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
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
55. The British Medical Association described
the current system for the transfer of records between the MoD
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.
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".
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.
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.
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.
57. The MoD Minister said the current system
was dependent on the patient identifying themselves as a veteran.
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.
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.
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.
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.
The British Medical Association suggested an "online tool/resource
centre" to raise awareness among the medical profession.
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".
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 veteransparticularly
those who left the service prior to the introduction of priority
access to treatment in 2008are 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
much publicity surrounds post-traumatic stress disorder (PTSD),
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".
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.
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.
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".
The British Medical Association also said that the quality of
NHS mental health services for veterans across Wales was patchy.
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".
ALL WALES VETERANS' HEALTH AND WELLBEING
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",
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".
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,
and the service was currently working with 150 veterans.
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.
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.
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
MENTAL HEALTH RESIDENTIAL REHABILITATION
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
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".
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
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.
75. When questioned on this matter, Combat Stress
said it would not be cost-effective to provide a specific centre
in Wales. 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".
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.
arguments both for and against a mental health residential facility
specifically for veterans
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
Ev 94; Ev 105 Back
Ev 106 Back
Q 293 Back
Q 54 Back
Ev 106 Back
Q 432 Back
Q 431 Back
Ev 105 Back
Q 431 Back
This had previously been limited to only those in receipt of a
War Pension. Back
The Royal British Legion, General Election Manifesto 2010. Back
Ev 105 Back
Q 60 Back
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
PTSD is a psychological response to an event of any intensely
traumatic nature that triggers mental distress. Back
Q 149 Back
Q 99 Back
Q 97 Back
Ev 114 Back
Ev 106 Back
Post-traumatic stress disorder treatment for services veterans,
Health, Wellbeing and Local Government Committee, National Assembly
for Wales, February 2011 Back
Q 89 Back
Q 93 Back
Ev 111 Back
Ev 117 Back
Q 138 Back
Q 32 Back
Ev w4 Back
Q 118 Back
Q 159 Back
Q 136 Back
'Health Minister calls for review into veterans residential
facilities in Wales'. Welsh Government press notice, 15 November