Support for Armed Forces Veterans in Wales

Written evidence submitted by Dr Alastair Clarke-Walker

Summary

· War veterans who suffer psychological damage from trauma (PTSD – Post Traumatic Stress Disorder) often do not receive the appropriate care. This can have the following consequences:

o Suicide - veterans have one of highest rates of suicide (more veterans of the Falklands conflict have subsequently taken their own lives than were killed in the conflict)

o Criminality – war veterans represent the largest occupational group in prison.

o Families - partners, wives and children are at risk of vicarious trauma and its consequences, resulting in dysfunctional relationships, behaviour and divorce.

o Co-morbidities - especially substance misuse massively increases risk and poor prognostic outcomes such as suicidality, deliberate self-harm, harm to others, self-neglect, mental health, general well being and integration into families, relationships and society.

· Currently the UK has more war veterans than at any time since the Second World War. In the words of Dr Liam Fox MP; "it is a time bomb about to explode."

The Challenge

1. At present the mental health care management of war veterans with Psychological Trauma and co-morbidities including substance misuse within the NHS services is inadequate and inefficient without accountability. There is no war veteran specific tertiary service to successfully treat their mental health and well being to meet the demand at present. War veterans who suffer psychological damage from trauma have resulted in morbid and mortal consequences with suicide as a potentially avoidable outcome. The government’s covenant with the armed services is important. Increases in legal claims for compensation of mental issues have not yet reached a maximum.

2. The NHS has two separate procedural routes of psychiatric management of PTSD and its co-morbidities; separate general adult mental health, and substance misuse health teams. Having worked as a dedicated practitioner in both camps, I have been left feeling very concerned about the level of care; even with experienced, knowledgeable and compassionate colleagues. The management of dual diagnosis consists of separate clinical teams working in parallel, or in series at best. With the best will in the world, communication between these two arms is not satisfactory as compared to a fully integrated model encompassing both arenas. I feel for the sufferers, especially the war veterans who are not empowered to argue their case. Not only is this group most disadvantaged, but also has the poorest prognosis and highest risk including suicide.

3. The provision of £485,000 for the Service Specification for Mental Health and Wellbeing Services for Veterans in Wales is insufficient to meet the real-life demands to aid war veterans. The funding is not sufficient for both a quantitative and qualitative holistic approach based upon the biopsychosocial model. There is no provision for the ‘Psychological Trauma Tsunami effect’ upon the associated families of war veterans. Such individuals, their partners, wives and children are at risk of vicarious trauma and consequences, potentially suffering the whole range of psychological trauma and its co-morbidities such as substance misuse, dysfunctional behaviours (fighting, delinquency, vandalism, and public disorder), criminality, recidivism, unemployment, enmeshed/dangerous relationships and divorce. In short the covenant of the government with the armed forces personnel is not being met in real terms.

4. War Veteran’s specific facilities need to be set aside for these individuals. A dedicated specialist tertiary hospital is needed based upon the biopsychosocial model. This will address the specific mental illness and substance misuse to reduce risk and optimise health outcomes. This unit is to work seamlessly with the social housing or therapeutic community, so the war veteran can be transferred at the optimum point in time, leading to the final integration into society. Feedback from war veterans is that from the start of the process to the end, there needs to be war veterans included in the staff. This is essential for engagement from the war veteran’s perspective. This is a fundamental reason for non-engagement with mental health care services for both the NHS and other organisations. War veterans who suffer have a tendency not to integrate well with the civilian populace that also suffer mental illness in the same environment. In the tragic event of suicide, these points become all the more important.

A Possible Potential Solution

5. The creation of a tertiary hospital to service the specific needs of war veterans is required. This would seamlessly integrate with dedicated social housing and the therapeutic community to permit war veterans to integrate into society. The ideal clinic will have an outpatient and inpatient provision. Victims of trauma will be promptly evaluated and obtain the most beneficial specific therapy. This recovery process would thus encompass the whole biopsychosocial model which also includes as required, spiritual and economic facets. Those who relapse can be supported by returning to higher levels of care including re-hospitalisation. The trauma service would offer an accountable, results defined process with considerable cost saving as compared to the NHS, and other government bodies such as the criminal justice system, determined by optimal patient outcomes. This will be achieved by a process of clinical and non-clinical management with the most objective critical evaluation.

The purpose of our service is that of a dedicated specific treatment centre, to successfully treat patients of their PTSD and co-morbidities. Part of the successful treatment is that of reduced re-admission rates and duration of inpatient stay.

6. One subset of these trauma sufferers is involved in the Criminal Justice System.  This group costs the UK government approx imately 1.7 billion pounds.  This service represent s a r ealistic approach to reduce the debt by d evelop ing the ability of war veterans to integrate pr operly into society , becoming productive tax pay ers rather than the converse - unemployment and recidivism . Such an organisation will be representative of a commitment by the government for a covenant with the armed forces. This process and structure will help towards a reduction in the costs, such as re-admissions, duration of admissions, legal claims, and costs incurred by the criminal justice system. Other benefits would include reducing premature deaths, and regaining a positive quality of life to self and others. All outcomes would be measured by transparent, valid and reliable rating scales, assessment of diagnostic criteria, mutual patient agreement and clinical judgement. The anonymous data (in accord to the data protection act) would be regularly updated to build up a medical evidence based approach, available for inspection, research and audit purposes.

7. The Trauma Clinic will optimise recovery of mental health, well being and risk by an individual tailored assessment and treatment of specific needs by a holistic approach, addressing their biopsychosocial requirements. Upon an individual basis, we would not deprive war veterans of the opportunity to optimise their treatment by only those interventions which possess the greatest medical evidence base. All therapeutic intervention will be positively challenged and innovation would receive the strictest scrutiny as demonstrated by the highest standards of critical appraisal. This clinic represents an excellent opportunity to treat Trauma victims i.e. PTSD and co-morbid conditions including Substance Misuse, those who have dual diagnoses and complex PTSD, in addition to those who appear refractory, regardless of physical disabilities such as the amputees. The aim of the clinic will be to provide the best of the NHS and Independent sectors by the provision of the highest ethical and clinical standards in the interests of the trauma sufferers. The aim will be to rapidly build the reputation of the clinic as a centre for excellence that is not prone to revolving door type of scenario, or undue duration of retention of patients that the NHS and Independent sectors respectively have a tendency to exhibit.

8. The war veterans’ the whole family, child and adolescent integrated model of treatment and the social aspects of the holistic approach are not manifest. If a war veteran is treated successfully and placed back into their family unit without addressing the family’s vicarious trauma, this will result in a higher likelihood of the veteran relapsing. The family will not understand the improvement, or not come to terms whilst the family still suffer the ‘Trauma Tsunami Effect.’ The partners, wives and children suffer vicarious psychological trauma such as PTSD which requires assessment and treatment. The requirement is a systemic, holistic family, child and adolescent provision to care for and educate the sufferers. This will provide opportunity to bring the whole family together to heal. This is not in existence currently.

9. The social aspect of the holistic model needs to be extended for the war veterans by a specific approach of social housing and therapeutic community to aid in life skills and vocational training. This aspect needs a war veteran lead, mentoring/buddy type system. Ideally, another veteran who has suffered, and has contact with other war vet’s. This will aid recovery, and positively influence their identity through being placed in touch with fellow soldiers with whom they served, and to also assist with integration into civilian life including employment. This can further enable war veterans to develop confidence, obtain a focus, maintain their dignity, self-esteem, and their military identity for life.

September 2011

Prepared 28th October 2011