Mental health and the Armed Forces, Part One: The Scale of mental health issues: Government Response to the Committee’s Eleventh Report

Twelfth Special Report

On 25 July 2018, the Defence Committee published its Eleventh Report of Session 2017–19 [HC 813] Mental Health and the Armed Forces, Part One: The Scale of mental health issues. The response from the Government was received on 18 September 2018. The response is appended to this report.

Appendix: Government Response

The Government welcomes the HCDC’s report and has considered its conclusions and recommendations carefully; the formal response to the Committee is set out below. The HCDC’s findings are highlighted in bold, with the Government response in plain text. For ease of reference, paragraph numbering follows that in the ‘Conclusions and Recommendations’ section of the HCDC’s report.

The effect of military service on mental health

1.It is very difficult to prove whether the mental health conditions that some serving personnel and veterans develop are caused by their military service. Non-military factors or underlying mental health conditions exacerbated by military service could all contribute to an individual’s mental health. However, there is a lack of reliable research and data to indicate how significant these factors might be. Although the Ministry of Defence does not take attribution into account when providing care, a better understanding would at least help it to make decisions where judgement on attribution is required, such as awarding compensation.

The Government agrees that it is very difficult to prove whether the mental health conditions that some serving personnel and veterans develop are caused by their military service. Chief of Defence People has provided £250,000 funding for the King’s Centre for Military Health Research (KCMHR) to further analyse data from its Longitudinal Cohort Study. This will help identify any associations between different factors that may affect mental health during military service. However, proving factors to be causative would be methodologically difficult.

2.The Ministry of Defence should support further research into the factors that may affect mental health during military service. This should include following a cohort of recruits over time to understand how military service may have affected them.

The tri-Service Health Outcomes Study (HOST) is being undertaken by the Army Personnel Research Centre in collaboration with Defence Statistics (Health). The first HOST cohort was identified retrospectively in 2015/16 as part of the Women in Ground Close Combat initiative. It is intended that the HOST becomes prospective in order to follow personnel from joining the Armed Forces as recruits over the period of their service in order to understand how military service may have affected them (for better or worse).

3.The unknown mental health implications of what an individual might be exposed to during military service adds further uncertainty over whether the Ministry of Defence is capturing the full extent of mental health issues amongst its personnel and is providing appropriate care. The Ministry of Defence relies on external research to inform its clinical diagnoses and care practices. The current lack of understanding in areas such as neurotoxicity and mild traumatic brain injury, however, means that it cannot be certain about the balance of risk it accepts in its practices.

The MOD has successfully advocated for military mental health to become an international military medical research priority. To that effect, a resilience working group is now well established within ‘Warrior Care in the 21st Century’, an annual international military healthcare symposium. This is co-chaired by the UK Defence Medical Services (DMS) and the hosting nation and brings together senior military and civilian representatives from NATO and other countries to share knowledge on this subject.

4.We recommend that the Ministry of Defence should commission further research into neurotoxicity and mild traumatic brain injury (mTBI) to determine whether exposure to these is likely to be causing mental health effects. If there appears to be a link the Ministry of Defence should set out what mitigating actions it will take to reduce the risk of mental health conditions from such exposures.

Due to a lack of the large numbers of patients required to draw statistically significant inferences about causation, and the breadth and depth of the MOD’s other competing medical research requirements, it would neither be methodologically robust nor an efficient use of resources for the MOD to commission its own research into whether exposure to neurotoxins during military service is likely to cause mental health effects. In the specific case of Mefloquine (an anti-malarial), the MOD follows the technical advice of national and international experts, such as the Advisory Committee on Malaria Prevention, as this will be based on a much larger patient cohort, including civilian as well as military patient experience.

KCMHR is using its Longitudinal Cohort Study data to assess whether or not those who report exposure to mild traumatic brain injury (mTBI) are more likely to exhibit adverse mental health outcomes. This Study provides an accurate reflection of the mental health of those who have deployed on recent operations.

5.Rather than causing problems, military service can have a positive effect on an individual’s mental health. At the very least, the vast majority of Service personnel leave with good experiences of their military career. The structure and social community found in the Armed Forces particularly help those who might have been more vulnerable to mental health issues before they joined, for example, those who were unemployed or socially isolated. All Government Departments, not just the Ministry of Defence, should be doing more to promote to the public the message that military service has a positive effect on mental health, for example, by drawing attention to the veterans they employ.

The Government agrees that military service can have a positive effect on an individual’s mental health. The vast majority of those leaving the Armed Forces will do so mentally fit and well, having benefited from the positive experience of serving their country.

The MOD is committed to recruiting and retaining the best possible people from across the country, regardless of background, gender, ethnicity, working pattern, caring responsibilities or sexual orientation. We are striving to be an employer of choice through recognising, encouraging and celebrating diversity, and ensuring everyone in Defence plays their part in promoting an inclusive working environment and respecting and valuing the unique contribution of each individual. Maintaining good levels of mental health and wellbeing is achieved by a through-life approach; ensuring people join well, train well and leave well, through the application of a wide range of measures based around a model of prevention, early detection and treatment. The MOD has launched anti-stigma campaigns, introduced resilience training and produced policy on workplace and operational stress. The need to embed mental health and wellbeing as an individual and leadership responsibility (such as physical health) are key themes.

Most veterans make a successful transition to civilian life, which includes those who, on joining the Armed Forces, were from a low socio-economic background or had experienced family dysfunction. In recent years there has been a propensity for this group to do well on returning to civilian life, highlighting that service has an overall positive influence on life trajectory.

6.This positive effect can be lasting, but the potential loss of support and community when personnel leave the Armed Forces may mean that, for some, military service will have only delayed the onset of mental health issues. Successful transition is therefore essential to ensuring that any mental health benefits from military service are retained. Support during transition is available but more could be done to ensure continuity of care and stop some veterans from falling through the gaps. We shall be examining the provision of mental health care to serving personnel and veterans, including during transition, in Part Two of our inquiry into Mental Health and the Armed Forces.

The MOD provides extensive and comprehensive support to Service personnel as they transition out of the Armed Forces. Consideration will be given to whether certain groups require additional support and, if they do, which is the most appropriate organisation to provide it.

The Government’s mental health data and its limitations

7.There have been significant increases in the number of serving Armed Forces personnel and veterans seeking mental health care over the last decade. The Ministry of Defence reports that since 2008–09 the proportion of serving Armed Forces personnel diagnosed with mental health conditions has nearly doubled, to 3.1%. Data on veterans is more limited, particularly in Northern Ireland, but statutory providers in England, Scotland and Wales also reported similar increases in the number of veterans they are seeing. A significant factor in the rise reported may be that, as in the civilian population, more serving personnel and veterans who have mental health issues are seeking help.

Although the absolute numbers and rates of mental health disorder among Armed Forces personnel assessed at a MOD Department of Community Mental Health (DCMH) has increased over time from 1.8% in 2007/08 to 3.1% in 2017/18, data for the last three years suggests that new episodes of care have stabilised at around 3%. We believe that the increase over the period may partly be because of campaigns to reduce stigma.

8.We are particularly concerned, however, by the lack of national data on veteran suicides. The evidence that is available suggests that the rate in veterans is likely to be comparable to the general population. However, without robust data to know whether there may be specific groups or areas that need to be monitored more closely, Government health bodies and Armed Forces charities may be missing opportunities to help those most in need.

The MOD currently publishes mortality rates and the causes of death (including suicide) for UK veterans of the 1982 Falklands and 1990/91 Gulf Conflicts by linking MOD data with that from other Government sources. The commissioning of studies about the causes of death among veterans during other periods is under consideration.

9.We recommend 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.

The cross-Government Ministerial Armed Forces Covenant and Veterans Board (MCVB) will consider how to work across Government Departments, and with the Devolved Administrations, to seek changes in the recording of veterans’ deaths by Coroners and the Procurator Fiscal.

10.UK Government statistics report only those who seek help and may therefore be significantly underestimating how many serving personnel and veterans have mental health conditions. The Ministry of Defence acknowledges that its statistics may not be representative of the overall veteran population. Current research suggests that the number of veterans with mental health conditions that require professional help could be up to three times higher than official statistics, at around 10%.

The causes of mental health are multi-factorial with prior and post-service experience being significant influencers, particularly in the case of complex mental health conditions. There is not necessarily a correlation between service and a veteran’s mental health condition.

11.There are a number of barriers such as stigma and the failures in the provision of care, that continue to dissuade serving personnel and veterans from seeking help from statutory services. Although there have been improvements in the provision of care in recent years, more clearly needs to be done, especially in improving the timeliness of care. We will be examining the provision of mental health care to serving personnel and veterans in our follow up inquiry, where we will explore the issues around barriers to care. We also support the work being taken by the Ministry of Defence and Armed Forces charities in campaigning against the stigma surrounding mental health. However, stigma remains a barrier and this work needs to continue.

We encourage all veterans to register their veteran status with their NHS General Practitioner (GP), and to inform the wider NHS of their status. This will ensure they can receive priority over patients with the same clinical need, and that they may be referred for veteran-specific services provided by the NHS, if required.

12.We are particularly concerned 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 on equality and clinical need constrain how it can provide priority treatment to veterans. This difference in interpretation is confusing not just to veterans but also to clinicians; this may add to veterans’ perception that the health service is failing them. The situation is similar in Scotland and Wales, while there remains a more fundamental difficulty in implementing the Armed Forces Covenant in Northern Ireland.

All veterans in Great Britain (England, Scotland and Wales) are entitled to priority access to NHS care (including hospital, primary and community care) for conditions that are service attributable. However, this is always subject to the clinical need of all patients and does not entitle a veteran to be prioritised over those with a greater clinical need for NHS care. Information is available at https://www.nhs.uk/using-the-nhs/military-healthcare/priority-nhs-treatment-for-Veterans/.

13.We recommend that in its forthcoming Veterans strategy, the Government should set out clearly whether Veterans may expect to receive priority treatment, subject to clinical need, and what that means in practice. The Government should ensure that this clarification is then cascaded down to both NHS staff and Veterans and their families across the UK.

The Veterans Strategy provides an opportunity for Defence to work with the NHS in England, Scotland and Wales to ensure that veterans and their families get a better understanding of priority treatment and what it means for individual veterans. Priority treatment is not available to veterans resident in Northern Ireland due to Section 75 of the Northern Ireland Act.

14.We recommend that, as part of the ongoing work to improve their knowledge of military health, civilian medical practitioners, especially GPs, should be made aware of the importance of asking about Veteran status and recording it correctly.

Increasing clinical awareness of the needs of the Armed Forces community is an important objective for the NHS and we welcome the Royal College of General Practitioners and NHS England’s joint Veterans’ Awareness General Practitioner Accreditation Programme. To date, the programme has been successful, with over 90 GP practices in the West Midlands area joining the pilot scheme.

The Veterans Covenant Hospital Alliance provides a forum to share knowledge and best practice, connect hospitals to other related services and generally improve awareness of veterans’ needs. It also allows hospitals in the Alliance to share education and training resources, to achieve recognition and accreditation and, in doing so, will increase awareness of the needs of veterans for its members.

Earlier this year the Department for Health and Social Care (DHSC) improved the Armed Forces question on the GSM1 form (GP registration). It now asks if the patient was a Regular member of the Armed Forces, a Reservist or a family member, which will help improve identification of the whole of the Armed Forces community.

In addition, DHSC will remind GPs about the importance of proactively enquiring about a patient’s status within the Armed Forces community and communicating the offer available to ensure there is no disadvantage.

Effects of operations in Afghanistan and Iraq

15.Deployment to Iraq and Afghanistan has clearly increased the likelihood of mental health conditions among those who saw combat or were deployed Reservists. The 2014 study by King’s Centre for Mental Health Research found that the rate of PTSD in Regular personnel in deployed combat roles was 6.9% and for deployed Reservists 6%, compared to 4% for the Armed Forces as a whole. Armed Forces charities also report more cases of mental health conditions in veterans in these groups.

The needs of specific groups associated with combat exposure and deployment will continue to be monitored and addressed.

Groups that might be more vulnerable to mental health issues

16.Certain groups of Service personnel, regardless of deployment, may also be potentially more vulnerable to developing mental health conditions, both during and after service. These groups include female personnel, both currently serving and Veterans, early Service leavers and recruits aged under 18. More reliable data is needed to show whether they are more at risk and hence whether the existing support they receive is good enough. We recommend that the Ministry of Defence conducts or commissions further research into these groups to determine the extent to which they are at higher risk of developing mental health conditions. The Government should then consider what specific monitoring and mental health support might need to be provided or enhance existing provision to those groups that are at higher risk.

MOD, through Defence Statistics, already has evidence of those groups of Service personnel who seek help for mental health conditions. This is supported by work undertaken with other academic institutions such as King’s College, London and the University of Manchester.

The MOD has undertaken a comprehensive review of mental health treatment services for the Armed Forces. An extra £2 million per annum was announced earlier this year, on top of the £20 million each year that is currently committed. This will enable the recruitment of more mental health specialists and further investment in existing contracted services from the NHS. Mental health assessment and care management within the UK Armed Forces is available at three levels:

Defence Statistics publishes an annual bulletin reporting all initial assessments for a new episode of care at MOD DCMHs for out-patient care, and all admissions to the ISP. The report for financial year 2017/2018 was published on 21 June 2018 at: https://www.gov.uk/government/statistics/uk-armed-forces-mental-health-annual-statistics-financial-year-201718. The report identifies several groups of Service personnel with higher presentations of mental disorders:

Comparison of mental health data sets

17.Knowing what the full scale of the mental health problem is across serving personnel and veterans is critical to determining the resources required to care for those that need it, yet there is no clear and agreed understanding across the sector. The Ministry of Defence, academic studies and Armed Forces charities all take different approaches to assessing and recording the number of serving personnel and veterans with mental health conditions. This has led to a wide range of estimates with at one end, the Ministry of Defence suggesting it is lower than the UK general population and at the other Armed Forces charities—which mainly see those veterans who need help the most—reporting much higher levels.

MOD, through Defence Statistics, is already in discussion 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.

18.We recommend that the Ministry of Defence and the health departments of the four nations work with Contact and the charity sector to agree and implement a shared set of methodologies for collecting and analysing data. This will enable 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.

In addition to work with the Devolved Administrations, Defence Statistics are also working with the Covenant Fund to develop wellbeing metrics for those accessing services through the fund. Defence Statistics are looking at how they can share statistics on those in Defence Recovery with Help for Heroes and the Royal British Legion.

19.We recommend that such common methodologies consider how mental health statistics are collected more widely, so that like for like comparisons can be made with the UK population as a whole or indeed with other countries. This would ideally include the Government developing data on mental health conditions assessed in emergency services personnel, who by the nature of their roles, are more likely to encounter traumatic situations than the general public.

Defence Statistics intend to explore opportunities with NHS England to determine measures that will be of value in the future, and how to compare that data with the UK emergency services.

20.The provision of healthcare is devolved, but the Ministry of Defence is responsible for ensuring that veterans across the UK are receiving the level of care set out in the Armed Forces Covenant. Yet it has an inadequate understanding of the extent of veterans’ mental health issues across the UK. The four nations take different approaches to both the provision of mental health care to veterans and the data they collect, which varies significantly. Without such information, it is difficult for the Ministry of Defence and the health departments in the four nations to ensure that there is sufficient coverage and adequacy of mental health services for veterans.

We continue to engage with the Devolved Administrations who have primary responsibility for the provision of many services for veterans living within their borders.

21.We recommend that the Ministry of Defence works with the health departments in the four nations to develop and publish a single set of statistics on the number of Veterans seeking help and being treated across all of the UK. This should include Veterans treated under commissioned services, such as from Armed Forces charities. These should, at the minimum, be broken down to individual nations and should ideally be at the local commissioning level, where provision of care decisions are made.

Although we are engaging with the Devolved Administrations, due to the current security situation, veterans residing in Northern Ireland will have a heightened awareness of risk to themselves and their families, and may be reluctant to record their veteran status with the NHS or any other public or private organisation.

22.We repeat the recommendation from our report on the Armed Forces Covenant Annual Report 2017 for the greater involvement of the devolved administrations at all levels of the structures charged with the implementation of the Covenant.

The Devolved Administrations are represented at the MCVB and the various working groups established to support the work of the Armed Forces Covenant and Veterans’ Strategy. Cross-Government collaboration with Other Government Departments and the Devolved Administrations is key to ensuring that the Armed Forces Community, including veterans, suffer no disadvantage due to their service in the Armed Forces.

23.We are concerned that the Ministry of Defence does not monitor regional variations in the mental health of its serving personnel. We recognise that personnel move around the country but the Ministry of Defence will know where they were recruited from, regardless of unit, where they have been based and their medical history. Where recruits come from can be a factor in whether they develop mental health issues, so it is surprising to hear that this monitoring is not already being done. We recommend that the Ministry of Defence assesses the extent to which there is variation in the mental health of its serving personnel, based on where they were recruited, not just at devolved administration level but at a local level.

The MOD is unsure of the value of undertaking an investigation into the effect of regional variations in residence at time of recruitment on the mental health of serving personnel, or what benefits such an investigation would bring, either to serving personnel, veterans, Defence or to wider society. Recruits are not trained differently dependent on where they lived or where they were recruited from. The same training is provided to all to ensure they reach a comparable level of fitness and maximise deployability.

Most veterans make a successful transition to civilian life, which includes those who, on joining the Armed Forces, were from a low socio-economic background or had experienced family dysfunction. In recent years there has been a propensity for this group to do well on return to civilian life, highlighting that service has an overall positive influence on life trajectory.

Public perceptions of mental health in the UK Armed Forces

24.The widespread public perception that all veterans are damaged by their military service is not only wrong but harmful. Even though current government statistics and Armed Forces charity providers may be underestimating the extent of mental health conditions, the vast majority of service personnel are likely to leave with no ill effect. The public impression to the contrary has in part been driven by media coverage and Armed Forces charity publicity on the subject which, although helping to improve mental health awareness and generate funding, has provided a distorted view of the extent of mental health conditions in both serving personnel and veterans.

The Government agrees with this conclusion. The MOD, through the Directorate of Defence Communications, is undertaking work, in conjunction with the Forces in Mind Trust, to look at the public perception of veterans, including ways to address such misconceptions.

25.Possible effects of this perception include an amplification of the stigma surrounding Veterans’ mental health and the mis-reporting of PTSD. Also, more common mental health disorders, such as depression, may not be sufficiently recognised as the focus has been on PTSD. We recommend that, using accurate and complete data, the Ministry of Defence work with the health departments of the four nations, charity providers and academics to change the public’s perception. Mental health providers should also ensure that the focus on PTSD does not mean that care provision for more common mental health disorders is neglected.

The public perception may be that serving personnel and veterans are suffering from Post-Traumatic Stress Disorder (PTSD) rather than common mental health disorders, but MOD is unaware of specific evidence to support this. Maintaining good levels of mental health and wellbeing is achieved by a through-life approach, via the application of a wide range of measures based around a model of prevention, early detection and treatment. This ensures that Service people can join well, train well and leave well.

The MOD has launched anti-stigma campaigns, introduced resilience training, and produced policy on workplace and operational stress. The key theme is the need to embed mental health and well-being as individual and collective leadership responsibilities, as currently takes place with physical health.

In addition, the MOD and Samaritans have jointly launched a pocket guide on suicide prevention and peer support, to help serving members of the Armed Forces identify when someone is in need, how to intervene and provide support, and advice on when to raise concerns. It also has a selection of potential routes for further support. The guide is part of a military-specific programme that Samaritans is developing to provide more focused support for serving personnel, Veterans and their families.

Other 24-hour support includes the Big White Wall, an online early intervention service; Veterans UK; and the Samaritans and the Combat Stress helplines which cater for both veterans and Service personnel and their families. In addition, The Veterans Gateway, launched in June 2017, is a consortium of organisations and Armed Forces charities, funded by the Armed Forces Covenant, that provides a single point of contact for veterans, Service personnel and their families to get information, advice and support.

We are not aware of any evidence that mental health professionals, in either the DMS or the NHS, do not recognise or diagnose common mental disorders or that they are mis-reporting PTSD.

Impact of military service on Armed Forces families’ mental health

26.Work on mental health in the Armed Forces has so far focused on those who have served, but their families’ mental health can be just as exposed to the stresses of service life. The impact of service life on families has been little understood, but there are now suggestions that spouses and other family members can also be affected by a traumatic event suffered by serving personnel or by constant redeployment. The Government accepts that it has a duty to support families as much as those who served but, as for veterans, the help they might get will depend on where in the country they live.

We recognise that a great deal is expected from Service families. Not only could a Service person face risk to life during their service on behalf of the nation, but periodically they will be required to deploy on operations, sometimes at very short notice, or for protracted periods, or having only recently returned from a previous separation. There is often little or no choice for the Service person or their families in these situations.

A Service career will also necessitate directed relocation within the UK or overseas. There are also the day-to-day realities of Service life such as working long or unsociable hours, with the associated impact that this can have on the family. All this places considerable additional pressure on Armed Forces’ families.

In 2016 we published the first ever UK Armed Forces Families Strategy: https://www.gov.uk/government/publications/uk-armed-forces-families-strategy and we are working to ensure that the aims of the strategy are achieved reflecting the important role that families have in the Armed Forces Community. The majority of Service families receive their healthcare, including mental healthcare, from the NHS in England and the Devolved Administrations as part of the wider population. For those families in the UK that receive their primary healthcare from the DMS, secondary care is provided by the NHS in England and the Devolved Administrations, as it is for the general population. Families are already familiar with NHS arrangements and there is no requirement for Service or veterans’ families to identify themselves as such when registering with a NHS GP.

NHS England-commissioned Veteran Mental Health Services Transition, Intervention and Liaison Service (VMH TILS) and Complex Treatment Service (VMH CTS) are working collaboratively with other organisations including the wider NHS, DMS and local authorities to provide holistic support for patients and their families. If needed, the VMH CTS supports families and carers to access care and treatment for themselves.

27.We recommend that the Ministry of Defence, in conjunction with the health departments of the four nations, places a greater focus on service and Veterans’ families as part of its mental health care provision. This should include supporting further research into the mental health of current and former Service families to determine what provision is needed. The Ministry of Defence should also monitor how this provision is applied across the UK as part of its annual report on the Armed Forces Covenant.

The Centre for Mental Health (an independent UK mental health charity), working in partnership with Kings College London and Forces in Mind Trust, has developed a Mental Health Research Programme to stimulate and fund research into veterans’ mental health. One of the research priorities is the impact on families, including aggressive behaviour, violence and domestic abuse. The programme will advance our understanding of the needs of veterans with mental health problems and how best to support them and their families when they need it.

Further information Q171

During the oral evidence session, the Surgeon General (SG) was asked ‘how many legal cases have been brought against the MOD for the misdiagnosis of mental health disorders over the last five years?’. SG responded that ‘we do not have evidence of any complaints or legal cases with regard to misdiagnosis attributable to the wrong diagnosis for a mental health condition’. After the session, the HCDC asked the supplementary question: ‘how many legal claims have the MOD had to defend where the serving personnel or veteran is claiming that they did not get the right care for their mental health whilst in service?’. SG directed that a manual review of database records and ‘hard copy’ case files from the MOD’s Directorate of Judicial Engagement Policy be conducted. Following this review, we now believe that, over the last five years, the MOD has had to defend up to 60 legal claims (out of around 700 clinical negligence claims) where the serving person or veteran alleged they did not get the right care for their mental health while serving.





Published: 16 October 2018