37.We concluded in our Part One report that a successful transition is an important part of ensuring that veterans manage any mental health issues as they seek to reintegrate back into civilian life. We recognised that support from the Department was available, but were concerned that some veterans fall through the gaps and lack continuity of care when they moved into civilian health care.
38.In its response to our report, the Department said that it “provides extensive and comprehensive support to Service personnel as they transition out of the Armed Forces”. The Minister, Tobias Ellwood MP, also told us in June 2018, that “the vast majority of personnel serve well, transition well and leave well”. The Scottish Veterans Commissioner, Charlie Wallace agreed and emphasised that context:
We must also remember that a vast majority of veterans go into the community very successfully, and bring some particular skills that are of a real benefit to the community. We must not forget that, as we deal with the small minority who have particular issues.
39.However, we heard during this inquiry that many veterans did not feel supported when they left the Services, and indeed felt abandoned. The Felix Health Group, representing an informal group of retired Ammunition Technical Officers and Ammunition Technicians, told us that most of them were unaware of the support available to them and that:
In one case, one person suggests that despite their condition being serious enough to discharge [him] from the service he has never received any follow up treatment or contact since leaving. This suggests that the ‘fire and forget’ attitude of the MoD still exists.
We also heard similar cases from individual veterans and their families (Case examples 3).
Case examples 3: Veterans not supported after discharge
“Before leaving the service I was in the care of DCMH, they took over 5 years to diagnose me with PTSD and once I left they just left me to find help by myself. It took a lot to admit I had a problem and then to be left to find help once out of the service was hard. It seemed that once my termination date was reached I wasn’t DCMH’s problem anymore.”
“I spiralled back into my depression and was suicidal again within days. My family tried to contact DCMH for help, but those horrible words, of our Duty of Care has been done, you will have to go through the NHS.”
Source: Annex 1: Summary of individual responses received
40.Some witnesses also did not believe that the Armed Forces provided adequate care once discharge had been accepted. The Ulster Defence Regiment and Royal Irish Aftercare Service reported that “it was seeing worrying evidence that WIS [Wounded, Injured and Sick] personnel discharged with MH [Mental Health] issues have had only fragmented and relatively superficial treatment before leaving the Armed Forces” and believed that it was due to “a resource and systemic/organisational issue”. One veteran also told us that “once you no longer meet those [medical fitness] requirements treatment falls off”.
41.Other witnesses were critical of the continuity of care as veterans were transferred from the military to the civilian health care systems, particularly the quality of subsequent care and the transfer of notes (Case examples 4). The Department offers veterans continued access to Departments of Community Mental Health up to six months after discharge, but Combat Stress reported that this is not consistently applied.
Case examples 4: Veterans’ experiences of continuity of care
“When he was discharged into the care of the local NHS Trust, Norfolk and Suffolk NHS Foundation Trust, the care received could not be recognised as good care.”
“The MoD can discharge you if there is suitable treatment available on the NHS. In my own case they didn’t actually hand any notes to my now civilian GP nor did they follow up on how any treatment may or may not have been going.”
“From experience of the NHS and settling into a different medical system. I would suggest that increasing the availability of mental health care for those that leave with mental health issues is increased by six months to a full year. Initially setting up my NHS medical care was difficult, and the paperwork I was given to hand to my NHS medical centre was dated… and looked at with amusement and somewhat scepticism by the staff at the centre.”
Source: Annex 1: Summary of individual responses received
42.The Minister, Tobias Ellwood MP, accepted that the Department had learnt the “hard way” through not providing for those who came back from Afghanistan and Iraq and who then left the Services without the “necessary support they deserved”. He believed, however, that the links between the Department and the NHS had been improved. Lieutenant-General Nugee, Chief of Defence People, told us that they have tried to create “at least a year of seamless transition between us and the NHS for any service person who is leaving as a result of mental illness” as the Transition, Intervention and Liaison Service in England can engage with leavers six months before discharge and link them to their local NHS trust or GP, while veterans can also access DCMHs for up to six months after discharge.
43.The Department currently contacts veterans a year after discharge and the Minister told us that it is now doing so more proactively, “to see how they are and whether they have shown any signs whatever”. General Nugee accepted that not all leavers consent to being contacted. However, following changes to GDPR [General Data Protection Regulations], the Department can now potentially access the details of everyone who has left, for example on HMRC databases.
44.David Richmond, a veteran and former Chairman of the Contact Group, pointed out some of the challenges of following up veterans:
I would say, through my own experience, if individuals want to drop off the radar, they drop off the radar, and there is nothing you can do to get them to pop back on again until they are ready to do so. Some of them drop off the radar consciously—and why not? Some drop off the radar because they are going into a bad place, but it is very difficult to raise them again, until they are ready to be raised, or somebody else does it for them.
45.Witnesses generally believed that there should be longer-term follow-up of veterans, particularly as mental health issues may not appear for some years after discharge (Case examples 5). A Help for Heroes survey in December 2018 found that it took veterans four years on average to seek mental health support and some waited far longer. Dr Busuttil, Medical Director at Combat Stress, told us for our Part One inquiry that the time between leaving the Services and seeking help was falling for younger veterans, compared to those who served in the Gulf War or Northern Ireland. However, it was still about “two years for Afghanistan after they leave the military and it’s about three or four years for Iraq veterans”.
Case examples 5: Veterans’ views of longer follow-up
“Since I’ve left the military the only contact my former family has had with me is an email from the resettlement team with information on possible jobs/career paths I might like. After 16 years this is just not good enough, I deserve a call, hi how are you, are you well, coping with civilian life and people ok. My answer would have been no. Appreciation, Consideration, Direction… I believe would have been crucial in helping me stabilise my mental health.”
“It is only after veterans have left for several years that I am seeing the real problems. By this stage their former service is all but forgotten and they receive absolutely no prioritisation, despite what they have sacrificed for their country.”
Source: Annex 1: Summary of individual responses received
46.Ulster University Veterans Research Group had also found that “during transition, support is more practical in nature, and focused on employment and training post-transition… as such, services focused only on this period are not likely to meet the long-term needs of this population”.
47.Both Lt-Colonel Braddick-Hughes and Andy Price believed that some groups of veterans needed follow-up and support at particular times of the year, such as the anniversary of an attack on their unit that led to a number of deaths in a single day. They cited the example of 2 Rifles who lost six soldiers in one day in Afghanistan and the fact that since then a number of veterans from that unit had taken their own lives on or about the anniversary. (We consider the issue of veterans’ suicides further in paragraphs 109–114.) General Nugee told us that the Department is currently gathering information to identify what units would be most susceptible at certain times of the year for particular operations or particular incidents. Once it had that information, the Department would determine what could be done, particularly as there are concerns about whether a formal process may also have detrimental impact on some veterans’ mental health.
48.We agree with the many veterans who believe that the Armed Forces are not doing enough to support and follow up with them once they have left the Services, leading them to feel that they had been abandoned. The Department has transition support programmes in place and, at least in England, there is now potentially greater coordination with the NHS for someone who is being discharged. However, there is little follow-up to establish what else might be needed once a veteran has begun to adapt back to civilian life or to identify any development of mental health issues. We recommend that the Department revises its follow-up policy, so that there is regular engagement and offer of further support to veterans for at least five years after discharge, including a formal medical health check for each leaver a year on. This engagement should ideally be supplemented by personal contact, for example a phone call, rather than just a derisory email.
49.One of the challenges faced by veterans with service-related mental health issues is applying for, and receiving, adequate compensation from the Armed Forces Compensation Scheme (AFCS). Combat Stress believed that the scheme “does not reflect the severity of those who are most seriously mentally unwell”. Some veterans also reported that they found the application process stressful and a barrier to applying or appealing, with one veteran telling us that:
The methods and time line that AFCS use to assess claims is inadequate and adds a great deal of pressure and anxiety to personnel; as compensation or not makes a difference to the employment choices they have to make. I want to appeal, but producing all the documentation necessary is causing me such anxiety that I feel paralysis each time I attempt to start the appeals process.
50.Some witnesses saw the difficulties with the Compensation Scheme as an illustration of the lack of support available once they had left the Services. During the Committee’s visit to Combat Stress, one veteran described it as the ‘biggest crime’, while Lt-Colonel Braddick-Hughes told us that:
I would say that the MoD is the least interested in what happens to individuals once they have left. That is reflected not only in their policies and in their failure to hold people accountable for the failings, but—I hate to say it—in things like their compensation scheme.
51.Following the Department’s review of the Compensation Scheme in 2016 and progress update in 2018, the Department reports that it is making improvements to the scheme regarding mental health. For example, it will be increasing the maximum level of award for those with the most severe conditions from April 2019, although it believes that only a few cases would qualify for this. However, it recognises that more still needs to be done to improve the scheme generally, for example on improving understanding. The Independent Medical Expert Group, a body that provides medical and scientific advice to the Department, is also currently following up recommendations from its own 2013 review, including how mental health is diagnosed and assessed.
52.The significant difficulties that some veterans, especially those with more complex conditions, have faced with the Armed Forces Compensation Scheme is one particularly glaring example of why veterans feel unsupported once they have left the Services. We welcome the Department’s work to improve the scheme but clearly more needs to be done and we look forward to receiving the results of its expert group’s follow-up review and the Department’s subsequent response.
51 Defence Committee, Eleventh Report of Session 2017–19, , HC813, para 27
52 Defence Committee, Twelfth Special Report of Session 2017–19, , HC1635, para 18 and 19
53 Defence Committee, Eleventh Report of Session 2017–19, , HC813
55 The Felix Health Group ()
56 UDR & R Irish Aftercare Service ()
57 Annex 1: Summary of individual responses received
58 Combat Stress ()
59 Q377 and Q383
61 Qq397 and 398
62 Q316. For more details of the Contact Group see paragraph 138
63 Help for Heroes, , website accessed 14 February 2019
64 Defence Committee, Eleventh Report of Session 2017–19, , HC813, para 75
65 Ulster University Veterans Research Group ()
68 Ministry of Defence ()
69 Combat Stress ()
70 Annex 1: Summary of individual responses received
72 Ministry of Defence (); Ministry of Defence, , 9 April 2018
Published: 25 February 2019