Support for Armed Forces Veterans in Wales - Welsh Affairs Committee Contents

4  Care under the NHS

53.  Serving Armed Forces personnel receive their healthcare through the MOD. Upon discharge, the NHS becomes responsible. Witnesses identified three particular issues where NHS support needed to be improved: the transfer of medical records between the MOD and NHS; priority access to treatment; and the provision of mental health care.

Transfer of medical records

54.  Witnesses raised concerns that medical records were often not transferred between the MoD and the NHS: the Welsh Government's Senior Medical Officer described this as a "perennial problem".[55] Medical organisations said it was important to receive medical records to assist in the diagnosis of disorders related to armed service, and to help medical personnel make evidence-based decisions on treatment.[56]

55.  The British Medical Association described the current system for the transfer of records between the MoD and NHS:

Currently, identification is dependent on ex-personnel volunteering information. Everyone leaving the armed forces undergoes a final medical examination. The Defence Medical Services (DMS) doctor completes a FMED-133 form for the discharged veteran to give to their civilian GP when they register. In practice, the civilian GP rarely receives this information. The form itself is rudimentary and whilst the civilian GP may write to the armed forces if specific information is required, this also rarely happens.[57]

Alternatively, formal requests for medical records could be made to the MoD by veterans themselves, but few were aware of the process. Colonel Hubbard told us that, on discharge after 38 years of service, the opportunity to apply for his medical records "was never mentioned to me".[58] Others were reluctant to reveal their status to GPs. Dr Andrew Dearden, a GP based in Cardiff, told us that he had had veterans as patients who had waited up to five years before telling him of their status:

... some servicemen do not want you to know where they have been or what they have done [...] there is not a [...] tradition of passing that information to and from the civilian and military medical personnel.[59]

56.  The British Medical Association called for the development of an electronic system to ensure that medical records were shared between the MoD and the NHS.[60] However, Rear-Admiral Williams from the MoD, argued that, under the Data Protection Act, issues surrounding a patient's consent to the movement of records made this difficult.[61]

57.  The MoD Minister said the current system was dependent on the patient identifying themselves as a veteran.[62] He said the MoD was therefore looking to improve the information contained in the documentation given to service personnel when they left the Armed Forces. The GP would no longer be reliant on the individual informing them that they are a veteran but would be aware of their care under the Defence Medical Services from the letter provided.[63] The improvements would be made in two stages:

We are moving to a system [...] whereby, on discharge, an individual's NHS records will automatically have a letter included with it informing the civilian GP that the person is a veteran and giving details of how the GP can obtain the individual's military medical records [...]

Within twelve months of that, there should be a further development that will allow for a summary of in-service care to be included with the NHS records. That would allow the receiving medical practitioner in the NHS in Wales to have a better understanding of the individual's health needs, and it should also help to build awareness of the veteran community among GPs.[64]

58.  We are disappointed that the level of care given to veterans can sometimes be compromised by the failure to transfer medical records between the MoD and NHS. We welcome the introduction of an improved system by the MoD later in 2013 and recommend that the Ministry updates Parliament about the establishment and effectiveness of the system by the end of the year.

Priority Access to Treatment

59.  In 2008, the UK Government extended priority access to NHS services across the UK to all veterans for any health condition related to their service in the Armed Forces.[65] GPs are required to include "veteran status" and whether the condition may be related to their service in referral letters to secondary care. Where secondary care clinicians agree that a veteran's condition is likely to be service-related, doctors are asked to prioritise veterans above other patients with the same level of clinical need.

60.  Witnesses told us that there was a lack of awareness of the prioritisation policy among both the medical community and veterans. A 2009 survey by the Royal British Legion found that 81% of 500 GPs across England and Wales knew "not very much" or "nothing at all" about priority treatment for veterans. 85% had not informed secondary care providers of a veteran's entitlement to priority treatment in the past 12 months.[66] The British Medical Association suggested an "online tool/resource centre" to raise awareness among the medical profession.[67] Dr Dearden believed that GPs and staff should receive training about veterans as part of their ongoing professional development provided by local health boards, although he recognised that there were many competing educational needs to include in a limited amount of time.

61.  Dr Dearden also spoke about the need to increase awareness of the arrangement amongst veterans. He suggested that it needed to be publicised in the general community, and not simply with a poster at the GP's surgery, where "it becomes part of the wall and is usually covered over by something else".[68] He referred to a successful advertising campaign to increase awareness of diabetes, where posters had been placed on the sides of bus stops and buses, and which had led to an increase of awareness amongst the population.

62.  The extension of priority NHS treatment to all UK veterans is welcome but lack of awareness of the policy is hampering its effectiveness. It is alarming that only one in five GPs have any familiarity with the policy. The Welsh Government should work with NHS Wales to raise awareness amongst the medical community to ensure that Armed Forces veterans receive the priority treatment to which they are entitled.

63.  Some Armed Forces veterans—particularly those who left the service prior to the introduction of priority access to treatment in 2008—are not aware of this policy themselves. The MoD must ensure the policy is widely publicised to the current veteran population as well as to all leaving personnel as part of the resettlement programme.

Mental health care

64.  A significant minority of military personnel go on to develop mental health problems after they leave the Armed Forces.[69] Although much publicity surrounds post-traumatic stress disorder (PTSD),[70] other mental issues suffered by veterans include depression, anxiety disorders and alcoholism. Many veterans endure the symptoms for many years before seeking help and, in some cases, there is a delay before symptoms become apparent. Lieutenant Colonel Poole of Combat Stress told us that it took an average of thirteen years "from incident to seeking help".[71] Professor Bisson, Director of the All Wales Veterans' Health and Wellbeing Service, said that the average age of veterans currently being treated by the service was 40.[72]

65.  Veterans can be reluctant to come forward with concerns about their mental health because of worries about how other people might perceive them. Professor Bisson told us that this was a "big problem" due to the stigma about mental health issues and because Armed Forces personnel often viewed themselves as mentally and physically robust.[73]

66.  We heard concerns that GPs often lacked understanding of the specific context of veterans' mental health problems: "Civilian PTSD has no resemblance to that suffered by those serving in the Armed Forces and then coming home after maybe six months or more serving on the front line in Afghanistan".[74] The British Medical Association also said that the quality of NHS mental health services for veterans across Wales was patchy.[75] A report published by the National Assembly for Wales's Health, Wellbeing and Local Government Committee found that services for veterans with PTSD were "inadequate and inappropriate".[76]


67.  One attempted solution to these problems has been the establishment of the All Wales Veterans' Health and Wellbeing Service (AWVHWS) (see box).
All Wales Veterans' Health and Wellbeing Service

The All Wales Veterans' Health and Wellbeing Service was established in April 2010, following a successful two-year pilot project based in Cardiff and Vale NHS Trust. The AWVHWS provides for a Veterans Therapist (VT) in each NHS Local Health Board: this is an experienced clinician with an interest or experience of military health problems. The VTs provide individual psychological treatment following referrals from health staff, GPs and veteran charities as well as self-referrals from ex-service personnel.

The AWVHWS is funded by the Welsh Government at an annual cost of £485,000.

68.  Witnesses identified two main concerns with the AWVHWS: inconsistency in waiting times for treatment; and funding. Although the AWVHWS aimed to "have equity of access to service across Wales",[77] Professor Bisson, the Director of AWVHWS, accepted that there were inconsistencies in the level of service (waiting lists) provided by different local heath boards. For instance, the waiting time between referral and assessment in the Cardiff and Vale Local Health Board was only a few weeks (because it had been the original pilot) while average waiting lists in other parts of the AWVHWS were between six and nine months. However, he compared this favourably to the non-veterans service, where the waiting list was about 15 months: he believed that veterans were "advantaged by the new service quite significantly".[78]

69.  Some witnesses expressed concern that the £485,000 budget for the AWVHWS was insufficient. The Royal British Legion told us that "demand may prove excessive relative to current resourcing", pointing out that the AWVHWS had already received many referrals in a small period of time,[79] and the service was currently working with 150 veterans.[80]

70.  Professor Bisson believed that the capacity of the service could be increased through collaboration with charities such as Combat Stress. Combat Stress currently provides a mental health outreach service in Wales, through a team for the South Wales and West Midlands area, and a team for the North Wales and the West Midlands area.[81] Each team comprises two clinical staff, one regional welfare officer and one welfare support desk officer. When questioned on this matter, Combat Stress agreed that it would be beneficial to work closely with the AWVHWS because each could provide a slightly different service depending on the needs of the veteran.[82]

71.  The establishment of the All Wales Veterans' Health and WellBeing Service (AWVHWS) across Wales is a welcome improvement to mental health treatment in Wales. The Welsh Government should ensure that the AWVHWS continues to receive sufficient funding. We encourage the AWVHWS to explore ways to work with the charity sector to improve the capacity of the service.


72.  NHS-provided services for mental health care amongst veterans focuses on a "community-based" model of treatment, without a residential provision. Combat Stress provides residential treatment for veterans with mental health issues in three short-stay treatment centres in the UK: Hollybush House, Ayr, Ayrshire, Scotland; Audley Court, Newport, Shropshire, England; and Tyrwhitt House, Leatherhead, Surrey, England. The length of stay at a centre can vary from two days to six weeks, depending on the medical treatment required. There is no residential provision in Wales.

73.  Some witnesses felt strongly that there should be a residential mental health facility for veterans in Wales. Clive Wolfendale from CAIS (Drug and Alcohol Rehabilitation North Wales and Powys) stated that there was "significant demand" for a residential centre in Wales which could offer "longer-term therapies and a holistic approach to rehabilitation".[83] Dr Alastair Clarke-Walker, a consultant with a specialist interest in PTSD, believed that there should be a residential facility for veterans with complex PTSD. This "trauma service" would offer "an accountable, results defined process with considerable cost saving as compared to the NHS, and other government bodies".[84]

74.  Others, however, were less convinced of the need for a rehabilitation centre specifically for veterans in Wales. Professor Bisson, Director of the AWVHWS, believed that there was no strong evidence to support the need for in-patient rehabilitation facilities for veterans:

... for me [...] the evidence very much points to you being better off having very effective rehabilitation programmes that are based within communities, which can keep individuals in their communities, and as they are being rehabilitated they are using the new skills they are developing within their communities. To detach people and take them away for two weeks or more, spend time there, and perhaps have time out and have a good time but then come back in, often does not address the real issues that need to be addressed.[85]

75.  When questioned on this matter, Combat Stress said it would not be cost-effective to provide a specific centre in Wales.[86] Veterans in Wales had access to the Audley Court facility in Shropshire, which would be able to take those veterans in Wales "who really need it".[87] The Welsh Government is currently considering the case for a specific veterans residential facility in Wales, and has asked Professor Rosemary Kennedy to chair a group to examine the issue.[88] There are arguments both for and against a mental health residential facility specifically for veterans in Wales. We welcome the establishment of a group by the Welsh Government to examine this issue and look forward with interest to its recommendations.

55   Q 380 Back

56   Ev 94; Ev 105 Back

57   Ev 106 Back

58   Q 293 Back

59   Q 54 Back

60   Ev 106 Back

61   Q 432 Back

62   Q 431 Back

63   Ev 105 Back

64   Q 431 Back

65   This had previously been limited to only those in receipt of a War Pension. Back

66   The Royal British Legion, General Election Manifesto 2010. Back

67   Ev 105 Back

68   Q 60 Back

69   The King's Centre for Military Health's Report, A fifteen year report, published in September 2010 and based on over 20,000 participants found that 4% of respondents displayed symptoms of PTSD, while 19.7% displayed common mental health disorders, such as anxiety and depression. Back

70   PTSD is a psychological response to an event of any intensely traumatic nature that triggers mental distress. Back

71   Q 149 Back

72   Q 99 Back

73   Q 97 Back

74   Ev 114 Back

75   Ev 106 Back

76   Post-traumatic stress disorder treatment for services veterans, Health, Wellbeing and Local Government Committee, National Assembly for Wales, February 2011 Back

77   Q 89 Back

78   Q 93 Back

79   Ev 111 Back

80   Q92 Back

81   Ev 117 Back

82   Q 138 Back

83   Q 32 Back

84   Ev w4 Back

85   Q 118 Back

86   Q 159 Back

87   Q 136 Back

88   'Health Minister calls for review into veterans residential facilities in Wales'. Welsh Government press notice, 15 November 2012 Back

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Prepared 12 February 2013