Scottish Government

Healthcare

The Scottish Government and the NHS in Scotland are committed to ensuring that we have the highest possible quality of healthcare in place for Reservists, those leaving the Armed Forces, Service families and veterans. Accordingly, Reservists and those who return to civilian life from the Armed Forces can and do access the NHS in Scotland just like every other citizen. In the vast majority of cases this transfer will be an easy and seamless process. However, the relatively small number who are discharged as a consequence of ill health or injury may require specific healthcare and welfare services to support their needs.

The MoD is responsible for meeting the health needs of Serving personnel, including the treatment of those injured on operations, while they remain part of the Armed Forces. Similarly, those who become ill or injured through accident in Service will be treated by the MoD in an appropriate setting determined by the Defence Medical Services. However, Serving personnel can and do access the NHS in Scotland as citizens.

The health needs of Reservists not on operations and of families of serving Armed Forces personnel fall entirely to the NHS in Scotland. Their clinical needs will be met at the appropriate point of entry to NHS support and services as and when it is required. However, it is vital that, as they move from base to base, sometimes from other parts of the UK and overseas, NHS services are prepared and ready to cope with demand when and where it arises.

Veterans may also have particular health needs. Most can readily
be met through access to routine primary and secondary NHS care. However, healthcare providers must be aware that some Service‑related conditions may take years to manifest, and be ready to enquire about former periods of Service.

In order to ensure that the NHS in Scotland is prepared and ready to meet the challenge of tailoring healthcare for the Armed Forces community, the Scottish Government has put in place a wide range of initiatives and programmes. These comprehensive measures have been designed to remove any disadvantage faced by the Armed Forces community in accessing NHS services. For example, we have:

• Extended the Priority Treatment scheme to allow veterans priority access to treatment for Service-related conditions (including Reservists, serving and retired);
• Committed resources so that Armed Forces personnel and veterans who lose limbs whilst on active Service receive a similar standard of state of the art prosthetics from NHSScotland, which match the standard of prosthetic limbs given by the Defence Medical Services;
• Accepted in principle all of the recommendations made in Dr Andrew Murrison's report, A Better Deal for Military Amputees, which was published on 31 October 2011;
• Provided millions of pounds in funding over recent years to support specialist mental health services for veterans and their families who experience mental health problems;
• Raised the level of awareness in the NHS of the needs of Armed Forces personnel and veterans;
• Put NHS Armed Forces Champions in place in every NHS Board in Scotland. These champions take responsibility for leading and co-ordinating issues related to the Armed Forces, their families and veterans in their Health Board area and help resolve local problems linked to access to medical care. They also link to local Firm Base Commanders and individual Unit Commanders in Scotland; and
• Increased dental services provision in areas with significant Armed Forces populations, to meet the needs of their families.

All these arrangements require a close working relationship at both strategic and operational levels. To support this, we have:

• Established an expert Armed Forces and Veterans Group to track delivery of our healthcare commitments. This group is Chaired by the Scottish Government's Director General for Health and Social Care, who is also the Armed Forces and Veterans Advocate for the Scottish Government. Membership is drawn from the senior military, local authority and NHS Armed Forces Champions, third sector organisations and NHS health professionals. The group meets twice a year; and
• Taken an active role on the MoD/UK Health Departments Partnership Board jointly Chaired by Sir Andrew Cash OBE from the Department of Health and Vice Admiral Philip Raffaelli QHP FRCP, Surgeon General at the MoD. The Partnership Board was established to ensure the UK works together to improve the healthcare of the UK Armed Forces, their families and veterans. The Partnership Board is supported by two MoD/UK Departmental groups - the People Working Group and the Services Working Group.

Future Plans

The Scottish Government hosted a conference on "Scotland's Health Commitment to the Armed Forces, their Families and Veterans", on 4 October 2011. It was directed at Local Authority staff, the third sector, NHS and Local Authority Chief Executives and frontline staff, Councillors and senior members of the Armed Forces.

The purpose of the event was to examine and develop practice taking place across Scotland and wider; and to hear about how messages are communicated to the Armed Forces community and how they are supported and informed.

Nine messages and themes emerged which will be further developed. Key amongst these are to:

• Build on the preliminary results of a recent exercise which indicated that veterans have health needs which differ from the non‑veteran community;
• Develop better joined-up working and methods to identify where the greatest needs lie for those leaving the Armed Forces each year who need additional support;
• Examine how the NHS can provide the best support possible for family members while Regulars and Reservists are away on operations;
• Consider whether other Local Authorities could implement welfare pathways similar to Fife Council's pathways pilot and to link these to the Armed Forces Community Covenant; and
• Look at how the services offered by Veterans First Point might be delivered to veterans across a wider geographical footprint.

Those who attended the conference were provided with the full list of themes and details of the web link for the booklet summarising the presentations that were made by the guest speakers. Both the letter and the booklet can be found at our Armed Forces and veterans website pages.

A number of specific interventions will now be explored in more detail.

Prosthetics

Dr Andrew Murrison MP published his report, A Better Deal for Military Amputees, for the UK Government on 31 October 2011. We welcomed this important report and accepted all 12 of his recommendations, in principle, for implementation in Scotland. A short-life working group will be established in Autumn 2012 to plan the implementation of the recommendations and to consider the most appropriate approach to fulfilling the recommendation on a multi‑disciplinary prosthetic centre to meet the needs of veterans across the country and ensure sustainable high quality care as locally as possible. The short life working group will be supported by our State of the Art Prosthetics Group, which is a multi‑disciplinary group consisting of representatives of all five Scottish limb-fitting centres.

The State of the Art Group is currently undertaking work to determine the practicalities and resource implications of delivering the Murrison recommendations in Scotland and how these might be rolled out. This work is being achieved in partnership with the Department of Health and the other devolved administrations.

Review of Ministry of Defence Hospital Units (MDHUs)

MDHUs are based in a number of NHS hospitals in England and facilitate the continuing training, development and maintenance of the clinical skills of Defence Medical Services (DMS) personnel. The arrangements differ in Scotland. Although there is not a specific MDHU, Scotland has a number of military medical staff who undertake equivalent training in Scottish NHS hospitals on terms negotiated with the individual hospitals.

The UK Government contracts for MDHUs are due to expire in 2013, at which time the MoD will have reached a view on whether to continue with this model of training. If the decision is to continue, we have indicated to the MoD that the Scottish Government would support NHS Boards in any bids to facilitate a MDHU or equivalent here.

Community Health Index Numbers

The Scottish Government is extending Community Health Index (CHI) numbers to all serving Armed Forces personnel currently based in Scotland to enable quicker and more reliable healthcare provision. This includes working with the Defence Medical Service Primary Care Medical Centres to include CHI numbers in all communications with NHSScotland.

In particular, this extension of the CHI numbers will enable eligible Armed Forces personnel to participate in Scotland's health-screening programmes such as breast and bowel screening. It will also allow the Defence Medical Service Primary Care Medical Centres in Scotland to access the Scottish Care Information (SCI) Store for electronic lab results and use the electronic referral process.

Other work is being undertaken to help support the smooth transition from Service to civilian life. The developments include early identification of a GP for the Service leaver and establishing processes to support the veteran in the community.

Reception Arrangements For Military Patients (RAMP)

RAMP is the cross‑department UK Government plan for the management of operational military casualties returned to the UK from conflicts overseas.

In 2011 the MoD reviewed its RAMP plan to include a wider geographical spread of provider hospitals. Devolved administrations were asked by the MoD if they wished to identify one or more Major Trauma Centres in the event of activation of RAMP Level 3 (i.e. where RAMP 1 and 2 capabilities located within or close to areas of pre‑existing military medical expertise, for example, the Royal Centre for Defence Medicine in Birmingham, proved unable to accept military casualties because of an unforeseen emergency.

There are no designated major trauma centres in Scotland along the same lines as those in England. However, the Edinburgh Royal Infirmary and the Glasgow Southern General Hospital will operate as RAMP centres as required. This new role will provide the MoD with valuable contingency backup for the treatment of seriously injured Servicemen and women. Scotland's contribution to RAMP will also have clear advantages to the NHS, as it will enhance the specialist skills of the multidisciplinary teams (surgeons, physicians, anaesthetists and specialist nurses) involved in trauma care.

Web-based Healthcare Information

The Scottish Government is developing relevant quality‑assured healthcare information for inclusion on the NHS Inform website. In particular, the site will give information specific to the Armed Forces community, Veterans and Reservists on immunisation and screening programmes, mental health services, how to access Service medical records and how to recognise symptoms such as post‑traumatic stress disorder.

There will also be a general information area to signpost the Armed Forces community, veterans and Reservists to other sources of on‑line help and advice.

Capturing Veteran Status on GP IT Systems

Priority access to NHS care is available to veterans for conditions directly related to their Service. Veterans are encouraged to tell their GP about their veteran status in order to benefit from our priority treatment commitment. However, some veterans are either reluctant to declare their status or are not aware that their status entitles them to priority access.

A revised General Practitioner Registration (GPR) form for Scotland has been devised to encourage veterans to declare their status at the point of registering with a GP practice. This will provide the GP and the veteran with an opportunity to discuss access to priority treatment.

It is anticipated that when the information on the GPR form is processed by the GP practice, the veteran's status can be recorded onto the practice system using the relevant read code(s) which will record a 'veteran flag' on the IT system against the patient record. This flag will then populate the SCI Gateway referral forms with the veteran status.

Veterans' Health Needs

The Scottish Government has just completed the first phase of a two-year study of anonymised health records to examine how veterans' health compares to the health of the general Scottish population in terms of rates of heart disease. We plan to extend this study over the coming months to examine outcomes for other diagnoses. This information will be invaluable in planning health and welfare services which will meet the needs and expectations of veterans.

Alcohol and Drugs Misuse

The Armed Forces are a reflection of the society from which they recruit. It is inevitable therefore that some individuals will become involved in problem alcohol and/or drug use. This may manifest itself in a number of ways but it is important to recognise that it is no more prevalent in the Armed Forces than in an equivalent demographic profile within wider society. Indeed the numbers within the Armed Forces are less than would be expected.

As well as being illegal, the use of drugs impairs performance and can create a highly dangerous situation for the individual and those around him or her. This is an obvious concern in the Armed Forces where the environment can be hazardous, involving heavy machinery, weapons and arduous training. The Armed Forces will not tolerate substance abuse and those who are suspected of being involved will be subject to investigation.

Although the numbers are not high the risk is sufficient that all personnel, regardless of rank who are serving in the Armed Forces are required to take part in Compulsory Drugs Testing (CDT) and this is conducted on a random basis.

A range of management measures are available which allow the Armed Forces to deal with those who are found to be involved in problem alcohol and drug use, which may include criminal proceedings and discharge. However, even if the results of the investigation prove that the individual has committed an offence they will (regardless of the penalty which is levied) be offered counselling and support in order to assist their rehabilitation. The range of support services includes referral to external agencies where appropriate.

Scotland's national drugs strategy, The Road to Recovery, acknowledges Scotland's disproportionate prevalence of problem drug use, affirms the value of evidence‑based harm reduction measures and, crucially, pushes expectations forward to focus on recovery and the unique dynamic of individual forms of addiction.

Changing Scotland's Relationship with Alcohol: A framework for action sets out a broader agenda and adopts a whole population approach. This framework is augmented by guidance for the provision of effective alcohol treatment and support services. The Quality Alcohol Treatment and Support (QATS) report outlines 14 recommendations which, when embedded in practice, will help to better identify and respond to the specific needs of people (including veterans and those in the Armed Forces) affected by alcohol use.

Recovery‑focused treatment and support services enable individuals with alcohol and drug problems to live as meaningful and satisfying lives as possible. This is just as true for those in the Armed Forces and for veterans as it is for the rest of society. There are many paths to wellbeing and recovery and a person's attempt to deal with their problem alcohol and/or drug use is a unique and personal process. It is important that a full range of high quality and accessible services are available at the point of need for all those both directly and indirectly affected (including veterans and ex‑Service personnel).

The provision of services is for each local area to consider, taking account of local needs, circumstances and resources. It is for local NHS Boards, Local Authorities and Alcohol and Drug Partnerships (ADPs) to ensure that appropriate services are provided to meet the needs of their resident populations. ADPs should also consider the specific needs of veterans and Service personnel.

Local areas are progressing well to achievement of the HEAT (A11) drug and alcohol treatment waiting times target which states that by March 2013, 90% of clients will wait no longer than three weeks from referral received to appropriate drug or alcohol treatment that supports their recovery. The achievement of this target will ensure that veterans and Service personnel in need of support will be able to access appropriate treatment at an earlier stage, which is likely to achieve a higher rate of successful outcomes.

Mental Health Care for Veterans

In recent years, Scotland has led the way in developing specialist services for veterans with a mental health problem. This reflects the positive partnership we have with key stakeholders and the wider veterans community.

We are building on that success with the publication of the Scottish Government's new mental health strategy planned for autumn 2012. This will identify and address key issues that will have a significant impact on improving outcomes across the entire population, as well as for veterans and their families. We know that veterans can experience barriers to accessing mental health care. We also know that, by setting the strategic direction for mental health as a whole across mental health improvement, prevention, care, services and support, this will also mutually support improvements for veterans and their families across a range of areas. For example, we will build on work to improve access to psychological therapies, responses to trauma, first contact services for people whether in crisis or not and other outcomes, which have a positive impact on veterans.

The overall goal is the same, whether for veterans and their families or the wider general population; that when people experience mental ill health, they should know how to access help and services should be able to intervene quickly, putting the person, their families and carer at the centre of care and treatment.

Veterans First Point

Following the positive evaluation by Sheffield University as one of six UK community mental health pilots, the Scottish Government continues to fund the Veterans First Point service which is making a significant contribution to improving care and support for veterans and their families in the Lothians. Since its establishment in 2009, over 600 veterans have used the service.

Operating on a 'drop‑in' basis, support and advice covering a range of areas such as health, social, employment and education is offered, with signposting where appropriate to other relevant agencies for further help and support.

We will continue to fund the Veterans First Point service at £200,000 for 2012‑13 and will explore with NHS Lothian and other Health Boards how the service could be extended as a model in other areas of Scotland.

We will continue to work in partnership with Combat Stress as a key partner, bringing their unique expertise to improving mental health care and support to the veterans community. This builds on the strategic relationship between Combat Stress, the UK Department of Health and the MoD, ensuring that we are all working collaboratively to achieve shared objectives.

We will continue to fund the Combat Stress Community Mental Health Outreach Team in the east of Scotland at £200k per year to 2014. We will also continue to fund the provision of specialist mental health services at around £1.2 million for the next three years and consider what further developments can be made to improve outcomes for veterans who need specialist care, treatment and support.

IVF Treatments

Access to IVF treatment, and in particular, the number of IVF cycles given to eligible patients, varies across the UK. One cycle of IVF is available in Northern Ireland, two in Wales, and access in England depends on where an individual lives. However, the majority of Primary Care Trusts in England allow patients one cycle of treatment.

Scottish Ministers agree that recipients of compensation under the Armed Forces Compensation Scheme for injuries which result in infertility should be entitled to appropriate infertility treatment, including IVF, within the NHS in Scotland. In Scotland, eligible patients can access two or three cycles of IVF treatment.

The National Infertility Group was set up in April 2010 to ensure equity and consistency of NHS infertility services across Scotland. The Group is currently reviewing access to IVF treatment, including the maximum number of cycles of treatment available to eligible patients in Scotland. Scottish Ministers would expect clinicians in NHS Boards to respond sympathetically to each individual case involving Armed Forces personnel.

Scottish Ministers are committed to addressing the variation in waiting times for IVF treatment, and are working to establish a maximum waiting time of 12 months by the end of this Parliament.