113.The Government announced in November 2007 that priority access to NHS medical treatment would be extended to all veterans whose injuries or ill health were attributable to their military service (before this the priority applied only to those in receipt of War Pensions). Guidance was issued to GPs that they should make it clear in referrals to secondary care for conditions related to military service that the patient was a veteran and should be considered for priority treatment over other patients of equal clinical need.
114.Nevertheless, the Royal British Legion in its comments on the 2016 Covenant Annual Report, identified lack of awareness amongst healthcare professionals of veteran priority treatment as a continuing problem. In its comments on the 2017 Annual Report, the Legion stated that it had worked closely with the NHS in England and in Wales to identify problems with the delivery of the policy of priority treatment and how it could be improved. The Legion welcomed the progress outlined in the Annual Report, but noted that there were still challenges to be addressed. In oral evidence to us, the Legion explained that “the issues lie in the delivery of the services that are available” which could be difficult to navigate, and that the provision of services is different in England (and there are differences within England) and the devolved administrations. The MoD said they had established an access and equity group to examine the issue of differences in accessing treatment. Helen Helliwell said that although delivery might not be the same, access should be the same across the devolved administrations.
115.The single Service Families Federations were pleased that Armed Forces and Veterans issues were now part of the national curriculum for GPs, and will be tested in their Royal College of General Practitioners membership examination. This, they saw as an extremely positive development.
116.In contrast, the Scottish Veterans Commissioner, in a recent report, called for a rethink of veterans’ priority treatment. While recognising the political and public support for veterans receiving ‘special treatment’ he argued that “the concept is flawed, often misunderstood and occasionally ignored by a number of health professionals and veterans—whether unwittingly or, in some cases, quite deliberately”. He added:
These views have been emboldened in recent months by feedback received from many individuals and organisations. This has reinforced the fundamental point that care within the NHS is based on clinical need and not on the background, occupation or category of a patient. As a consequence, the promise of priority treatment for veterans is a largely meaningless concept that rarely has any direct impact on individuals.
He believed the emphasis on waiting list times should be replaced by a greater focus upon the principles of excellence, and upon accessible and sustainable treatment for all veterans.
117.While we recognise the progress made, we are concerned to hear about continuing difficulties in veterans receiving priority access to NHS medical treatment, when their injuries or ill-health are attributable to their military service. We call on the Government, in partnership with the devolved administrations, to instigate a specific study as a priority to examine and tackle the inconsistencies in how veterans receive priority treatment. Part of the study should consider enhancing the role of local Covenant champions in ensuring that local health care providers are aware of, and implement, this right for veterans. We also note the recent call of the Scottish Veterans Commissioner for a rethink of priority treatment for veterans. In undertaking this reform, however, it is important that any changes are considered within the context of the entire UK, so as not to increase current inconsistencies.
118.In this section we comment briefly on the provision of mental health treatment to veterans and Service personnel. This topic will be covered in more detail when we complete our separate inquiry into these matters.
119.In 2017, NHS England launched the Transition, Intervention and Liaison Service. The 2017 Covenant Annual Report says that the service increases access to mental health services and treatment options, “doubling the size of the current regional bespoke mental healthcare for veterans in England”. It provides support for the general and complex mental health needs of Veterans and, for the first time, serving personnel preparing to leave the Armed Forces can also access NHS care and treatment for mental health conditions, providing continuity when it is most needed. In England, most veterans use mainstream NHS mental health services. These are expanding through the national Improving Access to Psychological Therapies (IAPT) programme that now has a duty to record Veteran status. In April 2017, this duty was extended to all mental health services.
120.Spending on mental health for the general population in England has increased to a record £11.4 billion in 2016–17, with a further investment planned of £1 billion every year by 2020–21. NHS England spends £6.4 million per annum on additional bespoke services for Veterans. NHS England has commissioned pilots of its Liaison and Diversion programme which aims to enhance means of identification and to improve care options for serving personnel and Veterans in the criminal justice system and to enhance the services provided to their families.
121.The 2017 Covenant Annual Report states “healthcare priorities in Scotland in 2017 included funding the provision of specialist mental health services for Veterans resident in Scotland at £1.2 million per year to 2018 in partnership with NHS Scotland and Combat Stress”.
122.Alongside the Wales’ National Action Plan, there are a number of schemes under way in Wales aimed at addressing the mental health needs of Veterans. A new partnership between Veterans NHS Wales and Change Step is helping Veterans in Wales access crucial mental health treatment and support. Two highly skilled Veteran peer mentors are working alongside specialist psychological therapists to support veterans who need treatment related to experiences during their time in service, or in adjusting to civilian life. The Welsh mental health charity, Hafal, is leading the Wales-wide Forces for Change programme which encourages Armed Forces and blue light Veterans to reach out to fellow Veterans who are experiencing mental health problems. Their goal is to support them in accessing the services needed to recover and to hear their ideas about how those services could be improved. At the end of the campaign, recommendations will be made on developing and improving services across Wales.
123.In Northern Ireland, Defence Medical Services provides mental health treatment for Service personnel and those in transition to civilian life. Outpatient services are primarily supplied via military Departments of Community Mental Health. Inpatient care is provided by the Health Service, contracted by the MoD.
124.As part of their observations on the 2017 Covenant Annual Report, the single Service Families Federations stated:
We would like to recognise formally the activity, support and engagement offered by the Armed Forces Commissioning Managers within NHS England, which has been outstanding; they continue to assist many families in need of advice and help. We also welcome the Defence People Mental Health and Wellbeing Strategy and we are pleased to note that Mental Health is at the forefront of the Health Agenda. We look forward to seeing the new services implemented over the coming months.
125.During our inquiry, a campaign was underway for the Government to provide a 24-hour mental health helpline for serving personnel. A 24/7 helpline for veterans, provided by Combat Stress, was already in existence which had clinicians available to provide assistance to callers. However, it was not clear whether this was also available to personnel who were still serving. In addition, campaigners did not believe it should be left to the ‘third-sector’ to provide this service. On 25 February 2018, the Secretary of State for Defence launched a new 24/7 Military Mental Health Helpline. He pledged an extra £2 million per year for mental health services for the next decade in addition to the £20 million already spent each year and added:
I will personally be working with all the Service chiefs to make sure there isn’t a single person in the forces who doesn’t know where to turn in times of trouble.
126.We are pleased to hear of the progress being made in mental health provision but acknowledge that disparities still exist across the UK. We call on the Government and the devolved administrations to ensure that best practice is shared and that services across all the different parts of the UK are of a comparably and consistently high standard.
127.We note the establishment in February 2018 of the new 24/7 Mental Health Helpline for serving personnel and their families. In response to our report, the MoD should set out how it will measure its effectiveness and ensure that it does not simply replicate the existing Combat Stress helpline. We expect to receive data on the number of calls received and actions taken in response to calls to both helplines.
128.COBSEO told us of their concerns that the Covenant Annual Report 2017 contained no mention of “the pressures that the MoD-owned Departments of Community Mental Health (DCMH) in the UK are under, and what this means in terms of the reduced access to mental health services for serving personnel in the UK”. For example, they understood that in Catterick the local advice was that low-risk Service personnel should be referred in the first instance to welfare agencies (including SSAFA) in order to ease DCMH waiting list pressures.
129.The Report stated that Defence Medical Services had agreed with the Care Quality Commission (CQC) a programme of inspections of Defence Medical Treatment Facilities in order to provide external scrutiny and assurance of the quality of medical care being delivered to Service personnel. 13 Medical and Dental Centres had been inspected in the first quarter of the 2017–18 financial year. Inspections of Regional Rehabilitation Units and Departments of Community Mental Health were due to start before the end of the year. Defence inspection reports were being published on the CQC website in a similar manner to NHS inspection reports. Where the CQC identified areas for improvement, covering governance, staffing and infrastructure, the Surgeon General was committed to addressing its recommendations.
130.The MoD provided further details of the Care Quality Commission (CQC) inspections of Defence Primary Healthcare (DPHC) which began in April 2017. To date there had been 57 inspections with 40 reports published on the CQC website. These reports related to 21 Medical Centres, 17 Dental Centres, one Regional Rehabilitation Unit (RRU) and one DCMH. All 17 of the Dental Centres inspected had been awarded a pass, although the CQC noted a significant number of infrastructure issues. The RAF Cosford RRU passed in all areas. The RAF Brize Norton DCMH was graded as ‘Requires Improvement’.
131.The outcomes of the CQC inspections of Medical Centres had been variable. Four Medical Centres have been graded as ‘Outstanding’, with several areas of notable practice. Six Medical Centres have been graded as ‘Good’, and 10 as ‘Requires Improvement’. One Medical Centre, RAF Scampton, had been graded as ‘Inadequate’. Corrective measures had been put in place and a follow-up report after a re-inspection in February was published in April 2018. The CQC has already produced summaries of issues identified, according to the Key Lines of Enquiry, and aimed to produce an annual report at the end of the first year of inspections in June 2018.
132.We welcome the Care Quality Commission’s inspection programme of Defence Medical Treatment Facilities, including MoD Departments of Community Mental Health, and the fact that their inspection reports are publicly available. We look forward to seeing the Annual Report on the inspections. In response to our report, the MoD should set out what work is planned to draw together any thematic concerns identified by the individual inspections that apply across the treatment facilities so that necessary improvements can be made.
165 Scottish Veterans Commissioner, Veterans’ Health and Wellbeing—A Distinctive Scottish Approach, April 2018, pp 9–10
166 Scottish Veterans Commissioner, Veterans’ Health and Wellbeing—A Distinctive Scottish Approach, April 2018, pp 9–10
174 “Defence Secretary shows commitment to Armed Forces mental health with over £220-million funding and new helpline”, Ministry of Defence press release, 25 Feb 2018
177 Ministry of Defence ()
179 Ministry of Defence (); The 5 Key Lines of Enquiry (KLOE) are: Are services safe? Are services effective? Are services caring? Are services responsive? Are services well-led?
Published: 30 June 2018