The Veteran Friendly Practice accreditation programme: a mixed-methods evaluation

Understanding veterans’ needs

Accreditation was perceived to have a positive impact on military veterans, with 67% (n = 10) of interviewees reporting a greater appreciation of veterans' needs since becoming accredited; 72% (n = 166) of survey responders believed this increased understanding benefitted veterans. GP practices became more understanding of veterans' experiences and were more aware of their need for veteran-specific care:

'Given the fact that he was a veteran with mental health issues, I did take time to explore his needs and what we can offer him. He was somewhat taken a back, I think it wasn’t something he expected. I explored his needs, his mental health, his friendships, his need for a system as a veteran.' (BB)

This resulted in more successful engagement with secondary health care. Similarly, interviewees believed their increased understanding had led to an improved doctor—patient relationship. Improved understanding was also demonstrated by nursing and administrative staff.

Understanding veteran-specific services

Ten interviewees had a better understanding of veteran-specific services since becoming accredited, particularly in relation to MH and orthopaedic referrals:

'Just having an awareness of what services are available, I didn’t know about things they could access — particularly with mental health. Now I know where I can refer that veteran who really needs that help.' (FF)

This knowledge was informed by RCGP updates and self-motivated online learning (webinars and veteran-specific websites). Overall, accredited practices have a good appreciation of the Armed Forces Covenant priority referral process and utilise this well. They felt it was being implemented by secondary health care, although there were isolated instances requesting further education to inform both primary and secondary care services about priority treatment:

'I didn’t understand what priority treatment is and I don’t think NHS trusts do, so they don’t follow it through on a secondary level. So, if I put a referral through and he’s in chronic pain, I don’t think they’d register it more than if it was a truck driver or a builder, to them they’re all the same.' (LL)

Eleven interviewees believed veterans were unaware of the veteran-specific services available, and GPs have essentially ‘bridged’ the gap between the veteran and available services, utilising veteran-specific services that would not otherwise have been accessed by the veteran:

'It’s me knowing it exists rather than patients coming to me telling me it exists … if I wasn’t there, I guess they would just get referred in the standard NHS way and longer waiting times and a less bespoke service.' (EE)

Several interviewees had developed a veteran resource database in their practice since becoming accredited, utilising it as a foundation to access guidance regarding signposting their veteran patients to the most appropriate service.

Veteran help-seeking and engagement

Five interviewees reported a small but definite increase in veteran help-seeking since becoming accredited, especially in younger veterans:

'I think it has made veterans more likely to come forward and seek help … I think a lot of patients are the type of patients who wouldn’t normally come to seek help. They tend to be younger to middle-aged men really, which you don’t see a lot of.' (JJ)

Participants felt it was easier to communicate with older veterans once they became aware their GP had an understanding of their military experience. Older veterans were considered to have little appreciation of their veteran status, with some being unaware they were classed as a veteran. Survey data supports this finding, whereby only 3% (n = 6) of survey responders believed veterans aged >80 years would engage with an accredited practice. This reinforces previous findings highlighting a need for further exploration into the needs of older military veterans.²² Eight interviewees reported that veterans had registered with practices directly as a result of hearing about their accreditation:

'We have patients who have registered with our practice deliberately because we are veteran friendly or transferred to our practice from other practices for that reason.' (CC)

As a direct result of the initiative, GP practices were better able to understand veterans' needs and have a greater awareness of how to meet them. Overall, GP practices have a good appreciation of the Armed Forces Covenant priority referral process and utilise this well. Veterans themselves are perceived to lack understanding of veteran-specific services, which highlights the importance of the GP practice’s veteran-specific knowledge and consideration. However, it is important to note that in the qualitative aspect of the evaluation, 10 interviewees were veterans themselves, which makes it difficult to assess whether their knowledge was influenced by their own military experiences. Indeed, interviewees who were veterans appeared to have greater access to priority health care as they had forged military connections within other health and social care services. Nevertheless, interviewees who were not veterans were equally motivated to use both priority referrals and veteran-specific services in order to maximise the care and support to their veteran clients.

Seven interviewees believed it was too early to gauge the impact of the accreditation on veteran help-seeking, largely owing to COVID-19, and felt this evaluation may be better timed in another 12 months. This was also evidenced in the open-ended survey responses.

Veteran registrations

Since becoming accredited, some GP practices reported an increase in veteran registrations:

'We’ve certainly seen more veterans. People have deliberately registered with us as a result of the accreditation including some who have been out of area who we wouldn’t normally register. They’re wanting to see somebody who understood the military and could assist them more.' (NN)

However, participants believed there was work still to be done to identify veteran patients, believing they needed more time to increase their veteran registrations. This was in part pre-empted by COVID-19. Nevertheless, participants felt that improved awareness had resulted in practice staff who were more motivated to identify veterans and willing to accept and adopt new strategies. Reception staff asked new patients, 'Have you ever served?', while nursing and GP staff asked patients during consultations whether they were veterans, and this was positively received by veteran patients. This form of proactive engagement was not done before accreditation. Awareness of veteran patients subsequently led to improved coding of veterans:

'I’ve been a lot more aware of registering veterans as the right Read Code … I’ve registered a lot more as the right Read Code since becoming accredited.' (FF)

Motivation to register veterans appeared to be guided by a desire to improve veteran health care, although two interviewees reported that their clinical commissioning group had not been allocated funding to undertake veteran-specific coding searches, suggesting that funding may be a motivator to further improve PHC engagement.

Working environment

Eleven interviewees described how PHC staff’s motivation and commitment to the programme invoked a sense of pride in all practice employees. This was considered to have benefitted the reputation of the practice:

'When we first got registered, there was huge support from the staff, particularly the admin team. They were really positive, quite a few of them have got spouses who are ex-military or children in the military. It raised the profile of military awareness. We have a real sense of pride in the staff, supporting the military.' (CC)

Several interviewees felt they had become a better practitioner as a result of the understanding and awareness gained from being accredited. Reinforcing survey results, all practice staff were described as having an improved appreciation of veterans' needs:

'The main thing is having somebody in the surgery who understands them. It’s not just me, it’s the fact the receptionists are more understanding … It’s allowed us to be more focused and because of the fact they know about the different referral pathways, we can often refer them into a service where they get a better answer, especially for mental health.' (NN)

The accreditation itself has had a positive and beneficial impact on GP practices. Participants felt accreditation resulted in increased veteran registrations, improved SNOMED and Read coding systems, and greater motivation to identify veterans. While there remains work to be done in terms of reaching all patients, the fact that improvements have been observed should be considered a positive outcome. A better working environment was also noted and staff motivation to improve veteran health care highlighted. This is an encouraging finding and suggests continuation of this programme would be warmly received by PHC staff.

Identifying veterans

Identifying veterans so they could be correctly coded on their medical records and made aware of the accreditation status was a primary concern for seven interviewees and was also highlighted consistently in the survey data:

'We are quite new to this so numbers are fairly small but we found several veterans who were relatively new out of service and we’ve been able to engage with them and they’ve been very positive about it, it’s been quite helpful for them.' (II)

Reaching these veterans was more problematic owing to the lack of footfall as a result of COVID-19. Several participants also raised concerns about veterans’ understanding of their status. Interviewees suggested many veterans had little appreciation of the benefits associated with disclosing their status to their GP, highlighting a need to promote understanding of veteran status in the veteran community.

Promoting veteran-friendly accreditation

PHC practices advertised their accreditation on their website, introduced veteran-specific material to posters and to the public health information shared on their internal TV screens in their practice waiting rooms and through local communication by 'word of mouth'. However, 11 interviewees felt these methods of advertising were not having maximum impact and were considering alternative ways of promoting their accreditation status. Interviewees believed ‘word of mouth’ was the most effective method of promoting their accreditation but acknowledged this would take time:

'I’m always looking for ways to help veterans. We are quite proactive. Veterans aren’t even aware that practices are veteran friendly so they’ve been quite shocked. I’ve put messages out to the Armed Forces Community that I’m in touch with, the armed forces breakfast clubs and things. A couple of our patients, when they’ve moved into area and gone along to armed forces breakfast clubs, they’ve said the surgery is veteran friendly so we’ve had a few patients come down and register.' (GG)

Training needs

Ensuring all practice staff were made aware of the programme was considered an additional responsibility for veteran leads, especially for practices with a high turnover of staff. Six interviewees advocated a need for further training, and the survey results revealed GP practices found RCGP updates extremely useful, although there were recommendations for these to be received on a more regular basis. This might suggest a need for more frequent veteran-specific updates from the RCGP and the NHS. Others suggested further training would be beneficial such as a conference, meetings, and/or study days.

GP practices have found it difficult to reach veterans as a result of COVID-19 and have had little time to implement changes, although the veterans they have reached have benefitted greatly from the programme. In addition, GP practices may profit from further opportunities to enhance their knowledge of how best to meet the needs of veterans and ensure they receive the optimum level of care.