SCOPING REVIEW: a Needs-Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and Their Families in Scotland
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SCOPING REVIEW: A Needs-Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and their Families in Scotland FINAL REPORT Professor Susan Klein1 1Director, Aberdeen Centre for Trauma Research, Institute for Health & Welfare Research, Robert Gordon University 2 Emeritus Professor David A Alexander 2 Former Director, Aberdeen Centre for Trauma Research, Institute for Health & Welfare Research, Robert Gordon University IN COLLABORATION WITH: 3 Dr Walter Busuttil 3 Director Medical Services, Combat Stress, Tyrwhitt House, Leatherhead December 2012 CONTENTS Acknowledgements 6 Abbreviations and Acronyms 7 Executive Summary 11 Section 1: Introduction 21 1.1 Background to the Scoping Review 21 1.2 Terms of Reference 21 1.2.1 Aim 22 1.2.2 Objectives 23 1.2.3 Parameters of the Scoping Review 23 1.2.4 Methodological Framework and Analytic Strategy 24 1.3 Format of the Report 25 Section 2: Veteran-Related Policy, Strategy & Commitments 26 2.1 Preface 26 2.2 Role, Composition, and Ethos of the UK Armed Forces 27 2.3 Scotland‘s Contribution to the UK Armed Forces 31 2.4 Composition of the Veteran Community 31 2.5 Key Drivers of Veteran-Related Policy and Strategy 33 2.6 Moral and Social Factors 36 2.6.1 Recognition of Sacrifice 36 2.6.2 ―Duty of Care‖ 38 2.6.3 No Disadvantage 38 2.7 Economic Factors 39 2.7.1 Recruitment 39 2.7.2 Retention 39 2.7.3 Litigation 40 2.8 Political Factors 41 2.8.1 Public Support 41 2.8.2 Social Exclusion 42 2.9 Evolution of Veterans Policy and Strategy 43 Section 3: Provision of Healthcare and Welfare Support 51 3.1 Preface 51 3.2 Defence Healthcare 51 3.2.1 Military Medical Care Policy and Strategy 51 3.2.2 Responsibility for the Delivery of UK Armed Forces 52 Medical Care 3.2.3 Trauma Care Provision for Severe Operational Injuries 54 3.2.4 Illnesses and Non Battlefield Injuries (NBI) 56 3.2.5 MoD Hospital Units: Secondary Care and Training 57 3.2.6 Rehabilitation and Aftercare 58 1 3.2.7 Mental Healthcare for Service Personnel 59 3.3 Operational Stress Management Policy and Strategy 62 3.4 Prevention and Management of Psychological Trauma 63 3.4.1 Screening 63 3.4.2 Trauma Risk Management (TRiM) 64 3.4.3 Decompression 65 3.4.4 Medical Assessment Programme (MAP) 65 3.4.5 Reservists Mental Health Programme (RMHP) 66 3.4.6 Evidence-Based Treatments for Combat-Related 67 Disorders 3.5 Medical Discharge 68 3.6 Service Family Healthcare Provision 71 3.7 Veterans Healthcare Policy and Strategy 71 3.8 Current Organisation and Delivery of Veteran 75 Healthcare 3.9 Development of a Community-Based Mental Health 79 Service for Veterans 3.10 Piloting the Implementation of a Community-Based 84 Mental Health Service for Veterans 3.11 Improving Access to Psychological Therapies (IAPT) 87 3.12 Healthcare Provision for Veterans who Encounter 89 the Criminal Justice System 3.13 Welfare and Support 91 3.13.1 Organisation of Welfare and Support Provision 91 3.13.2 UK Armed Forces Welfare Policy and Provision 93 3.14 Organisation and Nature of Resettlement Provision 96 3.15 Pensions Provision 100 3.15.1 War Pensions Provision 101 3.15.2 Benefits Provision 105 3.16 Housing Provision 105 3.17 Homelessness Initiatives 109 3.17.1 Homelessness Legislation, Policy and Strategy in 110 Scotland 3.18 Welfare Provision for Veterans who Encounter the 113 Criminal Justice System 3.19 Education and Skills Training Provision 114 3.20 Employment Provision 115 Section 4: Outcome of the Consultation Process 117 4.1 Preface 117 4.2 Method 117 4.3 Pre-Service Factors 117 4.3.1 Pre-enlistment Vulnerabilities 117 4.4 Service-Related Factors 118 4.4.1 Military Culture/ Ethos 118 4.4.2 Inter-Service Differences 118 4.4.3 Rank Differences 119 2 4.4.4 Gender Differences 119 4.4.5 Operational Exposure 119 4.4.6 Mental Health Screening 120 4.5 Resettlement and Transition 121 4.6 Post-Service Factors 121 4.6.1 Time out of the Services 121 4.6.2 Barriers to Care 122 4.6.3 Areas of Particular Difficulty 124 Section 5: Review of the Eminence- and Evidence-based 126 Literature 5.1 Preface 126 5.2 MOD and Government Commissioned Reviews 126 5.2.1 Delivery of Cross Departmental Support and Services 127 for Veterans 5.2.2 Defence Healthcare (In-Service and Post-Service) 131 5.2.3 Transition 139 5.2.4 Homelessness 144 5.2.5 Health and Social Outcomes/ Health Service Experience 146 5.2.6 Community-Based Mental Health 149 5.3 Veteran-Related Charities and Agencies Commissioned Studies 153 5.3.1 Veterans‘ Profile and Needs: Scotland 154 5.3.2 Treatment Effectiveness and Client Satisfaction 160 Evaluation 5.3.3 Service Provision Evaluation 163 5.3.4 Homelessness 166 5.3.5 Employment 169 5.3.6 Criminal Justice System 172 5.4 Academic-Based Research Reported in the Peer Review 172 Literature 5.4.1 Methods and Caveats 172 5.4.2 Pre-Service Factors 173 5.4.2.1 Childhood adversity 173 5.4.2.2 Socio-economic adversity 175 5.4.2.3 Psychiatric history 175 5.4.2.4.Personality 176 5.4.2.5 Coping style 176 5.4.3 In-Service Factors 176 5.4.3.1 Changing nature of combat 176 5.4.3.2 Changing nature of operational deployment 179 5.4.3.3 Social support 181 5.4.3.4 Unit cohesion 182 5.4.3.5 Mortality 183 5.4.4 Physical Health 187 5.4.4.1 Cancer 187 5.4.4.2 Diabetes 188 5.4.4.3 Thyroid disease 189 3 5.4.4.4 PTSD and endocrine diseases 189 5.4.4.5 Obesity 189 5.4.4.6 Arthritis 190 5.4.4.7 Reproductive health 190 5.4.4.8 Chronic Fatigue Syndrome (CFS) 192 5.4.5 Mental Health 194 5.4.5.1 Post-Traumatic Stress Disorder (PTSD) 194 5.4.5.2 Comorbidity 197 5.4.5.3 PTSD and physical injury 198 5.4.5.4 Alcohol misuse 199 5.4.5.5 ―Ripple Effect‖ 202 5.4.6 Transition-Related Factors 204 5.4.7 Post-Service Outcomes 206 5.4.7.1 Veterans in prison 206 5.4.7.2 Self-harm 207 5.4.7.3 Barriers to mental healthcare 211 5.4.7.4 Lack of integration across services 212 5.4.7.5 Durability of therapeutic gain 212 5.4.7.6 Stigma 212 5.4.7.7 Help Seeking 213 Section 6: Summary, Conclusions and Recommendations 217 6.1 Preface 217 6.2 Summary of Findings: Consultation Process 217 6.2.1 Pre-Service Factors 217 6.2.2 Service-Related Factors 217 6.2.3 Post-Service Factors 218 6.3 Summary of Findings: Review of Eminence-Based and 218 Evidence-Based Literature 6.4 Research Recommendations 220 6.5 Needs-Based Assessment and Population-Based 223 Survey of Veterans and Their Families in Scotland 6.5.1 Identification of an Appropriate Comparison Group 224 6.5.2 Data Protection and Ethical Issues 224 6.5.3 Tracing Issues 226 6.5.4 Regional Variation 227 6.5.5 Sampling Frame 227 6.6 Design and Funding Recommendations 233 Appendices 235 References 253 4 FIGURE AND TABLES Figure 1. Life History Trajectories of Interviewees 168 Table 1. Key Strategy and Policy-Related Papers and Reports 26 Table 2. Summary of Strategic Themes, Objectives and Potential 35 Benefits Table 3. Summary of Key Components of the Strategy for Veterans 44 Table 4. Medical Discharge Grades and Fitness Levels 68 Table 5. Medical Discharges for Tri-Services 71 Table 6. Outline of Partnership Board Approach 73 Table 7. Summary of MoD and Government Commissioned Reviews 127 Table 8. Key Findings by Domain 143 Table 9. Categorisation, Inclusion Criteria, and Numbers Identified 147 Per Category (N=76) Table 10. Key Findings According to Focus of Analysis 148 Table 11. Pilot Services Evaluation by Components 151 Table 12. Summary of Veteran-Related Charities and Agency 153 Commissioned Studies Table 13. Profile of Combat Stress Sample 161 Table 14. Issues Affecting Employment 171 Table 15. ―Cycle of Deployment‖ 181 5 ACKNOWLEDGEMENTS The completion of this Scoping Review owes much to many individuals, especially those who gave so generously of their time in respect of the Consultation process and for their helpful comments and suggestions. Thanks are also due to Commodore Toby Elliott OBE (Former Chief Executive, Combat Stress) for his encouragement and support in undertaking this endeavour and to Dr Anne Braidwood CBE (Medical Adviser, UK Veterans' Agency) for her invaluable assistance and expert advice. Finally, we are grateful to The Scottish Government for funding this work and, in particular, to Mr Geoff Huggins (Deputy Director of Health and Social Care Integration, Head of Reshaping Care and Mental Health Division). Susan Klein, Aberdeen Centre for Trauma Research, Robert Gordon University David A Alexander, Aberdeen Centre for Trauma Research, Robert Gordon University Walter Busuttil, Combat Stress 6 ABBREVIATIONS AND ACRONYMS ACDMH Academic Centre for Defence Mental Health ACTR Aberdeen Centre for Trauma Research AFCS Armed Forces Compensation Scheme AFP Armed Forces Project AFPPA Armed Forces Personnel Adminstration Agency AFPRABS Armed Forces Pension and Research Attributable Benefits Scheme AFPRB Armed Forces Pay Review Body AFPS Armed Forces Pension Scheme AMG Agency Management Group APC Army Personnel Centre APMS Adult Psychiatric Morbidity Survey ASOs Administration Support Officers AUDIT Alcohol Use Disorders Identification Test BLESMA British Limbless Ex Service Men's Association CABx Citizens Advice Bureau CAC Central Advisory Committee CAD Citizens Advice Direct CEA Continuity of Education Allowance CHI Community Health Index CHP Centre for Housing Policy CHR Combined Housing Register CI Confidence Intervals CIDI Composite International Diagnostic Interview CISD Critical Incident Stress Debriefing CLG Communities and Local Government CMO Chief Medical Officer COB Contingency Operating Base COBSEO Confederation of British Service and ex-Service Organisations CoSLA Convention of Scottish Local Authorities CPNs