GP Dr Ian Morris looks at why Government guidance to prioritise current or ex-service personnel in the NHS is not being implemented and what GPs should be doing when referring these patients.
With over 9,000 British armed forces personnel currently in Afghanistan and 46,000 at the height of operations in Iraq in 2003, the vast majority of us will have had a relative, friend or patient who has served in the armed forces.
After they return home, these armed forces veterans are meant to be prioritised for the treatment of service-related conditions in the NHS, but a recent poll found the vast majority of GPs had no idea about this requirement.
This article will look at the responsibilities of practices with regards to ex-service personnel and the sources of support that they can expect to receive.
Armed forces veterans
In order to qualify as an armed forces veteran, you need only serve in the armed forces for one day. This means there are approximately 5 million armed forces veterans in the UK.
Upon joining the armed forces, care of an individual is handed over to the Defence Medical Services (DMS), employing more than 6,500 uniformed medical staff.
One of the DMS's main roles is primary care, i.e. general practice, dentistry, occupational medicine, community mental health services in the UK and some overseas defence outposts.
It provides rehabilitative services in centres such as Headley Court and also commissions secondary care services from several NHS trusts. DMS would likely provide care for the families of personnel if relocated overseas, but if living in the UK, the NHS has that responsibility.
Currently in Britain there are over 190,000 serving personnel (and 32,000 reservists). Approximately 18,000 of these return to civilian life each year, most of whom will return back to NHS primary care. Only a minority, usually the severely injured, will continue to have input from DMS.
Toll of war
The wars in Afghanistan and Iraq have inflicted a terrible toll on all sides. There have been 451 deaths in British forces, up until Feb 28th 2010, and 1458 wounded servicemen. Mental health outcomes may difficult to predict, but rates of PTSD, vary from 1% to 8% of personnel studied following recent conflicts.
It is worth bearing in mind that the majority of combatants are unlikely to suffer service-related physical or mental injury in the short or long term. The most common reason for medical discharge is musculoskeletal disease (including disorders from over-use), which accounts for around one third of all medical discharges (DASA, 2003).
However, there is also evidence that the health needs of the ex-service community differ from the general population.
Compared with a third of the general population, around half of veterans have long term illness. Often, it's not straightforward, as besides the obvious musculoskeletal problems associated with carrying heavy packs or noise-induced hearing loss, there are the more unusual problems such as tropical illnesses and controversial problems involving ‘gulf war syndrome' and nuclear test veterans. American studies have even suggested a higher than average cardiac risk for veterans with PTSD (Boscarino 2008).
The risk of mental health disorders and alcoholism is higher in veterans (Lverson 2009). A recent study showed that the risk of suicide of males under 24 is at least three times higher if they have served in and subsequently left the armed forces (Kapur et al 2009).
Reservists have their own unique issues. For example, following a study of reservists in Iraq, they are twice as likely to develop mental health problems including PTSD. They also tend to return to a civilian life with a different support structure, compared to regular service personnel (Hoptof et al. 2006).
From a social perspective the outlook is also poorer for veterans, with higher unemployment in younger ex-service leavers (NAO 2007). Around 8.5% of the prison population is thought to be ex-service (NAPO 2009).
The only reassuring statistic is that targeted schemes may have helped reduce the number of homeless veterans from almost 25% in the late 1990's to a more recent study suggesting a figure of one in ten.
Since the publication of the Ministry of Defence's Command Paper: ‘The Nation's Commitment: Cross-Government Support to our Armed Forces, their Families and Veterans' in 2008, the future health needs of these UK veterans is now a topic being addressed throughout the tiers of the NHS and MOD.
It has been longstanding practice since the 1950's for NHS hospitals to give priority outpatient and inpatient treatment to veterans, for conditions ‘they receive a pension or gratuity'.
In 2008, the Department of Health changed this to extend that priority to all veterans, but only for ‘service-related conditions'. There is of course the proviso that this priority is annulled in the case of a separate clinical priority or emergency case.
However, a 2009 Mori poll of 500 GP's found that 81% of them ‘knew not very much or nothing at all of priority treatment' and a third of GP's polled knew nothing of the scheme. Unsurprising, the poll also revealed that 85% of them had not communicated that fact that a patient is an armed forces veteran to secondary care on referral letters.
From the guidance documenting that a patient is a veteran is essentially all that should need to be done (even if using Choose and Book) by GP's. Especially as the guidance also outlines that whether or not a condition is related to service is decided by secondary care clinicians on reading the referral letter, which would then allocate priority or not.
Coding of veterans can be a problem on GP systems, but as communicated in the guidance, veterans should be coded when receiving their medical records e.g. using 'history relating to military service code' Xa8Da.
Mental health support
In view of the heavy casualties and concern over PTSD, more returning personnel are starting to undergo ‘decompression'.
These programmes give personnel the chance to mentally and physically unwind, and talk about their experiences to friends, colleagues and superiors before returning home. In the Royal Marines a new approach is being pioneered called TRiM, where returning combatants are debriefed by trained peers.
Pilot schemes involving the charity Combat Stress have been set up across the UK, in London, Cardiff, Stafford, Newcastle, St Austell and Edinburgh. Each pilot is purposefully different, ranging from giving simple advice, to therapeutic treatments. Referral is self-directed, with GP referral via organisations such as the Royal British Legion.
Outside these areas, veterans who have been deployed on operations since 1982 can access the Medical Assessment Programme (MAP) at St Thomas' Hospital London. Here they can receive full mental health assessments and support and advice on treatment options.
Additionally, Combat Stress, the MOD, and Department of Health will also be jointly funding workers to be placed in mental health services in areas of the UK with a high proportion of veterans. (MAP Freephone 0800 169 5401).
The Reservists Mental Health Programme offers assessment and treatment for demobilised reservists and can be referred to by GP's: (Help line no 0800032658).
Advice and support can be accessed via Veterans UK (www.veterans-uk.info) or charitable bodies such as the Royal British Legion (www.britishlegion.org.uk) and Combat Stress (www.combatstress.org.uk).
Planning for the future
The myriad of issues surrounding the future care of veterans are still to be worked through, many being complex and some contentious.
Examples of ongoing work include:
• Nine out of ten SHA's have asked their PCT's to address veteran's needs in particular for example in their Improving access to Psychological Therapies delivery plans
• The MOD are also working to ensure that prostheses for amputees will be able to be maintained in the future by the NHS
• There are plans for Choose and Book options and even some ideas around QOF, but these have not been finalised
• The Royal British Legion in partnership with Combat Stress have recently been appointed ‘third sector strategic partners', and are hoping to improve communication and dialogue with the DOH and act as advocates for health and warfare for veterans
However referral guidance and clearer care pathways for primary and secondary care, would be helpful, as well as robust commissioning (particularly from PCT's with a higher proportion of veterans).
The ethics and morals can be debated, but what is clear is that these men and women who have served in hostile environments warrant our ongoing support for their physical and mental well-being.
Dr Ian Morris is a GP in Totnes, Devon, and a member of the South West Armed Forces ForumDr Ian Morris