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Abstract
About 5% of the UK population are military veterans and have specific medical needs sometimes different from the general population. Veterans may be reluctant to seek help or talk about their problems, which means they do not always access care, support and treatments that are available. Others may face difficulty getting the right help. Veterans may think ‘civilians’ do not understand military culture or know about options for help and services that are available. Experience has shown that general practitioners (GPs) would like more help and support when looking after veterans. The Royal College of General Practitioners has developed the ‘Veteran Friendly GP Practice Accreditation Programme’, which involves a simple online process of accreditation where practices are required to meet the specified criteria and provide evidence that they are supportive of veterans’ healthcare. The aim is to improve healthcare provided to veterans and their families by GPs working in primary healthcare.
- primary care
- social medicine
- adult psychiatry
- public health
Data availability statement
Data are available upon reasonable request. Qualitative data are held by the RCGP veterans’ programme.
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Key messages
About 5% of the UK population are military veterans and have specific medical needs sometimes different from the general population.
The Royal College of General Practitioners has developed the ‘Veteran Friendly GP Practice Accreditation Programme’.
The main aim of the programme is to make general practitioners and their practices more aware of the medical needs of veterans and their families.
This initiative seeks to ensure that all general practitioners ask their patients: ‘have you ever served in the Armed Forces?’
Introduction
There are an estimated 2.4 million UK veterans in Great Britain, making up an estimated 5% of the population over 16.1 Veterans are men and women who have served for at least one day in the Armed Forces. Service in the Armed Forces is different from other occupations, and military personnel often put themselves in harm’s way to protect others. The UK government promises to help and support people in the Armed Forces when they need it most. This is the Armed Forces Covenant, which has now been enshrined in law.2 The general principle set out by the government is simply for ‘no disadvantage’ to veterans and their families due to their military service, compared with society in general. To meet this requirement, general practitioners (GPs) need to have some understanding of the special needs of this group of patients.
On leaving the forces it is not uncommon for veterans to find the transition to life outside the military stressful.3 Although it is completely normal to experience anxiety or depression after traumatic events, this can be difficult particularly after leaving the military. More than half of veterans (52%) have long-term illness, disability or infirmity, which is higher than in general adult population (35%).4 Smoking is more common among veterans.5 They are also more likely to have higher rates of common mental health disorders, including alcohol misuse.4 Alcohol is part of military life6 and many 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.7 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 20148 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 signposting service that lists support and information on available resources for veterans.
Methods: veteran-friendly GP practices
The idea of promoting a practice as veteran-friendly came from an ex-military GP. A patient stated that he had specifically joined the practice to see someone who would understand his needs as a veteran. This patient made his GP reflect on how pivotal a GP surgery could be in identifying veterans to help ensure they received care and treatment that is considerate of their time in the military.9 This concept has since been further developed by NHS England, NHS Improvement and the Royal College of General Practitioners (RCGP), resulting in the development of the ‘Veteran Friendly GP Practice Accreditation Programme’, which commenced in April 2019. Most veterans are registered with a GP practice, and experience has shown that GPs would like more help and support when looking after veterans.8
After a successful pilot in the RCGP West Midlands Faculty, the programme has expanded to the whole of England. The RCGP is working alongside NHS England to accredit practices as ‘veteran-friendly’. This involves a simple process where practices are required to meet the specified criteria and provide evidence that they are supportive of veterans’ healthcare (Box 1). Training is provided to support the practice with information about veterans and available resources, such as referral pathways for mental health such as the NHS England’s Transition, Intervention and Liaison Service and Complex Treatment Service, or services that assist with physical health needs: the Veterans Trauma Network.10 11
Accreditation requirements for RCGP friendly practice
Nominated clinical veteran lead (registered healthcare professional).
New patients on registration asked if they have ever served in the British Armed Forces.
Code information on GP computer system.
Clinical lead takes dedicated training and commits to keeping up-to-date with veterans’ healthcare.
Ensure that the practice is meeting the health commitments of the Armed Forces Covenant.
Clinical lead available to provide advice to colleagues and potentially to neighbouring practices.
Eligible practices should have a Care Quality Commission rating of ‘good’ or higher.
Accreditation is done online through the RCGP website and requires renewal after three years.
GP, general practitioners; RCGP, Royal College of General Practitioners.
Results
The Veteran Friendly GP Practice Accreditation Programme continues to grow, now with more than 850 practices accredited across England (about 12% of all practices).
Accredited practices are asked to feed back on the value of the programme. A patient aged 101 was terminally ill and a home visit was requested to review palliative care medication. On the mantlepiece was a picture of a young soldier in uniform. The patient then spent 20 min describing his exploits towards the end of World War II. He described how he marched most of the length of Italy with what he described as ‘the best comrades in the world’. The patient was immensely proud and close to tears. Later that day, the practice received a telephone call thanking the GP for the visit. The patient had rested well and was much more comfortable following the home visit. No additional medication was required. Showing an interest in the patient’s military background, as a result of the knowledge gained from the veteran-friendly accreditation programme, helped in the care of this patient.
The first GP practice to have been accredited in the South West of England noticed that veterans were more likely to share their mental health problems (often alcohol-related) with a GP who had a good understanding of the military. There can be issues of trust, language and understanding that create barriers to engagement, and these barriers can be reduced and trust more easily established if the clinician has a reasonable understanding of the stress that military personnel face during service. Further benefits have also been recognised, with military families registered with the practice feeling better supported.
Many accredited practices describe how this initiative has brought the team together and that they are proud they are better able to support veterans. Within each practice, there are often staff members (all grades) who are ‘ex-military’ themselves and are keen to lead this programme.
The programme has been widely acclaimed with coverage from regional and national media and is fully supported by the government and the Defence Select Committee. The importance of the programme is recognised:
The lack of civilian medical practitioners’ understanding of military culture and military mental health issues remains a significant barrier to veterans accessing and receiving effective treatment for their mental health conditions. We welcome the work being done to improve the understanding of civilian medical practitioners, such as the creation of veteran-friendly GP surgeries.12
The NHS Long Term Plan has incorporated the programme and sets out the following commitment: ‘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 RCGPs’.13 A key element of being veteran-accredited is knowing the different and additional referral pathways available for veterans in England.
The Care Quality Commission (CQC) now promotes the programme and recommends accreditation for the care of veterans.14 As part of their inspections, CQC requires NHS GPs in England to have plans in place to look after those ‘whose circumstances may make them vulnerable’, and this includes members of the Armed Forces community and specifically veterans and their families. The CQC promotes the veteran-friendly programme, which is seen as instrumental to GPs in caring for veteran patients. This initiative has concentrated on supporting veterans and their families, and there are other disadvantaged groups such as asylum seekers and members of the Lesbian, Gay, Bisexual and Transgender community.
Discussion
Veterans often have special health needs that may not be obvious at the time of presentation to their GPs. Recognising that a presenting complaint may be linked to a time when the veteran was in service may help identify the cause of their problem. Mental health issues may well relate to the time served on military operations in austere environments. Under the Military Covenant, veterans should not be disadvantaged. An understanding of the health needs of veterans will better place GPs in providing healthcare to veterans and ensures their commitment to the Military Covenant.
The programme largely relies on the education of GPs and their team. This has been enhanced with provision of healthcare to veterans being added to the RCGP curriculum and training of future GPs.15 A bachelor of nursing undergraduate programme has incorporated the care of military veterans and their families into their syllabus so future nurses will have a better understanding of veterans’ healthcare.16 However, there is more education to be done in the UK particularly if comparison is made with the USA. The Veterans Administration (VA) is responsible for the healthcare of the majority of veterans. The training of all healthcare professionals is part of the VA’s statutory mission to enhance the quality of care provided to veterans.17 Almost 70% of USA-trained physicians receive training at a VA medical centre or clinic as part of a partnership between VA medical centres and US medical schools and teaching hospitals.18 The VA offers clinical training not only to physician trainees, but also to trainees of over 40 different health professions.18 There is more work to be done in the UK to ensure all healthcare professions understand the special needs of veterans.
Conclusion
By 2024, the aim of the programme is to accredit all GP practices in England as veteran-friendly. With the help of devolved nations, this programme could be rolled out across the UK. Ultimately, this initiative seeks to ensure that all GPs (and all those working in primary healthcare) ask their patients: ‘have you ever served in the Armed Forces?’ With the knowledge and training provided as part of the veteran-friendly programme, GPs will be better able to support the health and welfare of veterans (and their families).16
Data availability statement
Data are available upon reasonable request. Qualitative data are held by the RCGP veterans’ programme.
Ethics statements
Patient consent for publication
Footnotes
Contributors RGS was the main author and did the majority of the work for this article. JL contributed and checked the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.