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

Conclusions and recommendations

During Service

1.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. (Paragraph 17)

2.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. (Paragraph 18)

3.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. (Paragraph 23)

4.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. (Paragraph 33)

5.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. (Paragraph 34)

6.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. (Paragraph 35)

7.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. (Paragraph 36)

During the transition to civilian life

8.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. (Paragraph 48)

9.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. (Paragraph 52)

Statutory provision for veterans

10.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. (Paragraph 67)

11.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. (Paragraph 68)

12.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. (Paragraph 76)

13.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. (Paragraph 77)

14.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. (Paragraph 78)

15.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. (Paragraph 85)

16.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. (Paragraph 86)

17.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. (Paragraph 91)

18.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. (Paragraph 92)

19.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. (Paragraph 98)

20.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. (Paragraph 99)

21.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. (Paragraph 100)

22.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. (Paragraph 101)

23.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. (Paragraph 102)

24.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. (Paragraph 108)

25.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. (Paragraph 114)

Armed Forces charities

26.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. (Paragraph 131)

27.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. (Paragraph 132)

28.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. (Paragraph 133)

29.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. (Paragraph 134)

30.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. (Paragraph 144)

31.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. (Paragraph 145)

32.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. (Paragraph 146)

33.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. (Paragraph 147)


34.We are very concerned by the lack of Armed Forces’ family-specific specialist mental health care in the UK, including the very limited provision within the Armed Forces charity sector. As we reported in Part One, the mental health of families can be just as exposed to the stresses of Service life, especially if they are living with serving personnel or veterans who have complex mental health issues. Yet many may be reluctant to seek help, perhaps because of the perceived stigma or because civilian medical practitioners would not understand their situation as an Armed Forces’ family member. (Paragraph 156)

35.We repeat our recommendation from Part One that the Ministry of Defence, in conjunction with the health departments of the four nations, should place a greater focus on service and veterans’ families as part of their mental health care provision. This should include providing additional funding to statutory services, such as the Transition, Intervention and Liaison Service in England, to assist families. We also recommend that the Ministry of Defence, alongside the four health departments, review what assistance can be provided to family members of serving personnel and veterans with mental health issues. (Paragraph 157)

Published: 25 February 2019