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Oup Milmed Usy086 509..517 ++ MILITARY MEDICINE, 183, 11/12:e509, 2018 Finding the Forgotten: Motivating Military Veterans to Register with a Primary Healthcare Practice Colonel (Retd) Alan Finnegan, PhD RN FRCN*; Robin Jackson, Dr, TD,VR,MB ChB,DRCOG,MRCGP,Dip Occ Med†; Brigadier Robin Simpson, OStJ FRCGP MSc DRCOG DFFP DOccMed FRCGP L/RAMC‡ ABSTRACT Introduction: In the UK, primary healthcare practices choose from a series of Read codes to detail cer- tain characteristics onto a patient’s medical documentation. One of these codes is for military veterans indicating a his- tory relating to military service. However, veterans are poor at seeking help, with research indicating that this code is Downloaded from https://academic.oup.com/milmed/article/183/11-12/e509/4994226 by guest on 01 October 2021 only applied in 7.9% of cases. Clinical staff have a clear role in motivating veterans to declare their ex-Forces status or register with a primary healthcare center. The aim of this study was to motivate veterans to notify primary healthcare staff of their armed forces status or register with a general practitioner, and to improve primary healthcare staff’s under- standing of veterans’ health and social care issues. Materials and Methods: Data were provided by four primary health- care centers’ containing 40,470 patients in Lancashire, England during 2017. Pre- and post-patient medical record Read Code searches were conducted either side of a 6-wk intervention period centered on an advertising campaign. The data identified those veterans with the military specific Read code attached to their medical record and their age, gender, marital status and mental health disorders. Further information was gathered from interviews with eight mem- bers of staff, some of whom had completed an e-learning veteran healthcare academic module. The study was approved by the University of Chester’s Research Ethics Committee. Results: The pre-intervention search indicated that 8.7% (N = 180) of veterans were registered and had the correct military specific code applied to their medical record. Post- intervention, this figure increased by nearly 200% to N = 537. Mental health disorders were present in 28% (N = 152) of cases, including 15% (N = 78) with depression. Interviews revealed the primary healthcare staff’s interpretation of the factors that motivated patients to declare their ex-Forces status and the key areas for development. Conclusion: The primary healthcare staff took ownership and responsibility for this initiative. They were creative in introducing new ways of engaging with the local armed forces community. Many veterans’ and staff were unaware of veterans’ entitle- ment to priority medical services, or the wider provisions available to them. It is probable that veterans declaring their military status within primary healthcare, or registering with a general practitioner for the first time is likely to increase. Another review will be undertaken after 12 mo, which will provide a better indication of success. There remains how- ever an ongoing need to reach out to those veterans who never access a primary healthcare practice. This paper adds to the limited international empirical evidence undertaken to explore help-seeking behavior in an armed forces commu- nity. The positive outcomes of increased awareness and staff commitment provide a template for improvement across the UK, and will potentially stimulate similar initiatives with international colleagues. INTRODUCTION Since 1985, the UK has utilized Read Codes that are Before leaving the UK Armed Forces, service leavers receive applied to a patient’s PHC medical record to annotate char- a final medical examination. They then receive a written sum- acteristics such as diagnosis, ethnicity, and therapeutic inter- mary containing limited information regarding their medical ventions.1 The UK’s Department of Health directs that a and mental health (MH) history, and are directed to deliver Read Code should be applied to medical documentation this document to staff when they register with a civilian pri- indicating a “history relating to military service.”2 However, mary healthcare (PHC) general practice. The UK Ministry of there are multiple military Read Codes available for distinc- Defence (MoD) does not monitor if service leavers actually tions such as service, i.e., Royal Navy, Army, Royal Air register. Force or Royal Marine. While Health Education England (HEE) advocate the use of a single Read Code, there is no 3 *Westminster Centre for Research and Innovation in Veterans’ national agreement on which to apply. In addition, the utili- Wellbeing, Faculty of Health and Social Services, University of Chester, zation of different databases systems, including those that Riverside Campus (Rm 311) – Castle Drive, Chester CH1 1SL, UK. are not synched, does not facilitate the compatible exporting † NHS Bury Clinical Commissioning Group, 21 Silver Street, Bury BL9 of data.2 Even in the UK, where all patients have a unique 0EN, UK. fi ‡Ministry of Defence Deanery, The Keep, Whittington Barracks, NHS identi cation number, there are still differences in the Lichfield, Staffordshire WS14 9PY, UK. veteran numbering systems used in Scotland and Northern The views expressed are solely those of the authors and do not reflect Ireland from that used in England, Wales and the Isle of the official policy position of the UK Royal Navy, British Army, Royal Air Man. These factors contribute to an estimation that only Force, Ministry of Defence, or UK Government. 7.9% of PHC practices applied the Read Code correctly.4 doi: 10.1093/milmed/usy086 fi © Association of Military Surgeons of the United States 2018. All rights This low gure is despite a National Health Service (NHS) 5 reserved. For permissions, please e-mail: [email protected]. website informing veterans of the healthcare benefits and MILITARY MEDICINE, Vol. 183, November/December 2018 e509 Finding the Forgotten there are no perceived barriers that specifically prevent veter- This model has benefits over statutory NHS services,16 includ- ans from registering. This study was funded by the UK NHS ing a better understanding of service culture, and is most effec- and assesses a strategy aimed at motivating veterans to regis- tive for early services leavers.17,18 A transition, intervention, ter or notify their veteran status with their PHC General and liaison service offers another treatment option with multiple Practice, while improving PHC staff’s awareness and knowl- points of access including self-referral.19 edge of veteran related issues. Veterans often “bottle up” their feelings; fearing the impact of sharing personal burdens with their family or appearing weak.20,21 Veterans may believe that civilian health profes- BACKGROUND sionals will not understand their past military experiences and Armed Forces Community not register with a PHC practice,16 or not disclose their Veteran 22 The inclusion criteria for classification as a UK military vet- status. Poor help seeking leads to excessive delays in addres- Downloaded from https://academic.oup.com/milmed/article/183/11-12/e509/4994226 by guest on 01 October 2021 eran are 1 d of service in either the Regular Armed Forces or sing operationally attributable MH issues; often left until they 23 Reserves.5 The veteran population is estimated at approxi- are in crisis and social isolation. Innovations including social mately 2.6 million,6 embedded within the UK armed forces prescribing have emerged to positively and successfully pro- 24 community (AFC) of 10 M that includes veterans’ families, mote help seeking. EUROFIT is exploring the use of iconic 25,26 and personnel still serving.5 This AFC is a diverse heteroge- football clubs to reach out to men, while utilizing creative 27 neous group differing by factors such as age, gender, and motivators promoted by mobile applications. length of service. Veterans experience the same social and PHC have a clear role in improving and promoting the environmental stressors faced by the UK population,6 but physical and mental wellbeing of the AFC and PHC doctors 28 are perceived as being more susceptible to MH issues due to can positively change behavior patterns. NHS staff require previous “contact” situations (engagement with the enemy), an understanding and awareness of the health and social particularly when colleagues were injured. As such, there is issues associated with the AFC and the treatment/referral a public perception that Veterans are inevitably scarred by pathways. To achieve this, HEE have provided a free online 29 their military experiences,7 although a significant majority veterans education module and are supporting undergradu- are physically and mentally well,8 and there is a need to ate AFC training sessions that will provide a common foun- 30 redress this balance.9 dation for all clinical staff. Demographics AIM The veteran population is 89.5% (N = 2,348,000) male and To motivate veterans to notify PHC staff of the armed forces 10.5% (N = 276,000) female.6 A Royal British Legion status or register with a GP. study10 indicated that of those aged 16–44 yr olds, 1 in 10 The objectives were to: reports problems assimilating into society, and that they are more likely than the general population of the same age to a. Identify whether an advertising campaign would motivate report certain long-term illness such as depression. Veterans veterans to notify PHC staff of their armed forces status have entered the criminal judicial system in large numbers 11 or register with a GP. for violent crimes, while Australian research indicates that b. Identify trends regarding age, gender, and marital status. there is an increase in alcohol intake after leaving the Armed 12 c. Evaluate PHC staff assessment of the intervention, Forces. 52% of the veteran population is estimated at being fi 6,10 6 including the effectiveness, bene ts, problems, and means 75 yr old or older, and 70% are 60 yr and over.
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