Veterans' healthcare toolkit
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|Date:||Monday, 24 January 2022, 3:03 AM|
A range of guidance for GPs on the care of patients who have served in the armed forces, and their families.
The Veteran friendly accreditation
We are working with NHS England and NHS Improvement to accredit GP practices as 'veteran friendly'. This programme enables practice to deliver the best possible care and treatment for patients who have served in the armed forces.
Nearly 1,000 GP practices in England are already accredited through this programme. We support these practices to identify and code their veterans, and to appoint a clinical lead who undertakes training and other activities related to veteran healthcare.
We provide accredited practices with an information pack to help increase their understanding of the health needs of veterans, and the services available to them.
Accreditation is voluntary, but is included in the key commitments of the NHS Long Term Plan, which states: ‘To ensure all GPs in England are equipped to best serve our veterans and their families, over the next five years we will roll out a veterans accreditation scheme in conjunction with the Royal College of GPs.’
Accreditation is currently open to GP practices in England. We are working with the Devolved Nations to extend the programme.
For more information, please email firstname.lastname@example.org.
The Veteran friendly accreditation
Accreditation lasts for three years, and practices must commit to the following:
- Ask patients registering with the surgery if they have ever served in the British Armed Forces.
- Code it on the GP computer system. We recommend writing it out rather than using Read codes as these vary according to which computer system is used. We recommend that the term 'Military Veteran' is used.
- Have a clinical lead for veterans in the surgery. This should be a registered health care professional, but not necessarily a GP – it could be a nurse or paramedic
- This clinical lead is required to undertake dedicated training, attend training events (RCGP or other provider), stay up to date with the latest research and innovations and ensure that the practice is meeting the health commitments of the Armed Forces Covenant. They should also be available to provide advice to colleagues, as well as possibly seeing veterans themselves.
- Eligible practices should have a CQC 'good' rating or higher.
Where appropriate, you may need to refer patients to dedicated NHS services such as the Veterans' Mental Health Transition, Intervention and Liaison service (TILS), the Veterans' Mental Health Complex Treatment Service (CTS) and the Veterans Trauma Network.
To learn more about the experience of being a veteran friendly practice, listen to our podcast. In the podcast, RCGP clinical champion Dr Robin Simpson, accredited GP Dr Matthew Boulter and veteran Ashley Winter discuss the healthcare challenges faced by the veteran population in England and the impact of the accreditation scheme.
Prof Nigel Sparrow OBE, the CQC's former Senior National GP Advisor, signposts the programme in his best practice guidance: Take a look at Nigel's surgery 93: Caring for veterans and their families.
- Full list of accredited veteran friendly practices (129 KB XLS)
- A map of accredited practices can be see on Google Maps
How your accreditation helps veterans
As well as being supported to provide the best care to your veteran patients, you will be able to capture better epidemiological data to improve future health provision.
By becoming an accredited practice, you will also ensure that the NHS is better able to meet the health commitments of the Armed Forces Covenant. This states that the Armed Forces community, including veterans, should face no disadvantage in accessing health services and should receive priority care for military attributable conditions, subject to clinical need.
Guidance for GPs
We have produced a range of guidance for GPs on the care of patients who have served in the armed forces, and their families. This has been developed in partnership with NHS England and NHS Improvement. We are currently seeking input from Scotland and Wales.
The toolkit sits alongside our Veteran Friendly Accreditation Scheme, which supports practices to meet veterans’ healthcare needs.
The health needs of military veterans can differ significantly to those of other patients. Ensuring that all GPs in England are equipped to best serve our armed forces veterans and their families is a key commitment in the NHS Long Term Plan.
In this section:
- The veteran population
- Our duty to the armed forces community
- Requesting a patient's service medical records
The veteran population
A veteran is someone who has served in the British Armed Forces (Regular or Reserve) for at least one day. Veterans also include any member of the Merchant Marine who has served in a war zone. This includes crew from convoys in World War 2 and more recently in the Falklands conflict and Gulf Wars.
There are around 2.4 million British Armed Forces Veterans in Great Britain, of whom 89% are male and 60% are aged 65 and over. Clinical commissioning groups are responsible for the commissioning of health services for veterans, reservists and service families registered with NHS GPs in their area. However, there is evidence that some GPs are unsure of how many of these individuals are registered with their practice and more guidance is needed on how to meet the health needs of these patient groups.
About 18,000 service people move back into civilian life every year. While most of these individuals have similar levels of health to the general population, around 2,000 leave on medical grounds. The top reasons for medical discharge are for issues relating to back, knees, mental health and hearing.
Our duty to the armed forces community
The NHS has a duty to deliver on a number of health commitments in relation to the Armed Forces community (service personnel (regular and reserves), their families and veterans), which are set out in the Armed Forces Covenant and the NHS Constitution.
The Armed Forces Covenant
- The Armed Forces community should enjoy the same standard of, and access to healthcare as that received by any other UK citizen in the area they live.
- Family members should retain their place on any NHS waiting list, if moved around the UK due to the service person being posted.
- Veterans should receive priority treatment for a condition which relates to their service, subject to clinical need.
- Those injured in service should be cared for in a way that reflects the nation's moral obligation to them, by healthcare professionals who understand the Armed Forces culture.
Visit the Armed Forces Covenant for more information.
This is recognised in the NHS Constitution, which states:
"The NHS will ensure that in line with the Armed Forces Covenant, those in the Armed Forces, reservists, their families and veterans are not disadvantaged in accessing health services in the area they reside".
Requesting a patient's service medical records
Veterans are given a personal copy of their summary medical record when they leave the Armed Forces, together with information on how to obtain their full service medical record if they need it.
If this has been lost, you can send an email regarding a specific medical record to the contact details below.
Royal Navy / Royal Marines
RN Service Leavers
Institute of Naval Medicine
Hants PO12 2DL
Secretariat Disclosure 3 (Medical)
Mail Point 525
Army Personnel Centre
65 Brown Street
Glasgow G2 8EX
Royal Air Force
Lincs NG34 8HB
Dedicated services for veterans
Veterans' mental health services
Whilst there is often an emphasis on veterans with post-traumatic stress disorder (PTSD), the actual rates are not high (around 6.2%), which is broadly equivalent to the incidence amongst civilians. More common issues include other mental health difficulties, such as anxiety and depression, as well as problems related to alcohol. However, for those veterans who deployed when serving, rates of PTSD are higher at 9% and up to 17% for those who deployed in a front-line, infantry combat role.
There is growing evidence that a range of mental health conditions may appear (or patients may present) some years after individuals have left the armed forces. These conditions may relate to combat, training or other military experiences, transition out of service or indeed pre-service vulnerabilities.
The historical issues of stigma associated with mental health and a traditional culture of reluctance to admitting to a perceived weakness or being in a position of having to ask for help means that a substantial number of unwell veterans are unlikely to access the appropriate support and services. This is further compounded by a lack of awareness amongst veterans of what services are available to them, as well as varying levels of awareness across the NHS on the health needs of this patient group. In addition, the widespread public perception, often fuelled by mainstream media, that all veterans are damaged by their military service and all of them have PTSD is not only wrong but harmful.
Op Courage: the Veterans Mental Health and Wellbeing Service
Op Courage is the new over-arching name for the three NHS veterans’ mental health services (Veteran’s Mental Health Transition, Intervention and Liaison Service (TILS), Veteran’s Mental Health Complex Treatment Service (CTS) and Veteran’s Mental Health High Intensity Service (HIS). The new name has been developed by veterans and their families and is intended to make the services easier to find and access.
Veterans' Mental Health Transition, Intervention and Liaison Service (TILS)
This is a dedicated out-patient service for serving personnel approaching discharge from the Armed Forces and veterans who are experiencing mental health difficulties. The TILS provides a range of treatment, from recognising the early signs of mental health problems and providing access to early support, to therapeutic treatment for complex mental health difficulties and psychological trauma. Help may also be provided with housing, employment, alcohol misuse and social support.
The service comprises three elements:
- Transition: service for those in transition, leaving the armed forces The service works with the Ministry of Defence (MOD) to offer mental health support for Armed Forces personnel approaching discharge.
- Intervention: service for veterans with complex presentation Service personnel approaching discharge and veterans will have an assessment within two weeks of a receipt of referral. Where appropriate, the TILS will aim to see patients two weeks after this. This will be with a clinician who has an expert understanding of Armed Forces life and culture. They may also be supported by a care coordinator who will liaise with other services and organisations to ensure a coordinated approach to their care.
- Liaison: general service for veterans Patients who do not have complex presentations, yet would benefit from NHS care, will be referred into local mainstream NHS mental health services where they will receive treatment and support.
If an assessment finds that an individual has significant mental health difficulties that are service related and have not improved with previous treatment, they will be referred to their local CTS.
Veterans' Mental Health Complex Treatment Service (CTS)
This is an enhanced out patient service for ex-forces who have military related complex mental health difficulties that have not improved with previous treatment. The service provides a range of intensive care and treatment that may include (but is not limited to) support for drug and alcohol misuse, physical health, employment, housing, relationships and finances, as well as occupational and trauma focused therapies.
The NHS Veterans Mental Health High Intensity Service (HIS) for veterans needing urgent help who are in mental health crisis has been trialled in some regions since October 2020. It is now being rolled out across the country as part of a phased approach.
Those needing urgent help will receive a same day referral.
Veterans can self-refer or be referred by their GP, a charity or family or friends to access specialist care through this single route of Op Courage see below:
- North of England services: call 0303 123 1145 or email email@example.com
- Midlands or East of England services: call 0300 323 0137 or email firstname.lastname@example.org
- London or South East of England services: call 020 3317 6818 or email email@example.com
- South West of England services: call 0300 365 2000 or email firstname.lastname@example.org
- See the NHS website for more information as well as this leaflet on veterans mental health services
More than 13,000 veterans have benefitted from specialist care for problems such as anxiety and depression and almost 2000 have received help for more complex problems such as PTSD.
Further details are available on the NHS website.
Veterans Trauma Network (VTN)
Following feedback from veterans, their families and GPs, NHS England has worked with the MOD and key military charities to launch the Veterans Trauma Network, which provides care and treatment to those who have been injured during their time in service.
Located in ten major trauma centres across England (Plymouth, Oxford, London (three centres), Birmingham, Nottingham, Liverpool, Leeds and Middlesborough), the network links with the TILS, CTS and key military charities to provide a complete package of care.
GPs can use a single email (email@example.com) to refer veterans to the service, where they will benefit from specialist care by military and civilian experts..
Patients using the service will have a personalised treatment plan that links to other services where required, such as rehabilitation and mental health, whilst families and carers will be supported to access services they may benefit from.
For more information or to refer a patient, email the Veterans Trauma Network
A veterans' prosthetics programme was put into place to implement the key findings of A better deal for military amputees report by Dr Andrew Murrison MP.
Dr Murrison recommended that a small number of NHS disablement centres should provide specialist prosthetic and rehabilitation support to veterans to ensure that they continue to have access to high quality care similar to that which was provided to them whilst they were in the Armed Forces. The following nine Disablement Service Centres (DSCs) were selected to provide this support although veterans are free to attend the NHS DSC of their choice:
- Bristol – Bristol Centre for Enablement, North Bristol NHS Trust
- Leicester – Leicester Specialist Mobility Centre, provided by Blatchford Clinical Services on behalf of clinical commissioning groups (CCGs)
- Sheffield – Mobility and Specialised Rehabilitation Centre, Northern General Hospital
- Carlisle – Disablement Services Centre, Cumberland Infirmary, North Cumbria University Hospitals NHS Trust
- Preston – Specialist Mobility & Rehabilitation Centre, Lancashire Teaching Hospitals NHS Foundation Trust
- Stanmore – Stanmore Prosthetic Rehabilitation Unit, Royal National Orthopaedic Hospital Trust
- Portsmouth – Prosthetic Regional Rehabilitation Department, Portsmouth Hospitals NHS Trust
- Birmingham – West Midlands Rehabilitation Centre, Birmingham Community Healthcare NHS Trust
- Cambridge – Addenbrooke's Rehabilitation Clinic, Cambridge University Hospitals NHS Foundation Trust
In addition to providing support to nine DSCs, a Veterans' Prosthetics Panel (VPP) was established in 2012. The VPP was designed to ensure that veterans could access high-quality prosthetics regardless of which DSC they attend. Applications for funding from the VPP are made by a veteran's prosthetist.
The National Prosthetics Service (NPS) is Scotland's centre for designing and fitting prosthetic limbs.
Personalised care for veterans with a long term physical, mental or neurological health condition or disability
NHS England and NHS Improvement, together with the Ministry of Defence, have published the Personalised care for veterans in England, a guide for clinical commissioning groups and local authorities, which sets out a new personalised care approach for those veterans who have a long term physical, mental or neurological health condition or disability.
This guide is for those individuals and organisations who are leading or involved in supporting this patient group through the delivery of NHS Continuing Health Care or a jointly agreed care plan. A supporting patient leaflet is also available.
Eligible individuals will have a single personalised care plan for all their health and wellbeing needs that is developed with them and a range of organisations, including health and social care and military charities. This approach will give the individual more choice and control over how their care is planned and delivered, meaning they can choose how best to live their life and get the right care and support to make this happen. It will also take into account personal preferences that relate specifically to the individual’s military service. As part of this, they may get a personal budget to pay for some of the care and support they need, as well as more support in the community, such as emotional and practical support from people who have similar health conditions or disabilities. To apply, individuals should contact their local clinical commissioning group.
Veterans Covenant Health Alliance
The Veterans Covenant Health Alliance is a network of over 30 acute hospitals that have been accredited as exemplars of the best care for veterans, helping to drive improvements in NHS care for people who serve or have served in the UK armed forces and
The ambition is to have 75 NHS providers accredited by the end of 2019, with plans to expand this important initiative to mental health and ambulance trusts. For more information please email firstname.lastname@example.org or visit the NHS website.
Mobility equipment support
The Royal British Legion has a Veterans' Mobility Fund, which provides specialist wheelchairs, orthotic equipment and other mobility related items for veterans who have a service related serious physical injury and whose needs cannot be met through statutory services. Eligibility for the fund requires the condition to be attributable to service and typically applicants will be in receipt of a War Pension or relevant award under the Armed Forces Compensation Scheme. To find out more, visit the British Legion website.
The Armed Forces Healthcare Navigator Service
The Defence Medical Welfare Service (DMWS) provides emotional and practical support to the Armed Forces community when they are on a health care pathway, receiving treatment in hospital, community based health care, or at home.
Assessing, identifying, and addressing welfare and wellbeing issues that are a barrier to recovery or good health and wellbeing, DMWS work with the individual, their family, carers, and health and social care partners, to find solutions and provide onward supported referrals to other organisations for services beyond the scope of DMWS intervention.
DMWS' professional and expert medical welfare service evidences reduction in delayed transfers of care, reduction in frequent attendance at A&E, enables independent living, reduces social isolation, improves wellbeing, and provides a coordinated, holistic approach to accessing the right support, in the right place, at the right time
Veterans can be referred to DMWS or can contact DMWS directly. For more information, visit Defence Medical Welfare Service website
Other services available to veterans
Veterans' Gateway is for any ex-service personnel and their families looking for advice or support, 24 hours a day. It is the first point of contact to a network of military and non-military partner organisations to help veterans and their families find exactly what information, advice and support they need, when they need it - across key areas from physical and mental health to employability, housing, finances, personal relationships and more. For more information, visit the Veterans' Gateway website or call 0808 802 1212.
Veterans First Point - Scotland
Veterans First Point drop-in services are available across Scotland and were developed by veterans for veterans. This offers a “One Stop Shop” for help and assistance to veterans, and their families, no matter what that need might be, including physical or mental health issues, housing, socialising, education, employment and other issues. For further information visit the Veterans First Point website
Contact is a group of charitable, support and state organisations that have joined forces to enhance mental health support available to the Armed Forces community. The partnership consists of Big White Wall, Cobseo, Combat Stress, Help for Heroes, The Royal British Legion, Walking With The Wounded, the NHS, MOD, UK Psychological Trauma Society and King's College London. Contact aims to improve collaborative care management, increase instances of help-seeking behaviour, improve service provision, encourage best practice across the sector and improve public knowledge of what support is available and how best to access it. For more information, visit the Contact website.
Cobseo, as the Confederation of Service Charities, offers membership to charities who promote and further the welfare and general interests of the Armed Forces community, subject to fulfilling the membership criteria. Comprising 255 members, Cobseo provides a single point of contact for interaction with the Armed Forces community. For more information, visit the Cobseo website.
Help for Heroes
Help for Heroes provides direct, practical support for wounded, injured and sick service personnel, Veterans and their families. No matter when or where someone served, the charity offers the help they need, if necessary for life. They have four recovery centres in the UK that offer a wide range of services, including, but not exclusive to, psychological wellbeing, clinical support and sports recovery.
Alongside this they also offer two further services: Hidden Wounds and The Veterans Clinical Liaison Service (VCL).
The Help for Heroes Hidden Wounds service is a Step 2 IAPT guided self-help model supporting ex-service personnel, their family members and the families of serving personnel. Weekly sessions are delivered by psychological wellbeing practitioners using bespoke workbooks and practical tools and techniques to help individuals better understand and positively manage their emotions.
The service is suitable for those exhibiting low to moderate symptoms of depression, anxiety, stress, anger and excessive alcohol use, using evidence-based CBT interventions that have proven to be effective for a wide range of people. Support is delivered by phone, Skype or face to face. The service also works with the NHS, other charities and Armed Forces health networks to ensure the most appropriate care pathway for their beneficiaries. Beneficiaries can self-refer or be professionally referred. For further information, visit the Help for Heroes website.
The Veterans Clinical Liaison (VCL) Service acts as a point of contact for those with serious complex injuries and long terms health issues and focuses on holistic clinical support to improve an individual's quality of life. The VCL nurses engage and empower Help for Heroes beneficiaries to optimise their clinical status in partnership with statutory (NHS and social care) and voluntary organisations. Beneficiaries can self-refer or be professionally referred. For further information, visit the Help for Heroes website.
Combat Stress is the UK's leading mental health charity for veterans. They provide free specialised clinical treatment and support to ex-servicemen and women across the UK with mental health conditions. Combat Stress has a strategic partnership with the MOD and the Department of Health and Social Care. This enables them to work directly with NHS mental health trusts and Armed Forces health networks to develop services suitable for military veterans. For further information, visit the Combat Stress website.
Supporting Wounded Veterans
Supporting Wounded Veterans (SWV) understands the impact pain can have on a veteran and their family. They offer an online “review” with a Consultant in Pain Medicine who is also a veteran. This discussion considers the options that may be available for the management of pain. Following their discussion, they are sent a letter which, with their permission, will be copied to their family doctor; at no point do they become SWV “patient”.
One option available is attending the SWV online Veterans’ Pain Resilience Programme; designed by veterans, for veterans. They also have links to a NHS Veterans’ Opioid Weaning Service.
Blesma supports limbless veterans to lead independent and fulfilling lives. Blesma is dedicated to assisting serving and ex-service men and women who have suffered life-changing limb loss or the use of a limb, an eye or loss of sight. They support these men and women throughout the UK and provide centralised assistance to those living overseas.
Blesma works closely with the NHS to ensure the latest advances in the relevant medical fields are converted into practical solutions that can benefit all of their members. They do not provide members' prosthetics, but they do help prosthetists develop their skills at undergraduate and PhD level. For further information, visit the Blesma website.
Hearing loss and tinnitus services
If a patient has acquired hearing loss and / or tinnitus relating to their time in service, additional support can be funded through the Royal British Legion Veterans' Hearing Fund. To access the service, patients can be referred by their GP to their local NHS audiology department or an application form can be downloaded from the Veterans' Medical Funds webpage.
ATS & WRAC Association Benevolent Fund
The ATS & WRAC Association Benevolent Fund awards one-off and recurring financial grants to purchase specific goods, services or facilities for eligible former servicewomen, or their dependents, in need. The charity also provides annual maintenance grants to former servicewomen who are either elderly, alone, living on low incomes or in ill health, and makes contributions to top-up care-home fees. Any former ATS or WRAC servicewoman, including TA, with one day’s paid service or more prior to 1992, is eligible for assistance. All cases must be referred through the local branch of SSAFA or regional Royal British Legion (RBL) office. SSAFA or the RBL who will arrange for a trained caseworker to interview the applicant in their home to establish the full range of assistance needed. Please see ATS & WRAC Association Benevolent Fund website or contact 0300 400 1992 for more information.
Bravehound - Scotland
Bravehound provide companion dogs to veterans and then provide support for both the dog and veteran over the dogs’ life. They aim to support a smooth transition back into civilian life, helping ex-service personnel adjust to living with the visible
Breathing Space - Scotland
Breathing Space is a free and confidential phone line (0800 83 85 87), aimed at people experiencing low mood or depression. It provides a safe and supportive space by listening, offering advice and information.
This webinar is the first in a new series of resources to help GPs to meet the healthcare needs of veterans and their families. It features lived experience from veterans, currently available services, and referral pathways.
Podcast: General practice and the care of families serving personnel
This webinar is aimed at GPs and primary health care teams, who may not be aware of some of the issues facing service families and the implications this can have on their health, wellbeing and access to NHS Primary Care services. The purpose of the podcast is to raise awareness of the RCGP and NHSE work to meet these needs, and how healthcare professionals can improve care for the families of serving military personnel.
In this episode, Dr Veronica Grant - RCGP veterans Clinical Champion - is joined by Jenny Ward, Naval Families Federation, Karen Ross, Army's Families Federation, and Alison Cotton, RAF Families Federation, to discuss some of the challenges faced by military families and ways in which NHS GPs can best help and support.
In this episode, Dr Veronica Grant - RCGP veterans Clinical Champion - is joined by Iza Gill, military family representative, and Dr Nigel Fraser, GP, to discuss the practical experience of GPs and service families.
Video: Don't ask, can't tell
Some veterans have complex health care needs and may present to out of hours services in crisis. "Don't ask, can't tell", is an innovative animation designed for clinicians in the out of hours primary care setting, to offer insight and raise awareness of important veterans' health issues. It combines visual and audio information in a concise and captivating format to help better equip clinicians when caring for veterans and provides important sign-posting information to Op COURAGE: The Veterans Mental Health and Wellbeing service.
Screencast: Veteran’s health and honouring the military covenant
Looking after those who served in the United Kingdom’s armed forces is an important aspect of day to day general practice. This screencast introduces the current state of health of Britain’s 2.5 million military veterans and focuses on common aspects of veteran’s health, such as physical and emotional trauma and how all members of the primary care team can honour the military covenant by following appropriate referral patterns for ex-military personnel.
Transition from military to NHS GP care for veterans
In this episode, Niki Murdoch - Independent Chair of NHS England's Armed Forces Public Patient Voice Group, Dr Robin Simpson - RCGP Clinical Champion for veterans' healthcare, and veteran WO1 Colin Brown - RM Corps Drum Major and Buglers Spec Advisor, discuss transitioning from the military and the challenges that leaving can bring to former service personnel and their families.