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

5Armed Forces charities

115.In addition to the civilian health care services, veterans can also turn to Armed Forces charities for mental health care and support. A 2017 report by the Directory of Social Change and the Forces in Mind Trust identified 76 charities working in this field, about 7% of the total number of UK Armed Forces charities. About a third of the 76 exclusively focused on mental health.165 Some charities are also commissioned by national and local governments to provide care services.166

116.Many witnesses argued that veterans should not have to rely on charities to get help, particularly for complex needs. Both Dr Deirdre MacManus, Royal College of Psychiatrists, and Dr Jonathan Leach, Honorary Secretary of the Royal College of General Practitioners, believed that some gaps in provision, such as inpatient treatment of complex PTSD, should not be quickly filled by charities since those were areas for which the Government should be providing resources.167 Veterans and their families also felt that having to go to charities for help was an indication of the poor statutory provision available (Case examples 12).

Case examples 12: Veterans’ views on accessing charity care

“Now before I had seen anyone face-to-face, I was well advised to self-refer myself to Combat Stress–As great a name that they are, They are a CHARITY, not an NHS service… No member of our serving and ex-serving community should be referred to a charity by our own care system.”

“Again I must emphasise that funding for the agencies involved must come from government and not rely on the charity of the population at large; most of whom are disgusted by the way Veterans are treated once the services cease to have responsibility for their welfare.”

Source: Annex 1: Summary of individual responses received

117.The Department believes that there is “no clear line of demarcation between what is appropriate for state funding and what might fall to the voluntary and community sector”.168 The Department stressed the historic importance of Armed Forces charities providing support to veterans alongside publicly funded services. As the Minister, Tobias Ellwood MP, put it during our Part One inquiry, the Department is “reliant on the expertise and the knowledge and depth of experience that these charities provide … Some charities have existed for more than 100 years, doing an absolutely incredible job, which we rely on”.169

Effectiveness of services

118.Many witnesses praised the mental health care provided by Armed Forces charities (Case examples 13). We also heard similar praise from veterans we met during our visit to Combat Stress. As David Richmond, a veteran and former chairman of the Contact Group, told us:

I think what the charities are able to do is specifically offer support to veterans, families and servicemen that is tailored for them. An NHS service is often not tailored for an individual. It is a service, some of which may have “veteran” in the title and a degree of understanding, but most services do not have that understanding, and that is the fundamental difference.170

Case examples 13: Veterans’ views on the quality of care received from charities

“I found Combat Stress extremely helpful, being amongst similarly affected Veterans removed some of the stigma I felt. Alongside other agencies; RBL [Royal British Legion], H4H [Help for Heroes] and HighGround as well as various forms of medication I have learnt many coping mechanisms and have been able to begin to realise a more fulfilling life.”

“My wife did a search online and found a small advert for Combat Stress and as a final attempt phoned and asked for help. Within 2 weeks we were visited by a welfare officer who did a quick assessment, before leaving I was in tears as for once someone listened to what I was saying, not what they thought I should be saying. Within another month I was invited for a 1 week assessment where I was given a written diagnosis of severe PTSD. My life was about to change.”

Source: Annex 1: Summary of individual responses received

119.However, some veterans also reported poor experiences, particularly difficulties in accessing care, because of a charity’s limited capacity and limits on the treatment they could provide (Case examples 14). Matthew Green, a journalist, reported that he knew many veterans “who have knocked on the doors of those bigger organisations and have not received the support that they need”.171 Dr Jonathan Bashford, Director at Community Innovations Enterprise, also told us that:

To some degree, yes, they [Armed Forces charities] are plugging gaps. Some of that might be appropriate; some of it might be due to the systems not being adequate enough, and we don’t give enough support to those charities to enable them to deal with that level of demand. I know from cuts in local authority services that, across the board, charities have absorbed additional referrals—cases—sometimes with more complexity than they were designed to deal with, as a result of other system problems. That is equally true of the military charities.172

Case examples 14: Veterans with negative experiences of charity care

“I did get him down to [a charity] and saw a gentleman doctor there that was ex services and so he went for a two-week inpatient course which was totally the wrong thing to do for him… (think they opened up the wound even more and then said good bye).”

“I forced him to contact [this charity] and they arranged to have someone come to see him, but it was a long wait at the time. So, before that happened, he then took a huge overdose of his medication. It was enough to be fatal, but I found him in time.”

“[This charity] was contacted but we had a nightmare with them. To the point where we were told that my son didn’t qualify to be treated by them.”

Source: Annex 1: Summary of individual responses received

120.Sue Freeth, Chief Executive of Combat Stress, told us that the charity will struggle to meet the increasing demand for complex treatment over the next ten years:

We envisage, looking at the latest research that has been published by King’s, that we will expect to see a third more people, particularly in the area we are working in—people with complex needs or multiple traumas—over the next 10 years… to have the resources to continue to provide the range of services we believe work well and are needed without Government funding will be very difficult.173

121.Witnesses also raised concerns that some charities offer mental health care services that are not evidence-based and which could potentially be harmful to the veteran. For example, Anglia Ruskin University reported that there are organisations “offering spurious interventions based on flawed or pseudo-scientific understandings of psychology … , with the effects upon veterans receiving such care largely unknown”.174 Northumbria and Chester Universities, however, noted that it was not well understood as to why veterans choose to go to these charities for help.175

122.We heard a range of views on whether charities providing mental health treatment should be regulated to ensure veterans received evidence-based treatment. Dr Jonathan Leach believed that it should fall under the Care Quality Commission, although legislation would need to be changed to do so.176 Tony Wright, Chief Executive of Forward Assist, agreed with the principle of regulation and believed that the necessary structures already existed, but would have to be adapted to be “veteran-centric”. David Richmond and Sue Freeth told us that regulations already existed for any organisation offering therapies and the need was to educate veterans and their families:

to look for registrations, look for practitioners who are regulated and look for the best practice and make sure that they understand the system that they are working in—to do a little bit of relatively easy due diligence.177

123.David Richmond also told us that the Contact Group, as the umbrella organisation for charities involved with mental health, had established a set of practice guidelines for its members. The Group has also produced a layman’s version to help individuals “navigate that patchwork of therapists out in society”.178 Anglia Ruskin University, however, noted that Cobseo [the Confederation of Service Charities under which the Contact Group sits] does not have the capacity to serve a regulatory function, with no “powers to enforce standards of practice, evidence or evaluation”.179

124.The Department of Health and Social Care told us that some Armed Forces charities’ mental health services are already within the remit of the Care Quality Commission (CQC) but recognised that this is not comprehensive across all services. Following its Five Year Forward View for Mental Health in February 2016, the Department is considering how to regulate psychological therapy services but confirmed that any change to the CQC’s remit would require legislation.180

Coverage of services

125.The level of provision that Armed Forces charities offer varies across the UK (Case examples 15). Councillor Dryburgh, Dumfries and Galloway Council, explained that charities understandably tended to be focused on larger towns, where there were more veterans.181

Case examples 15: Veterans’ experience of geographical provision of charity care

“From there I underwent their 6-week Intensive Therapy Program (ITP). But then, apart from a 1 hour, 6-week review over the phone, that is all I can get from [them]—they don’t have a community outreach program further than the Central Belt—fantastic if you live in Glasgow, not great if you live in Aberdeenshire, like myself!”

“Many veterans live in isolated locations away from their former peers and away from where charitable organisations are based. To compound matters, many have lost their driving licences due to alcohol abuse so simply can’t travel to make meetings.”

Source: Annex 1: Summary of individual responses received

126.There are very few Armed Forces charities in Northern Ireland which provide mental health care to veterans. Dr Bethany Waterhouse-Bradley, Lecturer at Ulster University, emphasised that Combat Stress was the only voluntary sector organisation specifically set up to deal with mental health issues, out of about 20 veterans charities set up for Northern Irish veterans.182

127.Dr Oscar Daly, Psychiatrist at Combat Stress Northern Ireland, told us that they had only four clinical staff to provide care to veterans.183 Sue Freeth, Chief Executive of Combat Stress, told us that they will be reallocating resources to Northern Ireland following a reorganisation but emphasised that Northern Ireland work was not Government funded.184 In follow-up evidence, Combat Stress reported that it spent £800,000 in Northern Ireland in 2017–18, of which £150,000 was funded through a grant from the Armed Forces Covenant Fund that ended in January 2019.185

Navigating the range of services

128.The range of statutory and charity mental health care services available means that it can be difficult for a veteran or their family to know where to go for help, an issue raised by witnesses including Icarus Online. This may be a concern as veterans may not know what is available when they need it.186 For example, a survey in summer 2018 by Armed Services Advice Project, Lanarkshire Region, found that out of 52 veterans who responded, 24 were not aware or not sure of what mental health support services were available.187 Some veterans and their families believed that the difficulties of finding the service they need can be discouraging for those who seek help (Case examples 16).

Case examples 16: Veterans’ and family members’ views on finding the right care

“Why are there so many charities trying to offer similar things? … I’m confused who does what, but for the service person who likes avoidance and minimisation its likely a factor that may put them off rather than encourage engagement.”

“Whilst there is a vast support network available through charities that information is not readily accessible through a single POC. It requires major investigation which makes it difficult for someone who is struggling with MH issues, adding to stress and anxiety.”

“The environment can be mindboggling to a veteran in need of support and quite simply put them off seeking support. This in turn can lead to those that need it most, not seeking help.”

Source: Annex 1: Summary of individual responses received

Veterans Gateway

129.The Veterans Gateway—an Armed Forces Covenant-funded initiative and run by charities—is intended to provide a focal point and a single point of contact for veterans and their families to access services which meet their needs.188 The Royal British Legion reported that between its launch in April 2017 and July 2018, the Gateway had received 1,272 support queries in relation to mental wellbeing as well as recording nearly 1,200 self-referrals to Combat Stress.189 The Gateway also announced in January 2019 that it would now conduct follow-up calls with veterans who have contacted them for support.190 Professor Finnegan, Professor of Nursing and Military Mental Health at Chester University, however questioned whether veterans were really aware of the Gateway, a view reflected by some of the veterans who submitted evidence.191

130.Mental health care providers, such as Veterans’ NHS Wales and Help for Heroes, also raised the lack of data, such as how many referrals had been made to providers.192 In our last report on the Armed Forces Covenant annual report, we recommended that the Government devise Key Performance Indicators (KPIs) for the Gateway and commit to publishing performance against them in the Covenant Annual Report and we await an update from the Ministry of Defence on their review of the KPIs.193

131.Armed Forces charities play a significant role in the provision of mental health services to veterans and we highly value the work that they do. However, some Armed Forces charities exist only because of a gap in statutory provision and veterans report going to charities for their mental health issues because of poor NHS experiences or because they do not know where else to go. This emphasises the need for the four UK health departments to improve their statutory provision as we have already set out. Where it is more cost-effective to do so, however, we agree that the health departments should be working closely with and help fund Armed Forces charities to provide the services that are needed.

132.Veterans and their families continue to struggle to navigate the complex landscape of mental health providers across the UK, particularly in crisis situations when the veteran needs help the most. The Department established the Veterans Gateway to address this problem, but as we reported last year in our Armed Forces Covenant report, we await Government statistics to show whether the Gateway has been effective.

133.Furthermore, like the care provision provided by Government, there are issues with the services that Armed Forces charities offer. In particular, demand often exceeds their capacity which means that veterans either have a lengthy wait or miss out entirely. Where and how veterans can access a charity’s service is also geographically dependent, with Northern Ireland particularly lacking in charity provision. As we set out further below, it is critical that there is greater coordination of services and resources across the sector to ensure a greater consistency of care provision, regardless of where a veteran is in the UK.

134.Mental health care provided by Armed Forces charities is not necessarily accredited or quality assured, leading to some providing treatments that are not evidence-based and potentially even harmful to patients. We recommend that the four UK health departments work with the charity sector to identify and implement an enforceable form of regulation so that treatment is evidence-based or that the veteran is fully aware of the risks if not. This could include reviewing whether current legislation regarding the scope of the Care Quality Commission should be revised to extend its remit to charities. Such consideration should also include how to help smaller charities to comply with the regulations and to publicise them to veterans so that they are aware that mental health treatment is regulated.

Coordination

135.There are a number of structures in place to coordinate veterans’ mental health care across the four nations and between government and Armed Forces charities, much of those within the wider governance surrounding the Armed Forces Covenant. The written evidence submitted by the Government and Veterans’ NHS Wales, sets out many of these in more detail, including those specifically related to mental health.194

136.Many witnesses did not believe, however, that the mental health sector was effectively coordinated. For example, Help for Heroes argued that government departments and local authorities “do not share the drive and desire to collaborate” and that this “leads to serious blockages and failings in service provision and failure to abide by the Armed Forces Covenant”.195 Dr Jonathan Bashford, Director at Community Innovations Enterprise told us that:

We are siloed from the top, right down from departmental level, and there are iron curtains between those boundaries that prevent joint working. Yes, we need to have that specific, central leadership, but there is no point to that if it is not then linked to what is happening locally. We have an increasingly devolved and fractured system of health and social care, even where it is integrated.196

This was a view shared by veterans and their families (Case examples 17).

Case examples 17: Veterans’ views on how well services are coordinated

“There is no cohesive strategy to co-ordinate the response from all the different organisations offering support. Because of the debilitating symptoms of PTSD, veterans are not able to plan their own course through the minefield that is out there.”

“There is little to no evidence of govt departments, local authorities and charities across the UK working together in any meaningful way.”

“I hate money being wasted and I think there is a lot of waste with the military charities not working collaboratively and dove tailing their provision with each other and the governments provision.”

Source: Annex 1: Summary of individual responses received

137.There were examples of close partnership working. Tony Wright, Chief Executive of Forward Assist, told us how Combat Stress directly operates out of his charity’s community centre.197 Both Veterans’ NHS Wales and Councillor Dryburgh, Dumfries and Galloway Council, reported how Armed Forces champions could help develop such partnerships at all levels, with some success stories.198 Kate Davies, Director of Health & Justice, Armed Forces and Sexual Assault Services Commissioning at NHS England, also told us that all NHS England service commissioning was a collaboration with charities to ensure a multi-agency approach, particularly at local level.199

The Contact Group

138.The Contact Group was set up in 2016 as a forum to coordinate mental health providers across the UK. It is a collaboration of Armed Forces charities and other entities working with the NHS and the Ministry of Defence. It also acts as the Mental Health hub within the Confederation of Service Charities (COBSEO).200 It was founded to improve service impact and best practice across the sector. The Royal College of Psychiatrists is a member and welcomed its creation but believed that “it is not yet clear how effective this forum is at ensuring the various providers do work together” and that many charities may not be aware of the Group.201 Another member, PTSD Resolution, thought it was “just another talking shop”.202

Coordinating funding

139.Witnesses identified the way in which mental health services were funded—particularly the use of LIBOR funding—as a key example of the lack of coordination of mental health care provision. We recognised in our most recent Armed Forces Covenant report that LIBOR funding had delivered positive results but we raised concerns about how some of this money had been used.203 During this inquiry, Sue Freeth, Chief Executive of Combat Stress, told us that very little of the funding had been directed towards mental health clinical treatment service.204 David Richmond, former chairman of the Contact Group, raised the lack of a long term vision for how this funding was used:

The big issue for me has been the lack of a strategically big idea. With all this money, wherever it has gone—it has not all gone to mental health care—what was the big idea? What were we trying to create? Certainly with the Covenant Reference Group fund, I had the impression for several years—not all of that was for mental health, I accept—that the motivation was, ”How do we spend £10 million a year?”, not, “What could we do with £100 million in 10 years?” …205

140.Instead, charities and other organisations are competing for the available public funding and charitable donations. Smaller charities, for example, do not necessarily believe that the distribution of funding is fair in reflecting the services being delivered. Tony Wright, Chief Executive of Forward Assist, told us that “our tiny little grassroots charities that do so much to enable people to engage and have somewhere to go are not funded in the way they should be”.206 Icarus Online went further, believing that the larger charities “continue to think in silos, guarding their own preserves preciously, to the detriment of a seamless service across the UK”.207

141.There is a risk that insufficient funding may lead to services reducing their scope or even closing. For example, two of Veterans First Point centres covering the Grampian and Highlands regions in Scotland closed in 2017 as a result of the end of LIBOR funding.208 Tony Wright believed that Forward Assist might have to change how it operates given the lack of funding.209 The Government announced in the 2018 Autumn Budget that £10 million would be made available to projects to support veterans’ mental health and wellbeing needs, as part of the Armed Forces Covenant Fund Trust, with applications accepted from May 2019.210

Sharing information between providers

142.Another example of poor coordination between care providers was the frustration many veterans felt at having to repeat their story again and again as they moved from one provider or stage of care to another. Tony Wright, Chief Executive of Forward Assist, told us that “having to go and retell your story again is a problem for a lot of people”, while one veteran told us that with no long-term continuity of care “this can lead to duplication, re-living and re-telling the “story” five or six times”.211

143.Dr Deirdre MacManus, Royal College of Psychiatrists and lead psychiatrist for the London Transition, Intervention and Liaison Services, told us that this was something she also commonly hears and that TILS “is trying to overcome” this so where “data-sharing can happen, it does”. For example, she will ask patients coming into TILS for their consent to contact their previous providers for their assessments.212

144.We were disappointed to hear that there was no long-term vision for the use of LIBOR funding. As a result, although we noted in our Armed Forces Covenant report in June that the funding had delivered positive results, an opportunity has been missed to have used the funding for long-term investment in areas such as veterans’ mental health services. Instead charities continue to compete for short-term funding from both Government sources and public donations, risking the closure of services if future funding is lost, restricting their ability to plan long-term and with the possibility of resources not going where they might be most needed.

145.The lack of coordination of mental health care funding and services across the UK continues to demonstrate the lack of strategic direction and accountability from the Government on the Armed Forces Covenant. It has structures in place for cross-government working, such as the Veterans Board, and the Contact Group has been formed specifically for coordinating the mental health sector. However, their effectiveness is questionable and some veterans see only a disjointed system that fails them when they need it, not least by repeatedly forcing them to retell their story as they move from provider to provider. We will continue to urge the Government to improve its governance of the Armed Forces Covenant, as part of our annual inquiry, to ensure that the Covenant is being fully implemented across the UK.

146.We recommend that the Ministry of Defence works with the other partners in the Contact Group to ensure that it develops into an influential body, effective at coordinating funding and service provision across the whole mental health sector. This should include bringing more of the smaller charities into the Group and increasing stakeholders’ awareness of its work.

147.Charities are of course sovereign bodies, many of which wish to do the right thing—but only on the understanding that they will do it their way. Ministers have no formal power, other than via the Charity Commission which deals only with governance, to compel charities to do anything against their will. Nevertheless, given the stove-piping and lack of joined-up working clearly identified in the charitable sector within this report, Ministers should be prepared to work with COBSEO and the Contact Group to do whatever they practically can to “knock heads together” in the charitable sector to try and provide a far more joined-up service, which is to the benefit of the veterans rather than the charities themselves.


165 Directory of Social Change and Forces in Mind Trust, Focus on: Armed Forces Charities’ Mental Health Provision, June 2017, p4

166 NHS England (POC0113)

167 Q212 and Royal College of Psychiatrists (POC0112)

168 Ministry of Defence (POC0111)

169 Defence Committee, Eleventh Report of Session 2017–19, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, HC813, para 35

170 Q312

171 Q58

172 Q57

173 Q287

174 Anglia Ruskin University (POC0083)

175 Northumbria and Chester Universities (POC0096)

176 Qq199–205

177 Qq319–320

178 Q319

179 Anglia Ruskin University (POC0083)

180 Department of Health & Social Care (POC0130)

181 Councillor Archie Dryburgh (POC0010)

182 Q73

183 Q98

184 Q294

185 Combat Stress (POC0127)

186 Icarus On-Line (POC0046) and The Veterans Hub Part One inquiry evidence (VMH0020)

187 Armed Services Advice Project, Lanarkshire Region (POC0105)

188 Defence Committee, Ninth Report of Session 2017–19, Armed Forces Covenant Annual Report 2017, HC707, para 39

189 The Royal British Legion (POC0104)

191 Q58 [Professor Finnegan] and Annex 1: Summary of individual responses received

192 Veterans’ NHS Wales (POC0078) and Help for Heroes (POC0069)

193 Defence Committee, Eleventh Special Report of Session 2017–19, Armed Forces Covenant Annual Report 2017: Government Response to the Committee’s Ninth Report, HC1571, p8

194 Ministry of Defence (POC0111) and Ministry of Defence (POC0129); Department of Health & Social Care (POC0130); NHS England (POC0113) and Veterans’ NHS Wales (POC0078)

195 Help for Heroes (POC0069)

196 Q19

197 Q326

198 Councillor Archie Dryburgh (POC0010) and Veterans’ NHS Wales (POC0078)

199 Q401

200 COBSEO, Welfare, Health and Wellbeing Arena and The Contact Group, websites accessed 14 February 2019

201 Royal College of Psychiatrists (POC0112)

202 PTSD Resolution (POC0122)

203 Between 2012 and 2015, the Government fined banks to a total of £973 million for manipulating the banking markets, including the London Interbank Offered Rate (LIBOR)—a benchmark interest rate for inter-bank loans—for profit. Much of this went to Armed Forces charities. Defence Committee, Ninth Report of Session 2017–19, Armed Forces Covenant Annual Report 2017, HC707, para 58–69

204 Q282

205 Q285

206 Q280

207 Icarus On-Line (POC0046)

208 BBC News, Decision due on ‘lifeline’ service for Grampian veterans, 21 August 2017 and Scottish Parliament debate, Veterans and Armed Forces Community, 16 November 2017

209 Q288

210 Armed Forces Covenant Fund Trust, Veterans Mental Health and Wellbeing Fund, website accessed 14 February

211 Q314 and Annex 1: Summary of individual responses received

212 Qq156–165




Published: 25 February 2019