Introduction
The subject of mental health has become increasingly prominent both across the UK Armed Forces, not least following UK operations in Afghanistan and Iraq, and across UK society generally. In January 2018 we launched the first part of our inquiry into Armed Forces mental health, and published a report, Mental Health and the Armed Forces, Part One: The Scale of mental health issues, in July 2018. This focused on the extent of mental health issues among both serving personnel and veterans.
We concluded that the vast majority of veterans leave the Services with no ill-effects and that the public perception that most veterans are 'mad, bad or sad' was not only a myth but harmful to veterans.
Credit: Ministry of Defence
However, we were convinced that the minority of serving personnel and veterans who do suffer from mental health conditions need timely and appropriate care. The evidence we received suggested that they were not receiving this, that veterans had to wait too long to access treatment, and that the provision of care varied across the UK — as did implementation of the Armed Forces Covenant principle of 'priority care' for veterans. We therefore decided to look at the provision of mental health care for serving personnel, veterans and their families.
Key Facts
- The Care Quality Commission rated two out of four MoD mental health centres as inadequate or needing improvement between April 2017 and January 2019.
- There were at least 50% shortfalls in both uniformed and civilian psychiatrist posts in 2017-18.
- Armed Forces charities have found that it can take four years on average before Iraq and Afghanistan veterans seek help for mental health issues. Despite this, the Ministry of Defence follow-up period for writing to veterans is only one year after discharge.
- Veterans in England wait 18 days, on average, for an assessment from the Transition, Intervention and Liaison Service after referral against a target of 14 days, according to NHS England.
- Veterans can wait up to a year for mental health treatment after assessment, particularly in Northern Ireland.
- We estimate that total government spending on veteran-specific mental health services in England, Scotland and Wales is less than £10 million a year. However, there are no such services open to all veterans in Northern Ireland.
- It is difficult to obtain authoritative statistics on veteran suicides. However, a study conducted for ITV last year, produced a figure that at least 71 serving personnel/veterans unfortunately took their own lives in 2018. Even as a rough estimate this gives a good idea of the scale of the problem.
- There were 76 UK Armed Forces charities providing mental health support in 2017, according to the Directory of Social Change and the Forces in Mind Trust. Of these, one-third exclusively focused on mental health.
During Service
"It was very difficult for me to take that first step in seeking out aid, mainly due to stigma whilst serving in an infantry unit. But to be diagnosed by an RAF Corporal who was an unqualified psychologist and my treatment was a guidebook with no future referrals is a complete farce."
The Committee is calling on the Government to:
- 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 MoD 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.
- if recruitment does not improve, review what it can offer in pay and other benefits to attract people into military mental health roles, either as Regulars or Reservists.
- 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.
- 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.
We are deeply concerned that the MoD is not consistently providing the quality of mental health care to its Servicemen and women that they deserve. We welcome the MoD'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.
We are disappointed that the MoD 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.
Chart: Shortfalls in uniformed psychiatrists and mental health nurses against posts since 2010-11
Notes
- Figures show total shortfall across both Regular and Reservist posts.
- In 2010–11 the number of mental health nurses employed exceeded requirements by 13% (20 nurses)
- Actual manning figures for uniformed psychiatrists may be slightly higher as, other than in 2012–13, fewer than five Reservist psychiatrists were in post in each year. As the Department’s manning figures were rounded to the nearest five, we have assumed that no Reservist psychiatrists were in post, other than in 2012–13.
- Shortfall figures are measured against the number of staff not in post, as the Department states that all military personnel are full-time.
Source: Defence Committee analysis of Ministry of Defence data
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 MoD in campaigning against the stigma surrounding mental health issues and promoting help-seeking. Yet it is obvious that more still needs to be done.
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.
During the transition to civilian life
"Before leaving the service I was in the care of DCMH, they took over 5 years to diagnose me with PTSD and once I left they just left me to find help by myself. It took a lot to admit I had a problem and then to be left to find help once out of the service was hard. It seemed that once my termination date was reached I wasn’t DCMH's problem anymore."
The Committee is calling on the Government to:
- revise 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.
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 MoD 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.
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 MoD'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 MoD's subsequent response.
Statutory provision 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?"
The Committee is calling on the Government to:
- update us within six months on progress in improving civilian practitioners' awareness of veterans' mental health, including how this has been measured, what other actions it has since taken or plans to take for further improvement and on the work to exchange best practice across the four nations in the UK.
- address urgently the gaps in veteran-specific provision across the UK and develop 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.
- set 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.
- 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.
- 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.
- recognise the deficiency in funding 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.
- set out how it will develop long-term care provision for veterans with complex mental health conditions.
- ensure that patients are continually monitored and reassessed during the gap between initial diagnosis and the commencement of treatment.
- establish a world-class centre for the treatment of mental injuries relating to service. 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) at Stanford Hall, which treats physically injured serving personnel. This facility should be established with an initial operating capability within the next 12-18 months.
- support further research work into mTBI, including the testing of methods for clearly identifying this condition.
- consider options for regular statistical releases on veteran suicides once sufficient data is available.
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.
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. Even though health care is devolved, the MoD cannot abdicate its responsibility for ensuring that all veterans receive comparable care regardless of where they live.
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.
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.
Credit: ©Crown Copyright
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.
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.
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. 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.
Armed Forces charities
"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."
The Committee is calling on the Government to:
- 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.
- work 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.
- 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.
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.
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 MoD 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.
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.
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 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 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.
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.
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.
Families
"The impact of Mental Health on families seems to be wholly underestimated and unrecognised. We provide support 24/7 and have first-hand experience of how our partners are coping. We receive no training in how to support our loved ones or how to cope with someone with MH issues. This leads to a detrimental impact on our own mental health (as I can personally testify)."
Credit: Defence Images/©Crown Copyright, published under Creative Commons license
The Committee is calling on the Government to:
- 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.
- review what assistance can be provided to family members of serving personnel and veterans with mental health issues.
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.
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