In 2008 the Army volunteered me to go to a Royal British Legion conference. At the event there were 12 Royal Navy veterans, all of whom had significant mental health problems. When they discovered that I was a General Practitioner (GP), they gave me a really challenging time, as their own NHS GP had contributed (in their eyes) to a prolonged delay until a diagnosis of Post Traumatic Stress Disorder (PTSD) was made. At the time there was limited treatment available through the NHS. The charity, Combat Stress, was the only real source of support. It made me realise that at that time GPs had little understanding of the special needs of military veterans. So how has the NHS (and the GP) improved the care of the veteran since 2008?

The Veteran Population

I am sure that readers will know that a veteran is someone who has served in the British Armed Forces (Regular or Reserve) for at least one day. Veterans also include any members of the Merchant Navy who have served in a war zone. This includes crew from convoys in the Second World War and more recently, in the Falklands War and Gulf Wars, those serving in vessels used to support the UK Armed Forces.

The veteran population is a diverse group in terms of age, gender, ethnicity, socioeconomic group, length of service, and exposure to various things including combat, military training exercises, foreign travel, and separation from family while in the military. Most veterans will have served more than 10 years. From the 2021 Census, 3.8% of the population (England and Wales) over the age of 16 served in the Armed Forces (about 1 in 25). Of these 86% are male and 32% over the age of 80 (reflecting National Service policy 1939 to 1960).[1]

About 15,000 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. Many veterans will move back into ‘civvy street’ with no problems, but unfortunately some will have medical needs.[2]

Leaving the Military – Transition

On retiring from the Forces, it is common for veterans to find the transition to life outside the military stressful. Although it is completely normal to experience anxiety or depression after traumatic events, this can be difficult particularly after leaving the military. While serving you are alongside military colleagues who will have experienced similar events.

More than half of veterans (52%) have long-term illness, disability, or infirmity, which is higher than in general adult population (35%). Smoking is more common among veterans and as a result they are more likely to have long term respiratory conditions. They are also more likely to have higher rates of common mental health disorders such as anxiety and depression. Alcohol is part of military life and studies have found alcohol abuse a problem in UK Forces. Veterans are likely to use alcohol as a mechanism to socialise and/or cope with personal problems. As a result, alcohol related issues can be common amongst veterans.[3]

There is an increasing prevalence of Post-Traumatic Stress Disorder (PTSD) particularly amongst veterans who had a combat role in Afghanistan and Iraq. For veterans who deployed in a combat role in Afghanistan, 17% report probable PTSD (4% general population). Worryingly though, studies suggest that veterans are less likely to seek help if they feel their healthcare professional might not understand. Stigma, suboptimal healthcare access, and co-existing conditions can at least partially explain why PTSD can be underdiagnosed or misdiagnosed in routine clinical practice.[4]

The GP and the Veteran

On leaving the military the veteran should register with an NHS GP. Practices are duty bound by the Armed Forces Covenant to ensure that veterans receive effective and timely access to appropriate health care. In the NHS Long Term Plan,[5] raising awareness and improving access to health care for military veterans are key commitments.

Veterans may not disclose their military experiences unless specifically asked. In addition, veterans may think ‘civilians’ do not understand military culture and so would not understand their medical condition. These perceived ‘barriers’ may delay diagnosis of mental health problems such as post-traumatic stress disorder. Acknowledging a military background is a crucial first step in providing effective healthcare to veterans and their treatment may need some understanding of military life.

A study of GPs in 2014 found that most were unaware of how many veterans are there in their practice and few practices used the unique identifier computer code for veterans. However, the survey also found that GPs recognised that veterans have special health issues, specifically around mental health. They also wanted a comprehensive sign posting service that lists support and information on available resources for veterans.[6]

To meet the special needs of veterans, the Royal College of General Practitioners (RCGP) is working alongside NHS England to accredit practices as ‘Veteran Friendly.’ After a successful pilot in the RCGP Midland Faculty, the programme has been rolled out nationally across England. The Government and the Defence Select Committee fully support this work. The programme has been incorporated into the NHS 10-year plan.[7]

Accreditation is a simple online process that 76% of accredited practices have found ‘easy’ or ‘very easy’ to complete.[8]

To receive accreditation, a practice is required to:

• Ask patients registering with a surgery if they have ever served in the British Armed Forces.
• Use this information to code on the GP computer system, using the term ‘Military Veteran.’
• Appoint a clinical lead for veterans in the surgery (a healthcare professional).
• Eligible practices should normally have a Care Quality Commission rating of ‘good’ or higher.

Once successfully accredited, the practice will receive an accreditation pack and regular updates, guidance, and newsletters from the RCGP to support practices in delivering the best veteran support.

Training will be offered, including access to podcasts that will help practices understand the special needs of veterans. All clinicians are encouraged to include the question ‘have you ever served in the Armed Forces?’ in their consultations. This one question is likely to link the patient’s symptoms with the underlying aetiology. 84% of accredited practices say that they now have a better understanding of how to meet veterans’ health needs thanks to the comprehensive support from the RCGP, according to a recent evaluation by the University of Chester into the Veteran Friendly Accredited Practices programme.[9]

The review found that 72% of accredited GP practices believe that the programme has already benefited their veteran patients, with 99% of practices also declaring that they would recommend the accreditation scheme to others There are now more than 2,100 accredited GP Veteran Friendly Surgeries across England (33% of all GP Practices in England as of 4 July 2023). The RCGP is also working with the devolved nations to extend the programme. The RCGP veteran-friendly practice accreditation programme enables practices to deliver best care for patients who have served in the Armed Forces. Details of the programme and the online application process can be found on the RCGP Website.[10]

Mental Health and Physical Support Services for Veterans

Operation COURAGE is the NHS England mental health specialist service designed to help serving personnel due to leave the military, reservists, armed forces veterans and their families. Op COURAGE is supported by trained professionals who are from, or have experience of working with, the Armed Forces community.[11] You can contact the service in many ways, including:

• directly getting in touch yourself, or through a family member or friend.
• asking a GP or other healthcare representative to refer you.
• asking a charity to refer you.

For physical problems attributable to military service, veterans can be referred under Op RESTORE: The Veterans Physical Health and Wellbeing Service (previously called the Veterans Trauma Network). Op RESTORE is a service for veterans with a physical illness caused because of their time in the military. This NHS service uses a network of both civilian and military consultants, along with welfare support from military charities, to support veterans’ health using a holistic approach. Whilst Op RESTORE cannot shorten NHS waiting times, it seeks to ensure the veteran ‘waits well’ and is seen by the most appropriate clinician for their needs. Op RESTORE accepts only GP referrals.[12]

The Veteran and the GP

The NHS GP, in a RCGP Veterans’ Friendly Practice, is well placed to support the medical needs of the veteran. You as a veteran can help your GP, making sure you are recorded as a Veteran. The GP from this Practice will have some understanding of the physical and mental stresses of life in the military and be aware of the resources available. There is no doubt that the care of the veteran has improved, and the NHS has gone a long way in the last 15 years to ensure that the commitments in the Military Covenant are followed. If you are struggling with a mental health problem, please have the confidence to discuss it with your GP – they are now well placed to help you.

References

[1] Characteristics of UK Armed Forces, England, and Wales: Census 2021

[2] Office for Veterans` Affairs Veterans Factsheet 2010

[3] Simpson R et al. UK military veteran friendly GP Practices. BMJ Mil Health 2021; 0:1–3.

[4] Stevelink S et al. The British Journal of Psychiatry, Volume 213, Issue 6, December 2018, pp. 690 – 697

[5] NHS Long Term Plan » Veterans and the Armed Forces < https://www.longtermplan.nhs.uk/online-version/appendix/veterans-and-the-armed-forces/ > NHS 10-year plan accessed 04/07/2023.

[6] Simpson R et al. The General Practitioner and the military veteran. J R Army Med Corps 2015; 161:106–108.

[7] NHS Long Term Plan » Veterans and the Armed Forces, NHS 10-year plan accessed 04/07/2023.

[8] Finnegan et al. ‘An evaluation of the veteran friendly practice accreditation programme’. BJGP Open 6(3): BJGPO.2022.0012 April 2022 < https://www.researchgate.net/journal/BJGP-Open-2398-3795

[9] Ibid.

[10] < www.rcgp.org.uk/veterans >

[11] Mental health support for veterans, service leavers and reservists – NHS < https://www.nhs.uk/nhs-services/armed-forces-community/mental-health/veterans-reservists/ >

[12] email [email protected]