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The health and wellbeing of Norfolk’s
veterans
A scoping paper byHealthwatch Norfolk
Edward FraserHealthwatch Norfolk Project Officer
December 2014
The health and wellbeing of Norfolk’s veterans
Table of contentsPage
1. Context 22. Profile 4 The national picture 4 Local context 5 Types of veterans 73. Health and wellbeing needs 9 Overview 9 Service injuries 10 Mental health 12 Additional welfare needs 194. Veterans & health services 20 Veterans’ usage of the NHS 20 Third Sector organisations 265. Conclusion 29 What has Healthwatch Norfolk learned? 29 Recommendations for future work 29Bibliography 32
About this paper:This scoping paper is a first view of the profile and health and wellbeing needs of Norfolk’s veterans. It is not intended as a piece of academic research, rather its purpose is to establish whether further work by Healthwatch Norfolk with this group of people is justified in the future, by answering the following questions:1. How many veterans live in Norfolk and what are their characteristics?2. What are the health and wellbeing needs of local veterans?3. What health services are currently available for the local veteran
community and how effective are these services at meeting veterans’ needs?
4. Are there any areas where Healthwatch Norfolk can make a difference?
The findings and recommendations presented in this paper were compiled over the period October to December 2014 by the Healthwatch Norfolk Project Officer. The supporting evidence consists of national data from desk research and anecdotal information supplied by an anonymous sample of commissioners, providers, professionals, advocates and service users (veterans). A full list of the documents used is provided in the Bibliography on page 32.
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The health and wellbeing of Norfolk’s veterans
Unless specified otherwise, the focus of this paper will be on veterans rather than the wider ex-Service community, which also includes dependents. For the purposes of this paper, a veteran is defined as: “anyone who has served for at least one day in the Armed Forces (Regular or Reserve), as well as Merchant Navy seafarers and fishermen who have served in a vessel that was operated to facilitate military operations by the Armed Forces.”1
1. ContextIt has long been established that the UK has a duty of care to members of its Armed Forces, past and present. Current members of the Forces have their healthcare provided for them by the Ministry Of Defence (MOD) through the Defence Medical Services (DMS). Once they have left the Forces, the responsibility for their care passes over to the NHS. Since 1953, war pensioners have been entitled to priority access to NHS treatment for conditions relating to their Service (subject to the clinical needs of others). In 2008, the policy of prioritisation was extended to include all veterans whose medical conditions are suspected to be related to Service, regardless of whether or not they receive a war pension.2
Media attention on the men and women returning from Iraq and Afghanistan has renewed interest in the precise nature of the duty of care. The 2011 Armed Forces Covenant3 aims to enshrine the duty in law, and it has highlighted veterans as a group who may have specific needs. In addition to the priority of access to treatment, as outlined above, the Armed Forces Covenant states that veterans and their dependents should suffer no disadvantage due to Service when accessing public services like health and social care.
The current healthcare commissioning arrangements for members of the Forces, veterans and families are as follows (Figure 1):4
1 Department Of Health, Meeting the healthcare needs of Armed Forces Personnel, their families and veterans, 2008, p.4: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/28614/dh_091922.pdf.2 Royal College of General Practitioners (RCGP), Meeting the healthcare of veterans, September 2010, p.5:http://www.britishlegion.org.uk/media/1163063/veteranshealthcareneedsgps.pdf . 3 The Armed Forces Covenant refers to the mutual obligations between the nation and its Armed Forces. It sets out what safeguards, rewards and compensation military personnel can expect in return for military Service, and the risks and hardships that can involve. For more information see: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/49469/the_armed_forces_covenant.pdf.4 NHS Commissioning Board, Securing excellence in commissioning for the Armed Forces and their families, March 2013, p.11: http://www.england.nhs.uk/wp-content/uploads/2013/03/armed-forces-com.pdf.
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The health and wellbeing of Norfolk’s veterans
In spite of a growing appreciation of the fact that veterans may be a group of people with particular needs, there are limited bespoke services for veterans in Norfolk. Nationally, NHS England currently provides three specialist services for veterans:
1. A specialist fertility treatment programme, guaranteeing three cycles of IVF to veterans who have sustained serious genital injuries.5
2. Nine Disablement Service Centres, providing enhanced rehabilitation services to veterans who have lost a limb(s) as a result of their Service in the Forces. Norfolk’s nearest centre is at Addenbrooke’s, Cambridge.
3. Ten regional mental health centres specifically aimed at veterans, providing treatment for Post-Traumatic Stress Disorder and other combat related conditions. Norfolk’s nearest centre is run by Veterans First from the North Essex Partnership University NHS Foundation Trust, Colchester.
The responsibility for specialist mental health services for veterans will be passing from NHS England to local Clinical Commissioning Groups in April 2015. It is unclear as this time precisely what these services will look like in Norfolk. A more detailed discussion follows in section 4 of this paper. In addition to these services provided by NHS England, the MOD also provides specialist services for veterans who are suffering from injury or illness (mental or physical) as a result of their time in the Forces. More information about these services may be found in section 4.
5 The issue of IVF services has already been raised to Healthwatch Norfolk. We received a comment (2 September 2014) concerning a local military wife’s trouble accessing appropriate IVF services at the Queen Elizabeth Hospital, King’s Lynn.
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The health and wellbeing of Norfolk’s veterans
2. ProfileNo single agency holds information about the number of veterans who live in Norfolk. In the absence of solid local data, national statistics have been used by means of introduction and then the local context has been provided by extrapolation from these statistics.
The national picture
According to the results of a household survey study published in November 2014 by the Royal British Legion, the size of the UK’s ex-Service community (including veterans and their dependents) is estimated to be around 5.9 million people, which is equivalent to 9.2% of the total UK population of 64.51 million.6 Of this community, 2.83 million people are veterans.7
As a whole, the veteran community is much older than the general population. The average age of the adult veteran community is 67 years, compared with 47 years for the general adult population.8 Nearly two thirds (64%) of veterans are over the age of 65 and nearly half (46%) are over 75, as shown by Figure 2:9
6 Royal British Legion, A UK Household Survey of the ex-Service Community, 2014, p.4: http://www.britishlegion.org.uk/media/4093841/2014householdsurveyreport.pdf . This household survey of 2,121 members of the ex-Service community was compared with UK adults in the fourth quarter of the 2013 Labour Force Survey.7 Ibid.8 Ibid. p.6.9 Ibid. p.7.
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The health and wellbeing of Norfolk’s veterans
The cause for the older veteran community is primarily accounted for by National Service. National Service officially ended on 31 December 1960 and so anyone mobilised under the act would be at least 72 at the time of writing (December 2014).
The vast majority of veterans (88.9%) are male10 and the ex-Service community as a whole (including dependents) has fewer members from non-white minority ethnic groups than in the general population. The figures are 1.7% within the ex-Service community compared to 12.4% in the general population.11
The ex-Service community as a whole has reduced significantly (by 44%) since 2005, when there were an estimated 10.5 million members,12 and it is expected to continue to reduce in the future due to the high proportion of older members in the community.
The age profile of veterans is also changing, with significant reductions in all ages from 35-75 years and increases amongst the oldest and youngest groups. There will be especially large increases in the 85+ age group as a one-off result of the final National Service generation reaching old age at a time of longer life expectancy.13
Local context10 Ibid. p.14.11 Ibid.12 Royal British Legion, Profile and Needs of the Ex-Service Community 2005-2020, September 2006, p.2: http://www.britishlegion.org.uk/media/33526/summary%20and%20cons.%20report.pdf.13 Ibid, p.7.
5
16-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
0% 5% 10% 15% 20% 25% 30% 35% 40%
Figure 2: Age profile of UK veterans compared to UK adult population
UK adults UK veterans
The health and wellbeing of Norfolk’s veterans
The MOD asks Service leavers to provide a home address when they leave the Forces and so in theory it is possible to track the number and location of veterans in a particular area. However, as the MOD admits, the data collected by this exercise is incomplete; 25% of leavers do not provide an address and those who do may leave addresses that are not up to date. Taking the period 1 April 2010 to 31 March 2011 as an example, 89 Service leavers gave a home address in Norfolk.14
In terms of the wider local veteran community, Norfolk Insight15 estimated that there were 90,743 veterans living in Norfolk as of October 2012, which is more than 10% of the total (current) Norfolk population of 859,400. However, this figure was based on estimates made by the Royal British Legion in 2006 and it may have become outdated by subsequent research.
As explained on page 4, the Royal British Legion household survey of 2014 estimates that there are 2.83 million veterans across the UK, which is 4.4% of the total UK population. If one applies the 4.4% estimate to the total population of Norfolk (859,400), one might expect there to be somewhere in the region of 37,814 veterans currently residing in Norfolk. With the same method, one can estimate that the figure for the entire ex-Service community (including dependents) is likely to be around 79,065, which is roughly 9% of Norfolk’s population.
Using the 2014 Royal British Legion veteran age-range estimates outlined on page 4, one can extrapolate further from the figure of 37,814 veterans in Norfolk to reveal numbers of veterans in the following age ranges:
Age Number of local veterans % of local veteran population
Under 25 1021 2.7%25-44 3744 9.9%45-64 8697 23%65-84 20,571 54.4%85+ 3781 10%Total 37,814 100%
These figures should be treated as very rough estimates. On that note, it is important to realise that a higher proportion of veterans live in rural areas (like Norfolk) than in urban areas (like London) so it is possible that more than veterans make up more than 4.4% of Norfolk’s population.
In addition to the 37,814 or so veterans described above, there are ‘hidden’ populations of veterans in Norfolk, such as those in prison or living on the streets. According to a 2010 estimation by the Defence
14 Norfolk Insight, Profile of Veterans in Norfolk, October 2012, p.2: www. norfolkinsight .org.uk/resource/view? resourceId=656.15 Ibid.
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Analytical Services and Advise (DASA), 2,820 prisoners (or 3.5% of all UK prisoners) are veterans of the Regular Forces, 77% of whom are ex-Army.16 Applying the 3.5% estimate to HMP Wayland, which currently has 953 British National prisoners,17 one should expect to find 33 veterans within the prison.
There is no reliable national estimate of homeless veterans. The National Audit Office has previously suggested that 5% (around 900 people in 2010-11) of Service leavers may find themselves homeless each year,18 but this figure should be treated with caution. Although most of the research has focused on London, Norfolk Insight19 notes that a study of homelessness in rural areas found that the presence of a rural military base is likely to increase the prevalence of homeless veterans. For context, Norfolk has bases at Marham, Swanton Morley and Norwich.
As a final comment, there is no reason to suspect that veterans living in Norfolk will differ demographically from the national picture in any significant way.
Types of veteransIt is important to realise that the term ‘veteran’ covers a diverse group of people who have very different characteristics and needs. The only thing that veterans necessarily have in common is the fact that they have all served in the Forces, and this consideration may be more important to some veterans than it is to others.Indeed a significant number of people who have served in the Forces would not even identify themselves as veterans; younger veterans may describe themselves as ‘ex-military’ instead because they associate the term ‘veteran’ with the older generation that appear in Remembrance Day parades.20
16 MOD (DASA), Estimating the proportion of prisoners in England and Wales who are ex-Armed Forces, 2010: http://www.dasa.mod.uk/applications/newWeb/www/index.php?page=48&pubType=3&thiscontent=550&PublishTime=13:00:00&date=2010-09-15&disText=Single%20Report&from=listing&topDate=2010-09-15 . This 3.5% is a marked reduction from the National Association of Prison Officer’s (NAPO) 2009 estimation of approximately 10%.17 HM Chief Prison Inspector, Report for Wayland Prison July 2012 – August 2013, 2014: http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/prison-and-yoi-inspections/wayland/wayland-2014.pdf.18 Royal British Legion, Literature Review: UK Veterans and Homelessness, 2010, p.3:http://www.britishlegion.org.uk/media/31582/LitRev_UKVetsHomelessness.pdf.19 Norfolk Insight, 2012, op. cit. p.7. Also see Homeless Link, Supporting Homelessness Agencies to Deliver Services in Rural Areas, 2007: www.homelesspages.org.uk/node/22649.20 NHS Kent & Medway, Veterans’ health needs assessment for Kent and Medway, June 2011, p.6: https://www.google.co.uk/search?q=Veterans%E2%80%99+health+needs+assessment+for+Kent+and+Medway%E2%80%99&sourceid=ie7&rls=com.microsoft:en-GB:IE-Address&ie=&oe=&gfe_rd=cr&ei=A4WJVLTGDImFbI-cgqAI&gws_rd=ssl#safe=off&rls=com.microsoft:en-GB:IE-Address&q=Veterans%E2%80%99+health+needs+assessment+for+Kent+and+Medway.
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A veteran’s experience of life in the Forces will depend largely on the period in which they served and the conflicts in which they participated. The following table shows the major conflicts that the UK Armed Forces have been involved in since the abolishment of National Service in 1960, and the minimum current age of the veterans who were involved in these conflicts:
Conflict Minimum current age
Afghanistan (2001 – 2014) 18Iraq (2003 – 2011) 21Northern Ireland (1969 – 1998) 34Bosnia & Kosovo (1992 – 1995) 37First Gulf War (1991) 38Falklands (1982) 50
According to the Royal British Legion,21 around 91% of veterans served in the Regular Forces (54% served in the Army). This figure is likely to decrease in the future; the Regular Forces are expected to shrink following the withdrawal from overseas operations in Afghanistan and a greater reliance will be placed on Reservists. One may therefore expect to see Reservists making up an increasing proportion of the veteran community in the years to come.22
On average, veterans served with the Forces for seven years.23 Around 67% of veterans served for more than two years but less than 10 years. This large group of veterans are predominately National Service veterans.24
The average length of time since veterans were discharged from the Forces was 41 years (1973)25 and veterans were most commonly discharged 50-59 years ago (between 1955 and 1964).26 By means of concluding this section, it is possible to use the information that has been supplied thus far to identify four distinct groups of veterans:27
1. Younger veterans who have been in the Service a shorter time These veterans are less likely to have completed active Service
and include Early Service Leavers – men and women who are
21 Royal British Legion, 2014, op. cit. p.11.22 MOD, Reserves in the Future Force 2020, July 2013:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/210470/Cm8655-web_FINAL.pdf23 Royal British Legion, 2014, op. cit. p.12.24 Ibid.25 Ibid.26 Ibid.27 NHS Hertfordshire, Health Needs Assessment of Veterans, July 2011, p.8:http://www.hertsdirect.org/mm/16983563/16983569/item4bmentalwellbeing.doc.
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The health and wellbeing of Norfolk’s veterans
leaving the Forces before the end of their initial three to four and a half year contract (often earlier rather than later)
2. Those who have completed active Service A small subgroup includes those who are medically discharged,
with serious physical injury or mental illness as a result of active Service
3. Older veterans, who have often had over 20 years in Service4. Non-regular personnel: Reservists
3. Health and wellbeing needsOverview
Healthcare provision is known to be highly important to those in the Forces. According to a 2013 study by the MOD, the two factors most likely to decrease intention to leave the Forces are healthcare and dental
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The health and wellbeing of Norfolk’s veterans
provision.28 However, very little is known about how veterans experience health provision post-Service. The MOD’s 2008 Service Personnel Command paper emphasised the lack of knowledge about veterans’ health needs at both local and national levels:
“We need to improve our information about how veterans’ health needs differ from those of the population generally. Most healthcare professionals do not have direct knowledge of the Armed Forces and may not be sensitive to their particular needs.”29
As of 1 July 2014, the full-time trained strength of the UK Armed Forces was 163,670.30 Approximately 10% (18-22,000) of the Service community opt to leave each year; two thirds of those leaving are from the Army.31
Limited evidence suggests that most Service leavers do well in civilian life. The Forces aim to instil their personnel with a sense of self-respect, purpose and belonging as well as equipping them with life skills and training for successful transition from the Military. Many veterans, even those who have served in difficult circumstances, speak positively about their time in the Forces, and a career in the Forces gives some men and women access to opportunities that it would have been impossible for them to otherwise pursue.
Nonetheless, a significant minority of veterans suffer from poor health outcomes, especially when it comes to mental health. As this section will explain, at least some of these poor outcomes are directly related to the peculiarities of Service, or to a failure to make a successful transition from military to civilian life.
Discussions about the poor health suffered by veterans with so called ‘Gulf War Syndrome’ have died down in recent years, and the term has not been used widely since 2007.32 A 2009 national review of veterans’ health by the Department Of Health concluded that, taken as a whole, veterans have comparable physical and mental health to the general population.33 However, according to the Royal British Legion, veterans are much more likely to self-report as having poor health than members of the general population.34
28 MOD (DASA), Armed Forces Continuous Attitude Survey 2013 Report, July 2013, p.5: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/280012/2013_main_report.pdf.29 MOD, The Nation’s Commitment: Cross-Government Support to our Armed Forces, their Families and Veterans, July 2008, p.13: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/238719/7424.pdf.30 G. Berman, T. Rutherford, Note on Defence Personnel Statistics, September 2014, p.5: http://www.parliament.uk/business/publications/research/briefing-papers/SN02183/defence-personnel-statistics.31 Norfolk Insight, 2012, op. cit. p.4.32 NHS Hertfordshire, 2011, op. cit. p.13.33 Department Of Health, Health and Social Outcomes and Health Service Experiences of UK Military Veterans: a summary of the evidence, September 2009:http://www.networks.nhs.uk/news/health-and-social-outcomes-and-health-service-experiences-of-uk-military-veterans-a-summary-of-the-evidence-november-200934 Royal British Legion, 2014, op. cit. p.39.
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In fact, looking at the entire ex-Service community (including dependants), the picture seems quite bleak. More than half (58%) of the adult members report that they have a long-term illness, disability or infirmity that limits their day-to-day living, a proportion that is more than twice as high as in the general adult population (21%).35 However, the prevalence of any long term health problems or disabilities increases with age, so the poorer health of the ex-Service community as a whole is at least partly explained by their more elderly composition (as shown on page 4).
A closer inspection of Royal British Legion data, comparing cohorts of the ex-Service community with cohorts of the general population of the same age reveals that:36
The retired ex-Service community, particularly those over the age of 75, generally report as being in better or equivalent health to their peers.
The ex-Service community of working age generally report as being in poorer health.
Veterans show different prevalence of various types of conditions, relative to the general population of equivalent age (spaces left blank represent a similar prevalence of condition):37
Condition Age 16-44 Age 45-64 Age 65-74 Age 75+ Musculo-skeletal Higher Lower LowerCardio-vascular Higher LowerRespiratory HigherMental health HigherHearing Higher
It is fair to say that, for the most part, the health problems experienced by older veterans are the result of age. By contrast, the problems experienced by younger veterans are more likely to have something to do with their Service history. Indeed, more than half of veterans aged 25-44 with a long-term illness attribute it to their Service.38
Service injuriesServing in the Forces is a dangerous job and some of the poor health outcomes reported by veterans will be a direct result of the injuries they received in the line of duty. This is an important point when one considers the commissioning context, where veterans are entitled to priority of access to certain NHS treatments if and only if their condition is suspected to be related to their Service. 35 Ibid.36 Ibid.37 Norfolk Insight, 2012, op. cit. p.5.38 Royal British Legion, 2014, op. cit. p.35.
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The health and wellbeing of Norfolk’s veterans
Of the 20,000 or so personnel leaving the Forces each year, around 10% (2,000) are discharged for medical reasons, the majority of which are directly related to Service.39 The most common cause of medical discharge is muscular-skeletal injury, which accounted for roughly 55%-60% of all medical discharges in the period 2009-14.40 Other medical conditions relating to Service include:
Burns Injury, wounds and scarring Physical disorders including infectious diseases Neurological disorders (including spinal cord, head or brain injuries) Disorders with the senses Loss of limbs Fractures and dislocations
To put this discussion into local terms, according to Norfolk Insight,41 as of 12 July 2011 there were 2020 veterans in Norfolk in receipt of a disablement pension under the War Pension Scheme (WPS) and a further 85 in receipt of payments from the Armed Forces and Reserve Forces Compensation Scheme (AFCS). The WPS was a compensation scheme paid to ex-Service personnel who sustained serious injury, illness or death in Service prior to 2005, when it was replaced by the AFCS.
The total figure of 3015 veterans receiving compensation for conditions relating to Service consisted of just 3.3% of Norfolk’s total veteran population (at the time that the estimate was made) but it must be acknowledged that the figure is approximate and does not indicate the needs not met by the pension.
This chart (Figure 3) shows the types of injuries for which veterans were being compensated (nationally) in the period 6 April 2005 to 31 March 2011:42
39 MOD (DASA), Annual Medical Discharges in the UK Regular Armed Forces 2009/10 - 2013/14, July 2014:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/328699/medical_discharges_1_apr_09_31_mar_14_.pdf40 Ibid.41 Norfolk Insight, 2012, op. cit. p2.42 Chart taken from NHS Sussex, Military Veterans Health Needs Assessment, 2012, p. 34: https://www.google.co.uk/search?q=nhs+sussex+veterans+health+assessmnet&sourceid=ie7&rls=com.microsoft:en-GB:IE-Address&ie=&oe=&gfe_rd=cr&ei=e82BVIT5JIr4-gbN_oGACw&gws_rd=ssl#safe=off&rls=com.microsoft:en-GB:IE-Address&q=nhs+sussex+veterans+health+assessment .
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Of all the injuries listed on the previous page, it is worth considering loss of limbs in particular, because military amputees can often require significant and life-long care. Military amputees have featured heavily in the recent media coverage of the conflicts in Iraq and Afghanistan. Of course veterans from previous conflicts have also have sustained serious physical injuries, including amputations, but it is those from Iraq and Afghanistan who will present with the most significant health needs over the next few years. The frequent usage of Improvised Explosive Devices (IEDs) in these conflicts and the improvements in modern battlefield trauma treatment have meant that men and women are who are being discharged from the Forces today may leave with serious disablement, following injuries from which older generations of military personnel would never have survived.
The MOD’s quarterly amputation statistics for March 2014 show that, since 2001, 295 British Servicemen and women have suffered amputations after being wounded in Iraq or Afghanistan, of whom 109 (37%) have lost two or more limbs.43 This number may be small, but the level of ongoing care required for each amputee can be high, with costs set to continue to rise in the future.44 According to a leading charity for limbless veterans, there are 19 military amputees in Norfolk (from all conflicts) of whom two have lost two limbs and one has lost three.
In the case of the younger military amputees coming back from Iraq and Afghanistan, a different kind of rehabilitation and prosthetics service may be required. Traditionally NHS services have been set up to meet the needs of largely elderly patients, rather than young and previously active patients, many of whom are looking to maintain a high level of fitness.
It is not only military amputees who require ongoing care. More generally, as of September 2011, 750 Forces personnel had been seriously or very seriously injured in Iraq and Afghanistan.45
Mental healthAt first glance there appears to be no reason to connect time in the Forces with especially poor mental health. The second most common cause of medical discharge in the period 2009-2014 was mental and behavioural
43 MOD (DASA), Quarterly Amputation Statistics, March 2014: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307102/20140501_Amputation-statistics-March-2014_clean.pdf. 44 British Orthopaedics Association, The Chavasse Report, Spring 2014: http://thechavassereport.com/PDFs/TheChavasseReport-TheEvidence.pdf.45 NHS Kent & Medway, 2011, op. cit. p.35.
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disorders,46 but of the 2,000 or so members of the Service population who are discharged for medical reasons each year, only 10% (200) are identified as having a psychiatric problem. This group make up only 1% of the Service leavers each year.47
This figure feels low when one considers the context of the level of mental health conditions in the general population, where one in four British adults experiences at least one diagnosable mental health problem in any one year, and one in six experiences this at any given time.48
The MOD makes it a priority to provide high-class mental health support to all its staff. However, the accuracy of MOD discharge statistics as a measure of the true mental health needs of those leaving the Forces each year (and, by extension, the wider veteran community) should be questioned. For one thing, the statistics focus on the primary invaliding condition. Somebody who left the Forces as a result of losing a leg in combat could also have significant mental health issues, but their discharge would not be classified as psychiatric.
For another thing, anecdotal evidence suggests that current personnel may be discouraged from admitting that they are struggling with poor mental health for fear that their disclosure will damage their career prospects or cost them their job. The MOD operates a zero tolerance policy to drugs and alcohol, and the kind of operations performed by members of the Forces require such high levels of ‘nerve’ that current Servicemen and women may worry that they will be regarded as a potential liability by their superiors if they admit to having poor mental health.
In general, it is thought that veterans have similar mental health to the rest of the population. Numerous studies49 have found that prevalence rates of mental health conditions amongst veterans are (in order from highest to lowest):
1. Adjustment disorders2. Alcohol misuse3. Depressive disorders4. Personality disorders5. Post-Traumatic Stress Disorder (PTSD)6. Drug misuse
It may be surprising to find PTSD so far down this list. After all, PTSD remains the quintessential Service condition. The prevalence of PTSD in 46 MOD (DASA), July 2014, op. cit.47 M Fossey, Across the Wire: Veterans, Mental health and Vulnerability, Centre for Mental Health, May 2010, p.6: http://socialwelfare.bl.uk/subject-areas/services-client-groups/adults-mental-health/centreformentalhealth/128555Across_the_wire.pdf48 http://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/.49 For example, D Murphy et al. ‘The Mental Health of Veterans’ in Journal of the Royal Army Medical Corps, Vol. 15(2), pp.135-138, 2008: http://jramc.bmj.com/content/154/2/136.full.pdf+html (subscription required).
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veterans is currently a topic of hot debate. Where once the very existence of the disorder was denied, current thought is that the prevalence of clinically diagnosed PTSD in veterans has been exaggerated in recent years. Veterans are a highly politicised group, and PTSD has become such a ‘buzz word’ for civilians and military personnel alike50 that the diagnosis is sometimes used generically to refer to combat related mental health conditions.
The reality is that clinically diagnosed PTSD seems to be a problem for a minority of veterans. According to the nation’s leading veteran’s mental health charity, Combat Stress, around one in 25 veterans of the Iraq and Afghanistan wars, for instance, are likely to develop PTSD. This rate of prevalence (4%) is similar to that found in the general public (3%).51 Veterans are more likely to develop common mental health conditions like depression instead.
Arguably the biggest problem facing the mental health of the veteran community is alcohol misuse. All branches of the Forces have strong drinking cultures. On operations, alcohol is cheap and readily available, and (off-duty) drinking is not discouraged as a form of bonding and a way of letting off steam.52 Some veterans continue the habit when they leave the Forces,53 and alcohol may be used as a form of self-medication; helping a person to deal with traumatic events witnessed in Service, or with adjustment issues having left the Forces. Indeed, one in three veterans who admit to having a problem with alcohol attribute this problem to their time in the Forces.54
A 2007 study55 of the drinking habits in the Forces compared to the general population revealed that 67% of men and 49% of women in the Forces drink at a level that is defined as ‘hazardous’ by the World Health Organisation (WHO). These percentages are more than one and a half times as high for men and more than three times as high for women in the general population (all figures adjusted for age). Considering the clear links between alcohol misuse and wider social issues like unemployment, violent behaviour, imprisonment and homelessness, the current levels of alcohol consumption by Forces personnel (past and present) should be concerning for all public services.
If it is true that, alcohol misuse aside, veterans generally have similar mental health to the rest of the population, then it is also the case that those veterans who do suffer from poor mental health tend to present late 50 Anecdotally, it seems that PTSD has become something of a badge of honour by some veterans, sometimes being offered as justification for anti-social behaviour.51 http://www.combatstress.org.uk/mythbusters. Numerous American studies have found the rate of PTSD in Vietnam veterans to be much higher, with some estimates going as high as 70%. It is fair to say that PTSD may affect a greater proportion of veterans who were combat troops.52 It should be noted that the MOD has hardened its attitude towards the issue of alcohol misuse in recent years.53 Royal British Legion, 2014, op. cit. p.42.54 Ibid.55 NT Fear, A Iversen et al. ‘Patterns of drinking in the UK armed forces,’ in Addiction, Vol. 102(11), pp.1749–1759, November 2007: http://www.ncbi.nlm.nih.gov/pubmed/17935583 (subscription required).
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to mental health services with complex and severe needs, often involving co-morbid conditions. There are several risk factors associated with being a veteran that account for the complexity and severity of the mental health conditions suffered by this significant minority. The four main risk factors are as follows:
1. Pre-enlistment factors
Veterans are of course subject to the same wider socio-economic risk factors associated with poor health that affect the general population. The link between poverty and poor mental health is well established, and it should be of no surprise that, by and large, veterans who served as officers have better outcomes than those who were in the ranks.
Generally speaking, a disproportionate number of veterans come from impoverished backgrounds. The Army in particular recruits heavily from disadvantaged areas.56 Although the MOD’s mental health screening of recruits has become far more sophisticated, it is likely that at least some of the veterans with poor mental health were in fact already vulnerable before they joined the Forces. Underlying issues can be exacerbated by combat experience or by a failure to adjust to the transition from military to civilian life (see below for both).
It is also important to note that a career in the Forces attracts a certain type of person. People who join the Forces are, to some extent, ‘risk-takers’, which can have implications when it comes to lifestyle choices and mental health.
2. Combat experience
The most obvious potential risks to the mental health of military personnel are violent or traumatic experiences of combat. It should come as no surprise, for example, that combat troops are more vulnerable to developing PTSD than those in support.57 A 2010 study58 of the Iraq and Afghanistan conflicts examined the number of times military personnel had been exposed to specific traumatic situations to assess the impact on their mental health. Amongst other things, this study found that nearly half of those were surveyed had seen comrades wounded and killed, as shown in the table beneath (Figure 4):59
56 D Gee & A Goodman, Army recruiters visit London’s poorest schools most often, 2010: http://www.informedchoice.org.uk/armyvisitstoschools.pdf.57 King’s Centre For Military Health Research, A fifteen year report, 2010, p.22:https://www.cobseo.org.uk/files/kings-centre-for-military-health-research-15-year-report.pdf.58 N.T. Fear et al. ‘What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study,’ The Lancet, Vol.375(9728), pp.1783-97, 2010: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60672-1/abstract (subscription required).59 NHS Sussex, 2012, op. cit. p.39.
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The health and wellbeing of Norfolk’s veterans
The above table illustrates that men and women in the Forces face unique risks. If they go on to experience problems with their mental health, these problems may be very acute and they may be presented in a context that is unfamiliar to civilian mental health professionals. As a result of this, some veterans may require particular treatments.
As Combat Stress explains, in the case of PTSD:
“While the rate of occurrence is similar [to that of the general population], the complexity of the disorder tends to be much greater in Veterans. Furthermore, it often occurs alongside other medical problems such as pain, disability and substance misuse, particularly alcohol misuse.”60
It is worth mentioning that the majority of Norfolk’s 8000 odd service personnel are based at RAF Marham and are less likely to have seen personnel wounded and killed, for example, than front line combat troops.
3. The Armed Forces culture
Mental health conditions are known to be stigmatised in the general population. Men are widely recognised as being particularly reluctant to admit to having a mental health problem, and the vast majority of veterans are male. There is a very powerful ‘macho’ culture in the Forces; military personnel take great pride in what they do, and they do not want to appear weak in front of their comrades, who depend on them for survival in conflict situations.61 The military attitude when confronted with a problem may be described as simply to ‘crack on.’
It follows that one might expect male veterans to be even less likely to seek help than their counterparts in the general population. In an age when the term ‘veteran’ has become almost synonymous with ‘hero’, there is little wonder why some veterans might feel ashamed to identify themselves with a group of people who are often referred to as being the ‘victims’ and ‘sufferers’ of mental health conditions.
60 http://www.combatstress.org.uk/mythbusters.61 It is worth remarking that an additional problem is that it can be difficult for female veterans to find another female to talk to, due to the fact that the vast majority of current military personnel and veterans are male.
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The health and wellbeing of Norfolk’s veterans
The end result of this reticence is that veterans may repress mental health conditions for many years, perhaps with the aid of alcohol (as mentioned on page 14). Indeed, according to Combat Stress, the average delay between symptom onset of mental health conditions and presentation to services is 13 years for veterans,62 by which point the problems can be complex and severe, involving multiple conditions.
This means that health services may not yet be fully aware of true scale of the need. One may expect to see rates of diagnosis of mental health conditions in veterans increase in the future, as the full psychological impact upon the men and women who fought in Iraq and Afghanistan becomes apparent.
Another point to note on this topic relates to Forces training. As part of their training, all new recruits, especially those joining the Army, are conditioned to respond instinctively to stressful situations with anger and aggression. The option of flight is removed from a recruit’s natural ‘fight or flight’ reaction to a perceived threat. Whilst this kind of conditioning may serve a person well in a combat situation, aggression is rarely a suitable response to the stresses of normal civilian life, and it is not conducive to good mental health in the long term. The apparent incompatibility of the military mind-set with life as a civilian is illustrated by the fact that a higher proportion of veterans (57.6%) are imprisoned for violent and sexual offences than the general population (39.5%).63
It is crucial not to overstate the significance of this issue, but there is a growing body of evidence suggesting that Forces training itself, quite apart from the trauma of active duty, leaves men and women more susceptible to developing mental health conditions and less equipped to overcome them.64
4. Transition from military to civilian life
The transition from military to civilian life can be an area of vulnerability for some veterans, as demonstrated by the fact that adjustment disorders are the most prevalent of all the mental health conditions affecting veterans. After the intense highs and lows of active duty (which may be broadly characterised as long periods of inactivity punctuated by sharp bursts of intensity) the daily drudgery of life on ‘Civvy Street’ must be something of a come down.
Moreover, to some extent military personnel may be described as institutionalised in so far as they have all of their needs catered for; they 62 A Inversen & N Greenberg, ‘Mental health of regular and reserve military veterans,’ Advances in Psychiatric treatment, Vol. 15, 2009, p.104: http://apt.rcpsych.org/content/15/2/100.full.pdf. Note: younger veterans have been found to be more likely to seek support. The average length of time for veterans under the age of 24 is two years from onset of symptoms.63 MOD (DASA), 2010, op. cit.64 For further information, please see ‘You’re not in The Forces now,’ a video by Australian Psychologist and Vietnam Veteran Dr. Nic Fothergill. This video is shown to all new patients at Combat Stress’s residential centres: https://www.youtube.com/watch?v=7FwLpcpXNdM.
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The health and wellbeing of Norfolk’s veterans
do not need to worry about practical matters like cooking for themselves, paying Council Tax or finding a GP. When a person leaves the Forces, they lose all of this help; their job, their house, their medical services and so on.
Most importantly, when a person leaves the Forces they leave behind their comrades and their support network. It may be difficult for them to keep in touch with their old unit and they may feel as though their friends at home no longer understand them. Servicemen and women who are married spend the majority of their time away from their spouses, which can lead to relationship problems when they leave the Forces. Indeed, some sources have claimed that as many as 70% of marriages of soldiers who served in Iraq have since broken down, although this figure may be something of an exaggeration.65
It is easy to see how some veterans can struggle to adjust to this abrupt dislocation. Those who fail to make the adjustment may quickly become socially excluded, and are at risk of developing mental health conditions, if they haven’t developed them already. It must be noted that the pervading myth in the media, that military personnel are ‘mad, bad and sad’ does not help veterans when they seek to re-join the civilian world.66
People leaving the Forces receive support from the MOD to help them manage their transition (especially those being discharged on medical grounds) but the quality and quantity of this support largely depends on the amount of time the person has served in the Forces. Generally speaking, those who have had a longer career are given more support than those who have served for a shorter length of time. This is in spite of the fact that the people who find the transition the hardest to manage are those who have served the shortest amount of time. These veterans are called Early Service Leavers because they leave the Forces before completing the minimum term of their contract (which can be between three and four and a half years). Older veterans who have served in the Forces for many years may also struggle to adapt to life outside the wire.
Of the four groups of veterans identified on page 8, two groups are particularly likely to suffer from poor mental health. These groups are Reservists and Early Service Leavers.
Reservists:
Reservists do not have access to the same support networks that members of the Regular Forces enjoy and as a consequence they may find traumatic experiences harder to deal with. Reservists are thought to be more than twice as likely to develop PTSD, for example.67 This group might also find the transition from military to civilian life to be particularly 65 King’s Centre For Military Health Research, Symposium Summary - 16th April 2012, 2012, p.1: http://www.kcl.ac.uk/sspp/departments/warstudies/news/newsrecords/summary.pdf.66 Royal British Legion, 2014, op. cit., p.iv.67 King’s Centre For Military Health Research, 2010, op. cit. p.2.
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The health and wellbeing of Norfolk’s veterans
difficult, as the juxtaposition of serving on the front lines one minute, and then returning to a ‘day-job’ the next has the potential to be very sharp. The issue of Reservists’ relative vulnerability becomes a potentially significant problem when one considers the fact that a greater reliance is going to be placed on Reservists by the MOD in the future (as noted on page 7). The conflict in Afghanistan saw the largest mobilisation of Reservist Forces since the Korean War ended in 1953 and so it is difficult to predict what support will be needed for Reservists over the next few years.
Early Service Leavers:
Each year, there are around 8,000 Early Service Leavers (roughly 40% of all Service leavers).68 Early Service Leavers tend to be young men and women from disadvantaged backgrounds and most of them have few skills and training when they join the Forces; usually the Army,69 which has a minimum entry requirement for new recruits that is equivalent to the standard expected of a seven or eight year old in literacy and numeracy (9% of recruits have a have a GCSE grade A* to C in English compared with a 61% national average).70 Because they leave the Army before the career advancement process begins (around five years), Early Service Leavers do not have a chance to develop the new skills and qualifications that will enable them to find jobs upon discharge. Often Early Service Leavers will leave well before the end of their contract; they may not pass basic training, or they may be discharged on disciplinary grounds, for example.
All things considered, it is perhaps not surprising that Early Service Leavers are more likely to struggle in civilian life, with a disproportionate number of them finding themselves unemployed, homeless or in prison and/or suffering from poor mental health. Indeed, male veterans under the age of 24, many of whom will be Early Service Leavers, are two to three times more likely to commit suicide than their counterparts in the general population.71 The plight of Early Service Leavers is certainly not helped by the lack of support provided by the MOD, relative to veterans who have been in the Forces for longer. It must be noted, however, that the MOD is taking steps to improve their offer to Early Service Leavers.
Many of the issues that have been discussed in this section are brought together in this slide (Figure 5), which is a
68 Norfolk Insight, 2012, op. cit. p.8.69 The average length of Service for an Army infantryman is under 4 years.70 NHS Kent & Medway, op. cit. p.7.71 N Kapur, D While et al. Suicide after leaving the UK Armed forces- a Cohort study, in PLoS Medicine, Vol. 6(3), p.0269, March 2009: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2650723/pdf/pmed.1000026.pdf.
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The health and wellbeing of Norfolk’s veterans
profile produced by Combat Stress in 200972 of a ‘typical’ new referral into their service:
Additional welfare needs
The general welfare needs of the adult ex-Service community reflect the relative old age of its members. For instance, the 2014 Royal British Region household survey showed that the single most reported difficulty is the ability to get around outside of the home.73 This difficulty will be all the more apparent in a large county like Norfolk, where people living in rural communities can become isolated. The following table (Figure 6) from Norfolk Insight74 shows the proportion of veterans who report as experiencing each difficulty:
4. Veterans & health servicesVeterans’ usage of the NHS
As explained on page 3, there are limited veteran specific NHS services in Norfolk, although NHS England provides three specialist services at a national level. Norfolk’s Clinical Commissioning Groups (CCGs) joint fund one bespoke mental health service for veterans with the military charity Help for Heroes. This service is called Adventure Quest and it is open to veterans from across East Anglia. Adventure Quest helps around 25 veterans a year, who are struggling with poor mental health, by taking them out of the clinical setting and back to nature, providing them with one-to-one support whilst delivering training in a mountain leader qualification.75
72 Busuttil, W Management of Mental Health in Veterans: the role of the third sector charity, Combat Stress, 2010, p.18: www.rcpsych.ac.uk/pdf/6-Wbusuttil.pdf.73 Royal British Legion, 2014, op. cit. p.36.74 Norfolk Insight, 2012, op. cit. p.6.75 For further information visit the Adventure Quest website: http://adventurequestuk.org/.
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The health and wellbeing of Norfolk’s veterans
Adventure Quest aside, it is expected that Norfolk’s veterans will use local NHS services in the same way as the rest of the general public. It must be stressed that the vast majority of veterans do just this. Most individuals who leave the Forces are fit and healthy. However, as shown in the previous section, Service does not always prepare an individual well for life as a civilian and the more vulnerable veterans may need additional help to engage with health services.
According to the Armed Forces Covenant, the starting point for dealing with the health needs of veterans should be to ensure that they are at no disadvantage. Bearing this in mind, the two key issues relevant to NHS service provision for veterans are:76
1. Effective transition from Defence Medical Services (DMS) on leaving the Armed Forces
2. The need for culturally sensitive mental health services within mainstream mental health provision
Effective transition from DMS to NHS:
GPs are the ‘gatekeepers’ of the health system and they play a crucial role in the transition from DMS to normal NHS services. When a person leaves the Forces, they are no longer the responsibility of the DMS, and it is up to them to register themselves at a GP surgery to access healthcare. The MOD encourages veterans to register with a GP as soon as possible after discharge, and to identify themselves as ex-military.
However, veterans tend to be a very socially mobile group; some of them do not bother to find a GP (or indeed a dentist) until they have been out of the Forces for many years, and some do not at this point disclose that they are ex-military, either because they do not want to or because they do not think that it’s relevant. Veterans who have become socially excluded for reasons such as those that were discussed the previous section are even less likely to register with a GP, even though these veterans may be the most in need of help.
Even if a veteran does disclose their veteran status to their GP, GPs do not always have a system for recording the disclosure on the veteran’s health record and they are not always aware that they can call down the veteran’s medical record from DMS, or how to do so.77 GPs may also not always know how best to respond to the information they have been given.78 In the instance of mental health, for example, the picture is very complicated, not least because of the confused nature of the pathway to multiple providers, both within the NHS and charitable organisations (for example Combat Stress).76 Department Of Health, Health Services for the Armed Forces, their families and veterans – Guidance for SHAs, Gateway reference: 10070.77 NHS Kent & Medway, June 2011, op. cit. p.55. 78 Ibid.
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The health and wellbeing of Norfolk’s veterans
Given that this paper has provided several reasons to consider veterans as a potentially vulnerable group with particular needs, it is vital that veterans are encouraged to register and identify with GPs and that GP surgeries have the right procedures in place to respond suitably when a veteran identifies. Helping to tighten up the transition between DMS and NHS has been one of the responsibilities of Norfolk’s Community Covenant, about which more details follow on page 28.
As outlined on page 2, veterans are entitled to priority of access to treatment for conditions that are suspected to relate to their time in Service. Assuming a veteran has identified themselves, their GP should therefore be able to refer them if appropriate according to this policy. However, anecdotal evidence suggests that this is not always being done nationally or at a local level.
Part of the problem is that many GPs are unaware of the policy in the first place. In a 2009 survey of 500 GPs,79 81% of those questioned said they knew not very much or nothing at all about priority treatment. Admittedly this data is small scale and rather outdated, but according to some of the people involved in this scoping project, many GPs remain unaware of the policy today. Moreover, anecdotally, it seems that some GPs who are aware of the policy disagree with it and are reluctant to act upon it in practice.
The priority of access to treatment is contentious, even amongst veterans, many of whom do not want to be treated any differently to other members of the public. The debate is particularly controversial when talking about mental health conditions, where the direct cause of trauma is often difficult to establish, especially considering that veterans often do not present with problems until many years after they have left the Forces. Veterans should only receive priority for those conditions directly attributable to Service, and as this paper has shown, there are many non-Service factors that might affect a veteran’s mental health. Even considering PTSD, only 50% of cases arising in currently serving personnel can be directly attributed to deployment.80
Regardless of the controversy surrounding the priority of access to treatment, since the Armed Forces Covenant of 2011, the policy has been a law and health services should respond accordingly.
Mental health support:
The MOD has substantially improved the mental health support it offers to current personnel and veterans in recent years. The Veterans’ & Reserves Mental Health Programme (VRMHP), based at Chetwynd Barracks, 79 Ipsos-MORI online questionnaire completed by 500 representative GPs across England and Wales. For more details see NHS Kent & Medway, June 2011, op. cit. p.56.80 M Jones et al. ‘What explains post-traumatic stress disorder (PTSD) in UK service personnel: Deployment or something else?’ in Psychological Medicine, First-View, pp.1–10, 2012: http://www.kcl.ac.uk/kcmhr/publications/assetfiles/deployment/Jonesm2012ptsd.pdf.
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The health and wellbeing of Norfolk’s veterans
Nottingham, is available to veterans who have deployed since 1982 and are suffering from poor mental health as a result of Service. The service offers a full mental health assessment by a Consultant Psychiatrist with accompanying guidance on care and treatment for the veteran’s local clinical team. Referrals to the VRMHP will preferably be made by the individual’s GP, but self-referrals are also accepted.81
It is an oft repeated claim that veterans with mental health conditions would ideally prefer to receive their treatment from people with a Forces background. Whilst this is certainly not true in all cases, there is indeed a fairly widespread perception that the NHS is not suited to meet veterans’ mental health needs. The concern is that most healthcare professionals do not have direct knowledge of the Military and so they will not be able to understand what veterans have been through or help them to overcome their problems if these problems are Service related. This perception can increase the already discussed natural reticence of veterans to seek support.
Essentially, the issue comes down to trust. It takes a lot for veterans who have witnessed traumatic events to ‘open the box’ and talk about their problems – a ten minute conversation can lead to weeks of sleepless nights – and they need to trust that the person that they’re talking to will be able to close it again. Whilst stressing that they had been treated by some very capable individuals, the majority of the veterans involved in this project did not feel that NHS mental health professionals typically possessed suitable experience and expertise to be able to close the box once it had been opened. By means of example, one veteran told a story in which an NHS counsellor had to leave the room in tears half-way through their session. Another veteran said that they were asked to leave a group therapy session because they were upsetting the other people.
The apparent inefficiency of the NHS compared to healthcare provided by the DMS was also highlighted as something that could deter veterans from seeking help. On this subject, is interesting to note that 80% of the veterans who self-refer to Combat Stress have already tried to receive treatment from an NHS service.82
Whilst the supposed inadequacy of the NHS when it comes to providing mental health support for veterans is often exaggerated, it is certainly true to say that, historically, mainstream mental health services have been ill-equipped to identify and respond to the needs of veterans. The problems of ex-military personnel may fall between the cracks of existing services, too complex for primary care but not considered to cross the threshold for community mental health services, which are more focused on severe mental illnesses like psychosis.83
81 For further details see: https://www.gov.uk/support-for-war-veterans#the-veterans-and-reserves-mental-health-programme.82 https://www.combatstress.org.uk/medical-professionals/what-is-ptsd/ptsd-faqs/.83 This can be a problem for civilians too.
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The health and wellbeing of Norfolk’s veterans
A bespoke mental health service for veterans (a service staffed by veterans, for example) is beyond the means of the NHS. On a limited budget, the NHS cannot be all things to all people. Arguably, such a service would be counterproductive, because by surrounding veterans with other people from military backgrounds, one would simply be prolonging the institutionalisation of the Forces and discouraging transition to civilian life.
However, this is not to say that the NHS shouldn’t do more to support vulnerable veterans, as indeed it has an obligation to do so for any vulnerable community. In 2010, the Coalition Government tasked Andrew Murrison, MP and previous Surgeon Commander for the Royal Navy, with designing a mental health plan for current Service personnel and veterans. The ten regional mental health centres that were described briefly on page 3 of this paper were established following the recommendations made in Murrison’s report.84 Each of these centres receives money directly from the Department Of Health to provide a range of bespoke mental health services for veterans in their area.
The nearest regional centre to Norfolk is run by Veterans First, in Colchester. Veterans First provides an integrated health and social care assessment and treatment of veterans with severe, complex and enduring mental health difficulties related to their time in the Military. This service looks at the entirety of an individual’s needs, including things like housing and financial concerns, and links in with other services as appropriate.
The overall aim is to improve mental health outcomes for veterans, for example by:
1. Streamlining pathways for veterans within local NHS mental health service.
2. Adding an element of cultural understanding.3. Having a dedicated team solely dealing with the issue of veterans’
mental health.
There is no doubt that Veterans First offers a good deal to veterans, and it has won numerous awards for its innovative work.85 Still, one wonders how useful the service is for Norfolk’s veterans. Veterans First is responsible for providing specialist services for veterans in North Essex, and whilst it will not turn away a veteran from Norfolk (some of their patients have come from as far away as Manchester) it is clear that the core services provided by Veterans First (for example linking in to local NHS mental health services) are of little use to Norfolk’s veterans, unless they are
84 A Murrison Fighting Fit: a mental health plan for servicemen and veterans, August 2010:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/27375/20101006_mental_health_Report.pdf.85 For more information about Veterans First, please visit their website at: http://www.nevmhn.org.uk/.
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The health and wellbeing of Norfolk’s veterans
willing to relocate or spend substantial periods of time outside of Norfolk, away from their families and support networks. Although it receives no funding from the Department Of Health to pay for specialist mental health services for veterans, The Norfolk & Suffolk Foundation Trust (NSFT) is seeking to improve its offer to local veterans and a number of initiatives are underway. For one thing, the Trust has already provided training to ensure that a core group (20 or so) of its therapists have a sound clinical understanding of combat related PTSD. The additional and all important awareness of the Forces culture will be provided by closer partnership working with veterans’ charities. For example, NSFT works very closely with The Bridge for Heroes (see page 27) and delivers Wellbeing Service interventions from their Contact Centre in King’s Lynn to both veteran and non-veteran service users. NSFT also collaborates with Walking with the Wounded to deliver their Head Start programme (see page 27) by linking their clients into NHS mental health services where required. This programme involves one of NSFT’s senior clinical psychologists.
In spite of these initiatives, it seems that local services for veterans in Norfolk are not at the level of services provided for veterans in North Essex, and that Norfolk’s veterans are currently being disadvantaged because of where they live. This issue is going to be exacerbated by changes in the current funding arrangements, which come into place in April 2015. From this date, the responsibility for specialist mental health services for veterans will be passing from NHS England to local Clinical Commissioning Groups (CCGs). At this moment in time, only those CCGs in areas that are currently hosting a veterans’ mental health centre (i.e. North Essex’s CCGs) will receive funding to provide these services. This arrangement will be reviewed by NHS England later in 2015.
Military amputees:
Before concluding this section on veterans and the NHS, it is worth highlighting one other area in which local veterans seem to be on the receiving end of a particularly poor deal: prosthetics. Since 2001, all casualties (including amputees) from Iraq and Afghanistan have been received by Selly Oak, a specialist military hospital in Birmingham. Patients are then transferred to the Defence Medical Rehabilitation Centre at Headley Court, Surrey, to begin their rehabilitation, with a view to returning to active duty wherever possible. Military amputees receive their initial prosthetic limbs from the MOD. Once they have left the Forces it is the responsibility the NHS to maintain and replace these prosthetics.
On paper, the national prosthetics services on offer to veterans seem to be very good. Following recommendations made in a 2011 Government report, entitled ‘A better Deal for military amputees,’ (again by Andrew
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The health and wellbeing of Norfolk’s veterans
Murrison, MP),86 the NHS has paid special attention to prosthetic services for veterans. For example, the NHS has made a commitment to provide military amputees with prosthetic limbs of at least the same standard as they originally received from the MOD. There are 34 Disablement Service Centres in England and nine of these have received central funding (£15 million) from NHS England to provide enhanced rehabilitation services to veterans. Norfolk’s nearest centre is at Addenbrooke’s, Cambridge.
The problem with this national/regional focus is that the prosthetics offered to military amputees by the MOD are more advanced than those currently offered as a matter of course by the NHS, which means that local Disablement Service Centres typically do not have the equipment or expertise required to maintain them. Younger amputee veterans in particular often have complex injuries and co-morbidities and there are concerns that local NHS centres will find it a challenge to meet these increasing requirements within their budgets. Assuming that the NHS continues to honour its pledge to provide veterans with prosthetic limbs of at least the standard as they originally received from the MOD for the rest of their lives, one might expect this situation to worsen in the future.
There is an additional concern relating to military amputees in Norfolk, which is to do with social needs assessments. Amputees often have need of special household equipment to help them with their day-to-day lives, such as walk-in-showers or wet rooms. This equipment may be provided by the County Council subject to a means tested needs assessment.
In the spirit of the Armed Forces Covenant, these needs assessments should have a 100% disregard for the compensation money paid to military amputees by the MOD, as part of either the War Pension Scheme (WPS) prior to 2005, or the Armed Forces and Reserve Forces Compensation Scheme (AFCS), post 2005 (as explained on page 11). Military amputees receive this money in return for the sacrifices they have made for their country, and in theory they are not expected to have to use it to pay for their continuing care. This was recognised by the Government’s decision, in October 2012, to direct local authorities to exclude AFCS payments from social care means testing:
“In recognition of the contribution made by armed forces personnel injured whilst on active service, from 29th October 2012, they will no longer need to use Guaranteed Income Payments (GIPs) paid under the Armed Forces Compensation Scheme (AFCS) to pay for care and support services arranged by local authorities.”87
86 A Murrison A better Deal for military amputees, June 2011: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215338/dh_130827.pdf.87 Royal British Legion, Caring for our future: Consultation on reforming what and how people pay for their care and support, October 2013, p.3: http://www.britishlegion.org.uk/media/3754695/trbl-response-to-care-funding-consultation-october-2013.pdf.
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The health and wellbeing of Norfolk’s veterans
However, this policy of disregard does not extend to military amputees who were injured prior to 2005 and who are in receipt of the WPS. Some local authorities are reportedly using their discretion to ensure that there is parity between the AFCS and WPS compensation schemes by disregarding both from social needs assessments. According to anecdotal evidence, this informal approach used to be adopted in Norfolk but it is no longer being practiced.
As a result of the lack of state support, military amputees in receipt of the WPS are either paying for the equipment they need themselves, or else turning to military charities for funding.
Beyond military amputees, this issue affects the wider veteran community who are in receipt of the WPS having suffered other life-changing injuries in Service. One might expect this situation to worsen in the future, as greater financial pressure is placed on public services.
Third Sector organisationsThere is an expansive Third Sector community offering a range of services and support to veterans. Military charities play a disproportionate role in the welfare of veterans where elsewhere it would be the responsibility of the state. This may in part be a result of the fact that veterans are more likely to seek support from other veterans (by and large, military charities are staffed by veterans).
Nationally, there are an estimated 2,500 military charities with a collective net worth of around £1.2 billion. These are some of the major national charities that have a presence in Norfolk:
Combat Stress – is the UK’s leading mental health charity for veterans. Nationally, Combat Stress has three residential centres providing short-stay treatments. Norfolk’s nearest centre is in Surrey. Locally the organisation has a number of community outreach workers who visit veterans to perform an initial assessment. If the veteran is thought to need further mental health support, then Combat Stress will signpost them onto appropriate services, either provided by the NHS or by Combat Stress itself. Combat Stress also hosts support groups around the county for veterans and their families alongside the Royal British Legion and other charities.
British Limbless Ex-Servicemen’s Association (Blesma) - empowers and promotes the welfare and wellbeing of all serving and ex-Servicemen and women who may have rehabilitative needs post limb loss. Blesma has a number of community staff who cover Norfolk & Suffolk. The organisation also provides limbless veterans with small
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The health and wellbeing of Norfolk’s veterans
donations to ease their day-to-day living and campaigns on their behalf to secure social support from the County Council.
Soldiers, Sailors, Airmen & Families Association (SSAFA) - provides lifelong practical and emotional support for members of the Forces, past and present, and their families. SSAFA has a network of local branches, and case workers who cover Norfolk.
Royal British Legion - helps the whole Forces community through welfare, comradeship and representation as well as being the nation's custodian of Remembrance. There are a number of Royal British Legion drop-in centres in Norfolk, and the Legion often acts as a first port of call for beleaguered veterans. The Legion will then signpost veterans onto other charities and services according to their needs, but they will remain on hand to provide continued support.
Walking with the Wounded - raises funds to retrain and re-skill wounded veterans and support them in finding new careers outside the Military. Part funds Project Nova and runs the Head Start project (see below).
Help for Heroes – a large national charity. Has a network that gives direct and practical support to wounded veterans all over the country, in addition to funding other charities. Part funds Adventure Quest (see page 20).
In addition to these national charities, there are a number of local charities and initiatives supporting Norfolk’s veterans:
Outside The Wire - part of The Junction programme, run by the Matthew Project, Outside The Wire is a bespoke drug and alcohol support programme delivered by veterans for veterans in Norfolk & Suffolk.
Veterans Norfolk - set up in 2014 as part of Norfolk’s Community Covenant (more details on page 28). It is an umbrella organisation that aims to bring together all of Norfolk’s veteran charities and to streamline and simplify the picture for local veterans.
Bridge for Heroes - set up in June 2011. Based in King’s Lynn, it acts as a drop-in centre, providing a range of respite sessions and practical advice and support for veterans (pensions, housing, compensation etc.)
Project Nova – a joint initiative with Walking with the Wounded, Forces in Mind Trust, RFEA (The Forces Employment Charity) and the Norfolk and Suffolk Police Force, Project Nova is a unique project looking at supporting veterans who have entered police custody in Norfolk and Suffolk.
Head Start – managed by Walking with the Wounded and supported by The Norfolk & Suffolk Foundation Trust, the Head Start project focuses on increasing capacity within mental health services by introducing private psychotherapy from a nationwide network of qualified practitioners.
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The health and wellbeing of Norfolk’s veterans
One may also expect non-military charities like Mind and YMCA to come into contact with some veterans in the course of their general work.
Finally, there are numerous MOD and regimental organisations that continue to provide support to veterans and their families once they have left. Examples of these organisations include:
Veterans Advisory & Pensions Committee (VAPC) Royal Air Force Association (RNA) Royal Marines Association (RMA) Royal Naval Association (RNA) Royal Anglican Regiment Association (RARA) Reserve Forces’ & Cadets’ Association (RFCA)
The good work of military charities nationally and in Norfolk must be acknowledged, but there are some concerns about the sustainability of the current order in the future. Now that the UK Armed Forces have withdrawn from overseas operations, one might expect the currently high level of public interest to fade, with a proportional decrease in the number and size of donations to the cause. In this event it will be unreasonable to expect military charities to continue to provide such a high level of support and care for their members, when the responsibility for veterans ultimately belongs to public health and social services.
There are additional problems with the disproportionate role of the Third Sector when it comes to veterans, such as the duplication of effort and the sheer number of different charities trying to provide mental healthcare to veterans, not all of which are carrying out their work using accredited, evidence-based techniques.88 At the time of writing (December 2014), a national project was being undertaken by the Veterans’ Council in St. Helens to look at how a directory of accredited military charities might be implemented in the future.89
At a local level, the various military charities operating in Norfolk are brought together with the NHS and Norfolk County Council through the Norfolk Community Covenant, which is a written agreement intended to complement the national Armed Forces Covenant. Since the Covenant was signed in March 2012, it has initiated a number of programmes to support the local veteran community. For instance, the Covenant has encouraged GPs to ask the question ‘have you served?’ and has produced a leaflet of key Third Sector organisations to make GPs more confident that they will be able to signpost veterans appropriately.90
88 King’s Centre For Military Health Research, April 2012, op. cit. P.9.89 For more details see https://afcom.directory/.90 For more details about the work of the Covenant, see Norfolk Armed Forces Community Covenant – One Year On, Report by the Armed Forces Commissioner, March 2013: http://www.norfolk.gov.uk/view/cabinet040313item10pdf.
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5. ConclusionWhat has Healthwatch Norfolk learned?
It is possible to summarise the information contained in this paper into two important messages. The first of these messages is that the majority of Service leavers do well in civilian life, having benefited from their time in the Forces (see page 9). Broadly speaking, veterans enjoy the same quality of health as the general population. This is contrary to media coverage, which often focuses on the visible legacy of war, like military amputees, or else on the minority of Service leavers who become socially excluded through crime or homelessness or who suffer mental health conditions.
The second important message is that the minority of veterans who do become socially excluded and/or suffer from mental health conditions have very poor outcomes indeed (see pages 14-19). They tend to be complicated patients, suffering from acute and co-morbid conditions. As a result of the ‘macho’ Forces culture, they present late to health services, having repressed their problems for many years, perhaps with the aid of alcohol. If and when they eventually do present, they may have unique needs, especially if their conditions are rooted in traumatic Service experiences, and they may therefore require a slightly different kind of service than is usually provided by the NHS (see pages 22-24).
It is very likely that the more vulnerable veterans, like Early Service Leavers (see pages 18&19), will require particular attention from services if they are not to slip through the net. However, there is a real lack of local data about the specific health needs of Norfolk’s vulnerable veterans, and their experiences of accessing and using the NHS. It seems clear that the
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NHS has an obligation to do more to reach these veterans. By conducting future work with this group of people, Healthwatch Norfolk will be able to help in this process, by supplying commissioners and providers with qualitative information that will enable them to design services that are better suited to veterans’ needs.
Recommendations for future work
Any work with veterans must take into account the national policy context, more specifically the Armed Forces Covenant, which states that:
1. The ex-Service community should not face disadvantage compared with other citizens in the provision of public and commercial services.2. Special consideration (like priority of access to healthcare) is appropriate in some cases, especially for those who have given most, such as the injured and the bereaved.
With a field as complicated and vibrant as veterans’ healthcare, it is also important to avoid duplication, taking into consideration work that is being done by other local organisations.Bearing these two considerations in mind, this paper contains three recommendations for future work. These recommendations have been made on the grounds of the scale of the need, and the potential for Healthwatch Norfolk to make a difference.
Recommendation 1: undertake a nine-month research project gathering evidence about veterans’ mental health needs and their views and experiences of mental health services, with a focus on Early Service Leavers, Reservists and the problem of alcohol.
Veterans with mental health conditions have been shown to suffer from poor outcomes when compared to the general population and it has been suggested that they may have unique needs and require a slightly different kind of service.
The Norfolk & Suffolk Foundation Trust (NSFT) is currently developing a number of initiatives to improve its offer to veterans, but there is a lack of data about how veterans would like to receive their treatment and support. It is only by taking into account the views and experiences of local the service users that commissioners and providers will be able to ensure that they deliver services that are suitable.
This is also a good opportunity to feed into the national veterans’ mental health agenda. As noted on page 24, the national funding arrangements, which currently see specialist mental health services for veterans funded
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at a regional level, will be subject to review over the next year. This gives Healthwatch Norfolk the chance to ensure that the voices of local veterans are taken into consideration in any decisions about the future nature of wider mental health services for the Armed Forces Community.
The focus on Early Services Leavers has been chosen because they are, generally speaking, the group of veterans who are the most likely to struggle with the transition from military to civilian life, suffering from social exclusion, unemployment, violent behaviour, imprisonment, homelessness and mental health conditions. They are also offered the least support from the MOD, and they are the least likely to engage effectively with NHS services when they leave the Forces.
At the time of writing (December 2014), there was no clear way of knowing how many Early Service Leavers there were locally, nor even how those people leaving the Forces early each year could be identified separately from other Service leavers returning/relocating to Norfolk. This is clearly the starting point for any project involving Early Service Leavers.
The focus on Reservists has been chosen because this group of veterans have been found to be particularly vulnerable to poor mental health, which is a concern because they are expected to play an increasingly important role in the UK Armed Forces in the future.The focus on alcohol has been chosen because it is arguably the largest problem facing the mental health of the veteran community. Unlike PTSD, for example, little focused work has been undertaken on the topic to date. The presence of Outside The Wire, a bespoke alcohol and drugs service for veterans in Norfolk and Suffolk, would be very helpful indeed.
Recommendation 2: work with Norfolk’s Clinical Commissioning Groups (CCGs) and other key stakeholders to ensure that the terms of the Armed Forces Covenant are being met at a local level.
According to the Armed Forces Covenant, special consideration like priority of access to treatment (subject to the clinical needs of others) is appropriate for veterans in some cases, especially for those who have given most, such as the injured and the bereaved.
However, the anecdotal evidence provided by some of the people involved in this project suggested that the priority of access to treatment is not being adhered to in all cases. Healthwatch Norfolk should work with Norfolk’s five CCGs to find out what steps are being taken to ensure that local healthcare providers are compliant.
More generally, Healthwatch Norfolk should work with the CCGs to find out what steps are being taken to ensure that veterans are not being
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disadvantaged due to Service when accessing health services. For example, this might be an opportunity to explore the current status of CCG preparations for the 2014 mandate from Health Education England, according to which there should be a specialist GP in every CCG trained in the physical and mental health needs of ex-military personnel, as of summer 2015.91
Recommendation 3: work with the Norfolk County Council and other key stakeholders to understand why the War Pension Scheme (WPS) and the Armed Forces and Reserve Forces Compensation Scheme (AFCS) are not being treated with parity when it comes to social needs assessments.
There is a 100% disregard for the compensation money paid to military amputees and other seriously injured veterans in receipt of the AFCS, but in the case of veterans who receive the WPS, their compensation money is not exempt. On the face of things, this disparity seems to be unfair.
This is a complex and specialised issue and further work with Norfolk County Council and the Community Covenant will be needed for clarification, before any decision can be made about further action in the future.
91 Department Of Health, A mandate from the Government to Health Education England: April 2014 – March 2015, 2014, p.13: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310170/DH_HEE_Mandate.pdf.
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