The Armed Forces Covenant in Action? Part 1: Military Casualties - Defence Committee Contents



2  MEDICAL TREATMENT AND REHABILITATION

BACKGROUND

9.  We recognise that more Armed Forces personnel become sick or are injured in training or other peacetime activities than those injured or killed on operations and that the treatment given to them is identical to that of personnel injured on operations and is commensurate with their needs. The MoD provides medical support to injured or sick personnel until their condition is stable and has improved as much as possible. Alongside the medical treatment and rehabilitation, Armed Forces personnel are supported by the Services in other practical aspects of their recovery. After the medical conditions of individuals have stabilised, decisions are then made as to whether the person wishes to remain in the Armed Forces and whether there is a suitable role for the person or whether they should be medically discharged.

10.  The MoD described the Defence Medical Services (DMS) and the role of the Surgeon-General in the following figures:
DEFENCE MEDICAL SERVICES[9]

The uniformed medical and dental personnel from all three Services are known collectively as the Defence Medical Services (DMS). The DMS are grouped under the Headquarters Surgeon General (HQ SG), Joint Medical Command (JMC), Defence Dental Services (DDS) and the three single Service medical organisations.

Medical, dental and related support services are delivered to armed forces personnel by the Ministry of Defence (MOD), the NHS, charities and welfare organisations.

OVERVIEW
The primary role of the DMS is to ensure that service personnel are ready and medically fit to go where they are required in the UK and throughout the world - generally referred to as being 'fit for task'.

The DMS encompass the entire medical, dental, nursing, allied health professionals, paramedical and support personnel. It is staffed by around 7,000 regular uniformed medical personnel and provides healthcare to 196,000 servicemen and women.

Personnel from all three services, regulars and reservists, work alongside civil servants and other supporting units providing healthcare to service personnel serving in the UK, abroad, those at sea, and in some circumstances family dependants of service personnel and entitled civilians. It also provides some aspects of healthcare to other countries' personnel overseas, in both permanent military bases and in areas of conflict.

The range of services provided by the DMS includes primary healthcare, dental care, hospital care, rehabilitation, occupational medicine, community mental healthcare and specialist medical care. It also provides healthcare in a range of facilities, including medical and dental centres, regional rehabilitation units and in field hospitals.

The DMS has 15 regional rehabilitation units (RRUs) across the UK and Germany, 5 Ministry of Defence hospital units (MDHUs) embedded into NHS acute trusts, the Royal Centre for Defence Medicine (RCDM) in Birmingham, and 15 military-run Departments of Community Mental Health (DCMH) in the UK with 5 DCMHs at the major permanent overseas bases.

THE SURGEON GENERAL[10] is the 3* professional head of the DMS and the Process Owner for end to end Defence healthcare and medical operational capability. He is accountable to the Defence Board, reporting routinely through the Defence Operating Board and Service Personnel Board, both of which he attends as required.

The SG is responsible for:

  • Defining the boundaries and processes, organisational structures and composition of forces, and the standards and quality needed, to deliver advice on health policy, healthcare and medical operational capability in consultation with top level budget holders
  • Setting the overall direction on all clinical matters relating to the practice of medicine within the military
  • Setting and auditing the professional performance of all medical personnel
  • Setting clinical and medical policies and standards, and auditing compliance by military
  • organisations across Defence
  • Developing the science of military medicine to develop approaches and treatments that will best
  • counter threats to the health and well being of Service personnel
  • Providing deployable medical operational capability
  • Building and maintaining the medical infrastructure and cadre of people
  • Delivering a comprehensive healthcare system that provides the appropriate timely healthcare to Service (and other entitled) personnel
  • Ensuring coherence of health plans between Defence and the NHS
  • Chairing the Defence Medical Services Board, the forum for providing strategic direction and guidance to the DMS

THE STAGES OF MEDICAL TREATMENT AND REHABILITATION

11.  The seven stages of the medical pathway for personnel injured[11] are as follows:

1.  BATTLEFIELD - A soldier is wounded in Afghanistan. He carries his own field dressings and morphine, and will be attended initially by the team medic who is trained to deliver "enhanced" first aid. If too serious to be dealt with in the field, a call for assistance will be flashed to Bastion.

2.  EVACUATION - A medical emergency response team, including an anaesthetist, A&E specialist, medics and force protection soldiers travel to the scene in a Chinook helicopter. Two Apaches provide security. The median time from injury to arrival at Bastion is 99 minutes for the worst injuries.

3.  FIELD HOSPITAL - Bastion's hospital offers an intensive care facility, surgery, A&E, physiotherapy, dental and mental health care. It has CT and X-ray equipment and can provide blood transfusions. An even more capable coalition hospital is located in Kandahar.

4.  AEROMED FLIGHT TO UK - If the patient needs more care or if a period of recovery prohibits return to duty, he is evacuated to the UK aboard specially equipped RAF aircraft. The aeromed teams are trained to deal with medical conditions that may be exacerbated by high altitude.

5.  UK HOSPITAL - In the UK, patients needing more treatment are usually taken to the Queen Elizabeth Hospital in Birmingham. NHS staff are augmented by about 240 clinical military staff, delivering the whole range of medical care. When clinically appropriate, patients are cared for in a military managed ward.

6.  REHABILITATION - Patients recovering from orthopaedic and neurological problems may be removed to Headley Court, which hosts the unique Limb Fitting and Amputee Centre, that ensures prosthetic limbs are correctly fitted. Patients may then be transferred to regional rehabilitation units.

7.  RETURN TO DUTY - The goal is always to return injured personnel to duty. That may not always be possible, in which case continued support eases their return to civilian life. The majority of patients return to duty and increasingly even amputees are finding that their careers are not over.

12.  Mental health medical care for Armed Forces personnel psychologically injured on operations is predominantly through Community Mental Health Teams in the UK and Germany. If personnel require in-patient treatment, the MoD has a contract with Staffordshire and Shropshire NHS Trust who place patients in hospitals in nearby NHS Trusts.[12]

THE PROVISION OF MEDICAL TREATMENT

RESOURCES

13.  We asked the Minister for Defence Personnel, Welfare and Veterans, the Rt Hon Andrew Robathan MP, if the MoD could sustain the right level of resources for the Defence Medical Services (DMS). He told us that the MoD would like to increase funds in some areas and that DMS had improved over the last ten years:

[...] it was not until the invasion of Iraq in 2003 and subsequently the war in Afghanistan that we have been in a position where we had casualties and injuries such as we sustain now. [...] Although there was provision for field hospitals and so on, the casualties who have come back from Iraq and Afghanistan have completely changed the nature of what we have to deal with in the Defence Medical Services. That rather sets the scene.

Do we have the resources? I am tempted to say that we would always like more, but actually we do have the manpower to sustain the treatment that we are giving. We have the same work force needs, if I can put it that way, as the NHS, particularly in what is quite a new speciality—emergency medicine. [...] emergency medicine is a new speciality and we would like more of it. But we are able to manage it. We certainly are managing, but we would like to increase it in one or two areas .[13]

14.  Surgeon Vice-Admiral Raffaelli, the Surgeon General, told us that medical care was one of the few areas which had received extra funding as a result of the SDSR:

I am responsible for health care delivery and medical operational capability, some of it directly through my joint units, and some of them with process ownership across the three single Services. I have visibility of the end-to-end piece. We are one of the few areas during the SDSR that actually had additional funds committed, [...].[14]

ADVANCES IN MEDICAL CARE RESULTING IN MORE PERSONNEL SURVIVING INJURIES

15.  More Armed Forces personnel are surviving injuries which would have been fatal in previous conflicts because of advances in medical treatment in theatre, on evacuation and in hospital. Admiral Raffaelli told us that it is not possible to be precise about the proportion but he estimated some 210 additional people had survived:

We cannot say proportion-wise. The mechanism for calculating unexpected survivors is dreadfully complex. It is based on injury severity score comparators. Above a certain level, you begin to grade them as major casualties. With each case, we give them what is called a new injury severity scoring and then we sit in a peer group and compare with each other. In pure numerical terms we believe that about 208 or 210 in the last five years would have fallen into the "not expected to survive" group. [...] is that against all standard comparisons that we do—I am trying to avoid giving an exact number because it does not really exist—one in 10, or one in 15 end up surviving longer than we would have expected.[15]

16.  The very severe nature of the injuries experienced by some personnel in Afghanistan and Iraq means that they have very complex medical and rehabilitation needs with the consequence that the period of their recovery can be extensive. The average time spent in medical care is normally greater than 12 months and can be two years or longer depending on the needs of the individual, hence many personnel have yet to be discharged. The MoD told us that, as at September 2011, only 300 personnel injured on operations since 2006, some 8.7 per cent, had been discharged and only 21.5 per cent had left specialist medical care.[16] Admiral Raffaelli told us that it was important for individuals to get the most appropriate treatment:

The longer-term thing, though, is with the level of severity of injuries that they've received, and is much more challenging in many ways. You're well aware that, with the high level of IEDs, the lower halves of the body are particularly damaged. That can be really quite high these days, and people are still surviving. So it's about how to secure a good functional outcome for these young men, how to help them to heal as best they can, and then, in the longer term, how to provide them with whatever support, be it at one end prosthetics, at the other perhaps, in some cases, longer-term nursing, particularly if there are head injuries involved as well. The thing is to ensure that that support is delivered to them, and then carried on in the longer term.

From our perspective, we will not look to discharge people until we've got them to the best level of functional ability that we'd hope we would do. The work we have been doing at Headley Court [...]. Some of the high-level casualties we would absolutely expect to be with us for, say, three years, to ensure that we've got them to that best possible level.[17]

17.  Admiral Raffaelli stressed the importance of end to end treatment for wounded personnel and the need for partnerships with international military partners and the NHS. He also detailed some of the recent medical advances such those to reduce blood loss:

In quite specific terms, one of the direct focuses—working with Americans, in particular—was the recognition that catastrophic blood loss at the point of wounding was the single biggest killer in the short time frame. In fact, 50% of the people were dying from blood loss. So a lot of effort has gone into how to deal with that, by using things like combat application tourniquets, novel blood products and bandages to hold bleeding back. They are delivered not only by medical personnel forward, but by the soldiers themselves, who are trained, and by team medics. So the first thing is, at the very point of wounding, to save the life and then rapidly follow that up with our combat medical technicians or our medical assistants, who are trained to a higher level, and for them to take forward the blood products and the rest to deal with that.[18]

18.  He also described the importance of evacuation procedures in theatre:

The next stage of course is to retrieve the wounded as expeditiously as possible, and we do not just do that on our own; we also do it with our international partners, the Americans in particular; their PEDRO and DUSTOFF casualty retrieval helicopters are tremendous. We have a different, but complementary, approach to the US—we don't have the quantity of assets that they have, though as I say we do work in partnership, and we have the Medical Emergency Response Team capability, which is deployed in the Chinook. What that does is it takes to the casualties a higher level of care, almost taking the emergency room to the casualty. So with a consultant-led team on board, we can provide high-level resuscitation, we can incubate people and we can provide blood products—that is a big change, to deal with that physiological disruption that major trauma causes. We can reheat them and deal with acidosis, and we can even put on aortic clamps if they are severely injured high. We can certainly anaesthetise and bring them back safely. [19]

19.  He then told us about the importance of the work done at the hospital in theatre and in the evacuation of personnel back to the UK:

They get back to the hospital, and again it is a combined, consultant-led team approach. They know what is coming in, as best they can—in terms of the number of casualties, the problems they have—so they can prearrange the reception to deal with them, if necessary even bypassing the emergency department and going straight into operating theatre. The job is very much focused on what we call damage control surgery, which is that life-saving and physiological stabilisation surgery, to get the casualty into the best possible condition.

For UK-based and other multinational coalition partners, the next part in the chain is to get them back home as safely as possible. The RAF is quite exceptional at that—the critical care support team and transport system is quite remarkable. When I speak to colleagues in other health care systems, they sometimes say, "We wouldn't take that chap up three floors", but we bring them back 3,000 or 4,000 miles. That is again down to a consultant-led team, focusing specifically on the patients.[20]

20.  The Families Federations told us that the medical support received by injured personnel was very good:

DAWN MCCAFFERTY (CHAIR OF THE RAF FAMILIES FEDERATION): Certainly, the feedback that I get from family members and from those who are serving is that the medical support that they get, if they are injured on operations, is second to none. Indeed, many people are probably surviving on the battlefield who might not have survived years ago. They are brought home to the United Kingdom and they are given first-class treatment right the way through to, hopefully, recovery and rehabilitation.

KIM RICHARDSON (CHAIR OF NAVAL FAMILIES FEDERATION): I would say that families feel that their serving personnel are being cared for very well; [...] One of the things I don't think we're doing is going back to the families to say, "Where could we have done better?" [...]

JULIE MCCARTHY (CHIEF EXECUTIVE OF THE ARMY FAMILIES FEDERATION): I absolutely agree. Nobody doubts the quality of medical care that soldiers are receiving. [...][21]

21.  In written evidence, SSAFA told us that "the Armed Forces and the MoD, together with NHS and other Agencies, now have in place world class facilities for clinical treatment and rehabilitation".[22] The Royal British Legion told us that "the quality of trauma care on operations in Iraq and Afghanistan has progressed to allow an unexpected survivor rate of 25% which compares to some of the best NHS hospitals in the UK".[23]

22.  In its report of February 2010, the National Audit Office said that:

The Department's (MoD) clinical treatment and rehabilitation of the seriously injured is highly effective. The Department has a clear focus on providing a high level of care and rehabilitation to seriously injured personnel on operations and in the UK, and outcomes achieved are good relative to the seriousness of the injuries sustained.[24]

23.  THE EVIDENCE OF ADMIRAL RAFFAELLI, SUPPORTED BY THAT OF THE FAMILIES FEDERATIONS, SETS OUT THE EXTRAORDINARY QUALITY OF CARE GIVEN TO OUR ARMED FORCES ALMOST FROM THE POINT OF WOUNDING. WE COMMEND THE ARMED FORCES MEDICAL SERVICES FOR THE IMPROVEMENT IN ALL ASPECTS OF THE MEDICAL TREATMENT OF INJURED PERSONNEL IN THEATRE FROM EMERGENCY TREATMENT BY COMRADES AND THEN THE MEDICAL EMERGENCY RESPONSE TEAM FOLLOWED BY STAFF IN THE HOSPITAL AND THEN EVACUATION BACK TO THE UK. WE NOTE, HOWEVER, THAT THIS GREATER SURVIVAL RATE OF VERY SERIOUSLY INJURED PERSONNEL HAS SERIOUS IMPLICATIONS FOR THE QUALITY OF LIFE OF THESE PERSONNEL AND FOR THE RESOURCES REQUIRED TO MAXIMISE THIS QUALITY.

QUEEN ELIZABETH HOSPITAL

24.  Since the opening of the new Queen Elizabeth Hospital, Birmingham in June 2010, the majority of Armed Forces personnel have been treated in a military-managed ward. Surgeon Commodore MacArthur told us that the arrangements with the Queen Elizabeth Hospital were working well:

[...] we have learned a lot over the last three or four years. We have injected more military personnel into Birmingham, and there are now nearly 400 people working there. We have learned too to increase the welfare administrative support to soldiers, marines and airmen coming to Birmingham with increased J1 [in theatre] support. We have very close engagement with University Hospital Birmingham NHS Foundation Trust to make it work, and I believe it is working well.[25]

25.  Admiral Raffaelli stressed the need for a combined approach at the Queen Elizabeth Hospital:

[...] it's a completely combined approach within that unit now, and consultant led. It is very much an NHS lead by the time you get there, but our people are well embedded. So I think that that is the first challenge, to actually secure that survival, and they do very well. I'm delighted to say that very few people have actually ended up dying in Birmingham.[26]

DEFENCE MEDICAL REHABILITATION CENTRE AT HEADLEY COURT

26.  The Defence Medical Rehabilitation Centre (DMRC) at Headley Court provides a mixture of hostel beds for those undergoing less serious rehabilitation and in-patient beds for those more seriously injured. The number of hostel beds has remained constant at 110 over the last 10 years. The number of in-patient beds has risen from 36 before 2007 to 122 in October 2011 with a further planned expansion to 144 by July 2012.[27] We asked the MoD if this level of support was sustainable, particularly when the UK no longer has troops in combat roles in Afghanistan. Admiral Raffaelli told us:

Yes is the answer on sustainability. The core business for Headley Court, even today, remains dealing with the large number of soldiers, sailors and airmen who incur muscular-skeletal and other injuries. That is still about 70% to 75% of their daily activity, and that does and will continue. [...] We regularly model on what the capacity and capability requirements of Headley Court are. Last year, we put in a temporary ward to uplift the high-level beds to 96, and recently we submitted a new statement of requirement to the new Defence Infrastructure Organisation, with the intent of increasing capacity in two increments, between October and early next year, to 144 high-level beds.[28]

27.  The National Audit Office reported that Headley Court provided unique rehabilitation facilities:

Headley Court provides rehabilitation facilities for complex trauma, neurological injury and other complex injuries. There is no NHS equivalent for general rehabilitation from trauma and limited civilian provision for specialist rehabilitation such as neurological injuries. Seriously injured personnel needing rehabilitation are admitted to Headley Court, first as inpatients to the ward where they receive intensive support. [...] However, military commanders told us the quality of care at Headley Court was very good. Patients also considered the quality of care and support to be good, including from mental and occupational health specialists and rehabilitation staff.[29]

28.  WE NOTE THE SIGNIFICANT ADVANCES IN TREATMENT RESULTING IN A HIGHER PROPORTION OF INJURED PERSONNEL SURVIVING THAN IN CONFLICTS. WE WERE IMPRESSED WITH WHAT WE SAW AND HEARD ABOUT THE MEDICAL TREATMENT IN THE QUEEN ELIZABETH HOSPITAL AND REHABILITATION SERVICES AT THE DEFENCE MEDICAL REHABILITATION CENTRE AT HEADLEY COURT. WE COMMEND THE MOD FOR IMPROVEMENTS IN THE MEDICAL TREATMENT AND REHABILITATION GIVEN TO INJURED SERVICE PERSONNEL AND SEEK ASSURANCE THAT THE NEW ARRANGEMENTS WILL BE ADEQUATELY RESOURCED SO THEY MAY BE MAINTAINED OVER THE LONGER TERM.

29.  During our visit to the Walter Reed Hospital, we were impressed by the liaison and co­operation between the USA and the UK in their work supporting those with life-changing injuries. We would encourage the MoDand the Department of Health to continue collaboration between the UK and USA defence medical servies.

TRANSFER OF LESSONS BETWEEN THE MOD AND THE HEALTH SERVICES

30.  The relationship between the health services and the MoD is symbiotic. In the past, the MoD has drawn on the expertise of NHS personnel with greater experience in treating traumatic injuries. More recently, medical personnel working within Afghanistan and Iraq and at the Queen Elizabeth Hospital have unfortunately had far greater experience of emergency medicine. Claire Phillips, the Department of Health, told us that there were opportunities to learn from each other:

There are huge opportunities for us to learn from each other and we recognise that the huge advances that have been made are things that we can learn from in the NHS. So as the Surgeon General said, the Reserves are obviously very important because they are going back into the NHS and taking a huge amount of operational experience with them. It is often said that one Reserve spending some time in Bastion will have more trauma experience than he will see for months and months, if not years, in the NHS. So that is clearly important.[30]

31.  Claire Phillips also told us of the very recent creation of the National Institute of Health Research Centre for Surgical Reconstruction and Microbiology in Birmingham which would help in providing opportunities to learn from the work done by the Defence Medical Services and the NHS.[31] The Centre will carry out research to help people recover better and faster from severe injuries resulting in improved trauma care in the NHS. The contract is funded by the MoD (£10 million over ten years), Department of Health (£5 million over five years), and the University Hospital Birmingham NHS Foundation Trust and the University of Birmingham (£5 million over five years).[32]

32.  THERE ARE SIGNIFICANT OPPORTUNITIES FOR THE NHS TO LEARN FROM THE EXPERIENCES OF THE MOD IN DEALING WITH TRAUMATIC INJURY. IN RESPONSE TO THIS REPORT, THE DEPARTMENT OF HEALTH SHOULD TELL US WHAT MECHANISMS, OTHER THAN MEDICAL PERSONNEL RETURNING TO THE NHS AFTER OPERATIONAL SERVICE AND THE RECENTLY CREATED CENTRE FOR SURGICAL RECONSTRUCTION AND MICROBIOLOGY, IT USES OR INTENDS TO USE TO ENSURE THE TRANSFER OF SUCH VALUABLE EXPERIENCE AND ADVANCES IN MEDICAL TREATMENT, BOTH IN ENGLAND AND IN THE DEVOLVED ADMINISTRATIONS.

THE PROVISION OF TREATMENT FOR MENTAL HEALTH PROBLEMS

INCIDENCE OF MENTAL HEALTH PROBLEMS

33.  Admiral Raffaelli told us post-traumatic stress disorder (PTSD) was seen in those who have served on operations but, in general, the numbers were very low at between three and seven per cent, compared with the general UK population. Much more common were general mental health problems such as depression and anxiety although these were still in line with the non-deployed personnel and the general population.[33]

34.  Armed Forces personnel are still reluctant to come forward with concerns about their mental health because of worries about the impact on their careers and how other people might perceive them, and guilt that their condition is not the same as a physical injury. Professor Wessely, Head of the King's Centre for Military Health Research,[34] told us that this was probably no different from any other occupational group and indeed the military is now slightly more accepting of mental health problems:

[...] the majority of people with mental health problems do not present either in Service or after Service—only around 40% do, and 60% do not. As I say, there is a lot of undetected morbidity that we know about but no one else does, apart from the person themselves. [...] that is probably no different from any other occupational group. If we take a group of doctors—my wife runs a sick doctor service—it is very similar. If we took a group of MPs, I suspect it would be very similar as well. It is a much bigger social problem. Our own original, rather naive, view was that it was to do with the nature of Army culture. I think we have changed our mind; if anything, the military is now—we have some nice data on this—slightly more accepting of mental health problems than it was, and many problems with veterans begin when they leave, not when they are in Service. It is not that there is a bullying military culture, and then they join the touchy-feely, cuddly NHS and everything is fine. It certainly does not work like that.[35]

35.  General Rollo, Deputy Chief of Defence Staff (Personnel and Training), told us that mental health was a priority for the MoD:

[...] Ministers have repeatedly made quite clear to us that, despite the overall financial situation in the Department, mental health care is a priority and we are to say what we need.[36]

36.  In May 2010, Dr Andrew Murrison MD MP was asked to develop a mental health plan for servicemen and veterans and on 31 August 2010 he published his report, Fighting Fit, the Government accepted his recommendations. Key recommendations included incorporation of a structured mental health enquiry into existing medical examinations for serving personnel, mental health follow up of veterans 12 months after leaving the Services and the development of an online service, called "the Big White Wall".[37] Admiral Raffaelli told us:

As a result of the work that Andrew Murrison did on "Fighting Fit", we are working with the Department of Health and are in the process of introducing something called Big White Wall, which will be a self-referral into a carefully run, properly governed internet facility that will be open to serving people, veterans and families. Within it, they will be able to get advice and be signposted to what is appropriate for them.[38]

37.  Claire Phillips told us that they were working with the MoD on mental health issues for those leaving the Services:

We recently established a 24-hour helpline through Combat Stress. The contract was given to Rethink, who have a lot of experience in this field. We have received nearly 3,000 phone calls, which is quite a lot, within the first three or four months. The Surgeon General mentioned Big White Wall. That is an online therapeutic community, if you like, that is open to veterans, to serving personnel and indeed to families. We are trialling that; that is at a fairly early stage at the moment.[39]

The Big White Wall went live in September 2011 and the site is staffed by professional counsellors who can be contacted 24 hours a day, seven days a week.[40]

38.  THE NUMBER OF CALLS TO THE RECENTLY ESTABLISHED HELPLINE DEMONSTRATES THE HIGH LEVEL OF NEED FOR MENTAL HEALTH SUPPORT FOR VETERANS. WE WELCOME THE MOD'S INCREASED ATTENTION TO MENTAL HEALTH ISSUES. IN RESPONSE TO THIS REPORT, THE MOD SHOULD UPDATE US ON PROGRESS ON THE IMPLEMENTATION OF THE MURRISON REPORT, FIGHTING FIT.

RESEARCH INTO THE LEVEL OF MENTAL HEALTH PROBLEMS IN THE ARMED FORCES

39.  In 2003, following lessons learned from the first Gulf War, the MoD asked Professor Wessely, now the Head of the King's Centre for Military Health Research, and his team to start a large scale study into the physical and psychological health of those who were about to take part on the invasion of Iraq. The study was later expanded to include those deployed to Afghanistan. The first set of findings was reported in 2006 with the results of the further study in 2010. [41] In 2004, the King's Centre for Military Health Research was formed from the Gulf War Illnesses Research Unit of King's College London.

40.  Professor Wessely told us that results of their studies in 2006 and 2009 of 10,000 Armed Forces personnel showed that the rate of PTSD was unchanged at some three to four per cent with those having been in combat roles (some 25 per cent in 2009) at seven per cent.[42] The King's Centre research found more depression, anxiety disorders and alcohol problems than Post Traumatic Stress Disorder (PTSD) in the UK Armed Forces. Professor Wessely stressed that for a diagnosis of PTSD, the person had to be suffering from some impairment of function:

The first thing to say is that some of the symptoms of Post-Traumatic Stress Disorder are not, by themselves, abnormal. We would not say that coming back from a deployment with poor sleep, or being more irritable or a bit more angry and difficult, were signs of a disorder; that is a normal emotional reaction. [...] The best way of understanding a psychiatric disorder is that it is when it is not just that you have good or bad memories of your military Service, but when that impedes your function; because of those memories, you cannot work, you cannot keep down a marriage, you start doing drugs or drink—in other words, your performance is impaired. In cases of PTSD, everyone remembers symptoms such as flashbacks, anxiety and such things, but they forget that there is also a requirement that someone is impaired in their function. When someone is impaired in their function, they are moving towards a formal psychiatric disorder that may require treatment. Simply having memories of war is almost a sine qua non of having been deployed, and we go out of our way not to medicalise or pathologise that.[43]

41.  Professor Wessely also pointed out that the relationship between exposure to trauma and PTSD was not a simple one:

The point from that is that the relationship is not a simple one between exposure to trauma and Post-Traumatic Stress Disorder. When Marines had high levels of exposure, but lower levels of stress, the general view, which I think is the correct one, is that it was mitigated by high esprit de corps, training, professionalism, cohesion and leadership—all things that the military is good at. It is not a linear relationship between trauma and outcome in mental health.[44]

He also found less PTSD in the UK Armed Forces than in those of the USA following deployment. The reasons for this are not certain but American troops do longer tours, typically one year and are on average younger than UK troops.[45] We also note that they are also more likely to be reservists.

RESERVISTS

42.  The King's Centre research showed that reservists experienced more problems on return from deployment than regulars. Professor Wessely told us that the reasons for this were complex:

We know that they have worse mental health problems. [...] that these figures are not like some of those we have seen from the USA, where one third come back with neuropsychiatric problems. For us it is about 6%, so 94% do not come back with mental health problems. Nevertheless, Reservists are more vulnerable. We have had a long look at this in various ways, with various different studies and data sets. It is not to do with what happens to them in theatre. In particular, we showed that, between 2003 and now, morale and satisfaction with their role in theatre had increased from Telic 1 [first phase of the Iraq conflict] right through to now. It was a bit disappointing to see that that had not led to an improvement in mental health problems.

The problems are particularly to do with support and homecoming issues. Reservists are more likely to have problems with their employers; they are less likely to feel that the military is supportive; they are less likely to feel that their families are supportive; and they are more likely to have problems from their peer group. Let's say that the Reservists come back to King's. For two days it is great, and they tell their war stories, and you start telling them about the latest NHS reform and how terrible it has been while they have been away, or whatever the current problems are. We are clear that it is to do with different homecoming experiences, different support structures and different family structures.[46]

RESEARCH

43.  In 2009, the King's Centre for Military Health Research found no relationship between mental health problems and the number of deployments undertaken by personnel although Professor Wessely stressed that this was only "at that moment".[47] Professor Wessely told us that they had also completed research into the impact on mental health of physical injuries and had found that physical injury increases the risk of psychiatric disorder but the full results are not yet available.[48]

44.  The King's Centre found that pre-deployment screening for the likely development of mental health problems would be ineffective.[49] It is currently carrying out research for the Armed Forces of the United States on the efficacy of post-deployment screening using the UK Armed Forces as a control group.[50]

45.  WE LOOK FORWARD TO HEARING THE RESULTS OF THE KING'S CENTRE CURRENT RESEARCH ON THE IMPACT OF PHYSICAL INJURY ON MENTAL WELLBEING AND THE EFFECTIVENESS OF POST-OPERATIONAL SCREENING. THE MOD SHOULD REVIEW ITS PRACTICES IN RESPONSE TO THE RESULTS OF THIS RESEARCH. WE ALSO RECOMMEND THAT THE MOD CONTINUE TO FUND RESEARCH INTO THE MENTAL HEALTH OF THOSE DEPLOYED ON OPERATIONS, IN PARTICULAR, THE IMPACT OF MULTIPLE DEPLOYMENTS AND THE STRESS OF BEING IN A COMBAT ROLE.

46.  WE RECOMMEND THAT THE MOD SHOULD COMMISSION RESEARCH INTO THE HOMECOMING EXPERIENCES OF RESERVISTS AND THE SUPPORT AND UNDERSTANDING OF FAMILIES AND EMPLOYERS.

47.  WE RECOMMEND THAT THE MOD SHOULD MONITOR ARMED FORCES PERSONNEL WHO HAVE BEEN DEPLOYED ON OPERATIONS TO DETERMINE IF PTSD OR OTHER MENTAL HEALTH PROBLEMS EMERGE WHILE PERSONNEL ARE STILL SERVING. THE MOD SHOULD RESPOND TO ANY INDICATION OF FUTURE PROBLEMS RAPIDLY AND EFFECTIVELY.

MENTAL HEALTH PROBLEMS IN THEATRE

48.  Professor Wessely told us that the mental health problems which emerge in those deployed in theatre are a reflection of what is happening at home:

We know that many of the mental health problems that present in theatre are a reflection of what is going on at home. We also know that where the person in theatre feels that the family is not being supported, their own mental health is worse, and they are more likely to develop traumatic stress symptoms. It is not just a matter of being kind to families; we would suggest, and the data suggest, that it is an operational requirement to have good support and welfare for families of Reserves and Regulars, because that will improve mental health in theatre.[51]

General Rollo, told us that support for families when personnel were deployed was important in maintaining operational effectiveness:

The mental health surveys we have done show clearly that a significant factor in mental distress in theatre can be problems at home, as you would expect, because you feel very helpless stuck out in the desert somewhere when you know there is a problem at home that you cannot do anything about. Knowing that families are properly looked after is a really important element of operational effectiveness.[52]

49.  Dr Fear of the King's Centre told us that they were doing research into military families:

We are looking at 600 fathers from our military cohort, and we are interviewing them about their military experiences but also their relationships with their families and in particular with their children. We are asking how they feel that they relate to their children and how their children cope with them being in the military. We are also contacting their partners, or their wives, to get their views on how the father interacts with the family and with the children. For those children who are 11 or older, we are contacting them directly to ask them about what it is like having a father in the military and how they cope—what are the pluses and minuses of being a military child? That is work in progress.[53]

50.  WE RECOGNISE THE IMPORTANCE OF SUPPORT FOR THE FAMILIES OF DEPLOYED PERSONNEL, NOT ONLY BECAUSE IT IS RIGHT TO LOOK AFTER THE FAMILIES BUT ALSO BECAUSE ARMED FORCES PERSONNEL ARE LESS LIKELY TO DEVELOP TRAUMATIC STRESS SYMPTOMS IF THEIR FAMILIES ARE SUPPORTED. WE RECOMMEND THAT THE MOD REVIEW ITS SUPPORT FOR FAMILIES WHEN PERSONNEL ARE DEPLOYED ON OPERATIONS IN THE LIGHT OF THE RESULTS OF THE KING'S CENTRE RESEARCH.

ALCOHOL MISUSE

51.  Dr Fear told us that alcohol misuse was substantially higher in the military than in the general population, but not all of this was related to operational service:

[...] 13% of the Armed Forces are reporting levels of alcohol misuse compared with [...] between 3% and 4% with PTSD. Yes, there is perhaps some co-morbidity there—people with PTSD are misusing alcohol—but, obviously, not everybody who is misusing alcohol has got PTSD. We think there is some level of co-morbidity, but we do not believe that those 13% of people are harbouring mental health problems.[54]

Alcohol misuse within the military is substantially higher than we would expect with the general population. Obviously, the general population comprises people of all ages, and those who are occupationally inactive. If we take all those differences into account, the latest figure for the prevalence of alcohol misuse in the general population is 6%, compared with 13% in the military.[55]

52.  General Berragan, Director General Personnel, Land Command MoD, told us that there was not a problem of alcohol dependence in the Armed Forces but there was significant misuse of alcohol in personnel under 35 years old—about twice as high as in the broader society with an even higher difference for women. He explained that the Armed Forces recruited risks-takers, put them in a stressful situation and then returned them home with money and free time when they drank excessively. He described what their approach to such problems were:

On what we are doing about it, it is another pillar in our whole strategy. The first pillar of any strategy is awareness. On a cyclical basis, we go through a process of posters, awareness and briefings on the dangers of alcohol misuse. The first point about solving any problem is giving people the facts. That is what we try to do.

Beyond that, the second stage is informal warnings and counselling. Beyond that, there is administrative action and counselling. If you like, there is a clinical intervention and a disciplinary intervention. If the problem does not go away and they fail to control it, they can ultimately be discharged from the Army. If the problem affects their operational effectiveness and their ability to do the job, the ultimate sanction is discharge.

There is a four-stage treatment process involving both the chain of command and the clinical chain. [...] We also have pricing policies, where any alcohol sold in camp has to reflect local market prices, so we do not encourage people to drink by cutting prices. The pay-as-you-dine contractors have to provide non-alcoholic facilities in camp, like internet cafes or Costa Coffees, so that there is an alternative to the bar.[56]

53.  General Berragan explained the available treatments for those with severe problems:

I would say, however, that it is about trying to prevent the situation reaching the stage where you have to put the soldier or sailor into a formal treatment programme. Education is terribly important. That is a routine thing through all units in the Army, Navy and Air Force. There is an ongoing education programme. It is about mentoring, through the chain of command on a division basis, a squadron basis or a flight basis, trying to nip it in the bud if a guy is drinking too much.

Ultimately, treatment, can be provided if required, through the Department of Community Mental Health [MoD community mental health teams], which I mentioned before. Not every Department of Community Mental Health can put on an alcohol treatment programme, but some do. By and large that it is a week-long programme, with group-based activities and a good success rate. I will say from my perception as a medical officer who has served for many years, that the level of alcohol abuse and misuse, as the General said, has markedly gone down.[57]

54.  General Berragan said that the MoD recognised the issue of other risk-taking behaviour:

We are very conscious of it so they do get briefed on it [in decompression] and they are made aware of it. I think it still happens. The other aspect is that they have been living on an adrenalin rush for the best part of six months. Coming off adrenalin is like coming off any other form of substance; you have to do it in a measured way. That perhaps explains why people do risky things after operations, because they are still seeking part of that adrenalin rush that they have become accustomed to on operations.[58]

55.  IT IS UNCLEAR TO US WHETHER THE MOD REGARDS THE MISUSE OF ALCOHOL AND OTHER DANGEROUS RISK-TAKING BEHAVIOUR AS PART OF A PATTERN OF REPREHENSIBLE BEHAVIOUR WHICH REQUIRES PUNISHMENT OR DISCOURAGEMENT, OR A MANIFESTATION OF STRESS WHICH REQUIRES TREATMENT, OR INDEED A COMBINATION OF BOTH. WE RECOGNISE THAT THE MOD HAS BEEN TRYING TO TACKLE THE OVER-CONSUMPTION OF ALCOHOL BUT THERE IS MORE THAT SHOULD BE DONE. WE RECOMMEND THAT THE MOD CARRY OUT A STUDY INTO WHAT IS DRIVING THE MISUSE AND ABUSE OF ALCOHOL IN THE ARMED FORCES AND WHAT MORE COULD BE DONE TO MODIFY BEHAVIOUR WHICH IS SIGNIFICANTLY AT VARIANCE WITH THAT OF THE GENERAL POPULATION. THE MOD HAS YET TO RECOGNISE THE SERIOUSNESS OF THE ALCOHOL PROBLEM AND MUST REVIEW ITS POLICY IN THIS AREA.

DECOMPRESSION FOR THOSE RETURNING FROM OPERATIONS

56.  The MoD told us that that by their very nature, military operations are stressful for all involved and that individuals deal with their experiences in different ways. All troops returning from operational theatres go through a decompression period lasting 24 to 36 hours in Cyprus with mandatory briefings on mental health issues, including the misuse of alcohol, which might arise on their return to the UK. Personnel are given time to unwind to facilitate adjustment to non-operational duties and to home.[59] General Berragan told us that the Armed Forces had learned the lessons of previous operations and used decompression to identify people suffering from stress and put in place appropriate support.[60]

TRAUMA RISK MANAGEMENT

57.  In 2008, the Armed Forces introduced a non-medical response to traumatic events, starting with the Royal Marines and now used in all three Services, called Trauma Risk Management (TRiM). Traumatic events include sudden death, serious injury, near misses and overwhelming distress when dealing with disaster relief and body handling.[61] When asked how effective TRiM was, Admiral Raffaelli told us that personnel reported that they found it a very useful process but it had not been possible to formally evaluate it as having a control group not receiving such support would have been unethical. However, the MoD was confident it did no harm and believed it resulted in good mental health outcomes. As the trained TRiM counsellors are often warrant officers, TRiM reduces the stigma of seeking help.[62]

58.  WHILST WE RECOGNISE THAT IT IS NOT POSSIBLE TO DO A FORMAL PIECE OF RESEARCH ON THE TRAUMA RISK MANAGEMENT SYSTEM, WE RECOMMEND THAT THE MOD EVALUATE THE USE AND BENEFITS OF TRIM AND COMPARE IT WITH OTHER SIMILAR SYSTEMS. IN RESPONSE TO THIS REPORT, THE MOD SHOULD TELL US WHAT IT IS DOING TO MINIMISE THE NUMBER OF PERSONNEL WHO ARE NOT PICKED UP BY THE USE OF TRIM, PARTICULARLY RESERVISTS AND THOSE DEPLOYED AS SINGLE AUGMENTEES.

MENTAL HEALTH ISSUES FOR MEDICAL STAFF

59.  In 2006, medical staff deployed in theatre showed higher levels of mental health problems than other deployed personnel although this might be due to their greater willingness to come forward for help with psychological distress.[63] Medical personnel work in very difficult circumstances treating people with very serious and life-threatening injuries both in the theatre of operations and in the Queen Elizabeth Hospital and at Headley Court. The Defence Medical Services has introduced greater support for those employed in the Queen Elizabeth Hospital and Headley Court. For example, all professional groups are briefed on psychological issues and have confidential access to psychological support.[64]

60.  WE COMMEND THE MOD FOR ITS RECOGNITION OF THE IMPACT ON MEDICAL STAFF IN WORKING WITH VERY SEVERELY INJURED ARMED FORCES PERSONNEL AND FOR THE INTRODUCTION OF GREATER SUPPORT FOR SUCH PERSONNEL. SUCH SUPPORT FOR MEDICAL STAFF SHOULD CONTINUE AND SIMILAR SUPPORT SHOULD BE INTRODUCED FOR THOSE STAFF DEPLOYED IN THEATRE AND CONTINUED WHEN THEY RETURN HOME, PARTICULARLY FOR RESERVISTS WHO ARE DEMOBILISED ON RETURN.

SUPPORT FOR FAMILIES

61.  As noted in paragraph 48 above, it is important that families are supported whilst their family member is deployed. It is even more vital that they are supported if that person is killed or seriously injured on operations. We were told by the Families Federations and charities that the MoD had involved them in improving the support for families since the start of operations in Iraq and Afghanistan.[65] Mr Robathan told us that the MoD took the support of families of injured or killed personnel very seriously:

[...] That organisation [the Directorate Children and Young People, MoD] is closely involved with supporting children and young people, particularly when their parent has been killed in action. That is one of its focuses, besides the broader education system—indeed, it also deals with situations where a parent is medically discharged after an operational injury.

  [...] For bereaved children, I have mentioned scholarships, and we also work closely with the charitable sector—SSAFA, in particular, and the Child Bereavement Charity, to ensure that Service children, of both the injured and killed, are given as much help as possible.[66]

62.  General Cumming, controller of SSAFA, told us that the MoD had asked SSAFA to run a number of family support groups:

[...] Those groups have been going for about two years. They originally focused on those families who had been bereaved by bringing them together to enable them to talk, but they have expanded into another group for the families of those who have been wounded. Interestingly, out of that we found that the children of those who have been either killed or wounded did not want to do things with their parents but wanted their own group, so it is quite complicated with several such groups. They enable people to talk to each other, and we take them away for weekends and so on.[67]

63.  We asked the Families Federations whether there were issues on family support which needed to be addressed. Julie McCarthy, Army Families Federation, told us:

Can I give you a quote to illustrate the sort of things that families come up against? "My doctor told me to have a hot chocolate and not watch TV late at night when I told him I was struggling to cope and not sleeping well." Her husband was deployed, and it is not just about bereavement or somebody coming back with injuries. It is about coping sometimes with multiple deployments and seeing your friends getting knocks on the door telling them about their husbands. I spoke to a young wife the other day whose husband's best friend had been killed, and she just did not know how to cope. She said, "What do I say to him?" She needed support in knowing how to deal with it. How do they tell their children that their daddy's friend is dead, or that their friend's daddy has lost their legs? It is about that whole wider family. Too often I get told, "That's an NHS issue." Actually, no, it is because of military Service that that is being impacted, and we should be addressing that.[68]

64.  Dawn McCafferty, RAF Families Federation, told us:

I have certainly had evidence from one family where the individual in uniform was getting medical and mental health support through the MoD as required, and it was spot on, and just what he needed. She and the children were suffering in their own way. She was finding it very hard to adjust, went through to the NHS support, and found very little empathy or support available for her, because the perception was that it was an MoD responsibility. She couldn't get across to them that she doesn't come under the MoD for medical or mental health care. Someone must help them, and particularly the children. She was really looking for counselling support for the children, and all she could find was charitable support. There's an identified gap. I am not saying that it's a massive issue. It's probably a minority, but where it exists, there's a need to address it.[69]

65.  Julie McCarthy, Army Families Federation, further told us:

That is notwithstanding the fact that specialist support may be required, which is not immediately forthcoming, such as if young children were involved. Sometimes specialist counselling and advice are needed, and again, we are relying on families going out to look at the charitable sector. Winston's Wish is doing a lot of work with the military at the moment particularly to address children who are bereaved. There is very practical support, but emotional support such as counselling is an area that we need to look at.[70]

66.  When asked about support for the families of those severely injured, General Berragan told us that the MoD accepted that this was an area where they needed to improve:

The first point is that part of the responsibility of the personnel recovery units [...] is to look after the needs of the family and to ensure that the family are dealing with it. It is a really sensitive area, [...] I was talking about this very subject with one of our seriously wounded only yesterday. We talked about how the impact of his injury on his family, particularly on his children, took him by surprise. His wife was with him in terms of dealing with it, but they had not realised the impact on the children.

It is an area where we continue to learn lessons, but in our case the first point of contact is the PRO [personal recovery officer], who is our interface with the family. What we need to do is to bring in the other agencies—SSAFA and perhaps some qualified social workers—where necessary to support where the family are not dealing with it very well. That is an area where we probably need to improve.[71]

67.  IN THE REST OF THIS REPORT WE HAVE SET OUT THE MANY AREAS WHERE THE MOD IS PROVIDING OUTSTANDING CARE IN RELATION TO MILITARY CASUALTIES. THE MOD RIGHTLY RECOGNISES, HOWEVER, THAT THIS CANNOT ALWAYS BE SAID FOR THE SUPPORT IT GIVES TO FAMILIES, AND IN PARTICULAR CHILDREN, IN THE EVENT OF THE LOSS OR SEVERE INJURY OF A MEMBER OF THEIR FAMILY OR SOMEONE ELSE THE FAMILY KNOWS WELL. THE IMPACT OF SUCH AN EVENT CAN BE WIDELY AND DEEPLY FELT. WHILE THE MOD DOES IN OTHER CIRCUMSTANCES ACKNOWLEDGE THAT IT IS OFTEN THE FAMILIES LEFT BEHIND AT HOME THAT BEAR THE BRUNT OF THE DIFFICULTIES CAUSED BY DEPLOYMENT, IT IS TIME THE DEPARTMENT TURNED THAT ACKNOWLEDGEMENT INTO ACTION, AND WE URGE IT TO LOOK AGAIN AT THE SUPPORT SERVICES IT PROVIDES FOR THE FAMILIES AND CHILDREN OF ARMED FORCES PERSONNEL.


9   Defence Medical Services, www.mod.uk/DefenceInternet/MicroSite/DMS/WhatWeDo Back

10   Defence Medical Services, www.mod.uk/DefenceInternet/MicroSite/DMS/WhatWeDo  Back

11   Defence explained: The seven stages of medical pathway, www.mod.uk/DefenceInternet/PictureViewers/DefenceExplainedTheSevenStagesOfTheMedicalCarePathway Back

12   Ev 149, Q 371 Back

13   Q 474 Back

14   Q 345 Back

15   Q 310 Back

16   Ev 138 Back

17   Q 311 Back

18   Q 304 Back

19   Q 304 Back

20   Q 304 Back

21   Q 23 Back

22   Ev 159 Back

23   Ev 165 Back

24   HC (2009-10) 294, para 17 Back

25   Q 349 Back

26   Q 311 Back

27   Ev 144  Back

28   Q 312 Back

29   HC (2009-10) 294, para 2.18 Back

30   Q 309 Back

31   Q 309 Back

32   Ev 144 Back

33   Q 317 Back

34   The King's Centre for Military Health Research is a collaboration between three parts of King's College London-the Institute of Psychiatry, the Department of War Studies and the Medical School. Professor Wessely is the Director of the Centre and of the Academic centre for Defence Mental Health, a partnership between the MoD and King's College London. The mission of the academic Centre is to be a resource of research excellence and expertise within Defence Medical Services Mental Health Services and to act as a catalyst for the promotion of a strong research-based culture within Mental Health Services Back

35   Q 147 Back

36   Q 345 Back

37   Dr Andrew Murrison MD MP, Fighting Fit, August 2010, www.mod.uk Back

38   Q 317 Back

39   Q 328 Back

40   Ev 145 Back

41   King's Centre for Military Health Research: A fifteen year report, September 2010, http://www.kcl.ac.uk/kcmhr/publications/reports.aspx Back

42   Q 137 Back

43   Q 140 Back

44   Q 145 Back

45   Q 218 Back

46   Q 150 Back

47   Q 156 Back

48   Q 173 Back

49   Qq 172, 178 Back

50   Q 178 Back

51   Q 199 Back

52   Q 321 Back

53   Q 159 Back

54   Q 162 Back

55   Q 163 Back

56   Q 374 Back

57   Q 374 Back

58   Q 375 Back

59   Ev 127, Ev 149, Q 375 Back

60   Q 361 Back

61   Ev 126-127  Back

62   Q 325 Back

63   Q 145 Back

64   Ev 151-152 Back

65   Qq13, 15, 29-30, 247-248, 256, 409, 415 Back

66   Q 549 Back

67   Q 247 Back

68   Q 32 Back

69   Q 33 Back

70   Q 84 Back

71   Q 403 Back


 
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© Parliamentary copyright 2011
Prepared 15 December 2011