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

4Statutory provision for veterans

53.The Government defines a veteran as anyone who has served for at least one day in Her Majesty’s Armed Forces (Regular or Reserve) or Merchant Mariners who have seen duty on legally defined military operations.73 There are around 2.5 million UK Armed Forces veterans living in the UK and nearly half are aged 75 or more. Both the Royal Hospital Chelsea and Northumbria and Chester Universities emphasised that veterans over retirement age have their own particular mental health challenges, such as dementia and social isolation.74

54.The King’s Centre for Military Health Research (KCMHR), King’s College London, has been conducting the largest study into the effects of operations in Afghanistan and Iraq on UK Armed Forces. Its latest results, published in September 2018, found that on average the rate of Post-Traumatic Stress Disorder (PTSD) was 6% in their sample of veterans and still serving personnel who had deployed on those operations.75 A joint Help for Heroes and KCMHR study in 2015 suggested that at least 10% of veterans who served over the last 20 years may present mental health conditions that need treatment.76 However, as we concluded in our Part One report, there is no clear and agreed understanding across the sector as to what the full scale of the mental health problem is across serving personnel and veterans.77

Current provision

55.Statutory responsibility for mental health care to veterans falls to the four health departments for England and the devolved nations.78 Veterans can access the mental healthcare services available to the general population, but some nations also provide veteran-specific specialist services. We estimate that total spending on such services is less than £10 million a year across England, Scotland and Wales, as set out below.

England

56.NHS England reported that it spends £6.4 million a year on veteran-specific specialist services, including:

In addition, the Veterans Trauma Network was set up in 2012 to support veterans recovering from service-related trauma and is linked to both TILS and CTS services.79

Scotland

57.In Scotland, Veterans First Point (V1P) is co-funded by central and local government to provide a veteran-specific outpatient service. First established in 2009, it is a network of six regional teams providing coordinated care for mental health issues, including psychological and pharmacological treatment and supported onward referrals.80 The Scottish Government also commissions Combat Stress to provide residential care treatment.81 Together, the Scottish Government expects to spend £5.8 million in total on these services between 2018–19 and 2020–21.82

Wales

58.Since 2010, the Welsh Government has funded a veteran-specific outpatient service that provides assessment and therapy treatment through Veterans’ NHS Wales.83 The Welsh Government considers Wales to be the only nation in the UK with a national service of this kind and increased its funding to the service to nearly £700,000 in 2018–19.84

Northern Ireland

59.There is no statutory veteran-specific mental health provision in Northern Ireland, although Northern Ireland’s Health and Social Care Board has agreed a care pathway for veterans to access Combat Stress’ residential care treatment in Scotland.85 The Ulster Defence Regiment and Royal Irish Aftercare Service provides mental health treatment to veterans as part of its welfare support provision, but its remit is limited to those who served in those particular regiments during Operation Banner, the UK military operation in Northern Ireland.86

Key issues with current provision

60.Since the start of UK operations in Iraq in 2003 and in Afghanistan in 2006, witnesses recognised that there had been significant improvements in the provision of mental health care to Service personnel and veterans, including the introduction of veteran-specific services. However there remains much that could still be improved, and we will examine the main issues in the rest of this Chapter. For example, Tim Boughton, a veteran, believed that the difference in support available was a “quantum leap” but that people were still falling through the system.87

61.The Royal British Legion told us that veterans were unlikely to seek further treatment if their initial experience had been poor.88 Northumbria and Chester Universities went further:

It is imperative that veterans access care from the right person at the right time and in the right place. Otherwise, there is a “revolving door” pattern, where patient’s treatment is compromised.89

Understanding of military mental health by civilian health professionals

62.Witnesses across the board, for example Anglia Ruskin University, Icarus Online and veterans (Case examples 6), believed that, for a veteran’s mental health care and treatment to be effective, it is important that the medical practitioner understands military culture and the issues that veterans might be suffering.90 NHS England also stated in its written evidence that:

Good therapeutic relationship between the therapist and patient is a core factor to positive outcomes. This means the education of GPs, psychologists, psychiatrists in better understanding of military culture is a key component to helping veterans have confidence that they can engage and will be understood.91

Case examples 6: Views on need for an understanding of military culture

“Mental health care must be provided by those who understand military service, the psychological impact of training, deployment, and transition, and the effects on family life. In my observations, forces personnel tend to ‘play down’ their symptoms and there is a culture of stoicism, that is at odds with the prevailing healthcare culture of speaking openly about symptoms.”

“Military personnel do not respond well to the ‘professionals’ that are in this field. They do not feel a ‘civvy’ will understand them and will certainly not relate to anyone they feel is patronising and does not understand their mindset. Straight away there is a barrier in place and they are unlikely to engage.”

Source: Annex 1: Summary of individual responses received

63.We heard that civilian health professionals, such as GPs, generally lacked a sufficient understanding of military culture (Case examples 7), which made seeking treatment difficult for veterans. Some witnesses, such as The Thistle Foundation and the Scottish Veterans Commissioner, believed that location, for example if they were near to a military base, was a factor in the level of a GP’s understanding.92

Case examples 7: Cases where health professionals lacked understanding

“When my wife spoke to our son’s local GP in [Norfolk], he had no knowledge of PTSD and she had to refer him to a book and website explaining it! There was some knowledge of veterans having priority to some services but it was a bit patchy. The recently announced introduction of having one GP in every practice trained in this area is very welcome.”

“I was referred to a civilian doctor via Service Veterans, and I viewed that assessment as fairly useless. I found it hard to explain to a civilian how I felt or how things had come to pass, and this attitude was reflected by my civilian GP, who I found obtuse and negative. Hence, although things have remained as bad as they were before, I have sought no further medical help.”

Source: Annex 1: Summary of individual responses received

64.Witnesses also told us about the importance that clinicians who provide treatment have an understanding of what the veteran may have experienced. For example, all three of the veterans who gave oral evidence told us that they had ended up having to switch roles and comfort their civilian psychologist or therapist, because they were affected by the experiences the veterans were telling them.93

65.Matthew Green, a journalist, however, believed that “we should not perpetuate the myth that only veterans can treat veterans, because I think that does a disservice to some really excellent civilian clinicians”.94 David Richmond, a veteran and former Chairman of the Contact Group, also raised the point that some veterans “do not want to talk to somebody with a military background, so you need to offer them that choice”.95 Government departments and the Royal Colleges of General Practitioners (RCGP) and Psychiatrists (RCPsy) recognise the importance of ensuring that clinicians have a better understanding of military culture, what serving personnel and veterans may have experienced and the mental health services available to a veteran. For example, NHS England has been working with bodies such as the Royal Colleges and Chester University to improve training options on military mental health for GPs, nurses and other health professionals, particularly those at the start of their careers, and it is part of the membership examination for the RCGP.96

66.The RCGP is also now rolling out its scheme of veteran-friendly GP practices. Following a pilot in the West Midlands, there are now nearly 150 and it will be extended across England. NHS Digital statistics show that there were just over 7,100 GP practices in England at the start of July 2018.97 Dr Jonathan Leach, Honorary Secretary of the RCGP, also told us that there are discussions about how this could be established in other nations.98

67.The lack of civilian medical practitioners’ understanding of military culture and military mental health issues remains a significant barrier to veterans accessing and receiving effective treatment for their mental health conditions. We welcome the work being done to improve the understanding of civilian medical practitioners, such as the creation of veteran-friendly GP surgeries. However, this remains small-scale and much more still needs to be done to stop veterans feeling let down by the health care system.

68.We recommend that the Department of Health and Social Care updates us within six months on progress in improving civilian practitioners’ awareness of veterans’ mental health, including how this has been measured and what other actions it has since taken or plans to take for further improvement. The Department should also update us on the work to exchange best practice with the other nations in the UK.

Coverage and consistency of statutory services

69.As we have reported above in paragraphs 55 to 59, the different approaches taken by the four nations to providing veteran-specific care mean that there is variability across the UK in what a veteran could receive in mental health care.

70.Even within nations, the coverage and consistency of the veteran-specific services can vary. For example, the British Psychological Society told us that that there were parts of Scotland, such as the Highlands, where due to lack of funds there is no Veterans First Point coverage.99 While Andy Price, a veteran, set up his own community centre in Dorset in 2017 due to a lack of veteran mental health support in his area.100 He added:

Then you’ve got the TIL service, which is absolutely brilliant, but in the county where I live they haven’t got a therapist any more. The therapist that they did have was coming across from Somerset, and has now left because of the pressure she was under trying to support veterans countywide. Now we have a void.101

Other veterans and their families also told us of similar cases, including the variation in care when accessing mainstream NHS mental health services (Case examples 8).

Case examples 8: Geographical variation in care

“I saw two different people from Veterans First Point. Both were not professional in their approach and did not explain their roles. The second was a therapist who said they could not offer assessment because I was in Fife and a psychiatrist’s time had not been provisioned for in Fife but if I lived in Lothian I would have got this service. I felt poorly supported so chose to speak with my GP to be referred back to the NHS Fife Adult Psychology Service.”

“Now having moved up to live with family who are both ex-military, he has been seen by a NHS Team at Reading, Berkshire. This is far superior service than South Devon Health Care provided… NHS Reading Berkshire told us they are one of the most efficient in the country for military mental health. I do not think this is right. All military personnel should be treated in the same amount as time all over the country.”

Source: Annex 1: Summary of individual responses received

71.We concluded in our Part One report that the Department retains responsibility for ensuring that veterans across the UK are receiving the level of care set out in the Armed Forces Covenant, despite the devolved nature of healthcare. Yet it has an inadequate understanding of the extent of veterans’ mental health issues across the UK to ensure that there is sufficient coverage and adequacy of mental health services for veterans. This is due to differences in how each nation collects data on veterans’ mental health and we recommended that the Ministry of Defence works with the four UK health departments “to develop and publish a single set of statistics on the number of veterans seeking help and being treated across all of the UK”.102

72.In its response to our Part One report, the Department told us that, through Defence Statistics, it was already working with NHS England and the devolved administrations to “develop measures on veterans seeking help, and in treatment for mental health conditions, to support the Armed Forces Covenant”. They were also looking at how they can share statistics with Armed Forces charities such as Help for Heroes and the Royal British Legion.103

73.In the course of our current inquiry, Armed Forces charities continued to raise the lack of data on the outcomes of the veteran-specific services, and how this makes it harder to understand the effectiveness of the treatments offered, particularly by the two new NHS England services.104 Dr MacManus, of the Royal College of Psychiatrists, believed that an official comparison of veteran outcomes across or between the regions would be “a very helpful piece of work on which to base decisions about which areas are doing better and what aspects of the care that is delivered are working best”.105

74.NHS England also reported that early findings from the ‘Map of Need’ study suggested that there are “significant regional variations in disease presentations, patterns of accessing services and accessing patterns between NHS services and charities”.106 The ‘Map of Need’ study is being run by the Northern Hub for Military Veterans and Families Research, Northumbria University and had been commissioned by the Armed Forces Covenant. It seeks to map those veterans that receive treatment from statutory or Armed Forces charities to “determine the level of MH [mental health] issues regionally and identify specific concentrations and variances” and is ongoing for the devolved nations.107

Coordinating with other government services

75.In addition to the Ministry of Defence and health departments, veterans with mental health issues interact with other government bodies. Some witnesses raised the need for these bodies to consider veterans as a group with specific needs. For example:

76.The differences at both local and national level in the availability of statutory veteran-specific services have led to wide variations in the care a veteran might receive. The worst affected are veterans living in Northern Ireland as there is no statutory provision for many of them. The four UK health departments have the responsibility for ensuring consistency within their nation and for meeting increasing demand. However, as we concluded in Part One, even though health care is devolved, the Department cannot abdicate its responsibility for ensuring that all veterans receive comparable care regardless of where they live.

77.We recommend that the Ministry of Defence works with the health departments of England, Scotland and Wales, to address urgently the gaps in veteran-specific provision across the UK. We also repeat our recommendation from Part One on the development of a shared set of methodologies for collecting and analysing veteran mental health data across the UK. This should include outcomes so that best practice can be identified and shared across the four nations.

78.We also recommend that the Department sets out how it will help veterans living in Northern Ireland to access veteran-specific mental health treatment available to those living in the rest of the UK.

Speed of access

79.We heard that a number of veterans have struggled to be seen quickly enough by mental health professionals (Case examples 9). A number of Armed Forces charities also believed that veterans are not receiving treatment quickly enough, with for example, the RAF Association reporting that veterans “often present to mental health services at crisis and a delay in providing treatment can be detrimental to a population who require prompt attention”.110

Case examples 9: Waiting times experienced by veterans for treatment

“For my issues, seeing the GP was very quick (same day as crisis). However, appointments with appropriately trained mental health professionals was very slow (many months). I believe far more resources are required for mental health provision, particularly for veterans.”

“In our case, once my husband ‘broke down’ and was made to go to the GP, he had to wait 2 months for an initial consultation and then subsequently told he would have to wait 6 months for a first consultant appointment. He was covering up that he was suicidal and what were we to do in the meantime?”

“I had to wait 6 months after discharge before NHS sent me to a sub-contractor civilian psychologist, for a set number of sessions (which ended up doubling) but had no useful effect on my condition.”

Source: Annex 1: Summary of individual responses received

80.Current statistics on veteran-specific services in England and Wales show that, although the majority of veterans are seen within the target waiting times, they could still be waiting months for treatment. Data on waiting times for Scottish veterans attending Veteran First Point assessments and treatment was not available.

81.In comparison to the general population, where the waiting time target to access psychological treatments is 18 weeks, for veterans the target to access treatment through veteran-specific services in England is shorter at 4 weeks. This means that despite veteran-specific services not meeting waiting list targets, many veterans should be able to access mental health care through these services quicker on average than the general population through mainstream NHS mental health care.114

82.If care was needed urgently, a veteran might seek help from mainstream NHS crisis teams. Dr Oscar Daly, a psychiatrist at Combat Stress Northern Ireland, reported that this support could be received within hours in Northern Ireland.115 However, some veterans reported that such crisis care was not necessarily immediate. Andy Price told us that when he sought help, “the crisis line was so overwhelmed that it was going to take a week before they could do a phone assessment with us”.116 Another veteran reported that:

That night I took an overdose, as I waited to die I happened to notice a picture of my youngest girl, at 2am I woke my wife and told her what had happened and she took me to be committed in Hospital. Unfortunately due to the number of inmates I was put under the Crisis Team and told to see my GP yet again. They then referred me to the local mental welfare team, but with a waiting period of 12 to 18 months.117

83.Health officials and clinicians reported that insufficient capacity was a key reason why some veterans were having to wait longer than they should for assessment and treatment.

84.However, as we concluded in Part One, there is no clear and agreed understanding across the sector of what the full scale of the mental health problem is across serving personnel and veterans. Without this data, the Government is unable to determine the resources required to care for those who need it. We recommended that the sector develop a common understanding of what the demand for care services might be from serving personnel and veterans and for both Government and the Armed Forces charity sector to provision care accordingly.122

85.The creation of veteran-specific services has meant that veterans should generally be able to access mental health care more quickly than the general population. However, it can still take far too long for veterans to be able to access care when they need it, with missed waiting list targets meaning veterans could be waiting up to a year. In many cases, this is because capacity cannot keep up with demand. When veterans seek help for their mental health issues, some may need immediate treatment to prevent the problem from quickly worsening. Failure to do so can lead to serious, and even fatal, consequences.

86.We repeat our Part One recommendation that the Ministry of Defence and the four UK health departments, alongside charities, must develop a common understanding of demand for veteran mental health care and ensure that enough resources are allocated to meet demand so that waiting time targets are fully met.

Priority treatment

87.In our Part One report, we raised particular concerns that the Armed Forces Covenant principle of priority treatment, when a condition is service-related, is not being consistently applied across the UK. The Department of Health and Social Care considers that the NHS founding principles of equality and clinical need constrain how it can provide priority treatment to veterans and believes that the provision of veteran-specific services resolves this tension. We concluded, however, that the confusion over how it was being implemented may be adding to veterans’ perceptions that the health service is failing them and recommended that the Government should set out clearly in the forthcoming Veterans Strategy how priority treatment should be implemented in practice.123

88.In its response to our Part One report, the Department agreed in September 2018 that the Veterans Strategy was an opportunity “to ensure that veterans and their families get a better understanding of priority treatment and what it means for individual veterans”.124 However, when the Veterans Strategy was published in November 2018, there was no mention of priority treatment and only one reference in the accompanying public consultation paper.125 The Department for Health and Social Care told us as part of this inquiry that it recognises that more can be done and the Partnership Board between it and the Ministry of Defence was working towards a clearer definition of priority care for 2019–2020.126

89.The importance of clarifying what priority treatment means in practice has been reinforced by the evidence we have received from many witnesses that, for the most part, mainstream NHS health providers have not heard of the priority treatment principle or even the Armed Forces Covenant (Case examples 10). Other witnesses reported similar issues across the country:

There is no priority treatment in Northern Ireland, as confirmed by the Ministry of Defence in its Government response, “due to Section 75 of the Northern Ireland Act”.129 The Health Service in Northern Ireland instead seeks to ensure equity of access for serving personnel, veterans and their families on the same basis as the rest of the population.130

Case examples 10: Veterans’ experience of receiving priority treatment

“In my experience of supporting both my husband, his former colleagues and members of his regiment … many NHS providers have not heard of the armed forces covenant. When GPs are aware of it, they are unable to prioritise referrals, because they are not accepted as priority by mental health services.”

“I have seen no evidence of the Armed Forces Covenant’s principle of priority care. The suicidal soldier I met yesterday was not offered a bed as he was not viewed as a risk, even though he had just tried to take his own life a few hours before. He was sent home… this one specific case and many anecdotal cases show there is zero priority given to veterans”.

“I can personally testify (as can many others), that quoting the requirements of priority treatment in accordance with the Armed Forces Covenant, and even with an endorsement by local NHS management, access to treatment was not reduced and actually exceeded the 6 months maximum. This is another example of veteran’s expectations being crushed by the MoD and the supporting NHS system”.

Source: Annex 1: Summary of individual responses received

90.Witnesses also raised the lack of clarity within the veteran community about priority treatment. For example, Dr Deirdre MacManus, of the Royal College of Psychiatrists, told us that “some [veterans] do not know about priority care at all, and some expect to have priority care for every health need they have”. She believed, however, that there needed to be clarity on the clinical side first before raising awareness of what priority treatment a veteran was entitled to.131

91.We expressed significant concerns about the confusion surrounding priority treatment in our Part One inquiry, and it is clear that many veterans are not receiving priority treatment for their service-related injuries, with civilian medical practitioners’ lack of knowledge of this principle of the Armed Forces Covenant—and indeed of the Covenant itself—being a key factor. We welcome the work by the Ministry of Defence and Department of Health and Social Care to establish a clearer definition of priority treatment by 2019–20. However, this must be accompanied by a clear strategy to ensure that the definition and its consequences are understood and implemented across the NHS and that best practice is shared with the devolved administrations.

92.We repeat our recommendation from Part One that the Government should ensure that once it has set out how priority treatment should be implemented in practice, this clarification is cascaded down to both NHS staff and veterans and their families across the whole of the UK. For example, it may be that the only way to prioritise service-related mental health conditions is to have separate specialist facilities at which to treat them, but this approach needs to be made clear to all.

Complex and long-term care

93.Care for veterans who have complex mental health conditions and require long-term mental health care is a significant gap in the statutory provision. Help for Heroes reported that this area is “severely under resourced” while Sue Freeth, Chief Executive of Combat Stress, was concerned by the lack of respite care now available, “because for some veterans, that was the top-up they needed to keep going”.132 Matthew Green emphasised that veterans with complex needs were falling through the gaps in care.

The reality is that there are ex-forces—we do not know exactly how many, but significant numbers—who have really severe, complex presentations of post-traumatic stress disorder, often combined with alcohol misuse, which is an extremely toxic and dangerous combination. That is the gap in services. That is where there is literally nowhere for them to go. They cannot go to Combat Stress if they are not stabilised sufficiently. They will end up bouncing into an NHS secure or emergency psychiatric ward and then bouncing back to their family again.133

94.Complex treatment provision may be time limited or not suitable for the most complex cases (Case examples 11). The Department for Health and Social Care reported that the 32 weeks of support offered by the Complex Treatment Service in England was already longer than that recommended by the National Institute for Health and Care Excellence (NICE) for less complex PTSD.134 However, Help for Heroes did not believe that this was sufficient for those with complex needs given that the International Society for Traumatic Stress Studies recommended that a sufficient duration would be closer to 18–24 months.135 Other witnesses also criticised the limited number of sessions available for other treatments. Councillor Dryburgh told us that although veterans can access support quickly in Dumfries and Galloway, such support was short term and:

We are constantly fighting for further support packages for the person or in many cases the family members, as they are not cheap and sometimes are multi-agency support packages.136

Case examples 11: Veterans with complex mental health issues seeking care

“[His GP] referred him and he was offered another course of CBT [Cognitive behavioural therapy]. On the initial assessment appointment he was told that he had too many issues and was too complex a case and was sent away feeling very let down and on his own.”

“I had no effective treatment for nearly 28 months before placement on their [Combat Stress’] ITP [Intensive Treatment Programme]—however, because NHS Scotland and the Scottish Government are involved with funding, there is a caveat that individuals attending the ITP do it once, anything after is community outreach, if available”.

Source: Annex 1: Summary of individual responses received

95.Some witnesses believed that a national centre would be the solution. Help for Heroes noted that many other countries offered specialist military treatment clinics and argued that the Defence and National Recovery Centre (DNRC) could fulfil this role for veterans in the UK or that there could be a centre in each of the four nations.137 Matthew Green believed that a national centre was the ‘missing piece of the puzzle’, to ensure that there was provision of care even for very complex cases.138

96.Others were more cautious, believing that a national centre might help some but not all patients, and that there would still be a need for more local, community support. For example, Dr Oscar Daly told us that a residential course, including Combat Stress’ own six weeks’ course, helped but would not cure a patient, who would still need “significant community services as well”. Professor Alan Finnegan, Professor of Nursing and Military Mental Health at Chester University, also raised concerns that it might “isolate the veteran away from family and friends”.139 Mark Birkill believed that residential treatment

comes into its own for those veterans who do not get better in a community service, or maybe have an attitude to NHS or civilian services that perhaps would not allow them to make best use of those services.140

97.Kate Davies, emphasised to us that the existing Defence and National Rehabilitation Centre, not only treats the physical trauma injuries that Servicemen and women are admitted for at the centre, but also their mental health injuries.141 However, she acknowledged there is no national mental health residential rehabilitation centre that is exclusively for either serving or ex-serving personnel.142 As part of a detailed review of mental health services in 2016 to veterans and other source of evidence, NHS England believed that a community-based service would be more effective to veterans overall than residential care in a limited number of locations, thus the new Transition, Intervention and Liaison and Complex Treatment Services.143

98.The new Transition, Intervention and Liaison and Complex Treatment Services were created, not just to help veterans but also to try and get around the dichotomy whereby the Ministry of Defence and the Armed Forces Covenant argue that veterans should receive priority treatment in the NHS, whereas the Department of Health and Social Care traditionally prioritises strictly according to clinical need. The creation of a bespoke service for Armed Forces veterans is very much to be welcomed. Nevertheless, it is scandalous that in an NHS budget of over £150 billion UK wide, less than £10 million per annum (0.007%) has been allocated to this service, which is swamped by the scale of demand. Health Ministers need urgently to recognise this deficiency and use part of the very significant increase in NHS funding envisaged under the new NHS Ten-Year Long-Term Plan to increase substantially the resources provided to the TIL and CT services, in order to make them truly fit for purpose. Those who have worn the uniform of their country deserve no less and NHS Ministers must be prepared to be held firmly to account on this matter.

99.We are very concerned by the insufficient provision of long-term statutory care of veterans with complex mental health conditions. Time limits on treatment—which anyway may not be effective for the most complex cases—mean that those with the greatest need have nowhere to go. We recommend that the Ministry of Defence, in conjunction with the four UK health departments, set out how it will develop long-term care provision for veterans with complex mental health conditions.

100.Far too many veterans, whose relationships have broken down and who are in crisis, having already been diagnosed as suffering from severe conditions, such as PTSD, are having to wait up to a year to enter into a suitable treatment programme. This is utterly unacceptable. Many of these veterans only see their condition deteriorate further whilst waiting for access to treatment and, in the most extreme cases, they take their own lives whilst awaiting help. To prevent this, patients must be continually monitored and reassessed during the gap between initial diagnosis and the commencement of treatment.

101.There needs to be a highly professional place of safety to which these veterans can be sent as soon as they are diagnosed, in order to be stabilised and to begin to receive assistance for their recovery. Following residential treatment, they should then be discharged directly into a TILS/CT programme back in their own locality but without any discontinuity of treatment or gap in their care pathway.

102.The Committee strongly believes that it makes sense for such a centre to be co-located with the new state-run Defence and National Rehabilitation Centre (DNRC) for physically injured serving personnel at Stanford Hall. The DNRC evolved from Headley Court, which rightly established a world-class reputation for the treatment of the physically wounded from conflicts such as Iraq and Afghanistan and it should be a national aspiration to establish a similar world-class centre for the treatment of mental injuries relating to service as well. The NHS should urgently consult with the Ministry of Defence and the DNRC in order to establish this facility with an initial operating capability within the next 12–18 months.

Mild Traumatic Brain Injury

103.One potentially complex or long-lasting condition that current and former Servicemen and women may have developed as a result of service is mild traumatic brain injury (mTBI). It is often acknowledged in academia as the ‘signature injury’ of the conflicts in Iraq and Afghanistan, although there are currently differing views about the extent and long-term effects of mTBI on mental health.

104.As we reported in our Part One inquiry, research by King’s College London found only small rates of mTBI cases (3.2%) in UK forces deployed in Afghanistan during 2011 with little evidence to show that mTBI had anything but limited lasting mental health effects. In comparison, the rate in US forces has been found to be around 23% and, for this inquiry, Blind Veterans UK and the UK Acquired Brain Injury Forum referred to US research that suggests that repetitive exposure to mTBI can result in “long-term degradation of brain nerve cells” and conditions such as dementia.144 Dr Michael Grey, Reader in Rehabilitation Neuroscience at the University of East Anglia, also told us that it could lead to progressive sight loss or worse.145

105.We concluded in our Part One report that the current lack of understanding in areas such as mTBI and neurotoxicity from sources including the anti-malarial drug, Lariam, means that there is uncertainty over whether the Department is capturing the full extent of mental health issues amongst its personnel and is providing appropriate care.146 We recommended that the Department conducted further research and set out mitigating actions to reduce the risk from these conditions.147 In its response, the Department set out its reliance on external experts to understand conditions such as mTBI and neurotoxicity.148 Furthermore, General Nugee, the Chief of Defence People, told us as part of this inquiry that its Independent Medical Expert Group have been trying to fully understand mTBI but that it is very difficult to diagnose in order to know what action might be taken.149

106.Mrs Mandy Bostwick, a specialist trauma psychotherapist, told us in her Part One evidence that “services to detect mTBI in the UK have not been developed to any standard” and that “it is widely researched that MRI will not detect a mTBI”.150 The National Centre for Trauma reported that there were two specialist scanners in the UK, at Aston and Nottingham Universities, which may be able to identify cases of mTBI.151

107.The need to identify mTBI in both current and former Servicemen and women was raised by Blind Veterans UK and the UK Acquired Brain Injury Forum, who told us that mTBI and Post Traumatic Stress Disorder (PTSD) share many symptoms and there is a risk that brain injuries in serving personnel may be misdiagnosed as PTSD. For example, the most common mTBI symptoms includes headache, confusion, dizziness and difficulties with concentration and attention. As a result, this could be “making treatment and recovery more difficult”.152 Dr Michael Grey told us that “the primary treatment with PTSD, as you are all aware, is cognitive behaviour therapy, and that does not necessarily work with people who have sustained mild traumatic brain injuries”.153

108.The Government has a duty to not treat patients incorrectly as a result of misdiagnosis. In particular, Post-Traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI) share some similar symptoms, which increases the risk of misdiagnosis of these conditions in serving personnel and veterans. We recommend that the Ministry of Defence and the four UK health departments support further research work into mTBI, including the testing of methods for clearly identifying this condition.

Suicides

109.Witnesses raised the number of tragic cases of serving personnel and veterans taking their own lives as a result of not being able to cope with their mental health issues, particularly during 2018.154 For example, Andy Price, a veteran, told us what he saw in his area in Dorset, where:

four men have taken their own lives, and they all knew each other as well … On top of that, we are continually dealing with guys attempting to take their own lives, just where I live. I talk to the emergency services down there. We have good links with the local police, good links with the inland rescue, the coastguard. They give us some figures, which is that four to five people a day are making attempts on their lives or self-harming, and a large proportion of them are veterans.155

110.ITV news also reported in December 2018 that, with the help of veterans’ organisations, it found that at least 71 currently serving personnel and veterans had taken their own lives during 2018, with at least a third having suffered from post-traumatic stress disorder.156

111.However, there are no comprehensive figures for veteran suicides in the UK as coroners are not required to record whether the deceased had been a veteran.157 Matthew Green told us in September 2018 that “various veterans groups online come up with different figures from the data they have gathered, but the fact is that nobody actually knows for certain how many veteran suicides happen”.158 This was a data gap that we raised particular concerns about in our Part One report, as it means that Government health bodies and Armed Forces charities may be missing opportunities to help those most in need and we recommended that:

the Ministry of Defence works with the justice departments across the four nations to record and collate, as part of existing suicide records, whether someone had been a veteran to monitor the level and locations of veteran suicides. This will enable it to identify whether there are particular groups of veterans or particular locations where more effort is required to prevent such tragic events from occurring.159

112.The Minister, Tobias Ellwood MP, subsequently told us in December 2018 that the Department is “absolutely engaged” with developing a better understanding of veteran suicides and he is working with the Ministry of Justice on datasets.160 However, the Ministry of Justice has no plans to require coroners to record the deceased’s occupational history given the potential difficulties of accurately identifying this information.161 In the same evidence session, General Nugee also told us about other work in this area, including:

113.The Health Minister, Jackie Doyle-Price MP, also emphasised the importance of veterans seeking help early for their mental health issues, telling us that “the biggest vulnerability that we have with all suicides is that two thirds of people who take their own life are not in contact with any kind of mental health service”.164

114.We welcome the Department’s work on improving its identification of veteran suicides following our recommendation in Part One, including working with the Ministry of Justice and Department for Health and Social Care. We look forward to receiving an update on progress as part of the Government’s response to this report, including the results of the study into suicides by Iraq and Afghanistan veterans. We recommend that the Department considers options for regular statistical releases on veteran suicides once sufficient data is available and includes these options as part of its response to this report.


73 Ministry of Defence Part One inquiry evidence (VMH0029)

74 Ministry of Defence, Annual Population Survey: UK Armed Forces Veterans residing in Great Britain, 2017, January 2019, p3; Ulster University and Forces in Mind Trust, Current and Future Needs of Veterans in Northern Ireland, November 2017, p12; Royal Hospital Chelsea (POC0128) and Northumbria and Chester Universities (POC0096)

75 King’s Centre for Military Health Research, King’s College London, The Mental Health of the UK Armed Forces (September 2018 version)

76 Help for Heroes Part One inquiry evidence (VMH0021) and King’s Centre for Military Health Research, King’s College London, Counting the Costs, November 2015, pp iii and iv

77 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 82

78 Ministry of Defence, Defence People Mental Health and Wellbeing Strategy 2017–2022, July 2017, pp31–32

79 Q384; Defence Committee, Ninth Report of Session 2017-19, Armed Forces Covenant Annual Report 2017, HC707, para 120; ITV News, Oxfordshire woman calls for more mental health support for military veterans suffering from PTSD, 13 November 2018; NHS England (POC0113); NHS England, Veterans: NHS mental health services, website accessed 14 February 2019 and NHS England, Transition, intervention and liaison mental health service for armed forces personnel approaching discharge and veterans, April 2017

80 Veterans First Point Part One inquiry evidence (VMH0024)

81 Combat Stress (POC0080)

83 Veterans’ NHS Wales (POC0078)

84 Department of Health and Social Services, Welsh Government (POC0119)

85 Ulster University Veterans Research Group (POC0106) and Ministry of Defence (POC0111)

86 UDR & R Irish Aftercare Service (POC0041)

87 Q224 [Tim Boughton] and Q437 [Johnny Mercer]

88 The Royal British Legion (POC0104)

89 Northumbria and Chester Universities (POC0096)

90 Anglia Ruskin University (POC0083) and Icarus On-Line (POC0046)

91 NHS England (POC0113)

92 Q74 [Charlie Wallace] and Thistle Foundation (POC0072)

93 Q245 [Catherine Braddick-Hughes]; Q263 [Andy Price]; Q216 [Tim Boughton]

94 Q29

95 Q292

96 NHS England (POC0113); Royal College of Psychiatrists (POC0112); Q65 [Professor Finnegan], Qq 144–146 and Q168 [Dr Leach] and Q154 [Dr MacManus]

98 Qq 144–146 and Q168 [Dr Leach]

99 The British Psychological Society (POC0093)

100 Q216

101 Q224

102 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 92 and 93

104 The Royal British Legion (POC0104); Combat Stress (POC0080) and Help for Heroes (POC0069)

105 Q192

106 Early findings were based on veterans accessing the mainstream NHS Improving Access to Psychological Therapies (IAPT) programme and Combat Stress treatment. NHS England (POC0113)

107 Northumbria and Chester Universities (POC0096) and Northumbria University, Mapping the needs of veterans across the UK, website accessed 14 February 2019

108 Annex 1: Summary of individual responses received

109 Q65 and Q211

110 For example, Forward Assist (POC0057); Icarus On-Line (POC0046); The RAF Association (POC0089); The Felix Health Group (POC0102) and Thistle Foundation (POC0072)

111 NHS England (POC0113)

112 Department of Health & Social Care (POC0130)

113 Q72 and Q111; Veterans’ NHS Wales (POC0078) and Veterans’ NHS Wales, Annual Report April 2016 March 2017

115 Q82

116 Q267

117 Annex 1: Summary of individual responses received

118 Q335 and Q385

119 Veterans’ NHS Wales (POC0078)

120 Q79

121 Ulster University Veterans Research Group (POC0106) and Qq82–83

122 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 82 and 83

123 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, paras 51, 58 and 59

125 HM Government, The Strategy for our Veterans, Cm 9726, November 2018 and HM Government, The Strategy for Our Veterans: UK Government Consultation Paper, Cm 9727, November 2018

126 Department of Health & Social Care (POC0130)

127 York St John University (POC0091)

128 Veterans’ NHS Wales (POC0078)

130 Department of Health & Social Care (POC0130)

131 Q186

132 Help for Heroes (POC0069) and Q315

133 Q29

134 Department of Health & Social Care (POC0130)

135 Help for Heroes Part One inquiry evidence (VMH0049)

136 Councillor Archie Dryburgh (POC0010)

137 Help for Heroes (POC0069)

138 Q34 [Matthew Green]

139 Q34 and Q117

140 Q115

141 Q364

142 Q367

143 Department of Health & Social Care (POC0130)

144 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 13 and Blind Veterans UK and UK Acquired Brain Injury Forum (POC0126)

145 Q178

146 In response to this inquiry, Dr Ashley Croft (POC0081), a consultant public health physician, also raised the mental health effects of Q fever. The Ministry of Defence is currently being sued by a veteran for not protecting him from the disease, which may be a test case for other veterans who have contracted Q fever. BBC News, ‘Dozens’ of British troops diagnosed with Q fever, 22 January 2019

147 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 19 and 20

149 Qq428–430

150 Mrs Mandy Bostwick Part One inquiry evidence (VMH0047)

151 Q428

152 Blind Veterans UK and UK Acquired Brain Injury Forum (POC0126)

153 Q177

154 Annex 1: Summary of individual responses received and also Jimmy Johnson who wrote to the Committee as co-founder of the charity, Veterans in Prison.

155 Q272

157 UK Government and Parliament e-Petition 225899, Ministry of Justice response

158 Q38

159 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 45

160 Q413

161 Ministry of Defence (POC0129)

162 Q412

163 Q210

164 Q413




Published: 25 February 2019