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Abstract
Background Relatively little research is available regarding the specific needs of older military veterans and the services introduced to support them. In 2016, the Armed Forces Covenant Fund Trust launched the Aged Veterans Fund (AVF), to understand the impact that military service may have on ageing, and to support initiatives targeting their health and well-being. This fund was financed for 5 years and included 19 UK portfolio projects.
Method The paper presents a retrospective evaluation on the processes and impact of the AVF, with the intent of informing policy, educational services, service providers and stakeholders of the lessons learnt. The inclusion criteria was veterans and their families aged 65 years of age or over. In 2019, data were drawn from documentary evidence related to the programmes. Qualitative analysis were performed on 78 eligible sources and 10 themes were identified.
Results Programmes were rolled out via collaborative partnerships referrals, focusing on person-centred or skill-exchange approaches. Challenges were encountered, such as capacity and timelines issues. A limited amount of associated cost-savings was observed, even if examples of sustainability and high satisfaction were reported. Evidence was found of programmes boosting health and well-being outcomes, in raising awareness, and in positively impacting on clinical practice, such as re-admission rates.
Conclusion The AVF programmes were successful in their intent to provide support to older veterans and their families. The findings provide indicators of the next steps required for the support of ageing veterans. Further investigation of the cost-effectiveness of age-friendly veterans’ services is needed.
- health policy
- quality in health care
- medical education & training
- depression & mood disorders
- old age psychiatry
Data availability statement
Data are available on reasonable request. Data may be obtained from a third party and are not publicly available. Data are available on request. However, consent from the involved third parties would be required to obtain the data.
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- health policy
- quality in health care
- medical education & training
- depression & mood disorders
- old age psychiatry
Key messages
There has been relatively little research regarding the needs of older veterans and the services to support them.
In 2016, the Armed Forces Covenant Fund Trust launched the Aged Veteran Fund (AVF) to support initiatives targeting older veterans health and well-being.
AVF programmes were rolled out via partnership referrals and commonly adopted a person-centred or a skill-exchange approach.
Evidence of programmes cost-effectiveness was limited; however, outreach, sustainability and high satisfaction were reported by both staff and beneficiaries.
AVF programmes appeared successful in improving the health and well-being of older veterans and positively impacting on clinical practice and community awareness.
Introduction
As the average human life expectancy has increased, so too has the impact of ageing on society.1 Ageing is biological, is associated with a decline in the physiological reserves, involving changes in social roles. Current health responses to ageing consider comprehensive approaches, and the UK National Health Service (NHS) supports ‘healthy ageing and caring’ as priority areas part of their long-term plan.2
In the UK, the Armed Forces Community (AFC) is approximately 9 million people, of which 2.64 million are veterans.3 Of these, veterans were predominantly white males and 60% were aged 65 years and over.3 Veterans do not differ from the general population in terms of health determinants, with 18% of veterans aged 65+ years self-reporting their health as good.3 The common physical problems reported by veterans include musculoskeletal conditions, hearing, dementia and mental health illnesses such as depression, anxiety, alcohol problems,3–9 with some older veterans facing financial problems and social isolation.10
Helping veterans and their families to cope with health problems and their overall well-being has become increasingly important in recent years.11 Older veterans are a unique cohort whose ageing experiences, needs and related specific services are still relatively little known.8 9 To address this gap, the Armed Forces Covenant Fund Trust (AFCFT) in 2016 launched a UK Aged Veteran Fund (AVF). This was a competitive grant that funded £30 million to portfolio projects contributing to the understanding and the support of the health, well-being and social care needs of veterans (born before 1950) and their families.12 Veterans with dementia or socially isolated were especially targeted.
A total of 19 programmes were awarded grants in two rounds (9 in 2016 and 10 in 2017).12 Programmes engaged collaboration between different organisations (using a portfolio structure), and differed in geographical area and in provision. Programmes aimed to improve beneficiary’s well-being and avoid social isolation, and included a mixture of staff training, practical support (eg, assistance with finance or housing), courses (educational or skill-based), outreach, social or holistic activities such as gardening and one-to-one support (for details see Table 1). Some projects (mostly those funded in round 2) were also able to spend part of their funds on original research, or evaluations (see Table 1).
Organisations and programmes awarded the Aged Veterans Fund (AVF)
This paper summarises findings of the external independent evaluation that was undertaken by University of Chester’s (UoC) Westminster Centre for Research in Veterans in 2019. Lessons learnt from the AVF were used to inform further actions of the AFCFT, stakeholders and grant holders. The paper is not an exhaustive review on the programmes, nor does it advocate any specific programme.
Aims
The aim was to provide an initial comprehensive summary of the impact of the AVF programmes, focusing on both the processes adopted by the programmes, and the outcomes achieved (impact). Objectives were: (1) evaluate how the programmes worked (eg, Have they followed the objectives/processes established at the outset? Have the organisations worked together to deliver the portfolio? Have they reached the estimated number of beneficiaries? Are they common approaches?; (2) identify challenges, barriers and gaps in provision; (3) identify programmes sustainability, outreach and cost-savings (eg, is it value for money?); (4) examine staff and client perceptions; (5) evaluate the impact for the beneficiaries and/or the wider community, including the NHS.
Method
The AFCFT authorised and provided access to the awarded programmes and contact leads. Data collection started in February 2019 and ended in June 2019. Contact leads submitted any documentary information on the programmes processes, their progression and outcomes. The UoC evaluators contacted the grant holders on a maximum of four occasions to request further information. Evidence was diverse and included case studies, briefing documents, media outputs and external evaluation reports. Quarterly, interim and end of grant reports to the AFCFT were also included. These were reports monitoring how the projects were meeting the agreed goals and quality standards.
Each organisation adopted different monitoring systems for collating evidence about their outputs, and given the projects’ complexity and their ongoing delivery and lack of quantitative data, a qualitative methodology was adopted. Retrieved sources were 86 (see Table 2), from which 78 were retained and identified as suitable. Eligibility criteria included evidence informing on processes, barriers and challenges, programmes costs-savings, outreach and sustainability, attitudes and any positive or negative outcomes of the projects (eg, health and well-being benefits of the beneficiaries or the wider community or the NHS). Due to not meeting the report objectives one programme was excluded, whereas eight sources were not analysed due to information not fitting with the eligibility criteria (see Table 2).
Data breakdown by organisations, programmes and retrieved included and excluded sources
Analysis were conducted on the available evidence via NVivo V.12.13 The approach adopted was a modified Constructivist Grounded Theory (GT).14 GT is the primary qualitative method that has been used within the British Armed Forces research,6 15 and is a systematic approach that fits complex phenomena’s that require a flexible approach.14 Focused line by line coding identified words and phrases that related to the evaluation criteria. Emerging categories were used consistently to facilitate the exploration of themes. Themes were identified and provided answers to the five objectives. Themes and dimensions were interlinked, and feed into each other (see Figure 1). Findings were reviewed and validated by members of the research team.16
Model representing the findings and NVivo word search. The model representing the identified themes and dimensions grouped into the two evaluation areas (on top) and the NVivo word search (on bottom).
Results
Ten recurrent themes were then grouped reflecting the two areas of the evaluation processes and impact achieved.16 This is presented in Figure 1 as a model.
AVF process and methods
Approaches
The provision was made up of multiple services (eg, meals, medications, social activities) and involved coordinated actions to tackle often complex numerous issues (eg, isolation, bereavement or mental health conditions). The service involved dedicated professionals with extensive experience and often with a military background. Programmes were rolled out via collaborative partnerships referrals, focusing on person-centred or skill-exchange approaches. Portfolios acknowledged the employment of experienced professionals, dedicated staff and volunteers (including peer veterans). These structures enabled an approach aligned to support beneficiaries’ individual needs. Skill-exchange models, consisting of peers or other members passing their skills to the beneficiaries were also common, such as IT and Internet training.
The key to our success is … to help each other, so we’ve recruited volunteers and really specific volunteers who understands veterans, who’s got the time and the commitment and the certain amount of skill, to make sure they make the process as simple as possible.
Beneficiaries
The majority of individuals supported in the projects were between 75 and 80 years of age, and were predominately male veterans. Overall, the number of beneficiaries (veterans, family members and carers) the projects reached was reported to be in line with expectations. The focus was quality of care rather than quantity.
We have taken longer than anticipated to issue X and will stop at 1000 as opposed to 1500 as originally planned… quality over quantity is the right outcome for this Project.
Monitoring
Overall programmes objectives and process were maintained and adopted a coherent delivery approach. Most of the portfolios established project governance; used engagement strategies and proactive approaches. They used management tools and project officers for the delivery. Administration was enhanced through good working relationships and open contact, consisting of regular steering group meetings and periodic contact with stakeholders. Monitoring included quarterly reports to the Trust, internal meetings and evaluations in line with contractual agreements. Most grant holders assessed the projects both during the delivery (‘formative’ monitoring) and at the end of the projects (‘summative’ monitoring). Yet, the quality of the monitoring systems varied. Due to timelines and costs, projects included ‘softer evaluations’ such as internal forms, ‘Thank you’ letters, hits to websites or social media.
With regular updates and this close internal working relationship we were able to monitor project delivery and discuss feedback in order to achieve continual improvement.
Outreach
Public relations and media promotion (eg, launches, websites, media advertising and coverage) appeared to be actively and effectively engaged by programmes, with four programmes winning recognition awards. All of these actions were intended to attract participants, connect with people who were deemed hard to reach and promote the service sustainability.
Barriers and challenges
A number of challenges were encountered that related to timelines, staffing, difficulty in practical delivery such as accessing premises, maintaining media interest, safeguarding concerns and capacity, with some services being more resource-intensive than anticipated. The main ongoing concerns were related to recruitment and project uptake, including transportation issues, or problems in reaching veterans, particularly those isolated. A minority of the programmes reported challenges in operating in practice the interactive portfolio approach, due to altered agreements or different modus operandi. Yet, these issues were addressed, mostly by adopting pragmatic solutions and constructive liaison.
Our biggest problem was recruiting the right staff… It also took time initially to establish ourselves and build up relationships with other agencies…”
Positive perceptions
Positive experiences and high levels of satisfaction rates were reported by staff, volunteers and clients. These demonstrated good engagement and encouraging feedback towards the programmes, with participants willing to recommend the services. Staff were praised for their enthusiasm, commitment and professionalism, showing the development of a good rapport and trust. Additionally, high demand and positive feedback were narrated for the staff training programmes (eg, dementia and the AFC awareness courses).
I think the project is excellent, to see those smiling faces when they have taken a photo and sent it… For me, to receive an email of thanks from a family member … is very pleasing.
AVF impact
Cost-effectiveness
The information on expenditures was limited, varied and specific to certain times and programmes. Some projects overspent or underspent against their grant budget, and these costs were mostly related to administration, staff placements, activities/services, materials/equipment and travel/subsistence. Programmes (see Table 2) who had undertaken cost benefit or Social Return of Investment or other forms of economic impact evaluations, showed positive returns. The sustainability of the projects was highlighted by some grant holders who demonstrated developments in their intrinsic capacity of engagement, partnerships and in the search for more funding.
Dance to Health potential cost-saving of over £149m over a two-year period, of which £120m is a potential cost-saving for the NHS England.
Impact on health and well-being outcomes and the wider society
Evidence was found of programmes boosting health and well-being outcomes, and in raising community awareness. Programmes improved user’s physical and mental health (especially those with significant health conditions), and their overall quality of life by responding to their specific needs. Support was offered to address a range of issues including finance, housing and transport. Tackling these issues appeared to indicate a significant impact on reducing stress, anxiety levels and depressive states. Increases in social activities reported a boost in confidence, self-worth and decreases in loneliness. Awareness was raised in the community by pushing for identification, engagement and behaviour change. This was mostly achieved by staff educational programmes (eg, AFC awareness or dementia training) and project promotion in the community.
I did in the sessions and then again at home. The improvements have been amazing. I have less pain, I stand a lot straighter and can now walk five miles…
I feel better from top to toe.
Practice
A minority of the programmes reported an impact on health services and their delivery of effective care. By improving cross-referrals and signposting to other support services, programmes freed clinical staff time, decreased both the length of stay in hospital and re-admission rates. Additionally, improvements in hospital experiences were reported by both veterans and their families and linked to the introduction of staff educational courses. Finally, reaching out to connect with veterans who had previously failed to disclose their military history resulted in improved access to health and social care services.
Working with specialist services including NHS care divisions, showed the value of the coordinated care pathways and showed effects in reducing A&E re-admissions.
Discussion
This report has provided preliminary evidence of the processes and impact of the AVF. As veterans age, their healthcare needs tend to become more chronic and complex. Responding to their specific needs requires integrated person-centred care built around comprehensive systems and common goals. This requires a coordinated response from multiple sectors and organisations.16
Data collected on the AVF programmes reported to have been successful in meeting the Trust’s intent to support the health, well-being and social care needs of older veterans. Programmes positive impact showed a range of encouraging outcomes leading to them being successfully rolled out via multiple platforms. Findings showed that overall aims and process were maintained, via the agreed monitoring systems that were in place, and the projected number of beneficiaries was reached. Beneficiaries were primarily men over 75 years of age, which is in line with aims12 and national estimates,3 and included families, carers and staff.
Grant holders primarily adopted two approaches. First was to incorporate the experience of ex-armed forces and health professionals to meet the needs of beneficiaries by adopting a person-centred approach. Second, organisations applied a skill-exchange model which facilitated the transfer of skills from peers and members of staff to clients. These approaches are common in health and social care for older adults and based on the notion of empowering care and educating patients on how to manage their health.17 Healthcare reviews report benefits associated with these models in terms of patient satisfaction and perceived quality of care.18 19
Problems with capacity, timelines, staffing and project uptake were identified. These issues are common to healthcare programme and/or evaluation.20 To positively address these setbacks, collaboration and communication between organisations were reported as the key for success.
Media promotion was wide, and enabled the outreach and sustainability of some projects, with four programmes winning recognition awards (Soldiering on Awards, 201921 ; Defence Medical Welfare Service, 202022). Whereas the information provided regarding cost-savings was limited, yet the few programmes that submitted economic analysis showed positive societal returns and healthcare-related savings.
Beneficiaries, staff and volunteer’s perceptions were positive. AVF achievements were related to reported improvements in the beneficiaries’ physical and mental health. A significant positive impact of the AVF was found in the reported overall well-being of the beneficiaries. This was achieved by supporting participants and addressing/improving the situational stressors in their lives such as finance, housing and social issues. Working on these issues appeared to boost resilience and led to positive improvements in the beneficiary’s reported quality of life, reducing stress and anxiety. The programmes were successful in notably reducing social isolation and loneliness, a key objective of the AVF.
These outcomes are in line with similar programmes that are delivered to veterans across the UK15 23–26 and overseas.27–32 A UK report published this year by the Armed Forces charities showed how the third sector, by working in partnerships with multiple statutory and non-statutory organisations, is providing a wide range of these programmes to the AFC across three main areas: social groups, menta health and education.33 A major cause of stress is aligned to physical ill health and other multifactorial psychosocial problems such as family problems and (not military-specific) occupational issues.6 10 Research is showing that stress in the AFC may be managed by these alternative or complementary initiatives and social prescribing interventions, which can positively and successfully improve the physical and mental well-being, promote help-seeking and reduce stigma. Examples of such programmes include mindfulness, yoga, canine or equine therapy, and organised educational or recreational activities such as archaeology, horticultural or fly-fishing.15 23–32
Moreover, AVF programmes raised awareness of the AFC in the wider society and provided a platform for grant holders to promote their services. Cross-referrals between statutory services and grant holders showed an impact and costs-savings into healthcare practice, by decreasing the length of stay in hospitals and re-admission rates, as well as ensuring the early identification of veterans. Help-seeking in veterans is poor, within primary care only approximately 8% of veterans are correctly registered. 34 This leads to excessive delays in care; often left until they are in crisis and socially isolated, or had a ripple effect onto families.32 35 These initiatives can aid by providing a community interface, and signpost veterans and their relatives to specific care. Similar initiatives for effective prevention and promoting access to health and social care services have shown promising results.7
Limitations
Given the complexity, the methodological frameworks and the timelines differences between the programmes, not all of the reported evidence is conclusive. The data within this article were reviewed at an interim stage of project delivery. Some sources contain unclear or preliminary evidence due to the project phase and therefore their activities are not fully captured. As more portfolios complete their grants (by the end of 2020) a richer picture is likely to emerge.
There are limitations with the information provided, as some grant holders have found it difficult to quantify outcomes due to shortcomings, or poor data collection methods. Methodologies used to evaluate the programmes were varied, and statistical data were only included in some reports. Sources were mostly case studies or contained ‘initial stage’ of evidence shared via internal grant communications, therefore there may be a positive retrospective bias. Data from programmes that commissioned external evaluations were more rigorous.
The aim of this evaluation did not involve the assessment of documents for their accuracy and depth of information. These limitations are balanced through the rigorous methodology adopted for the production of this article. A further evaluation would be required at completion of all the projects.
Conclusion
Overall, the available data provided evidence that the AVF portfolio projects were successful in delivering the intent of supporting the health, well-being and social care needs of older veterans. The programmes that were successfully rolled out via referrals, project promotion and collaboration were strong, but this was not without challenges.
The initiatives were positively identified by beneficiaries, staff and volunteers. There was testimony of improving health, well-being and boosting resilience, raising awareness in the wider community, which influenced current healthcare.
Older veterans are a unique cohort, and there is a lack of robust research about the exact benefits regarding specific services, social prescribing and the outcomes of support in this population and their families. This paper represents the first overview of the available evidence of the impact of the AVF in the support of older veterans and their families, and provides indications of ways to provide a comprehensive service. Due to the available sources at the time of the production of the report, findings are preliminary. Nevertheless, these findings will help address this research gap, inform policy, educational programmes and aid stakeholders in the development of targeted services.
Data availability statement
Data are available on reasonable request. Data may be obtained from a third party and are not publicly available. Data are available on request. However, consent from the involved third parties would be required to obtain the data.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to thank the programme providers and their programme leads that collaborated in sharing their information. The authors would also like to thank all the participants involved in the programmes.
References
Footnotes
Contributors LCGDL contributed to the planning, and was responsible for data collection, analysis and reporting of the work described in the article, and submitted the paper. AF was responsible for the planning and supported the analysis and drafting of the paper. SH supported the planning, reporting and supervised throughout the data collection process.
Funding This research was commissioned and funded by the Armed Forces Covenant Fund Trust.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.