it more difficult to measure outcomes, shape policy and address the health inequalities that affect this group. We recognise the importance of being able to identify veterans so we can understand their distinct needs, including health inequalities and specific issues such as drug misuse. The Scottish Government is refreshing our drug strategy - Road to Recovery – which will be published in autumn 2018. The new strategy will recognise that there needs to be a range of services supporting different people with different needs.

In April 2019 a new database will be introduced - the Drug and Alcohol Information System ( DAISy). DAISy will gather key demographic and outcome data on people who engage in drug/alcohol treatment services and a field identifier for veterans has been included. Therefore, data will be available on the nature and scale of drug misuse among veterans across Scotland in the future.

DAISy will provide a single data record for individuals as they move through treatment and recovery services, giving detailed pictures of treatment journeys. Alongside this, there is potential to link this data set to other health and social care datasets providing a more detailed picture of service demand.

Recommendation 7 – Barriers to Accessing Services

The Scottish Government and NHS(S) should build on existing work aimed at reducing barriers to veterans accessing mental health services. This will include measures to address issues of stigma, seeking help, and improving awareness and understanding within the medical profession. This should be taken forward by the Joint Group and network, and included as part of the Mental Health Action Plan.

We will work with the Joint Group through the refreshed structure to identify barriers to accessing mental health services. As noted above, we are exploring the establishment of an MCN for veterans.

As a result of discussions at the Joint Group, updated materials to raise awareness of veterans’ health needs have recently been shared with NHS Board Champions and healthcare practitioners, focusing on those in primary care. This includes guidance for GPs on how veterans can share their full service medical record with their GP.

Recommendation 8 – Access to Life-long Services

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

Veterans Champions are in place in every health board and Local Authority in Scotland. We are considering how we can make best use of this network going forward and how it can better feed into strategic level discussions and influence national policy where required. There are local models of strong networks which support Armed Forces and veterans’ healthcare and which are working effectively and we are keen to build on and share this information so that veterans across Scotland can expect the same quality of care and support. We aim to share local models of best practice with Champions by the end of the year.

In Scotland, commissioning for adult health and care services is undertaken by Integration Joint Boards ( IJBs). They have a duty to consult their constituent populations and service planning is undertaken based on a population needs assessment. These will include needs of specific population groups such as veterans where they can be identifiable in health statistics or via the stakeholder engagement process.

Recommendation 9 – Funding for Multiple Injuries

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

This will be considered through our engagement with the National Trauma Network (see below) and through our discussions with NSD (around establishing an MCN).

Recommendation 10 – The National Trauma Network

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

The South East Trauma Network is exploring the introduction of exercise rehabilitation instructors as part of the multi-disciplinary team within the acute trauma pathway.

Still in its early stages, this is based on evidence from rehabilitation in the military. The Scottish Trauma Network’s Rehabilitation Group is looking at the draft rehabilitation plan developed by the North of Scotland region to develop a tool that can be used to support the management of patients across Scotland. More information is being sought from the network around timescales.

Regions are active in producing their own rehabilitation plans with the advice of UK wide experts.

We will continue to work with the Scottish Trauma Network to see how we can ensure veterans’ needs are met.

Recommendation 11 – Wheelchairs for Amputees

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

Specialist wheelchairs are provided based on clinical need in line with nationally agreed criteria.

The mobility needs assessment takes account of each individual’s wider circumstances and goals in order to ensure that the most appropriate solution is provided for the individual. Long-term specialist wheelchair provision in Scotland is the responsibility of the NHS, and is delivered by clinicians across a hub of five regional centres.

We are working with NHS Boards to clarify whether they are having any difficulties sourcing appropriate specialist wheelchairs for veterans, and how this might be made to work more flexibly.

Recommendation 12 – Chronic Pain Management

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

NACCP is taking forward strands of 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 minimum dataset and a set of Quality Performance Indicators ( QPIs) that could be used to measure services, outcomes and improvements for people living with chronic pain, including veterans. We are continuing to monitor this.

Recommendation 13 – Funding Hearing Aids

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

The Scottish Government is committed to improving the care, support and services available to people who have deafness, sight loss and dual sensory loss through its long term strategy ‘See Hear’.

The strategy is jointly endorsed by COSLA and is being implemented through local partnerships between statutory and third sector partners. In Scotland, hearing aids are provided through NHS audiology services, following a specialist assessment of each person’s individual needs. Veterans (including those who have served as reservists) receive priority access to NHS primary, secondary and tertiary care, for any conditions relating to their service, including audiology, for hearing loss. NHS audiology services in Scotland are delivered by NHS Boards from their baseline funding.

Each NHS board's audiology service has policies that detail service provision. This will typically cover the types of product used and the methods of assessment and fitting of devices to patients. When replacing broken or obsolete hearing aids, where appropriate, a like for like replacement should be provided.

We are working to establish whether there are any barriers to veterans receiving the hearing aids and support they require.

Recommendation 14 – The Invictus Games

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

Scottish Government officials and Event Scotland are considering what would be required to progress a bid to host the Invictus Games in Scotland. They will evaluate the Sydney games taking place in October this year which will provide a sense of the scale, budget and delivery required.

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.

We recognise the importance of supporting veterans’ healthcare needs. Work around establishing a distinctive Scottish approach to veterans’ healthcare will help tackle health inequalities. Discussions about how best to achieve this are ongoing with the Joint Group and with stakeholders. Wider work being done by the Scottish Government, Health and Social Care Partnerships and NHS to tackle health inequalities in the wider population will also have a positive impact on veterans’ health.

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.

As the Commissioner’s report recognises, there are barriers around veterans identifying themselves to health and social care services. We are working with the Joint Group to consider how we can overcome these and increase the number of veterans declaring themselves to health care providers, while recognising that it is a veteran’s personal choice whether they do so or not.

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.

We have worked with Veterans Scotland to update information about veterans’ health on the NHS Inform website. This was followed with a campaign to raise awareness of the updated information and the signposting services available to coincide with Armed Forces Day 2018. NHS Inform are currently evaluating the impact of this.

As already highlighted, updated materials to raise awareness of veterans’ health needs have recently been shared with NHS Board Champions and healthcare practitioners.

We recognise the importance of being able to identify veterans so we can understand their distinct needs, including health inequalities and specific issues such as drug misuse. We note the recommendation that MOD publish statistics at Local Authority and Clinical Commissioning Group level.

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.

We are working with stakeholders including Veterans Scotland to consider how we can make better use of the network of champions in health boards and Local Authorities. We aim to share local models of best practice with champions by the end of the year. Champions will also play a key role in the refreshed Joint Group which will strengthen their role.