Memorandum from Ex-Services Mental Welfare
Society (Combat Stress)
The media and Ministerial in trays testify
to the widespread view that neither the MoD nor the NHS have anything
to offer veterans with mental health problems; this view is supported
to a great extent by the findings of a report entitled "Improving
the Delivery of Cross Departmental Support and Services for Veterans"
by Kings College London (Dandeker, Wessley, Iverson and Ross)
published in March 2003. This study identified that the Health
Service provided to veterans with mental ill health was in their
view inadequate. A later report made by the Health and Social
Care Advisory Service in 2005 makes similar findings (see below.)
Since 2000 the Ex-Services Mental Welfare Society (also known
as Combat Stress) (CS) had also been reporting that many of the
veterans it was supporting were saying that the experience they
had had with the Health Services was not a good one.
CS tempers its remarks by observing that
this group of veterans, by the very nature of their disability
and social circumstances, are often extremely difficult to deal
with in an NHS setting, often quickly exhausting the patience
of practitioners and the limited and frequently overstretched
community mental health care resources available. This particularly
applies to the much younger veterans which were starting to dominate
in its treatment centres as early as 2000, a group with complex
and chronic mental health and social problems whose needs were
very much more difficult to meet than the more elderly WWII veterans
the Society's services were at that time best configured to cater
for.
Like so many of the Services Charities
which still exist to do their much needed work today, the Ex-Services
Welfare Society was established in 1919 providing care in a residential
setting to Great War veterans who were suffering from what was
then commonly known as "shell-shock." Much of this pioneering
work was extremely innovative, in terms of the provision of occupational
rehabilitation aimed at getting the disabled veteran back into
work. The Society had both a factory (which manufactured heated
flying clothing and electric blankets) and its own village in
which veterans and their families lived, many for the whole of
their lives.
Now known as the Ex-Services Mental Welfare
Society, CS remains the sole specialist ex-charity in its field,
looking after men and women who have served in the Royal Navy,
British Army, Royal Air Force or the Merchant Navy suffering from
mental ill-health. It provides a UK wide welfare service and has
three treatment centres offering remedial treatment, respite and
convalescence to veterans with a variety of mental health problems.
In most of the veterans it helps, it sees disability related directly
to in service experience and exposure to traumatic events is the
main contributory cause of mental illness. However, combat experience,
or a service related injury is not a pre-requisite for an admission
any more than the need to be a qualifying War Pensioner to access
the service.
Today, CS works in a spirit of cooperation
and partnership with a whole range of interested organisations,
the MoD, the Service Personnel and Veterans Agency, the War Pensions
Welfare Service, the NHS, RBL, SSAFA Forces Help, the Service
Benevolent Funds and many other service and civilian organisations
in order to provide a whole range of capabilities to the benefit
of its group of veterans. It helps other organisations to care
for veterans with mental health problems within its capability
to deal with, not least those dealing with homeless and rough-sleeping
ex-service personnel.
Government funding for the so-called
remedial treatment provided by CS was started in 1942. For about
the last 50 years the War Pensions Scheme has funded War Disabled
Pensioners with accepted service related mental ill health conditions
to be provided with such treatment in a short stay residential
setting at the Society's homes. Currently, some 60% of the Society's
treatment is provided to veterans with a qualifying War Pension.
The remaining 40% will be veterans who have a mental illness,
usually attributable or aggravated by service, but for which they
have either not applied for a War Pension or if injured post 6
April 2005 puts them under the Armed Forces Compensation Scheme
(AFCS). The AFCS does not have in it any arrangement to fund treatment
that might be provided by CS; it is the MoD's view that this would
be for the NHS to fund.
Back in 2000 admissions to the three
CS homes were tailored almost exclusively to provide good, old-fashioned
benevolent care to badly damaged WWII and Korean War veterans.
These short stay residential admissions were mainly shaped to
provide respite and convalescent admissions. For these old men
the care provided by CS is extremely beneficial, not least because
it is first class. These older veterans enjoy being taken out
of social exclusion into a quasi-military setting where they feel
safe and benefit from being in the unique therapeutic environment
that is maintained in the homes. Indeed, this setting is an essential
element for the veterans of all ages who use these treatment centres,
and to which the old veterans contribute so much, particularly
by helping to maintain the right level of good conduct expected
by all residents regardless of age or degree of ill health, and
to act as a moderator when the need arises.
In 2000, recognising that the needs of
the younger and much more challenging group of veterans already
referred to were not being properly addressed, the Society embarked
on an ambitious programme of change, looking to improve its clinical
capability through a Clinical Standards Uplift Programme to provide
appropriate treatment programmes, and to modernise its UK wide
Regional Welfare Service in order to achieve efficiencies and
savings. It also set out to complete an expensive modernisation
of its establishments to meet the new Care Standards Commission
requirements (a programme which completes in October 2007 at an
estimated cost of £4.5 million).
Despite its often severe and constraining
financial position CS had made much positive progress by 2005.
One of the issues which had been the subject of almost constant
debate between CS and the MoD was the level of fees being set
for the treatment of qualifying War Pensioners, one of the limiting
factors in being able to put in place the extra clinical staff
and additional skill mixes required to modernise its service.
Discussions inevitably lead to the conclusion that it was time
to review the Society's services and its approach to the treatment
to the veterans receiving MoD funding for remedial treatment,
its approach to clinical government and so on.
The Health and Social Care Advisory Service
(HASCAS) was then commissioned by the MoD with the Society's full
agreement to conduct a review of the Society's programmes. The
HASCAS team led by Professor John Hall completed its work and
made its final report "Review of Combat Stress by HASCAS"
in August 2005.
In its report HASCAS commented on the
service provided by the NHS, observing that comments [by veterans]
on the lack of help significantly outweighed positive comments.
The report noted that Combat Stress was the only agency of any
size in Britain dedicated to addressing the mental health needs
of veterans and recognised the importance of the Society's understanding
of the experiences of veterans and their confidence in the Society;
it also noted the significant changes over the previous five years
in the nature of the services offered by the Society, designed
to offer a wider range of interventions. It reported that considerable
work at all levels of the Society had resulted in significant
improvements in its capability to provide the care needed and
that the current staff compared well with the NHS in their level
of skill and expertise, although the professional skill mix was
relatively limited.
HASCAS made a series of detailed recommendations
as to how CS services provided could be further improved, and
CS has continued to refine and improve these services based on
much of this advice. CS now has a service that focuses in on getting
the veteran to engage in the first place, a very important component
of its work. It is expert in the assessment of whole person needs
(social as well as clinical) and in providing the safe therapeutic
environment in which the most complex and enduring cases are often
best dealt with. It continues to develop the necessary treatment
options to be delivered by its staff and to continue the diversification
of skill mix required to provide a holistic service capability.
It has the capacity to deliver respite and convalescent care to
the more elderly veteran, and values their presence in its treatment
centres for the reasons already stated. Pilot schemes have successfully
demonstrated that the needs of carers and adolescent child can
be met through support programmes which have been successfully
piloted and which it will start to roll out during the next year.
Returning to the work that followed the
HASCAS Review, it was clear that any new model for the delivery
of care to this needy group had to go beyond CS Services and to
cover all veterans with mental health problems. The model and
processes also had to have the NHS, and GP at the centre, reflecting
current Health policy and practice.
CS collects statistics on veterans approaching
the Society and confirms an increase year on year over the last
several years (from 759 new referrals in 2005 to about 985 in
2007 last year—an increase of 30%). CS also has data that
reflects the heterogeneity of diagnoses seen in clients and the
wide variety of their different support needs. Beyond doubt, a
very small number of those referred to CS do not actually have
a mental health need. Some will be well able to be managed by
GPs, others by more specialist community based services. A few
will have complex severe enduring disorders that make them suitable
to be dealt with CS. Future assessment programmes will need to
address such criteria, as well as come to terms with the need
to provide solutions to social as well as clinical needs where
both are encountered (and they so frequently are.) There are also
issues of accessibility and acceptability of treatment settings,
all of which will need to be addressed.
However, on the basis of the HASCAS report,
it was recognised that CS was needed as an integral component
in any new arrangement being put in place to improve the delivery
of cross Departmental support to veterans with mental ill-health.
On this basis, an aim of any new model will be to integrate Combat
Stress into NHS commissioning arrangements for the specialist
service HASCAS suggests is appropriate.
22 May 2007
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