Objectives To assess the knowledge of members of the Royal College of General Practitioners (RCGP) on veteran's health issues, assess present support, and establish what support is required for GPs when treating veterans.
Methods An electronic survey of RCGP members across selected faculties.
Results Forty-seven per cent of respondents were ‘unsure’ or ‘didn't know’ how many veterans they were responsible for. However, many GPs replied that they had seen a veteran in the last month. Only 7.9% of respondents used the unique Read Code for veterans. Disappointingly, 75% of GPs indicated that they had not seen the RCGP leaflet on veterans’ health, and less than 2% had used the RCGP On-Line e-learning resource.
Conclusions Surveyed GPs had little understanding of how many veterans were registered with their practice, and only a few had accessed learning resources available. GPs requested more information on how to assess veterans and where they could be referred. Further work is required to identify the true size of the problem, while continuing to provide proactive guidance and support to GPs on the health needs of veterans.
- Primary Care
- Medical Education & Training
- Rehabilitation Medicine
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In the UK, there are 4 million veterans-about 6% of the UK population.
NHS general practitioners (GP) are not aware of how many veterans are in their practice population.
Few GPs use the unique identifying code for veterans (Read Code).
The Royal College of GPs has tried to raise the awareness of veterans’ issues, but few GPs surveyed were aware of the educational resources available.
GPs recognised that veterans have special health issues specifically around mental health.
GPs requested a comprehensive signposting service listing support and information about available resources for veterans.
Veterans are the men and women who have served in the Royal Navy, Army and Royal Air Force (regular or reserve), and who have now left to rejoin civilian life. It is estimated that there are around four million veterans, around half of whom left the Services before 1960 (about 6% of the UK population).1 If veterans were evenly distributed across UK, it would be expected that each general practitioner (GP) would have about 100 veterans under their care (assuming an average list size of 1600 patients). Additionally, in the Armed Forces community, there are 5.4 million adult spouses, partners, widowers and child dependants. Around 18 000 Service people move back into civilian life every year, including around 2000 who leave the Services on medical grounds.1 Veterans may present to their GP with medical problems such as ‘tiredness’ complicated by multiple social problems including difficulties with employment, marital breakdown and debt.2 Because of their military service, their healthcare needs can be different from those of other patients. As a result, veterans do not fit conveniently into existing diagnostic or treatment pathways.
The Royal College of General Practitioners (RCGP) produced an online leaflet for its members in 2010 entitled ‘Meeting the Healthcare Needs of Veterans’.1 The RCGP has also developed a free-to-access e-learning module on the healthcare of veterans.3 However, in a recent report on the consultation on the healthcare needs of injured veterans and their families,4 many of the veterans were dissatisfied with the quality of healthcare they experienced in civilian life. Many of them said that medical personnel did not understand the military context, and that there was only ‘very limited time’ available to talk to medical staff, in particular in GP consultations. Specifically, they commented that GPs did not provide them with adequate information on which to base decisions about their care. Mental Health problems may be a specific challenge for the NHS GP. The four UK health departments, the MOD, and the charity Combat Stress, have been working together closely to develop community-based mental healthcare for veterans.5 Combat Stress is the UK's leading military charity specialising in the care of veterans’ mental health.4 Only 7.3% of veterans referrals to Combat Stress are by GPs. Combat Stress receives most referrals by self-referral (57%), while 9% are referred through their family and friends. Many veterans find it difficult to admit that they have a mental health problem to a medical practitioner who has not served in the military; thus, unless they ask a direct question, GPs may find it difficult to identify who is a veteran and what their needs might be. This may mean that veteran's mental health needs are unmet. Equally, it might mean that even when a GP identifies veterans with mental health disorders, they are not aware of Combat Stress or an alternative clinical service that may be able to provide specialist care.
In the UK, virtually all general practices have modern computer systems which allows for the swift identification of patients with specific characteristics used by almost all GPs in the UK since the mid-1990s. There is a specific code for patients with a ‘military background’ (Xa8Da).6
Given this background, the aim of this study was to assess the knowledge of members of the RCGP on veterans’ health. Secondary aims included ascertaining what support GPs would like when treating such patients, and if Read Codes for veterans were actually used.
A questionnaire was sent to GPs who are current members of the RCGP in the central region of England (RCGP faculties of the West Midlands, Leicester and Vale of Trent) plus the Wessex and Thames Valley faculties identified from the RCGP membership database. Apart from questions about the demography of the respondent, questions focussed on GPs’ knowledge of veterans healthcare needs and available resources (Figure 1). The questionnaire was piloted on members of the Faculty Board of the Midland Faculty of the RCGP and amendments made accordingly. An electronic link to the questionnaire was placed within a routine newsletter sent to all members. Replies were coordinated by the Midland Faculty Administrator and a reminder was sent to Midland Faculty members on two further occasions. Respondents had 30 days to respond (15 September–15 October 2013). Ethical approval was not sought for this online voluntary survey of RCGP members.
The questionnaire electronic link was sent to 10 611 GPs, and after two reminders, 303 were returned. The response rate was therefore 2.9%. Respondents indicated that more than 137 (45%) of respondents had more than 20 years’ experience as GPs; 176 (58%) of respondents were GP partners, but only 30 (11%) of those replying had served in the Defence Medical Services at any time in their professional career (Figure 2).
In response to the question asking how many veterans each GP was responsible for, 132 (47%) of them were either ‘unsure’ or ‘didn't know’. However, 140 GPs replied that they had seen a veteran in the last month (Figure 3).
The questionnaire specifically asked respondents whether they used the Read Codes for veterans—only 22 (7.9%) indicated that they used the veterans Read Code.
Three-quarters of respondents (209 GPs) said they had not seen the 2010 RCGP leaflet on veterans health, and only five had used the RCGP online e-learning resource.
Within the questionnaire, there was an opportunity for respondents to provide a text response. Many of the respondents recognised that veterans had specific mental health issues including post-traumatic stress disorder, alcohol and drug problems. Often these problems presented as issues around poor sleep, relationship problems and difficulty with employment. Many GPs complained about a difficulty in obtaining the notes of veterans from the Defence Medical Services which made it difficult to assist veterans with the adjustment to civilian life. GPs found that veterans often delayed presentation with illness. Some GPs were not convinced that veterans were any different from NHS patients who had been exposed to stress.
The questionnaire asked respondents: ‘What help would you like as a GP when dealing with veterans?’ Many responded requesting a comprehensive signposting service for available support for veterans listing contact details and information about available resources for veterans and, in particular, details of ‘3rd’ section organisations, such as British Legion, Combat Stress and other ‘Veteran’ Associations. There was also recognition of the need for ‘specialised’ counselling. Several requested education on the needs of veterans, including coverage in RCGP curriculum. One suggested ‘Posters for the Waiting rooms highlighting any services for veterans’, while another asked for a leaflet for all primary healthcare staff. Several responded that veterans should be looked after by the MOD as well as wanting more information how to ‘fast track veterans’ for medical problems relating to their time in the Armed Forces.
This study has considered the understanding and experience of RCGP members in the Central Region and the Wessex and Thames Valley Faculties of the RCGP. Only 303 questionnaires were received (a response rate of 2.9%), so considerable care needs to be taken in generalising the findings to the overall NHS GP population because of responder bias.
It is estimated that there are over four million military veterans in the UK, which is more than the total number of patients with diabetes (estimated to be 2.5 million in England). Many veterans do not need to access healthcare, or their needs are no different from other members of society. However, the UK government Armed Forces Covenant recognises that the health of military personnel and veterans is a high priority, and that individuals should not be disadvantaged in comparison with other members of society.7 ,8 In particular, the Covenant states: ‘Veterans receive their healthcare from the NHS, and should receive priority treatment where it relates to a condition which results from their service in the Armed Forces, subject to clinical need’. Iverson and Greenberg's summary2 details the continuing mental health problems of some regular and veteran personnel. These include adjustment disorders, drug and alcohol-related problems, mood disorders and post-traumatic stress disorder.
When a service person leave the Forces, they are given a copy of the Department of Health letter relating to priority treatment at their final medical; they are advised to pass this on to their civilian GP on registering. They are also given an FMed133 which allows civilian GPs to request a copy of their medical records from their time in service. On registering with a NHS GP, the veteran completes the NHS GMS 1 form (Family Doctor Services Registration) which includes the question: “If you are returning from the Armed Forces”, and seeks details of pre military addresses so ‘old NHS notes’ can be sought.9 However, this information may not actually be recorded by the GP within the medical notes of the veteran.
The RCGP has taken initiatives to raise the profile and provide education to GPs on veterans’ health. This has been specifically by producing a leaflet designed to highlight potential health issues with veterans, and provide information on specialist referral pathways, plus providing a free-to-access online learning resource. While the RCGP report that the online learning packages have been accessed 1205 times since 2009 (Abisola Amoo, personal communication 5 Nov 2013), this study shows that 75% of respondents were not aware of the leaflet, and only five individuals had accessed the online learning resource. The RCGP current membership is about 48 000 GPs. Accepting the current pressures on the National Health Service generally, and specifically general practice, and in the context of the major themes of the narrative feedback, further work is needed to highlight these resources plus providing information on referral resources.
GPs in the UK use their computer systems in virtually all consultations with patients. The computers have the ability to highlight patients with specific characteristics which provides the clinician with a greater ability to place the presenting complaint in context. Some geographical areas such as NHS Worcestershire have recommended that all adult patients be asked whether they have a military background when they register with a practice, and that the computer system is annotated with the appropriate Read Code. However, this is not universal. This study has shown that there was considerable uncertainty regarding whether GPs had seen a veteran recently and only 7.9% stated that they used the Read Code. Implementing this simple change nationally would significantly improve the identification of veterans, and thus allow for any problems to be placed in context.
NHS GPs do not expect to be experts in the management of military mental health nor of the consequences of injury when specialist care is required. However, this study has revealed that the commonest narrative comment was the need for increased ‘signposting’ of specialist resources to which patients could be referred. As one responder succinctly stated, [what I need are an] ‘easily accessible website with details of organisations which may help (for me to refer to or for veteran to self refer), and maybe some info on common conditions and how to recognise and treat’.
This study has considered the knowledge and understanding of NHS GPs of military veterans health. Based on this study (which had a very poor response rate) GPs had little understanding of how many veterans were registered with their practice, few had accessed the freely available learning resources available via the Royal College of GPs, and three-quarters were not aware of the RCGP leaflet that provides assistance to both GPs and patients on accessing healthcare. The commonest narrative comment was that GPs wished for more information on how to assess veterans and where they could be referred. Additionally, few practices used the available computer Read Code, which would assist in identifying military veterans. Further work is needed to identify the true size of the problem, while continuing to provide proactive guidance and support to GPs on the health needs of veterans, and where they can seek health advice. It is recommended that the new patient registration procedure for adults include a question on whether the patient is a military veteran.
We are grateful to the Faculty Support Team of West Midlands Faculty Royal College of General Practitioners for assisting with conducting the electronic survey and consolidating the results.
Contributors RGS was the lead author, with JL contributing equally to the work, and writing the paper. The RCGP Midlands Faculty Office provided administrative support for the online survey. This work has been discussed at RCGP Council.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.