Veterans' Health PSP protocol

Purpose of the PSP and background

The purpose of this protocol is to clearly set out the aims, objectives and commitments of the Veterans’ Health Priority Setting Partnership (PSP) in line with James Lind Alliance (JLA) principles. The Protocol is a JLA requirement and will be published on the PSP’s page of the JLA website. The Steering Group will review the Protocol regularly and any updated version will be sent to the JLA.

The JLA is a non-profit making initiative, established in 2004. It brings patients, carers and clinicians together in PSPs. These PSPs identify and prioritise the evidence uncertainties, or ‘unanswered questions’, that they agree are the most important for research in their topic area. Traditionally PSPs have focused on uncertainties about the effects of treatments, but some PSPs have chosen to broaden their scope beyond that. The aim of a PSP is to help ensure that those who fund health research are aware of what really matters to patients, carers and clinicians. The National Institute for Health and Care Research (NIHR) coordinates the infrastructure of the JLA to oversee the processes for PSPs, based at the University of Southampton.

Members at the Office for Veterans’ Affairs (OVA) and key stakeholders agreed that it was important to gain a better understanding of the health needs of veterans in the United Kingdom. To ensure that servicemen and women who have served in the UK Armed Forces get the support they need, OVA approached the James Lind Alliance to set up a Priority Setting Partnership to identify the unanswered questions about veterans’ health.

This PSP defines a veteran as anyone who has served for at least one day in HM Armed Forces (Regular or Reserve), or Merchant Mariners who have seen duty on legally defined military operations. The PSP will also use the term ‘former service personnel’ to describe veterans.

Aims, objectives and scope of the PSP

Initiated by the Office for Veterans’ Affairs, with the agreement of Cabinet Office Ministers, the aim of this PSP is to identify the unanswered questions about Veterans’ Health from the perspective of veterans, their families, friends and carers, health and care professionals, and then prioritise those that these groups agree are the most important for research to address in order to improve quality of life for veterans and their families.

The objectives of the PSP are to:

• work with advocates of and individuals from the following groups to identify uncertainties about physical and mental health and wellbeing:
  • former service personnel, with physical or mental health challenges
  • families, friends and carers of veterans
  • professionals involved in treating, supporting and caring for veterans and their supporters
• to agree by consensus a prioritised list of those uncertainties, for research
• to publicise the results of the PSP and process
• to take the results to research commissioning bodies to be considered for funding.

The scope of the Veterans’ Health PSP is defined as:

• All aspects of physical and mental health and wellbeing of anyone who has previously served in HM Forces, regardless of where they were born or where they now live, although the focus of the possible impact of this PSP is on research opportunities that will influence UK-based health and care services. The scope also includes questions that relate to the physical and mental health and wellbeing of family members and carers of veterans.

The PSP will exclude from its scope questions about:

• Veterans of non-UK armed forces
• People currently in military service.

The Steering Group is responsible for discussing what implications the scope of the PSP will have for the evidence-checking stage of the process. Resources and expertise will be put in place to do this evidence checking.

The Steering Group

The Steering Group includes membership of veterans, carers, families and health and care professionals, as individuals or representatives from a relevant group.

The Veterans’ Health PSP will be led and managed by a Steering Group involving the following:

Veteran and carer representative/s:

• Andrew Huggins, representing veterans
• Heledd Kendrick, Recruit for Spouses, representing veterans
• Jo Luhman, representing carers
• Katie Watson, representing veterans
• Kayam Iqbal, The OppO Foundation, representing veterans
• Paul Rennie, representing veterans
• Paula Edwards, Salute Her UK, representing veterans
• Tony Wright, Forward Assist, representing veterans
• Zoe Morrison, representing carers

Clinical representative/s:

• Dan Barnard, Consultant Clinical Psychologist. Clinical Lead Ex-Armed Forces MH (Midlands OpCourage), Stratford Healthcare.
• Gwen O'Connor, Highly Specialised Clinical Psychologist, Veterans NHS Wales
• Jonathan Leach, NHS England Associate Medical Director for Armed Forces and Veterans Health. General Practitioner, Davenal House Surgery Bromsgrove. Jonathan is a veteran.
• Shehan Hettiaratchy, National Specialty Advisor, Armed Forces Health. Chair, Armed Forces Clinical Reference Group. National Clinical Lead, Veterans Trauma Network, NHS England & NHS Improvement. Shehan is a veteran.
• Sue Ferrier, Consultant Clinical Psychologist. Head of London NHS Operation Courage Veterans’ Mental Health and Well-being Services. Partnership Lead NHS Veterans’ Mental Health and Well-being Services – London and South East. Armed Forces Clinical Lead, Camden & Islington NHS Foundation Trust
• Peter Le Feuvre, Professional Development Officer (Critical Care) Physiotherapy, Royal Centre for Defence Medicine, Oxford. Peter is a veteran.

Charity representative/s:

• Kirsteen Waller, Health Programme Manager and veteran, Forces in Mind Trust
• Rachel Price, Programme and Cluster Manager, Cobseo – Confederation of Service Charities

Government / NHS representative/s:

• Alison Treadgold, Head of Armed Forces Health (Operations), NHS England
• Liz Brown, Head, Northern Ireland Veterans’ Support Office
• Lindsey Restrick, Senior Policy Manager, Person Centred and Participation Unit, Directorate for Healthcare Quality and Improvement, Scotland
• Jo Davies, Team Leader – Armed Forces and Veterans Health, Department of Health and Social Care
• Welsh representative TBC

James Lind Alliance Project Coordinator:

• Caroline Whiting

Office for Veterans’ Affairs Project Leaders:

• Nikil Patel, Assistant Head for Research and Evidence
• Tom Caplin, Policy Advisor (Steering Group member until July 2023)
• Sam Tillotson, Deputy Director
• Tammy Cheng, Assistant Head for Data and Research
• Tom Verney, Deputy Head of Policy (Steering Group member from July 2023)

James Lind Alliance Adviser and Chair of the Steering Group:

• Suzannah Kinsella

The Information Team:

• Kristina Staley, Information Specialist
• Beverly Bergman, Honorary Civilian Consultant Advisor (Army) for Veterans’ Health & Epidemiology, Scottish Veterans Health Research Group. Beverly is a veteran.

The Steering Group will agree the resources, including time and expertise that they will be able to contribute to each stage of the process, with input and advice from the JLA.

Partners

Organisations and individuals will be invited to be involved with the PSP as partners [this section will be updated as partners are confirmed]. Partners are organisations or groups who will commit to supporting the PSP, promoting the process and encouraging their represented groups or members to participate. Organisations which can reach and advocate for these groups will be invited to become involved in the PSP. Partners represent the following groups:

• veterans and their families, friends and carers
• health and social care professionals - with experience of working with veterans and their families.

Exclusion criteria

Some organisations may be judged by the JLA or the Steering Group to have conflicts of interest. These may be perceived to potentially cause unacceptable bias as a member of the Steering Group. As this is likely to affect the ultimate findings of the PSP, those organisations will not be invited to participate. It is possible, however, that interested parties may participate in a purely observational capacity when the Steering Group considers it may be helpful.

The methods the PSP will use

This section describes a schedule of proposed steps through which the PSP aims to meet its objectives. The process is iterative and dependent on the active participation and contribution of different groups. The methods used in any step will be agreed through consultation between the Steering Group members, guided by the PSP’s aims and objectives. More details of the method are in the Guidebook section of the JLA website at www.jla.nihr.ac.uk where examples of the work of other JLA PSPs can be seen.

Step 1: Identification and invitation of potential partners

Potential partner organisations will be identified through a process of peer knowledge and consultation, through the Steering Group members’ networks. Potential partners will be contacted and informed of the establishment and aims of the Veterans’ Health PSP.

Step 2: Awareness raising

PSPs will need to raise awareness of their proposed activity among their communities, in order to secure support and participation. Depending on budget, this may be done by a face-to-face meeting, or there may be other ways in which the process can be launched, e.g. via social media. It may be carried out as part of steps 1 and/or 3. The Steering Group should advise on when to do this. Awareness raising has several key objectives:

• to present the proposed plan for the PSP
• to generate support for the process
• to encourage participation in the process
• to initiate discussion, answer questions and address concerns.

Step 3: Identifying evidence uncertainties

The PSP will carry out a consultation to gather uncertainties from veterans, carers and families, and health and care professionals. A period of two months will be given to complete this exercise (which may be revised by the Steering Group if required).

The Veterans’ Health PSP recognises that the following groups may require additional consideration.

• Foreign and Commonwealth veterans
• Women veterans
• LGBTQ+ veterans
• Veterans from ethnic minority backgrounds

including families, friends and carers of the above.

The Steering Group will use the following methods to reach the target groups:

• Online surveys
• Face-to-face consultations where groups are unlikely to access the internet

Existing sources of evidence uncertainties may also be searched. [To be updated to indicate which other sources of research uncertainties may be searched, for example question-answering services for veterans and carers and for clinicians; research recommendations in systematic reviews and clinical guidelines; protocols for systematic reviews being prepared and registers of ongoing research.]

Step 4: Refining questions and uncertainties

The consultation process will produce ‘raw’ questions and comments indicating areas of uncertainty from veterans, carers and families, and health and care professionals. These raw questions will be categorised and refined by Kristina Staley into summary questions which are clear, addressable by research, and understandable to all. Similar or duplicate questions will be combined where appropriate. Out-of-scope and ‘answered’ submissions will be compiled separately. The Steering Group will have oversight of this process to ensure that the raw data is being interpreted appropriately and that the summary questions are being worded in a way that is understandable to all audiences. The JLA Adviser will observe to ensure accountability and transparency.

This will result in a long list of in-scope summary questions. These are not research questions and to try and word them as such may make them too technical for a non-research audience. They will be framed as researchable questions that capture the themes and topics that people have suggested.

The summary questions will then be checked against evidence to determine whether they have already been answered by research. This work will be led by Beverly Bergman and agreed by the Steering Group. The PSP will complete the JLA Question Verification Form, which clearly describes the process used to verify the uncertainty of the questions, before starting prioritisation. The Question Verification Form includes details of the types and sources of evidence used to check uncertainty. The Question Verification Form should be published on the JLA website as soon as it has been agreed to enable researchers and other stakeholders to understand how the PSP has decided that its questions are unanswered, and any limitations of this.

Questions that are not adequately addressed by previous research will be collated and recorded on a standard JLA template by Kristina Staley, with agreement from the Steering Group. This will show the checking undertaken to make sure that the uncertainties have not already been answered. The data should be submitted to the JLA for publication on its website on completion of the priority setting exercise, taking into account any changes made at the final workshop, in order to ensure that PSP results are publicly available.

The Steering Group will also consider how it will deal with submitted questions that have been answered, and questions that are out of scope.

Step 5: Prioritisation – interim and final stages

The aim of the final stage of the priority setting process is to prioritise through consensus the identified uncertainties about Veterans’ Health. This will involve input from veterans, carers and families, and health and care professionals. The JLA encourages PSPs to involve as wide a range of people as possible, including those who did and did not contribute to the first consultation. There are usually two stages of prioritisation.

1. Shortlisting is the stage where the long list of questions is reduced to a shorter list that can be taken to the final priority setting workshop. This is aimed at a wide audience, and is done using similar methods to the first consultation. With the JLA’s guidance, the Steering Group will agree the method and consider how best to reach and engage stakeholders in the process. The most highly ranked questions (up to 25) will be taken to a final priority setting workshop. Where the shortlisting method does not produce a clear ranking or cut off point, the Steering Group will decide which questions are taken forwards to the final prioritisation.

2. The final priority setting stage is generally a one-day workshop facilitated by the JLA. With guidance from the JLA and input from the Steering Group, up to 30 veterans, carers, family members and health and care professionals will be recruited to participate in a day of discussion and ranking, to determine the top 10 questions for research. All participants will declare their interests. The Steering Group will advise on any adaptations needed to ensure that the process is inclusive and accessible.

Dissemination of results

The Steering Group will identify audiences with which it wants to engage when disseminating the results of the priority setting process, such as researchers, funders and veteran and clinical communities. They will need to determine how best to communicate the results and who will take responsibility for this. Previous PSPs’ outputs have included academic papers, lay reports, infographics, conference presentations and videos for social media.

It should be noted that the priorities are not worded as research questions. The Steering Group should discuss how they will work with researchers and funders to establish how to address the priorities and to work out what the research questions are that will address the issues that people have prioritised. The dissemination of the results of the PSP will be led by the Steering Group and the Office for Veterans’ Affairs.

The JLA encourages PSPs to report back about any activities that have come about because of the PSP, including funded research. Please send any details to jla@soton.ac.uk.

Agreement of the Steering Group

The Veterans’ Health PSP Steering Group agreed the content and direction of this Protocol on 9th February 2023.