Select Committee on Defence Seventh Report

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.[66]

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.[67] 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.[68]

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 travel time.

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.[69]

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.[70]

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".[71]

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".[72]

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.[73] 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.[74]

97. We 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".[75] 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.[76]

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 health.[77]

The pilot projects were announced as being in Camden, Stafford, St Austell, Newcastle-upon-Tyne, Cardiff and somewhere in Scotland.

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.[78]

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.[79]

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 second".[80]

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".[81] 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.[82] 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".[83] 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.[84]

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."[85]

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 may present.

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.[86] 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.[87]

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".[88]

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

67   ibidBack

68   Ev 110 Back

69   Q 440 Back

70   ibid. Back

71   Ev 93 Back

72   Q 215 Back

73   Q 441 (Lieutenant-General Baxter) Back

74   Q 451 Back

75   Ev 138 Back

76   ibidBack

77   Q 372 Back

78   Ev 108-09 Back

79   Q 96 Back

80   Q 97 (Commodore Elliott) Back

81   HC Deb, 21 November 2007, col 891W Back

82   Q 45 Back

83   Q 211 Back

84   Q 221 Back

85   Q 98 (Commodore Elliott) Back

86   Ev 121-27 Back

87   ibidBack

88   Q 439 Back

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