6 Mental health |
Mental healthcare for Service personnel
90. We now turn to another key aspect of healthcare
for Servicemen and women, mental health. In 2002, the MoD published
the conclusions of its Medical Quinquennial Review, as a result
of which there was a reconfiguration of mental health services
it provided. These were based on the principle of community mental
health and carried out primarily through 15 military Departments
of Community Mental Health (DCMHs), with satellite centres overseas.
These are staffed by mental health teams comprising psychiatrists,
mental health nurses, clinical psychologists and mental health
social workers. The MoD's aim is to treat personnel who present
with mental health needs as out-patients where possible.
91. For in-patient care, since the Duchess of Kent
Psychiatric Hospital at Catterick closed in April 2003, the MoD
has used a central contract with the Priory Group of hospitals
to treat Service personnel in psychiatric units which it claims
allows patients to be treated much closer to their parent units
than was the case when the Armed Forces operated its own psychiatric
hospitals. There is close liaison between local DCMHs and Priory
units to manage the in-patient care of Service personnel.
There are agreed communication protocols between the Priory Group
and the MoD at admission, after 48 hours, at 14 days if further
inpatient stay has been requested, and at discharge.
92. In terms of preventative measures, we heard on
several occasions about efforts to provide opportunity for 'decompression'that
is, for personnel returning from front-line duty to have an opportunity
to recover in a group setting and absorb their often traumatic
experiences before returning to their families and friends. The
Minister noted that this was a problem made more acute by reduced
In the old days where you might spend a few months
coming home, whether you were in the Second World War or elsewhere,
on a ship for a long time, has of course gone in the main now.
93. When we visited Cyprus in October-November 2006,
we were told that one of the facilities offered by the development
of the Forward Mounting Base was space to allow this decompression.
For example, the 3 Para battle group had used Bloodhound Camp
for this purpose after returning from a tour of duty in Afghanistan.
The Royal Marines have formalised a comparable arrangement known
as Trauma Risk Management or TRiM. The Minister described this
as "a sort of a buddy system led by warrant officers in terms
of talking through their issues or concerns with each other",
and noted that it seemed to be working well.
94. The MoD's memorandum noted that medical discharge
from the Armed Forces due to psychological illness was low. Only
around 150 personnel, less than 0.1%, were discharged annually
for mental health reasons "whatever the cause".
95. We heard some criticism of the contract with
the Priory Group. Dr Christopher Freeman, a consultant psychiatrist
at the Royal Edinburgh Hospital and a Fellow of the Royal College
of Psychiatrists, said that he was not convinced that the Priory's
clinicians had the relevant expertise, and that they lacked the
ability to relate to the experience of Service personnel. He also
expressed an anxiety that "the private sector makes its money
by keeping people in beds, the longer someone is in hospital,
the more money they get, and that is a tension between the NHS
and the private sector".
96. In general, Dr Freeman characterised the MoD's
mental health provision for serving personnel as "an okay
job but not a great job". He took the view that assessment
and monitoring of mental health needs was good overall, but that
the psychiatric services were stretched. MoD and Department of
Health witnesses were more positive. They stressed that the concentration
on community care was the right one, and that the relationship
with the Priory group, with its "joined-up regional, across-the-UK
footprint", was bearing fruit.
Professor Louis Appleby, the Department of Health's Mental Health
Clinical Director, added:
The model that is being described is very much in
line with current service provision. The modern idea of providing
mental health care is that it is primarily community-based, that
small in-patient units provide back-up of a very specialist kind
linked to what is then provided in the community. It seems to
me from what I know of the MoD version of mental health care that
it is very much in line with those NHS principles.
consider that the MoD provides adequate mental healthcare for
serving members of the Armed Forces. We have been told on visits
that there is a culture of individuals 'bottling things up' inherent
in the Services, but we note with approval the steps which have
been taken to attempt to prevent problems through 'decompression'.
This should be an integral part of the procedures for all personnel
returning from operational tours. It is also important that the
problems which can arise are recognised throughout the Services,
so that early warning signs can be spotted and dealt with before
problems get worse. We believe it is sensible to approach mental
healthcare from community-based provision, delivered in conjunction
with local military units, in-patient treatment being a last resort.
The MoD should also review its contract with the Priory Group
to assess its effectiveness.
Mental healthcare for veterans
98. One of the problems in dealing with the mental
health needs of Service personnel arising from traumatic experiences
during combat is that the effects can remain hidden for many years
and only become apparent when they have left the Services. The
MoD cooperates with the Department of Health and the Ex-Services
Mental Welfare Society (Combat Stress) "to ensure that good
quality and appropriate services are available for those who need
them". The stated
aim is to:
Bring Combat Stress services into alignment with
current best practice and to achieve greater integration with
the NHS services to allow appropriate and speedy referral for
those who need it.
99. Shortly before the Ministers, Derek Twigg and
Ben Bradshaw, appeared in front of us, the MoD and the Department
of Health announced the establishment of six two-year pilot schemes
for mental health for veterans, at the initial cost of £500,000.
These schemes are intended to work:
via the veterans units as well as with the NHS providers
of mental health in these locations and that will be really to
enable clinicians in the Health Service to gain a better understanding
of the issues around those who have served in the Armed Forces
and the issues that might arise, which often impact on their mental
The pilot projects were announced as being in Camden,
Stafford, St Austell, Newcastle-upon-Tyne, Cardiff and somewhere
100. There are two major challenges facing the MoD
and its partners in dealing with mental healthcare for veterans.
The first, given the decision to work so intimately with a private
organisation like Combat Stress, is making sure that there are
adequate resources to manage demand. The second is identifying
those veterans with mental health needs and directing them towards
the appropriate treatment.
101. We took evidence from Combat Stress, and visited
their facility at Leatherhead in Surrey, in June 2007. In its
written memorandum, it said that major reports in 2003 and 2005
had found the provision of healthcare for veterans with mental
health issues was inadequate. Combat Stress acknowledged that
those veterans were a group with which it was difficult to engage,
and noted that younger veterans were also starting to become much
more prominent in its treatment centres, bringing new challenges.
102. Commodore Elliott, Chief Executive of Combat
Stress, expressed his organisation's difficulties to us.
We have had a very large increase in the number of
referrals. In the past three years we have had a 27 per cent increase,
or nearly 1,000 referrals a year. For a small organisation like
ours that is causing us a great deal of overstretch. I am prepared
to use that term. I also use it when speaking to the Secretary
of State and the Veterans Minister whenever I possibly can.
He went on to explain that referrals to Combat Stress
came from three different sources: 10% came from the NHS and social
services, 30% came from ex-Service organisations such as the Royal
British Legion and SSAFA, but the majority, around 60%, were self-referrals.
103. In terms of funding, Combat Stress received
money from the Veterans' Agency and from the war pension treatment
and travel allowance. However, this was in itself problematic,
as a very small proportion of those whom it treated (around 2%
in 2006) were in receipt of a war pension. Commodore Elliott explained
that "we do not turn them away; we worry about them first
and how the hell we are to fund what we are doing for them comes
104. The MoD announced in November 2007 that it was
increasing the fees it paid to Combat Stress from £2.5 million
in 2006-07 "rising to 45 per cent. from January 2008 to enable
them to enhance their capability to treat veterans".
We welcome this additional
funding, and pay tribute to the work which Combat Stress is doing.
The MoD is right to engage with private organisations such as
Combat Stress where that is appropriate, but it must continue
to ensure that the organisation is adequately funded and has the
clinical capability to deal with the patients who are referred
to it. The MoD should also think more strategically about, and
explain in their response to this report, their relationship with
private and charitable organisations, and the extent to which
they should provide services on behalf of the Government.
105. One of the reasons that the NHS must bear much
of the burden in terms of mental health needs arising from service
in the Armed Forces is that these can take many years to emerge,
as mentioned in paragraph 98. Combat Stress told us that the average
period between leaving the Services and developing mental health
problems was around 15 years.
The problem of early intervention with veterans suffering from
mental health problems was identified to us by Dr Freeman. He
was particularly critical of the lack of proactive provision of
mental healthcare for veterans, saying that the NHS "hardly
deals with them at all".
His diagnosis was that substantial change was needed:
I think what we do need is a really good monitoring
system, a central point of referral so that these men who find
it very difficult to seek help can have walk-in shop front clinics
where they can go, where they can see other veterans working as
volunteers, where they can have an assessment triage for their
appropriate treatment. After that stage, and they may well still
link in with that shop front service for many years, they would
go for their specialist treatment, getting psychotherapy or drug
addiction treatment or whatever. It is the point of entry we need
to manage better. It would cost hardly any money to have a triage
system like that, an assessment service for veterans.
106. Commodore Elliott identified a similar shortcoming
in the NHS, telling us that veterans' problems were not always
understood by civilian clinicians. A veteran who had undergone
a traumatic experience in battle could find himself referred to
a Post-Traumatic Stress Disorder (PTSD) support group with people
who had been in car accidents or had suffered traumatic childbirths.
This, he argued, was inappropriate: "when it comes for him
to talk about his experience [
] either he bottles out and
leaves the group straight away or reduces the group, including
the therapist, to tears. He traumatises the group. They just do
not fit in."
107. This problem requires a twofold solution. First,
it is only possible to treat veterans with mental health needs
if there is a robust system for tracking and identifying patients
who have served in the Armed Forces (as we have discussed in Chapter
5 above). Second, the NHS has to be able to respond to the particular
needs of veterans, and be aware of the symptoms with which they
108. We also received a memorandum from Major General
Robin Short, former Director-General of Army Medical Services,
and others, which focused on the treatment of PTSD.
The memorandum argued that PTSD was a considerable problem, both
among Service personnel and among veterans, and that the extent
of the problem was likely to grow due to the high tempo of operations.
It also argued that the MoD was failing to learn lessons from
the way in which the US military had improved the treatment of
PTSD. The US had made progress in de-stigmatising PTSD, and now
included psychological maintenance as an integral part of post-deployment
activity. By contrast, the MoD lacked a coherent policy towards
the detection and treatment of PTSD, and, indeed, he asserted,
had not even acknowledged the existence of the condition.
109. Derek Twigg denied that the MoD did not pay
adequate attention to the issue of PTSD. He told us in November
2007 that only between 25 and 30 Service personnel each year were
discharged with PTSD, but "that is not in any way belittling
the fact that for those people that is a tremendous difficulty
and is affecting their lives".
110. We are
concerned that the identification and treatment of veterans with
mental health needs relies as much on good intentions and good
luck as on robust tracking and detailed understanding of their
problems. If the NHS does not have a reliable way of identifying
those who have been in the Armed Forces, then it already has one
hand behind its back when it comes to providing appropriate clinical
care. We repeat our belief that there must be a robust system
for tracking veterans in the NHS, and this should feed into enhanced
facilities for addressing their specific needs.
66 Ev 93 Back
Ev 110 Back
Q 440 Back
Ev 93 Back
Q 215 Back
Q 441 (Lieutenant-General Baxter) Back
Q 451 Back
Ev 138 Back
Q 372 Back
Ev 108-09 Back
Q 96 Back
Q 97 (Commodore Elliott) Back
HC Deb, 21 November 2007, col 891W Back
Q 45 Back
Q 211 Back
Q 221 Back
Q 98 (Commodore Elliott) Back
Ev 121-27 Back
Q 439 Back