On military service and health

Some thoughts on health needs assessments for ex-military populations

Local authorities in England have documents called Joint Strategic Needs Assessments, which describe the health of the local population. A review of these documents in 2015 for the Forces in Mind Trust found that most don’t specifically address the ex-military population, and of those that do, most only have a passing mention to former members of the Armed Forces. This is despite the fact that all local authorities have signed up to the Armed Forces Covenant, which commits them to make sure that people who serve in the UK’s Armed Forces aren’t disadvantaged in accessing public services, and in some cases get special consideration.

Last year we set out to address this in Tameside* by doing a health needs assessment for our local ex-military population. Some of what we produced might be useful for other local authorities who want to do the same. This blog is about some of the things that I learned along the way.

You can’t generalise about the health of people who serve in the armed forces

People who join the Armed Forces come from a range of different backgrounds. Some join straight from school with few qualifications. Others join after university with lots of qualifications. Some come from deprived estates. Others come from expensive private schools.

They have very different experiences depending on which of the Armed Forces they serve in, the job they do, whether they join as an officer or not, how long they serve in the Armed Forces, and so on.

All of these things are likely to affect a service person’s health and prospects after they return to civilian life. So it shouldn’t be a surprise that the literature review that I did found that, while overall differences between people who’ve served and those who haven’t are relatively slight, some ex-military personnel are at real risk of a range of bad things. This includes mental illness, alcohol and substance misuse, homelessness, unemployment, and suicide. The ex-service people at most risk are those who left service early, served a relatively short time, or were exposed to combat. This should not come as a surprise either, as this group often have the lowest levels of educational achievement and are likely to be recruited from more deprived areas of the UK.

If we are forced to lump all ex-service people together, then former members of the UK’s Armed Forces appear to have similar health to those who haven’t. This is true even in areas where serving personnel are different from civilians. For example, while we know that serving members of the Armed Forces are more likely to drink alcohol at harmful levels, one big cohort study found no difference in alcohol-related illness between people ex-service personnel and the general public.

One reason for this might be that drinking, like most behavior, depends on context. So when people leave the Armed Forces, their alcohol consumption probably starts to reflect the civilian population. The ex-military people that I spoke to said the same about exercise – on the whole, they didn’t think that many of those leaving the Armed Forces maintained the same levels of fitness that are required of serving personnel.

Even where there is evidence of increased risk of ill health in ex-military populations, such as with mental health, misconceptions are common. The published research literature suggests that while the risk of mental illness is higher among people who have served in the Armed Forces, mental illness is far from a universal experience. And for those that do suffer mental illness, common mental illnesses like anxiety and depression are more common than post-traumatic stress disorder, regardless of what you see on the TV or read in the paper. As one interview participant put it:

“There’s a big thing at the moment about with people … chucking phrases about ‘dark places’ and ‘isolation’ … Not every soldier, male or female, comes out of the military and goes into a dark place.”

We need better data…

So if there is important variation within the ex-military population, simply estimating the total number of ex-military people in an area isn’t enough to inform a good needs assessment. We don’t pretend that the population of Tameside looks like the population of Trafford**, so why would we assume that the ex-military populations look the same?

To do meaningful needs assessments, local authorities need more detail on the makeup of their local ex-military populations. This includes information like how many were officers versus non-officers; the proportion that served in each of the Armed Forces; the distribution of lengths of service and numbers of operational tours; the number who left service early; the numbers who served in combat roles. Ideally, those most likely to need help would be put in contact with local support networks as they leave, rather than later.

Sadly, the data that currently exists is not up to the job. People who have served in the Armed Forces should have their medical records flagged to indicate their service. This data could be used to get a good picture of illness and use of health services. Unfortunately, we found that this only happened in a small number of cases, and the coding was often inconsistent. Work is happening in Tameside to try to fix this, and there are examples of good practice from elsewhere.

…But talking to people is a good place to start

So in the absence of great local data, what’s a local authority to do? Well, talking to local ex-service people is a pretty good place to start. It turns out that if you ask local residents who have served in the Armed Forces what they think of the health of ex-military people, their answers are pretty similar to published research literature. Which suggests that local residents’ views can be a valid source of information on health needs. And their views can tell you some things that the numbers probably wouldn’t. For example, about their experiences of using healthcare, and the things that get in the way (more on this later). Or about how their service affected their family, a topic on which there isn’t enough published research. You can read more about what local ex-military people had to say here.

Some dedicated health services are probably worthwhile…

There are some areas of health where dedicated services for people with military service make sense. The most obvious one is mental health. This is an area where it is really important that the people delivering the service understand the military context and culture.

In Greater Manchester, there is a military veteran mental health service in addition to nationally funded services. The ex-military people that I spoke to said that this service was really valuable to those that needed it.

…But we also need to think about barriers to accessing standard health services.

However, it isn’t feasible or desirable to have specialised ex-military health services for all areas of health. For one thing, people who have served in the Armed Forces aren’t that different from the general public in terms of their health needs, so the burden of illness probably wouldn’t justify a separate ex-military health service.

For another thing, the effectiveness of the health service is probably going to be similar for people who’ve served in the Armed Forces and those that haven’t. A veteran who needs a replacement for an arthritic hip isn’t likely to benefit much from a military-specific operation (indeed, they may be worse-off as such a service would probably do far fewer procedures).

But if most ex-military health needs are going to be met by standard NHS services, then they need to be accessible. The interviews that I did as part of our needs assessment threw up some interesting ideas about how people who have served in the Armed Forces might face subtle barriers to getting care. On the one hand, there’s the military culture of ‘soldiering on’. As one interview participant put it:

“if you’ve come down with a cold or sprained an ankle, you know full well you were going to get ripped to high heaven …So you never went sick.”

On the other hand, there’s a lack of understanding among some health care workers, as well as waiting times for healthcare in civilian services that don’t exist in the Armed Forces. Together, these factors could delay access to treatment, resulting in worse outcomes. As ever, more research is needed.

It’s not always easy to know if a health issue is related to military service or not.

The Armed Forces Covenant says that in some circumstances, people who have served in the UK’s Armed Forces should get special consideration. This is sometimes taken to mean that if someone has been injured as a result of their service, they should get priority over other people with similar clinical needs.

However, lots of the health needs identified in the literature review and interviews are things that develop over time. This means it’s not so easy to say they were caused by military service. As one interview participant put it:

“It’s like how do you prove, if forty years down the line if you’ve got arthritis … Is it because, I don’t know, seventy percent of the UK population have arthritis, or is it because you did military service?”

We need to know more about the effects of military service on close family members

Although the Armed Forces Covenant recognises the UK’s responsibility to military families, I found very little evidence about the health of close family members of UK service personnel. The ex-military people that I spoke to thought that military service can have a negative impact on their family’s health. Frequent moves, sometimes abroad, loss of social networks, disruption to school, and the stress of being separated from the serving family member were mentioned as possible causes. One participant talked about how they felt the impact on their children had been greater for their older child, which suggests that the effects could be greater at key points. If we’re going to honour the Armed Forces Covenant commitment to families, then we need better information about their needs.

Footnotes

*Tameside is a local authority area in Greater Manchester in the North West of England.

**Trafford is a local authority area, also in Greater Manchester in the North West of England, which is less deprived than Tameside.