Mental Health and the Armed Forces, Part Two: The Provision of Care Contents

2During Service

Current provision

8.The Ministry of Defence (“the Department”) is responsible for providing mental health care to all currently serving military personnel and mobilised Reservists, primarily through its Defence Medical Services.3 As at the start of April 2018, there were 146,560 Regular UK Armed Forces personnel, plus a further 36,480 Reservists.4 The Department reported that in 2017–18, 3.2% of serving personnel were diagnosed with a mental health disorder.5 However, this figure represents only those who sought help from Defence Medical Services, and we concluded in our Part One report that this may be a significant underestimate of how many serving personnel have mental health conditions.6

9.Defence Medical Services provides specialist mental health care at 20 locations across the UK, including through 11 Departments of Community Mental Health (DCMHs), which have multi-disciplinary mental health teams.7 They do not have in-patient facilities, which are instead contracted out to a consortium of eight English and Scottish NHS Trusts and used by around 300 serving personnel each year.8 The Department also pays Combat Stress to provide a 24-hour mental health helpline for serving personnel, while NHS England commissions the Big White Wall to provide 24-hour online support for all serving personnel, veterans and their families across the UK.9 The Department expects to spend around £22 million a year on mental health services over the next decade.10

Quality and effectiveness of care

Independent inspections

10.Although it is not a requirement that the services provided by Defence Medical Services should be inspected by the Care Quality Commission (CQC), the Department invited the CQC to conduct a programme of inspections, initially for 2017–18 but subsequently also for 2018–19.11 By January 2019, the CQC had reported on four DCMHs—including one follow-up report—rating two as meeting or exceeding standards and two as failing to do so (Table 1). Key failings included poor leadership and “destructive interpersonal relationships within the management and staff team” at DCMH Scotland, as well as inadequate staffing and poor facilities at DCMH Brize Norton.

Table 1: Care Quality Commission inspections of Armed Forces mental health centres between April 2017 and January 2019

Department of Community Mental Health

CQC overall rating

DCMH (Colchester)

Outstanding

DCMH (RAF Digby and RAF Marham)

Good

DCMH (RAF Brize Norton)

Requires Improvement

DCMH (Scotland)

Inadequate (first report)

Requires Improvement (follow-up report)

Source: Care Quality Commission12

11.The Rt Hon Tobias Ellwood MP, Minister for Defence People and Veterans, and Lieutenant-General Nugee, the Chief of Defence People, told us that the Department welcomed the CQC findings which had identified where “things are lacking”. General Nugee added that there had since ‘been a huge amount of work’ done to rectify these problems and that the Department had asked the CQC to return to DCMH Scotland to report on the improvements made. Both emphasised that the issues reported arose from infrastructure problems and manning levels at the two DCMHs and that the CQC had rated the care provided as at least good in all cases.13

Individual experiences of care

12.Some serving personnel and veterans praised the care they received from Armed Forces mental health services. For example, one individual told us that:

I felt compelled to let you know about my experiences over the last year as all I have seen at DCMH is utter professionalism and life changing treatment, not only for myself but for fellow Royal Marines of all ranks.14

Professor Alan Finnegan, Professor of Nursing and Military Mental Health at Chester University and Armed Forces nurse consultant until 2015, also told us that a survey during his time in Service found 94% of soldiers were satisfied with the support they received from military mental health services.15

13.However, other serving personnel and veterans had poor experiences with the care they received (Case examples 1).

Case examples 1: Poor care experienced by veterans

“It was very difficult for me to take that first step in seeking out aid, mainly due to stigma whilst serving in an infantry unit. But to be diagnosed by an RAF Corporal who was an unqualified psychologist and my treatment was a guidebook with no future referrals is a complete farce.”

“We have had greater success personally funding regular sessions with a private counsellor over a 2-year period rather than the haphazard military MH [mental health] care pathway.”

“The infrastructure of these resources is also very poor, e.g. Mental Health Unit RAF Cranwell, is shoved into a rotting porta cabin, the door of which for several years was so swollen and rotten with damage the physical security of the buildings records could easily be compromised”

Source: Annex 1: Summary of individual responses received

14.Serving personnel and veterans also reported differences in how quickly they were treated. One said that “access to mental health services for me was swift (once the need for them was recognised) and well organised”. However, another had to wait over a year to be seen, telling us that he “was invited to a DCMH appointment 6 months after referral and 15 months after originally seeking support and was almost immediately discharged”.16 In oral testimony, Catherine Braddick-Hughes, a recently retired Lieutenant-Colonel, told us:

There was a long period of time when I was not seen by anybody. This was about 18 months after I had got back. I had been asking for help… I had a word with [the psychiatrist], and he apologised to me by telephone that he could not get me any treatment for a while—there was probably going to be about a six-month delay—because he had to make a stand. They had such a lack of resources at the Tidworth DCMH that I had to be an example.17

Accessing care overseas

15.A few witnesses told us they had found it difficult to access mental health care because they were overseas or had not been deployed as part of a unit. One witness stated: “There is no MH med [Mental Health medical] plan provision for France to my knowledge”.18 Lt-Colonel Braddick-Hughes also felt that she was not supported by the UK Armed Forces, when she joined the NATO Headquarters in Afghanistan as an individual augmentee.19

16.General Nugee told us that all deployed personnel should have access to a medical centre regardless of how they were deployed. Serving personnel also now have the option of going direct to a DCMH, without needing to be referred, as the Armed Forces are piloting self-referrals.20

17.We are deeply concerned that the Ministry of Defence is not consistently providing the quality of mental health care to its Servicemen and women that they deserve. We welcome the Department’s invitation to the Care Quality Commission (CQC) to inspect the care provided by Defence Medical Services. However, two of the four Departments of Community Mental Health (DCMHs) inspected failed CQC standards. Service personnel have reported a wide range of experiences of military mental health care provision, including problems with speed of, and access to, treatment. This situation is completely unacceptable.

18.We recommend that the Ministry of Defence should fully review how it manages military mental health services in order to understand why there are such variations in the care offered to Servicemen and women. The Department should also set out what it is doing to ensure that the other DCMHs are up to the standards necessary to pass future Care Quality Commission inspections and how best practice is being shared across all its mental health centres.

Staffing

19.Our analysis of the Department’s data shows that, since the start of the decade, the Armed Forces have had at least a 50% (20 posts) shortfall in filling the number of uniformed psychiatrist posts required, although in recent years the shortfall has been reduced (Chart 1). It has also had an increasing shortfall in mental health nurses. General Nugee pointed out that during the last few years increases in the number of mental health nurses needed by the Armed Forces, particularly in reservist posts, had increased the size of the shortfall.21 Matthew Green, a journalist, however, told us that mental health nurses generally stayed for only three years and left once they qualified.22 The Department also reported that the shortfalls in its mental health staff were generally higher at officer ranks.23

Chart 1: Shortfalls in uniformed psychiatrists and mental health nurses against posts since 2010–11

Notes

i) Figures show total shortfall across both Regular and Reservist posts.

ii) In 2010–11 the number of mental health nurses employed exceeded requirements by 13% (20 nurses)

iii) Actual manning figures for uniformed psychiatrists may be slightly higher as, other than in 2012–13, fewer than five Reservist psychiatrists were in post in each year. As the Department’s manning figures were rounded to the nearest five, we have assumed that no Reservist psychiatrists were in post, other than in 2012–13.

iv) Shortfall figures are measured against the number of staff not in post, as the Department states that all military personnel are full-time.

Source: Defence Committee analysis of Ministry of Defence data24

20.To manage these gaps, the Department has sought to employ full-time civilians instead, with more civilian posts created; but it is seeing similar levels of shortfall. The Department did not centrally hold data on civilian manpower requirements for mental health roles until 2015–16. However, our analysis of 2017–18 figures shows that, like their uniformed counterparts, there was a 50% shortfall (5 posts) in the number of filled civilian psychiatry posts and a 27% shortfall (15 posts) in filled civilian mental health nursing posts (Chart 2). Even in military mental health posts that are solely filled by civilians, such as psychology and social work, there were shortfalls of around 30%.25 As a result, the Department has had to employ temporary staff, particularly mental health nurses, to cover these gaps.26

Chart 2: Shortfalls against civilian mental health posts in 2017–18

Notes

i) Shortfall figures are measured against the number of posts not filled.

Source: Defence Committee analysis of Ministry of Defence data27

21.The Department told us that it has taken steps to reduce the shortfalls but stressed that mental health staff recruitment was a national issue. The Department’s written evidence stated that the new Delivery Improvement Plan 2018–2020 had been formally launched in March 2018 with £2.3m funding. It is expected that this funding would be used to recruit 18.5 full-time equivalent staff to reduce the reliance on temporary staff and increase capacity.28 The Minister, Tobias Ellwood MP, denied however that the inadequate ‘offer’ of pay and other rewards for mental health posts was a reason for the shortfall. General Nugee told us that:

We made one change to our recruiting mechanisms in where we recruit. Previously we recruited in competition with the NHS. Now, we are recruiting with the NHS. It is proving to be more beneficial. By working in partnership with them, we have increased the number of people coming through into the military as a direct result of a different approach with the NHS on recruiting.29

The Royal College of Psychiatrists said that it had been working with the Defence Medical Services to launch a campaign to encourage more trainee doctors to choose a career as a psychiatrist in the Armed Forces.30

22.The Department accepted that these shortfalls have affected the speed of care provision.31 The Minister, Tobias Ellwood MP, admitted that although the target was for 95% of patients to be seen within 15 working days, figures were now at 91% though they had been as low as 75%.32 Matthew Green told us that long waiting lists over the past few years had resulted in welfare officers suggesting that serving personnel go outside the military for treatment. He knew of at least one case of someone self-funding private care.33 Other witnesses also reported similar cases.34

23.We are disappointed that the Department continues to struggle to address its longstanding shortages of mental health staff. With continued 50% shortfalls in some mental health posts, it is no surprise that some serving personnel are not being seen sufficiently quickly and a few are having to take the drastic step of funding their own care elsewhere. If recruitment does not improve, we recommend that the Department should review what it can offer in pay and other benefits to attract people into military mental health roles, either as Regulars or Reservists.

Seeking care during Service

24.Witnesses were clear that the early diagnosis and treatment of mental health issues is vital for preventing the development of more serious mental health conditions. Andy Price told us that “If you are not dealing with something at root level when it first starts, or if it has been dealt with wrongly or you get the wrong support or not enough support, that problem steamrollers and becomes worse and worse”.35 A number of individual submissions reported cases where mental health issues had not been diagnosed for some time, and in some cases the delay led to serious consequences (Case examples 2).

Case examples 2: Mental health issues being missed

“In the seven years since his first deployment and major change in behaviour and increased aggression there was never a suggestion made by anyone that his change in demeanour might be related to mental health.”

“No one picked up that my son was suffering in silence and he was finally diagnosed with severe PTSD in 2018 it had got that bad.”

“Despite showing signs of deteriorating mental health as early as the late 1990s, I was not diagnosed with PTSD until 2018. During the intervening 20 years my condition worsened and became more deeply embedded but was not recognised by myself, military Medical Officers, my GPs, or any other clinician until the day that I was gently talked off Beachy Head.”

Source: Annex 1: Summary of individual responses received

25.We noted in our Part One report the continuing stigma around mental health issues, and why serving personnel may not seek help. High profile campaigns, such as the Royal Foundation’s Heads Together and the Department’s own “Don’t Bottle It Up” and “Time to Change”, are seeking to challenge this.36 However, we heard during this inquiry that stigma remains a barrier for some in coming forward with their mental health issues, fearing the consequences for their careers. One witness told us that:

Serving personnel seeking help with mental health come forward with great courage, in fear of reprisal, repercussion and potential career loss … This is a fundamental reason that Service personnel hide & suppress their suffering from their chain of command, and an underlying cause of self-medicating through various coping mechanisms, such as becoming a workaholic, substance misuse, alcohol, violence, disciplinary issues and suicide.37

26.The Felix Health Group, an informal group of retired Ammunition Technical Officers and Ammunition Technicians, and Tim Boughton, a veteran, raised the particular difficulties of raising mental health issues in specialist roles. Tim Boughton told us that:

if I had gone ahead and reported in the way that I did and I was on a serving squadron at the time, I would have been removed from flying duties, and that was my career. In that sense, my career would have been dead in the water.38

27.Servicemen and women also reported that their unit and chain of command did not offer a supportive environment for reporting a mental health issue, because of the culture, their rank or their role. One family member of a Serviceman told us that “There is a culture of ‘man up and get on with it’ … It was clear that people were afraid to show their weaknesses, especially senior NCOs and officers in positions of command”.39

28.Witnesses believed that the role of the commanding officer was vital in tackling this stigma. Matthew Green provided us with an example of a Parachute Regiment battalion commander leading the conversation about mental health by discussing his own in front of his troops.40 Johnny Mercer MP told us that:

It comes back to what I was saying before about the personalities of the individuals involved. I was with somebody today who presented with a mental health problem and was immediately cut off by his commanding officer. That was only last year. You can have all the structures around them you like, but while you still have individuals who do that, it comes down to personal command decisions.41

29.A few witnesses suggested that a career break could help those with mental health issues. Andy Price, a veteran, told us that: “A career break is an absolutely brilliant idea … If someone has a mental health breakdown in a civilian job, they are given time out. In the military, that is frowned upon and they lose their careers”.42 However, Tim Boughton believed it could be difficult for those in the Special Forces or in other specialist roles to return to those units.43 General Nugee told us that “sending somebody to recover at home is probably one of the worst things you can do, because they need to have a degree of continuity”. He thought, however, that the flexible working option being introduced in the Armed Forces from 1 April 2019 could allow people more time to recover but still keep them in work.44

30.General Nugee also accepted that, despite assurances from the Department, Servicemen and women still believed that their careers would be damaged if they reported mental health problems. Nevertheless, he strongly emphasised that Servicemen and women should seek help.45 The Minister, Tobias Ellwood MP, confirmed that support would be provided without affecting someone’s career:

We promoted this at every single level in all three Services all the way down, including every ship’s captain and every platoon commander, to say, “Look out for each other. It is okay if you are not okay. You can go and get support for that without any detriment to your potential career, promotion prospects and so on”.46

Occupational health

31.Witnesses raised the tension between the need of the Armed Forces to have Servicemen and women returning to duty and what individuals might need to treat their mental health conditions. For example, Matthew Green and Lt-Colonel Braddick-Hughes raised the point that the Armed Forces medical services are there to provide an occupational health service.47 As a result, treatment is time-limited, with one witness telling us that “many DCMH units have a 6-week treatment policy and if you require further treatment it has to be approved by the OC [Officer Commanding]”. Conversely, another witness told us that a colleague was not referred to a DCMH as “the doctor stated it was not in the ‘interests of the service’ to medically downgrade him from active duty”.48

32.The Department was clear that the occupational need to treat Service personnel is particularly significant for the Armed Forces compared to other employment sectors, as the forces are “diminishing in size and [Service personnel] have access to weapons and equipment that may be used to harm themselves or others. Their fitness for role must be maximised”.49 As a result, the Armed Forces may also consider that it would be better for some Service personnel to be medically discharged so they could continue to receive care in the civilian health system instead.50

33.Early intervention can be crucial in preventing mental health problems from developing into more severe conditions. However, despite significant improvements in how mental health issues are perceived in the Armed Forces, the fear of damaging their career remains a significant barrier to Servicemen and women coming forward for help, with the level of support often being dependent on individual commanding officers. As we reported in Part One, we support the Department in campaigning against the stigma surrounding mental health issues and promoting help-seeking. Yet it is obvious that more still needs to be done.

34.We also appreciate that the Armed Forces medical services have an occupational health role focused on returning Servicemen and women back to full duties. However, this needs to be balanced against the time and care that an individual might need for recovery, and medical discharge should be only a last resort.

35.We recommend that the Department should clearly demonstrate to Servicemen and women that mental health problems are taken seriously and their reporting does not lead to the end of their careers. This could be done by publicising examples of senior officers or non-commissioned officers (NCOs) across a wide range of Armed Forces specialisms who have sought mental health help previously without adverse effects upon their careers.

36.We also recommend that the Department must provide better mental health awareness training to officers and NCOs so that they can respond effectively and sympathetically to anyone in their unit coming forward to seek help.


3 Ministry of Defence (POC0111)

6 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, paras 43 and 56

7 Ministry of Defence, Defence Medical Services, website accessed 14 February 2019

8 Qq8–10; Ministry of Defence (POC0129); Ministry of Defence, Defence Medical Services, website accessed 14 February 2019

9 Ministry of Defence (POC0111) and Big White Wall (POC0114)

11 There is no statutory requirement for Defence Medical Services to be registered under the Health and Social Care Act and so its services are not subject to inspection by the Care Quality Commission. Care Quality Commission, Defence Medical Services CQC inspection programme – Year 1 (2017/18), p6.

12 Care Quality Commission, Defence Medical Services, website accessed 14 February 2019

13 Q355 and Q369; Ministry of Defence (POC0129)

14 Annex 1: Summary of individual responses received

15 Q6

16 Annex 1: Summary of individual responses received

17 Q214

18 Annex 1: Summary of individual responses received

19 Q213

20 Q357

21 Q372

22 Q17

23 Ministry of Defence (POC0129)

24 The Ministry of Defence has previously employed a small number of uniformed psychologists in addition to civilian psychologists, but these have been fewer than five per year. In 2017–18, it employed no uniformed psychologists. PQ 195457, 4 December 2018

25 Ibid

26 Ibid; Ministry of Defence (POC0129)

27 Ibid

28 Ministry of Defence (POC0111) and Ministry of Defence (POC0129)

29 Qq371–372

30 Royal College of Psychiatrists (POC0112)

31 Ministry of Defence (POC0111) and Ministry of Defence (POC0129)

32 Q371

33 Qq3–4

34 Case examples 1 and Paragraph 15

35 Q224

36 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 47 and 48 and Ministry of Defence, Defence People Mental Health and Wellbeing Strategy 2017–2022, p19

37 Annex 1: Summary of individual responses received

38 The Felix Health Group (POC0102) and Q217

39 Annex 1: Summary of individual responses received

40 Q21

41 Q444

42 Q219 and Q222

43 Q219

44 Q388

45 Qq389–391

46 Q392

47 Q10 and Q218

48 Annex 1: Summary of individual responses received

49 Ministry of Defence (POC0111)

50 Ministry of Defence Part One inquiry evidence (VMH0029) and Q10 [Matthew Green]




Published: 25 February 2019