Mental Health and the Armed Forces, Part One: The Scale of mental health issues Contents

Conclusions and recommendations

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. (Paragraph 17)

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. (Paragraph 18)

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. (Paragraph 19)

4.We recommend that the Ministry of Defence should commission further research into neurotoxicity and mild traumatic brain injury 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. (Paragraph 20)

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. (Paragraph 26)

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. (Paragraph 27)

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. (Paragraph 43)

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. (Paragraph 44)

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. (Paragraph 45)

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%. (Paragraph 56)

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. (Paragraph 57)

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. (Paragraph 58)

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. (Paragraph 59)

14.Poor recording of veterans at primary care level may also lead to an underestimation of the extent of mental health conditions in veterans and affect how they are being treated. GPs failing to ask, veterans themselves not telling and inadequate recording are all leading to an incomplete picture. If GPs are not aware that their patient is a veteran then they will not be able to refer them to the veteran-specific services that are available in England, Scotland and Wales. 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. (Paragraph 60)

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. (Paragraph 72)

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. (Paragraph 74)

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. (Paragraph 82)

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. (Paragraph 83)

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. (Paragraph 84)

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. (Paragraph 92)

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. (Paragraph 93)

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. (Paragraph 94)

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. (Paragraph 95)

Public perceptions of mental health in 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. (Paragraph 105)

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. (Paragraph 106)

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. (Paragraph 111)

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. (Paragraph 112)

Published: 25 July 2018