Examination of Witnesses (Questions 220-237)
DR CHRISTOPHER
FREEMAN
11 OCTOBER 2007
Q220 Willie Rennie: Does the actual
Armed Forces make them have more mental health problems or is
it because they go in like that in the first place?
Dr Freeman: There is clear evidence
that deployment in certain theatres of war causes a wide range
of psychological problems and if you compare different theatres
of war the rates are different. These are higher rates than those
people who did not get deployed at all. There are some paradoxes
in that, in that within those who were deployed, if you look at
those who served on the frontline compared with those who were
in support services, paradoxically those in the support services
sometimes have higher rates of psychological breakdown. You cannot
make a clear link between exposure to frontline warfare and psychological
breakdown, but exposure to deployment overseas in certain theatres
of war increases your risk.
Q221 Willie Rennie: I would just
like to come to serving soldiers and other Armed Forces. You said
they would benefit from having a separate service where they are
treated together. Would that apply also to ex-Servicemen?
Dr Freeman: I certainly do not
think we should go, and I do not think there are plans to, down
the route of the Americans' veteran system. There are all sorts
of problems with that which we probably cannot go into. It is
very expensive and it supports illness rather than getting well
because people live in the VA system and feel secure there. I
do not think we could possibly have a veterans system in the UK
that separately treated people for depression, alcoholism, anxiety
disorders, PTSD, we would need a whole new branch of the NHS.
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.
Mr Jenkins: I just want to labour
a point with regard to ex-Servicemen and that they have more mental
health problems. As you said correctly, the Army does but not
the Air Force or the Navy, which is rather a funny way of putting
it because they are ex-Servicemen. There must be a rational reason
why they do not suffer the same problems. Then you said it is
because of the recruitment base we take the Army from. I am suggesting
that you might be right at some point because almost every weekend
in this country three or four of our young people get killed in
road accidents and these are the very adventurous, risk-taking
group that we recruit from in the Army anyway. Probably if we
did not recruit them there would be more dead in our country as
civilians than there are Armed Forces, but that is not the problem.
The problem is—
Chairman: What is the question?
Mr Jenkins: I am trying to make
a statement here, Chairman. I think it is important we actually
put this ground right.
Chairman: I know.
Q222 Mr Jenkins: The difficulty I
have got is I have not got a control group to say, "This
is what would happen to them if they did not join up" and
"This is what would to them if they did join up". We
are in the realms of speculation, are we not, because we do not
have enough records on these individuals to prove the result?
We have not got any records on the probability of an individual
suffering harm from his Service career.
Dr Freeman: I think that is partly
true because, of course, even if you compare those who are deployed
versus those who are not deployed the soldier has some choice
in that. When they sign up, they sign up to be a cook or a technical
officer rather than a frontline soldier and there is some choice
in that. It would be a great disservice to our serving men to
think that being exposed to frontline warfare has no effect on
them. What would that say about humankind if that were so?
Chairman: Thank you. We have ten
minutes more.
Q223 Robert Key: Dr Freeman, could
you help me understand what I perceive to be mixed messages here.
On the one hand, I think we are being told that psychiatry thinks
it is better if people with mental health needs are treated in
the community together in the round rather than singled out; on
the other hand, the Chief Executive of Combat Stress said it could
be damaging to put veterans into those circumstances with everybody
else because they could disrupt everybody else with their terrible
stories and it would not be a very helpful thing to do. Can you
explain how I should reconcile those two statements?
Dr Freeman: I think the issue
is that Combat Stress has a residential programme. As you know,
it has three centres around the UK and there is no doubt that
many men find that two week stay once a year extremely beneficial.
It recreates for them something of what they get in their Service
career and they meet colleagues and comrades. I have no problem
with that. I think the issue is that most people can be treated
on an outpatient basis. I would fully agree if I had a soldier
with severe depression and was having nightmares and flashbacks
and had a horrific trauma story and I felt they were so disrupted
that they needed to be made safe and admitted somewhere I would
rather they went to Hollybush in Ayr than they went into a general
psychiatric ward, but that is a tiny proportion of the total.
For each one like that I would have 15 or 20 more I could treat
on an outpatient basis coming up once a week offering them home-based
assessment. I do not think there is a tension really. I have no
problem with the inpatient services being around a particular
specialist area but you cannot travel to Hollybush from Inverness
once a week for your outpatient treatment, you need to have distributed
community-based services for the majority of these men. We need
to work in partnership with Combat Stress, and it needs to be
something where the triage could be done jointly between the NHS
and Combat Stress, most of the outpatient treatment could be done
in NHS services, because Combat Stress has difficulty in treating
people with drug and alcohol problems, which is a big part of
that, but if we wanted inpatient treatment then a specialist unit
would be fine.
Robert Key: Thank you.
Q224 Chairman: We seem to be giving
you the third degree.
Dr Freeman: It is okay, the sun
is going down.
Q225 Mr Jones: Can I just follow
up because you made a point, Dr Freeman, about the Priory. I think
you just reinforced what we were told this morning, that you are
actually dealing with very small numbers of people each year who
do need inpatient care. In Civvy Street that is the case as well.
In my PCT, for example, one hospital has closed and has been replaced
with a smaller unit because that is the way the service has gone.
It is not the fact that the Priory care contract is not in the
NHS, it is the fact if they are keeping them in longer than they
should or they cannot provide what you say they should do, that
is actually about the contract rather than the actual—
Dr Freeman: Yes. Obviously it
is not something that is unique to the veterans contract, it happens
across the UK with patients with eating disorders.
Q226 Mr Jones: So it does not make
it wrong that is in the private sector?
Dr Freeman: No.
Q227 Mr Jones: In terms of the Lancet
evidence we received recently, it said that it could be counterproductive
to intervene too quickly with people who suffer from traumatic
experiences, that natural resilience would work in many cases.
Can you let us know what your view is of that?
Dr Freeman: There is very strong
evidence now that the vogue for psychological debriefing, ie doing
something early, 48 hours to ten days after a traumatic event,
be that to civilians or to soldiers, can be harmful. The reason
for that is by nature most of us are very good at avoiding that,
the best way of coping in the short-term—
Q228 Mr Jones: Politicians better
than most people!
Dr Freeman: — may well be
to try not to think about it. Some people can do that really well
and if you sit them down in a psychological debriefing group and
say, "You've got to tell me your story, and not only will
you hear your story again but you are going to hear five other
stories from other people", that can be damaging.
Q229 Chairman: We have heard stories
about there being difficulties about the transfer of records from
the MoD to the NHS. Have you heard anything like that?
Dr Freeman: Yes. Historically
I have had great difficulty but now I have to say it works extremely
smoothly with a phone call and you can often get through to the
Service GP or psychiatrist and get details. That really has not
been a problem recently and I think that has been a big change.
Q230 Mr Hamilton: Combat Stress told
us ten% of the referrals they receive are from the National Health
Service and the vast majority from ex-Service organisations are
the ones who direct people to the appropriate organisations. Does
that mean that the National Health Service is failing veterans
in getting that information forward?
Dr Freeman: Yes.
Q231 Mr Hamilton: It does?
Dr Freeman: The National Health
Service in general does not do well in getting young men into
treatment, and this is a problem across the board, not just for
Service personnel. We know that the highest rate of complete suicide
is in young men, even though women have many more attempted suicides.
We need to be much more innovative in how we get these men into
treatments. The idea that you have a clinic somewhere, that your
GP refers you up, you sit in a waiting room with ten other people
and you have a largely verbally based psychological treatment
is just a complete turn-off for many men. There have been quite
a lot of experiments in Scotland about running clinics in ASDA,
running evening classes, having quite a different approach to
getting men with stress problems into treatment.
Q232 Mr Hamilton: Could I follow
up something you said earlier on, and what you have just said.
In my constituency, which is Midlothian, just south of here, there
are six ex-Servicemen's clubs. Could the MoD not utilise the facilities
they already have that exist recognising the fact that many of
the ex-Service personnel will frequent these places because that
is where their comrades are and people who have been through the
Services would understand? Is there not an argument that the MoD
should utilise these facilities far more than they are doing at
the present time?
Dr Freeman: Or do that in partnership
with the NHS. There is now a retired psychiatrist called Dafydd
Alan Jones who ran an infamous unit in Wales called Ty Gwyn and
he came up to Scotland to run clinics, he did them in Boswell
and Perth, and he managed to get 60-80 men in an evening to come
to a church hall to discuss these issues. Clearly the men valued
that peer group relationship, valued seeing a psychiatrist who
knew about military matters, and that is the sort of approach
you need, I think, rather than, "Here's a specialist clinic.
Go to your GP and your GP will send you a referral, you will be
on a waiting list for a few weeks, you will go and sit there next
to someone with depression, anorexia, etc."
Q233 Mr Hamilton: You deal with Lothian
NHS, it would be quite good if Lothian NHS, the MoD and the various
legions all worked together to see if they could come up with
a pilot.
Dr Freeman: The same with TA centres
as well, we should have links there.
Q234 Mr Jenkins: Drug and alcohol
addiction is high among ex-Servicemen. Should we treat this as
a separate special group to try and tackle that for these veterans?
Dr Freeman: A cultural change
needs to happen in the Services about the use of alcohol to relieve
stress. It should be less tolerated than it is, but that is a
social rather than a medical issue I think. In terms of special
treatment services, I think there are probably enough ex-Servicemen
with alcohol problems to set up some limited programme for Scotland,
for example, one in Glasgow, one in Lothian, perhaps one in Tayside.
There would be enough people where they could be treated on a
group basis. As you know, the problem is the AA approach, which
is very widely used in the non-statutory sector, does not go down
well with most soldiers. They are not going to buy complete abstinence
and they are not going to buy God.
Q235 Mr Jenkins: The other one is
about our prison population, that there is a disproportionate
number of ex-Army. Not ex-RAF or ex-Navy, ex-Army again. Because
of the mental problems they have and because of the prison system,
should they be treated separately as a priority within our prison
system?
Dr Freeman: Yes, and it is one
of the things we are just trying to plan in Scotland. We have
had a very extensive programme of early intervention, guided self-help,
all sorts of things for people in primary care with depression
and anxiety, and I think we now need to transfer that to the Prison
Service. Not the men who are banging their heads against the wall
and are psychotic in prison, the severely mentally ill, but there
is a significant morbidity of depression and anxiety, and these
men are there, you could treat them, you have got a captive population.
Q236 Willie Rennie: Do you not think
it is a disgrace that veterans have to rely on charity, organisations
like Combat Stress?
Dr Freeman: I do not think it
is a disgrace, no, because about half of Combat Stress's money
comes from central sources, so it is not all charity. I do think
that it should not rely on charity alone. Conversely, there is
something about the independence from the establishment which
may be an advantage for some men. Some of these men feel very
disenfranchised from the Army and from the NHS but can ally themselves
to something that they see as independent. If you could maintain
that independent streak but have secure funding that would be
a good idea.
Q237 Chairman: Dr Freeman, I think
we have got to draw this to an end now. May I thank you for what
has been one of the best episodes of evidence I think this Committee
has ever had. You have been extremely straightforward, clear,
clipped, you have kept to time and we are most grateful.
Dr Freeman: Thank you.
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