DRIVING IMPROVEMENT THROUGH INDEPENDENT AND OBJECTIVE REVIEW. Healthcare and the Armed Forces Community in Wales

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1 DRIVING IMPROVEMENT THROUGH INDEPENDENT AND OBJECTIVE REVIEW Healthcare and the Armed Forces Community in Wales May 2012

2 This publication and other HIW information can be provided in alternative formats or languages on request. There will be a short delay as alternative languages and formats are produced when requested to meet individual needs. Please contact us for assistance. Copies of all reports, when published, will be available on our website or by contacting us: In writing: Or via Communications and Facilities Manager Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road CAERPHILLY CF83 3ED Phone: hiw@wales.gsi.gov.uk Fax: Website: Printed on recycled paper Print ISBN Digital ISBN Crown copyright 2012 WG15453

3 Contents Page Number Chapter 1: Background 1 Chapter 2: The Armed Forces Community in Wales 3 Chapter 3: Current Position 5 Chapter 4: What We Did 9 Chapter 5: What We Found 11 Chapter 6: Conclusions and Recommendations 25 Chapter 7: Postscript 29 Appendix A: Appendix B: All Wales Veterans Health and Wellbeing Service Case History of a Former Welsh Guardsman and Falkland Islands Veteran i

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5 Chapter 1: Background 1.1 In 2010 the Welsh Government established an Expert Group on the Needs of the Armed Forces Community in Wales, chaired by the Minister for Local Government and Communities, with representation from the Ministry of Defence (MoD), the three Armed Services and their respective Families Federations, the Royal British Legion (RBL), the Soldiers, Sailors, Airmen and Families Association (SSAFA Forces Help), the Confederation of Service Charities (COBSEO), HIVE 1,the Veterans Pensions and Advisory Committee (VAPC) and the Service Personnel and Veterans Agency (SPVA). 1.2 The Terms of Reference of the Expert Group are to consider: The public service needs of Armed Forces personnel, their families, and veterans in Wales. Whether existing service delivery meets the needs of the Armed Forces community on equal terms with civilian society. What scope there may be for making services more responsive to the needs of the Armed Forces community. 1.3 In support of the Expert Group, Healthcare Inspectorate Wales (HIW) undertook to carry out a survey of the experiences of the Armed Forces community in Wales with regards to: The adequacy and availability of health provision for Armed Forces personnel, their families and veterans in Wales. Access to health services and the effectiveness of priority treatment provision for veterans 2. Experiences when using healthcare services. 1 HIVE Information Centres are provided by the Army, RN and RAF to provide information support to all members of the Service community. 2 Welsh Health Circular (2008) 051 a commitment to prioritise improving the health and well-being of Service personnel and veterans in Wales. This extended the provision of priority NHS treatment from war pensioners to all veterans who have a health problem as a result of their Armed Forces service. 1

6 1.4 The information gathered from this survey is intended to contribute to the Expert Group s assessment of whether existing service delivery meets the needs of the Armed Forces community. It will also be used to inform consideration of the possible development of specific quality requirements for Armed Forces personnel, their families and veterans in Wales, as well as ways in which HIW s assessment and reporting processes can ensure an on-going focus on improving the experiences of the Armed Forces community in Wales when accessing healthcare. 1.5 The survey was carried between December 2011 and February 2012 and focussed on capturing the views and experiences of members of the Armed Forces community of healthcare provided by the NHS in Wales. In addition, responses and contributions were received from a number of Armed Forces organisations and charities who primarily support the needs of Armed Forces veterans. Those elements of healthcare that are the responsibility of the MoD to provide were not included. 1.6 This report therefore constitutes a snapshot and its findings and recommendations form the basis for further work to assist the Expert Group, the Welsh Government generally and the NHS in improving the provision and delivery of healthcare to the Armed Forces community in Wales. 2

7 Chapter 2: The Armed Forces Community in Wales 2.1 The Armed Forces community is defined, for the purposes of the Armed Forces Covenant (the Covenant) 3, as including all those towards whom the Nation has a moral obligation due to Service in HM Armed Forces. This community and those who have responsibility for their healthcare provision, is summarised as follows. Regular Personnel Those currently serving as members of the Royal Navy/Royal Marines (RN/RM), the Army and the Royal Air Force (RAF). This group is widely dispersed between formed units or stations such as RAF Valley in Anglesey and 14 Signal Regiment (Electronic Warfare) in Pembrokeshire, to personnel supporting the Infantry Battle School in Brecon, 203 (Wales) Field Hospital and HMS Cambria. The MoD is responsible for primary healthcare whilst secondary care is provided by the local healthcare provider. The total number serving personnel in Wales is approximately Families of Regular Personnel, Reservists and Veterans 2.2 Unless accompanying service personnel serving abroad, healthcare for families is provided by the NHS. The Covenant makes provision for families of Regular personnel where their position on NHS waiting lists may be affected due to Service postings. They may also act as carers for veteran spouses who have injuries or illnesses caused by their service. 3 The Armed Forces Covenant was published in May From 2012 there will be a statutory duty to lay before Parliament an annual report which considers the effects of service on Regulars and Reservists, veterans, their families and the bereaved. It will also examine areas of potential disadvantage and the need for special provision where appropriate on Regulars and Reservists, veterans, their families and the bereaved. 3

8 It is very difficult to estimate the numbers in Wales that fall within this category. Reservists This group comprises the Volunteer Reservists, who form the RN/RM Reserve, Territorial Army and the Royal Auxiliary Air Force, as well as the Regular Reservists, comprising the Royal Fleet Reserve, Army and RAF Reserves. The MoD is responsible for their healthcare when they are mobilised, otherwise this passes to mainstream NHS services. The total number in Wales is approximately Veterans Categorised as those who have served for at least one day in HM Armed Forces, either as a Regular or as a Reservist. Veterans receive their healthcare from the NHS and are entitled to receive priority treatment from the NHS where it relates to a condition resulting from their service in the Armed Forces. In practice, this means that they are scheduled for treatment quicker than other patients of similar clinical priority. The number in Wales is estimated at 220,000. The Bereaved The immediate family of Service personnel and veterans who have died. 4

9 Chapter 3: Current Position 3.1 In summary, healthcare for Regular Service personnel is the responsibility of the MoD, for Reservists it is responsibility of both the MoD and the NHS and for veterans, families and the bereaved it is the NHS. 3.2 The Armed Forces community is, where relevant, entitled to at least the same standards of, and access to, healthcare as any other citizen in the area were they live. In addition, veterans should receive priority treatment where it relates to a condition from their Service, subject to relative clinical need. 3.3 The specific policies that the Welsh Government has in place, or plans to implement in relation to its obligations to the Covenant, were published in November This Package of Support is very much a living document and will be subject to revision as and when new initiatives are agreed. 3.4 Healthcare occupies a prominent position within the Package of Support and the areas it covers include: the mental health needs of veterans; transition protocols and transfer of medical records when military personnel are discharged from the Services 5 ; the priority care and treatment for veterans; the provision of prosthetics 6 and; the level of awareness amongst GPs 7 and NHS staff about the specific health issues and needs of the Armed Forces community. 3.5 Each Local Health Board and Trust in Wales has since 2010 designated one of its non-officer members as a Champion of the Armed Forces and Veterans 7. The purpose of this role is to ensure that the health needs of the Armed Forces community are reflected in local service planning and provision and to make links with Armed Forces organisations and charities. 4 Welsh Government Package of Support for the Armed Forces Community in Wales (2011), which should be read in conjunction with the UK Government s Armed Forces Covenant package, the Armed Forces Covenant: Today and Tomorrow and the full government response to the independent Military Covenant Task Force Report. 5 Package of Support paragraph Package of Support paragraphs 4.5 and Package of Support paragraphs 4.7 and

10 3.6 Research 8 would indicate that while the majority of the veteran population in Wales do not suffer from major mental health difficulties related to their service, an important minority do. Since 2010, the Welsh Government has funded, following a successful pilot service established in 2008, the development within the NHS of a specialist mental health service for veterans in the form of the All Wales Veterans Health and Wellbeing Service (AWVHWS). More details on this service are provided at Appendix A. 3.7 As well as mainstream NHS provision there are a number of third sector organisations that provide healthcare, particularly in the area of mental health for veterans. For example, Combat Stress (a UK charity founded in 1919) provides community and inpatient support and treatment for over 300 veterans living in Wales, working in partnership with the AWVHWS and NHS mental health services generally. In addition, a number of other charities have been established both in Wales, such as Healing the Wounds, and the UK more widely to address what are perceived as shortcomings in NHS mental health services for veterans. 3.8 The provision of healthcare to the Armed Forces community in Wales is complemented by the work of a number of organisations (both governmental and third sector) that provide advice, welfare support and help in signposting to appropriate healthcare services. These include, amongst others, the RBL, SSAFA Forces Help and the SPVA. 3.9 The NHS in Wales works in close partnership with Local Government in many areas of services such as public health, social care, community safety, housing etc. In 2011 the MoD launched its Armed Forces Community Covenant grant scheme initiative 9 whereby local authorities can sign up to the Armed Forces Community Covenant, a voluntary statement of mutual support between a civilian community 8 By the Wales Veterans Health and Wellbeing Service (AWVHWS), Combat Stress, King s College Centre for Military Health Research (KCMHR) and the Service Personnel and Veterans Agency (SPVA). 9 The Community Covenant aims to bring together the Armed Forces community and the civilian community on a local level, nurturing mutual understanding and raising awareness of issues faced by the Armed Forces. Signatories to the Community Covenant can also access a c. 30m Grant Scheme to support Armed Forces related projects. See also Armed Forces Covenant: Today and Tomorrow, p 5. 6

11 and its local Armed Forces community. It is intended to complement the Armed Forces Covenant itself and usually establishes a Champion within the Local Authority. Once signed, Local Authorities can access a MoD funding pool via a grant scheme. This initiative has the potential to benefit health and social care partnership working in meeting the needs of the Armed Forces community in Wales So far in Wales, the Vale of Glamorgan (in June 2011) and Powys (in February 2012) Councils have signed up to the Community Covenant with at least three others in the process of doing so. 7

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13 Chapter 4: What We Did 4.1 HIW gathered information between December 2011 and February 2012, using the following methods. On-Line Survey 4.2 Questionnaires were developed and made available in both electronic and hardcopy format through the HIW website and on request. Two were produced: one designed to capture the views of Armed Forces veterans and the other specifically for Serving Personnel and their families and Reservists. Targeted Focus Groups 4.3 These were held to capture the collective views and experiences of the following groups and organisations: Service organisations and charities - including the RBL, SSAFA Forces Help, Combat Stress, British Limbless Ex Servicemen s Association (BLESMA), the SPVA, the VAPC and Healing the Wounds. In addition to staff working for service charities approximately 35 veterans also attended these groups. Regular and Reserve units - including 14 Signal Regiment (Electronic Warfare), 203 (Wales) Field Hospital, the Reserve Forces Cadets Association for Wales, the Army Welfare Service and 160 (Wales) Brigade at Brecon. Exchanges and Telephone Interviews I m sometimes so scared to admit my fears and I feel frightened it took a lot to call you today (HIW) and try and tell my story. I am in a lonely, lonely place. (Army Veteran) 9

14 4.4 The majority of veterans who contributed, and their family members, preferred to discuss their circumstances in this way, mainly because they knew they felt more comfortable talking to someone who would likely understand. Those who responded in this way commented that they found questionnaires an inappropriate way to describe sensitive and often emotional issues. Other 4.5 Further information was collected from a variety of sources including: contact and attendance at community groups such as the West Wales Action for Mental Health Forum; discussions with NHS Armed Forces Champions; discussions with individual serving personnel and veterans; attendance at service organisations and charities meetings; attendance at the WG/WLGA Supporting our Armed Forces Community conference in February 2012 and a small random telephone sample of GP practices. 10

15 Chapter 5: What We found 5.1 Approximately 250 responses were received from members of the Armed Forces community, service organisations and charities. Whilst comments and responses were received from across the spectrum of the Armed Forces community, the majority of individuals who responded were veterans, generally in the age bracket years of age, with experience of war/operational tours mainly in areas such as the Falkland Islands, Northern Ireland, the Balkans, Iraq and Afghanistan. 5.2 There were, however, very few responses from veterans in the Early Service Leaver (ESL) 10 category, although it is generally recognised that this group, many of whom will have served on operations in Iraq and Afghanistan, can leave the Services with significant potential health issues. SSAFA Forces Help welfare workers, the RBL and even an Armed Forces Champion in a Job Centre Plus described the transitory contacts they had had with ESL veterans of whom very little is known in terms of health status and location. Research indicates that ESLs are more likely to have adverse outcomes (e.g. suicide, mental health problems) and risk taking behaviours (e.g. heavy alcohol consumption) than longer serving veterans 11. Physical Health and Wellbeing Regular Personnel 5.3 Responsibility for the healthcare of Regular personnel rests with the MoD. However, several comments were made about the importance of ensuring that the continuity of healthcare baton was not dropped on discharge as well as developing far easier access to military health records by civilian GPs. 10 Those who have served for less than four years. 11 Fear, Wood and Wessely (2010) Health and Social Outcomes and Health Service Experiences of UK Military Veterans: A Summary of Evidence, November

16 Families of Regular Personnel, Reservists and Veterans 5.4 As stated earlier, the families of Regular personnel have access to the same NHS healthcare as their civilian counterparts in Wales. In some areas they are able to register with a GP who is also a designated medical officer supporting a Military Medical Centre 12 where their serving spouses are treated: this was commented on as being beneficial. They are, of course, subject to the same arrangements as the civilian population with regard to accessing secondary or more specialist treatment and care, however, the increased mobility of service families can sometimes cause problems in this respect: it was commented that this could add to the general stress of military life for a family. The following specific issues were highlighted in the comments made to us. 5.5 Dental Care. The long waiting times experienced before being able to register with an NHS dentist was a prevalent concern especially compared to the comparatively rapid treatment available to their serving spouses. However, whilst this delay was generally on a par with their civilian counterparts, service families pointed out that regular service moves created a real disadvantage for them. 5.6 For example, in Pembrokeshire, families of 14 Signal Regiment (EW) personnel can wait on average months to secure a place. Most families remain registered in their home town and arrange dental treatment when they return on leave. Other families remain with the practice at their previous unit location, potentially making it more difficult for those service families currently posted there to secure a place. One respondent, a German wife of a serving soldier, found it simpler to return to Germany for her dental treatment. 5.7 Some service families experienced additional costs to their civilian counterparts since dentists do not pass on their records and each move involved a new set of x-rays and examination expenses. 12 There are five Military Medical Centres (MMC) in Wales that look after the primary care needs of serving personnel. If a serviceman is located over miles from a MMC they can, if necessary, access a NHS GP closer to their home. 12

17 5.8 Waiting Lists. The Covenant and the Welsh Government s Package make provision that service families should not be prejudiced due to frequent service moves. These arrangements appeared to be working well with just one example provided by a Regular Unit in Wales where this was not achieved due to the disruption of service postings. A spouse had an injury to her leg and she was referred for a MRI scan. The waiting list was 12 months, but the serviceman was posted to another unit before the appointment date. This was then replicated at the next unit where the waiting list was 18 months and the serviceman was posted again. In summary, it took three years for the spouse to receive the MRI scan, as every time they moved to the new NHS authority the process had to be repeated. Reservists 5.9 Responsibility for the healthcare of mobilised Reserve personnel rests with the MoD. However, many concerns were raised as to how NHS care links with MoD responsibilities as the Reserves increase in number and play a major role in frontline activities. For example, when a Reservist is mobilised they are in the Regular Army and receive healthcare on this basis However, a Reservist who is injured whilst not mobilised but still on duty (for example, a training weekend in the Brecon Beacons), receives treatment from the NHS. In such cases, the injuries are reported and actioned within Reservist channels, with individuals receiving forces pay if signed off work, until such time as fit to return to civilian work and to Reservist duty. These arrangements have the potential to cause challenges with regards to continuity of care between the NHS and the Defence Medical Services. I m in the TA, have served on the front line in Iraq and I m worried what happens if I get injured we are not Dad s Army anymore. (Taxi Driver, Cardiff, Jan 2012) 13

18 5.11 Reservists expressed a general concern that given their current increased role in supporting front-line operations, it followed that the risk of serious injury would similarly increase putting them more on a par with their Regular counterparts insofar as healthcare provision was concerned There were concerns expressed that the role of the Reservist was not well understood by the NHS. We were told on more than one occasion that a serving Reservist had been categorised as a veteran. There was also general uncertainty over how the continuity of care would be managed when a serviceman finally returned to civilian life after one or more periods of mobilisation. For example, over a 20 year + period service Reservists may be subjected to a number of injuries that could have an accumulative impact on their physical and/or mental well-being Reservists commented that while they were subject to a medical on joining and required to meet the minimum medical standards, there is no medical when they leave the service. Veterans 5.14 The majority of feedback received related to the treatment of back, hip and knee injuries attributable to service but which may not present fully until well after discharge. The comment was made frequently that some GPs did not seem to understand the rigours of service life even when made aware of a patient s veteran status. Some veterans expressed little confidence that eligibility for priority treatment was properly reflected in the referral process and, even when mentioned, was properly taken into account within secondary care Prosthetics. According to the Personnel Recovery Unit at Brecon, serving personnel with prosthetic limbs have expressed worries about what will happen when placed into NHS care, particularly with regard to replacement and repair. Limbs can cost 30k or more and those fitted at Headley Court are state of art and very complex. In Wales there are NHS Artificial Limb and Appliance Centres (ALAC) at Swansea, Wrexham and Cardiff. 14

19 5.16 The case of one veteran outlined the difficulties she was currently experiencing in Wales (despite the Welsh Government s commitment in the Package of Support that NHS Wales would as a minimum match the provision of prosthetic limbs by the Defence Medical Services). She was medically discharged from the Army in After leaving the Forces her left leg was amputated below the knee attributable to an injury sustained in the Services. In 2009 the Swansea ALAC recommended the fitting of an echelon foot to significantly improve the patient s quality of life. The echelon foot, costed at a c. 3500, was eventually approved by the NHS, but fitting has been delayed because it couldn t be decided who would fund it. A meeting held as late as 19 March 2012 could still not agree the funding line. I have spent two and half years fighting my corner thank God for BLESMA s support otherwise I would have given up and taken to a wheelchair. The personal stress has been vast. Mental Health and Wellbeing Regular Personnel 5.17 Few responses were received from Regular personnel relating to mental healthcare whilst serving as this is a MoD responsibility, however some comments were received that the awareness of mental health issues within the military had increased significantly in recent years. Families of Regular Personnel, Reservists and Veterans 5.18 Unlike their serving spouses, mental health provision for the families of Regular personnel rests with the NHS, as of course does that for the families of veterans. Comments were made by the Army Welfare Services and a Unit Welfare Officer about the high levels of stress and worry amongst service families when a 15

20 serving spouse is deployed on operations. For example, serving family members commented that waiting for the phone call or knock on the door when their spouse was away on operational duty could be extremely stressful. The effect was accumulative, adding to the pressures of essentially being a single parent when their spouse was away. Both Unit Welfare Officers and the Army Welfare Service commented that mental health issues amongst service families appeared to be on the increase, including an increase in alcohol misuse As families may be the first to detect the first signs of mental illness in their spouses after operations, comments were received that there would be benefits in family members being made aware of how to recognise these symptoms and take the necessary action It was also commented that the impact of frequent and sometimes unexpected postings could place further stress on a Regular Forces family and it was felt that it was therefore important for the family to be registered with a GP who understood and was sympathetic to the effect that the military environment can have on families The families of veterans experiencing service related mental health illnesses commented on being under particular pressure. I was never quite sure what I would find when I got home. Would he be angry or sad, sitting quiet in a bedroom or not wanting anyone. The strain was enormous. (Wife of Army Veteran) 5.22 There were few comments or responses about mental healthcare for children of service families. However, one particular case was reported that illustrates what can happen. A Regular serviceman based in Wales has an eight year old son who is on the autistic spectrum. The waiting list with the requisite LHB for him to be formally assessed is four years and the family have been on 16

21 the list for three years. The serviceman is due to be posted to England in March 2012 and if he were to move his family he has been told that his son will go to the bottom of another four year assessment waiting list. The serviceman elected to be posted unaccompanied to allow his son to be treated in Wales. This will add additional pressure on the family unit due to separation. Reservists 5.23 It was generally perceived that GPs do not routinely consider if any mental health problems experienced by a Reservist are connected to service life Given that Reservists can now routinely serve in front-line conditions and can experience the same traumatic experiences as the Regular Forces, it was commented on that this should be taken into account when assessing any mental health problems experienced by Reservists. Currently, the Armed Forces do make provision for Reservists who require help in respect of any service related mental health problems, but there is potential issue of continuity of care over the longer term once the Reservist becomes the responsibility of the NHS, or when there is a delay in the emergence of the individual s service related mental health problem, in circumstances where there might be little information available about his or her service history. Veterans 5.25 This category accounted for the majority of the comments and responses received and focussed on trauma related mental health issues such as Post Traumatic Stress Disorder (PTSD) A recurrent theme was the lack of knowledge and self-awareness amongst older veterans and their families regarding service related mental health issues Many of those who responded spoke of the stigma associated with declaring or even recognising such issues, based upon a long-held perception that it reflected 17

22 a lack of moral fibre and would prejudice promotion. Even in civilian life, seeking help was regarded as a weakness A large number of comments were made by veterans about not knowing where to go to get the most appropriate treatment and support and that when they were in real need of support they were generally not thinking straight and needed clear and simple signposting. Many comments were received about the lack of clarity between those services and organisations that provide treatment and those that provide generic, pastoral support. Most had heard of Combat Stress and Healing the Wounds, but very few were aware of the existence of the AWVHWS or how mainstream NHS mental health services were accessed. The recurring theme of a very crowded playing field or finding your way around the London Underground without a map emerged. Comments were also received about what appeared to be unhelpful competition between treatment providers in some areas Many veterans told us that there was a need for good, clear information about who they should seek expert help and therapy from. Most respondents expressed a preference when seeking help to receive it from an individual practitioner or organisation with an understanding of the military and some also commented that they found it frustrating having to explain basic military terminology and conditions of service to their therapist Some comments were received about the sometimes long intervals between being assessed and the commencement of therapy sessions. I have been waiting since October 2011 for my next appointment. It is so difficult trying to pick up the pieces of your life when you feel so alone and have this illness bottled up inside. (Army Veteran February 2012) 5.31 Comments were received that veteran support groups, where they existed, were a helpful complement to therapy. For example, in Conwy, SSAFA runs a well established veterans support group and Combat Stress organises a number of support groups across Wales. These groups have so far been set up in Pontypool, 18

23 Cardiff, Pontypridd, Bridgend and Swansea, with further groups to be set up in Carmarthen and Rhyl. Networking has also been developed with other similar veterans groups in Rhondda, Llanelli, Barry and Merthyr Concerns were expressed about the capacity of the relatively new veterans specialist mental health service (AWVHWS) to cope with the potential demand for treatment, although it was also noted that not all veterans mental health problems were service related or were due to PTSD and that they could also access treatment from mainstream NHS mental health services. Many comments were received about the likely increase in demand for specialist mental health treatment as the effects of operational deployments to Afghanistan and Iraq begin to impact on the NHS once individuals begin to leave the Forces in the next few years. General Healthcare Issues Signposting to and Awareness of Healthcare Services It is a confusing picture across Wales for those who seek help and assistance in a hurry, and they have no idea where to turn and to know what is available. (Army Veteran) 5.33 The general lack of effective signposting to appropriate healthcare services was a predominant issue reflected by the majority of respondents. Almost all highlighted how very crowded and confusing it was to identify who and where to go to get help particularly to address mental health problems. One veteran likened the healthcare landscape in Wales to a football team with 100 players on the pitch all good players but so many crowded into a small space that the ball couldn t be found and the goal could not be seen. All that was needed was a good manager whose sole job was to sort it. 19

24 5.34 There was also a broad consensus that a key element in creating effective access to health services for veterans was to build a coherent and uniform structure across the whole of Wales While Service organisations and charities such as SSAFA Forces Help, the RBL, SPVA and Combat Stress are generally well-known, accessible and able to signpost to appropriate healthcare, the survey revealed that some of their welfare workers were unaware of NHS services such as the AWVHWS or the existence of the NHS Armed Forces Champion role. General Practitioners In my experience most GPs are not up to speed with PTSD the easy opt-out is to prescribe pills for simple depression. (Army Veteran) I d gone before to various GPs, but all I got were handfuls of pills and told I was suffering from depression and work-related stress even though they knew I was a veteran. (Falklands Veteran) 5.36 A common theme in comments made by veterans was a lack of consistency amongst GPs: in their experience few displayed any knowledge of priority treatment for service-related conditions 13 (both physical and mental), provisions within the Covenant, service related mental health problems or even about the military culture in general 14. This contrasted with what was viewed as a very small number of GPs who were described as showing real understanding and empathy. 13 A survey conducted by the RBL in 2009 of 500 GPs across England Wales, revealed that 81% knew very little or nothing about the priority treatment arrangements. 14 The February 2011 National Assembly for Wales Health Wellbeing and Local Government Committee report on PTSD treatment for military veterans recommended that primary care staff receive training in the symptoms and treatment of PTSD (recommendation 8) and that the Welsh Government reviews the training of NHS staff to ensure they are aware of the priority treatment scheme for veterans and that the scheme is available to all veterans. 20

25 5.37 The RBL commented that it had received several reports from veterans revealing poor experiences of GPs, as well as of some primary care mental health services, who had no knowledge of military conditions of service and culture. In their view, a first contact with a GP who shows little empathy or understanding could serve to discourage further contact and, in turn, might exacerbate the veteran s condition. Similar comments were made by Combat Stress Welfare Officers. Resettlement and Discharge My final Army medical was conducted by a junior soldier with no medical background he just filled in the tick boxes on the form.i received no guidance from MoD regarding future health issues or signposting. (Falklands Veteran, discharged 1993) 5.38 The majority of older veterans commented negatively on the way they were discharged 15 from the military and how important this process is to achieving effective continuity of healthcare within the NHS. They also expressed the view that this was a major contribution to the confusion amongst many existing veterans as to where they should go to get healthcare appropriate to their needs. Whilst work is in hand to address transition protocols and continuity of care for current service personnel 16, there is a large legacy veteran population in Wales who report having received virtually no support in this regard Concerns were expressed that some Early Service Leavers had been returned summarily to civilian life as the result of disciplinary issues, including drug misuse. It was felt that this group were the ones most likely to lose their way in civilian life and were not always receptive to counselling/signposting regarding healthcare issues, which often surrounded alcohol, drugs or the later effects of mental health issues following operational tours. 15 Current MoD policy provides a Full Resettlement Programme for those who have served six years or more and all those who have been medically discharged. Those serving less than four years (Early Service Leavers) only receive a Service briefing and advice but this is targeted for improvement by the MoD. 16 Welsh Government Package of Support paragraph

26 Service Medical Records 5.40 Many veterans were unaware of the processes required to obtain their service medical records through their GP. The general comment was also made that the process of transferring medical records on discharge from the Forces should be a matter of routine practice with consent from the individual service man or woman formally actioned as part of the resettlement and discharge process. Residential Centre for Veterans in Wales This would serve as a tangible example of visible commitment to Welsh Servicemen, who account for at least eight percent of the total UK veteran population. (Royal Marines Veteran) 5.41 Many members of the Armed Forces community commented on the desirability of having a residential centre for veterans in Wales as something you can see, touch and feel and of real psychological benefit. It was suggested by some veterans and charities that such a centre could serve as a central location from which the organisational and signposting hub for the Welsh Armed Forces community might be coordinated while others suggested a multi-disciplinary treatment facility. General Issues Armed Forces Support Groups 5.42 A large number of respondents also commented on the desirability of developing a Wales-wide network of Armed Forces Support Groups, with these groups being set up as partnerships embracing health, employment, housing, social care etc. There was also a general consensus that there needed to be consistency in this respect across Wales although one size did not have to fit all. 22

27 5.43 One example of such a group is being developed in West Wales by the West Wales Action for Mental Health (WWAMH) 17, which has been co-ordinating and facilitating a regional network within the Hywel Dda LHB area that enables exservice personnel, statutory agencies, service organisations and the third sector and to work together to develop services across this region. A similar group is being established in Powys. LHB Armed Forces Champions 5.44 The survey found that the LHB/Trust Champion role was not well known or understood within the Armed Forces community. Also, within LHBs the role had developed differently with apparently little coordination or consistency across Wales. Local Authority Armed Forces Community Covenant 5.45 Although not part of the HIW survey, many respondents commented positively about the benefits of every Local Authority in Wales signing up to the Armed Forces Community Covenant with Community Champions working more closely with LHB Champions. 17 West Wales Action for Mental Health is a mental health development organisation, providing a range of services to voluntary groups, carers and individuals who have used or are using mental health services and living in Carmarthenshire, Ceredigion and Pembrokeshire. They are currently involved with over 100 local groups advising on such matters as fundraising, training, local forums, planning and information technology. 23

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29 6. Conclusions and Recommendations The healthcare provisions within the Covenant must be firmly embedded into the fabric and culture of the NHS through training, education and awareness. (SPVA Welfare Manager, Wales) 6.1 It needs to be emphasised that this survey was not intended to be a systematic review of the adequacy and effectiveness of healthcare services for the Armed Forces community in Wales but focussed on capturing the comments of the members of this community about their experiences of accessing and using healthcare in Wales. In addition, many comments were received both from the Armed Forces community and service organisations and charities about the general provision and adequacy of healthcare for this community in Wales. The experiences and views of one veteran are included in Appendix B as an example of the comments we received. 6.2 The engagement work that HIW carried out with the Armed Forces community and this report represents a snapshot and the findings are based on the comments from those individuals and organisations that responded. Nevertheless, some consistent themes and messages emerged from this work and a number of recommendations are set out below that the NHS in Wales, the Welsh Government, service organisations and charities and the Armed Forces community itself should consider. 6.3 The main general themes arising from this work centre on information, coordination and awareness/education. In addition, some specific issues were identified concerning present arrangements with regard to accessing healthcare, liaison between the MoD and the NHS, and the overall provision and organisation of healthcare for the Armed Forces community. 6.4 This survey has also highlighted that while there does not appear to be a need to develop additional or specific quality standards for the Armed Forces 25

30 community with regard to healthcare, there does need to be a continuing, long term focus on their distinctive circumstances and health needs. In this context, HIW will ensure that it integrates the views of the Armed Forces community into its routine NHS inspection and review work and this will extend to involving members of this community as lay reviewers. Recommendations 6.5 With regards to healthcare provision for the Armed Forces community in Wales it is suggested that each Local Health Board and Trust should establish an Armed Forces Forum. The Forum should bring together military representatives, health managers, clinicians, social services, military and family welfare bodies, service charities and organisations, the third sector, the LHB Champion, the Community Champion (where they exist) and members of the Armed Forces community themselves. Given the comments made to us about primary care, it is suggested that an addition to the membership of the Forum should be a GP Champion. The Forum should be supported by suitable, dedicated senior management and administrative time and support. 6.6 The main purpose of the Forum would be to: ensure that the health needs of the Armed Forces community are identified, kept under review and are reflected fully in local plans for service provision and development; develop and maintain a local directory of health and wellbeing services that will assist members of the Armed Forces community and service organisations and charities to help individuals in accessing appropriate healthcare in a timely and effective manner; positively monitor and keep under review the effectiveness of the priority treatment arrangements within the services provided by and for the Health Board; develop and implement a rolling programme of education, training and awareness raising within NHS and contractor professions and staff of the particular health needs and issues of the Armed Forces community; and 26

31 ensure that the commitments in the Covenant and the Package of Support concerning healthcare are being implemented and adhered to locally. 6.7 The issue of mental health problems amongst veterans, caused as a result of experiences during service, was the subject of a significant proportion of the responses received. It is clearly an area of significant current concern and where more work needs to be done in developing a coherent and accessible range of appropriate services. To achieve this, it is proposed that each Health Board (except Powys which does not itself provide mental health services) should build on the new hub and spoke All Wales Veterans Health and Wellbeing Service that has been implemented over the past year by establishing a veterans mental health clinical network within each Health Board area. This clinical network should be made up of the AWVHWS therapists, clinicians from the spectrum of mental health and primary care services in the Health Board area and also representatives from third sector providers of treatment and support. It might also be desirable to develop an All Wales clinical network around the hub of the AWVHWS. These networks should: act as a focus for the mental health needs of veterans; ensure that there is coordination of existing services between the AWVHWS, general mental health services and third sector providers; collect and monitor information on overall access to mental health services, in particular waiting times and the general capacity of services to meet known need and within the context of the priority treatment directive; collect data on the mental health needs of veterans in their area and use this data to determine the overall future demand for services locally; develop local plans to meet any identified unmet need. In this respect it is suggested that the AWVHWS is formally evaluated sometime in 2013 after the end of its first full year of operation and the outcome of this to be used in developing plans both nationally and within each Health Board area; act as a source of expertise in assessing the suitability of psychological therapies used in treating veterans; and engage with the veterans community and service organisations to determine if there are any barriers locally to veterans accessing treatment appropriately. 27

32 6.8 The NHS, supported by the Welsh Government, should ensure that service families do not experience any detriment with regards to issues such as registering with dentists or maintaining their place on secondary care waiting lists. Likewise, the provision of prosthetic limbs and the commitment made in the Package of Support needs to be implemented equitably across Wales. 6.9 The Welsh Government should ensure that the direction issued in 2011 that individuals veteran status is recorded through using the appropriate clinical code in their General Practice medical records is being implemented as intended. It is also suggested that this should be extended to include Reservists There needs to be continuing liaison between the Welsh Government and the Welsh NHS with the MoD to ensure that there are robust arrangements in place to deliver continuity of care when Regular Service Personnel are discharged and likewise for Reservists The Welsh Government should consider the utility of establishing a form of residential facility within Wales. 28

33 7. Postscript What happens when the glare of interest and emotion fades away will the interest and impetus be maintained? (Senior Officer Veteran) 7.1 One overriding theme from the comments and responses we received was the concern that the current focus on the Armed Forces community might fade with time, which could have a detrimental impact on the overall needs and wellbeing of this community in the decades ahead. 7.2 It is suggested therefore that the Welsh Government, building on the Expert Group and the Armed Forces Advocate role, considers what further measures it could take to fully embed the interests of the Armed Forces community and the measures set out in the Package of Support across all its Departments and services in a cross cutting way that will stand the test of time. 29

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35 Appendix A All Wales Veterans Health and Wellbeing Service Background The All Wales Veterans' Health and Wellbeing Service (AWVHWS) was established in 2010 to improve the mental health and well-being of veterans who live in Wales. The service operates on a hub and spoke basis, with the hub being managed through the University Hospital of Wales, while also being part of each Health Board s mental health services. Each of the Local Health Boards has appointed an experienced clinician(s) as a Veterans' Therapist (VT) with an interest in or experience of military mental health problems. The AWVHWS also has effective links with service organisations and charities such as Combat Stress, RBL, SPVA and SSAFA Forces Help. Aims and Outcomes The primary aim of the AWVHWS is to improve the mental health and well-being of veterans. The secondary aim is to achieve this through the development of sustainable, accessible and effective services that meet the needs of veterans with mental health and wellbeing difficulties who live in Wales. The services should be firmly based within existing NHS and Social Care Services and fully integrated with the other services and agencies that cater for the health and social needs of veterans. The service will be one part of the welfare pathway for veterans and adopt a stepped care approach to ensure veterans needs are addressed by the most appropriate agency. 31

36 The key outcomes of the service will be: A. Veterans who experience mental health and wellbeing difficulties are able to access and use services that cater for their needs. B. Veterans in this service are given a comprehensive assessment that accurately assesses their psychological and social needs. C. Veterans are signposted or referred to appropriate services for any physical needs that are detected. D. Veterans and others involved in their care are able to develop an appropriate management plan that takes their family and their surroundings into account. E. Veterans' families are signposted to appropriate services if required. F. This service will develop local and national networks of services and agencies involved in the care of veterans to promote multi-agency working to improve outcomes for veterans and their families. G. The service will link with the military to facilitate early identification and intervention. H. The service will promote a recovery model so that veterans can maximise their physical, mental and social well being. I. To provide brief psychosocial interventions. J. To provide expert advice and support to local services on the assessment and treatment of veterans who experience mental health difficulties to ensure local services, including addictions services, are able to meet the needs of veterans. K. To raise awareness of the needs of veterans and military culture to ensure improved treatment and support across services. L. To identify barriers to veterans accessing appropriate services and attempt to highlight and address these as appropriate M. To collect data on patterns of referral, routine outcomes and referral on. 32

37 Appendix B Case History of a former Welsh Guardsman and Falkland Islands Veteran In 1982 I took part in the Operation Corporate to recover the Falkland Islands from Argentinean forces and was on board the Sir Galahad in Bluff Cove when it was attacked by Argentinean fighters. I was trapped below decks for some time in the dark in choking conditions, but eventually managed to escape suffering only minor burns and smoke inhalation. I continued to serve in the Welsh Guards until the end of 1993, during which time I saw service in places such as Kenya, Falklands, Germany, Canada, Northern Ireland and Cyprus during which I time I witnessed the deaths of a number of fellow soldiers. The first symptoms of PTSD started to emerge around two years after the Falkland Islands, but these were not formally and professionally diagnosed until after my discharge in My final medical was actually conducted by a junior soldier with no medical background and who was merely responsible for completing the required tick box forms. Other than very basic resettlement documentation, I received no guidance from the MoD regarding future health issues and entered civilian life with little preparation. Things might be improving for servicemen now, but there are many veterans out there who were probably discharged in the way I was. On retirement I was unemployed for over six months, ran out of savings and found difficulty finding housing. At that time I went through a divorce, with the increasing symptoms of PTSD contributing largely to the breakdown of my family unit. I worked hard and gained meaningful employment within the British Red Cross and the charity MIND in Carmarthen until 2008, when a serious and ongoing physical illness prevented further employment. 33