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Combat Stress

Volume 496: debated on Wednesday 15 July 2009

Thank you for the guidance that you will provide us with, Lady Winterton, through the next half hour—if the debate lasts that long—and for the chance to raise the issue of combat stress. Hopefully, the debate will be very short. My greater hope is for a positive response from the Minister, who should be sympathetic.

I intend to focus predominantly on the UK-wide organisation Combat Stress, which is one of the main treatment establishments and which has a main base in my constituency. As the organisation’s name indicates, it treats ex-UK service personnel suffering post-traumatic stress disorder derived from combat. PTSD is recognised in civil life, including among police, ambulance and fire brigade personnel, among whom it has the nickname, “the silent disease”. The effects on sufferers can be total destruction, for them as individuals and for their families. Sufferers get nightmares and flashbacks, become hyper-vigilant, suffer panic and fear of attack, and frequently descend into alcoholism.

The effects can lead to suicide. It is estimated that 262 British Falkland veterans have taken their own lives, compared with 255 lives lost in Falkland combat. Statistics released by the Ministry of Defence in March last year reveal that between 1 April 1991 and 31 December 2007, 162 British Gulf veterans died

“due to intentional self-harm or from other incidents where the intent was unclear, leading to open verdicts at inquests”—

that is a “Yes, Minister” type quote—which compares with 24 killed in action.

I congratulate my hon. Friend on introducing this debate. Is he aware of the American experience, which involves far greater numbers? The suggestion is that young men who have served are twice as likely to take their own life than those who have not served. We need to be particularly mindful of the American experience, given that it is greater than ours, when making our projection of the long tail that current operations are likely to have.

My hon. Friend pips me at the post, because I was about to say that those who serve are 2.13 times more likely to take their own life. Saying that it is twice as likely will do, because it shows why it is important to deal with the problem.

Increasing recognition of combat stress has, I hope, inspired the Government to ensure that general practitioners are aware of the causes and that they seek help for ex-personnel who show symptoms. Recognition is the key, but there is a need for treatment, which brings me back to Combat Stress, which specialises in the care and treatment of ex-service personnel suffering from combat-induced PTSD. It is recognised as the leading organisation in such treatment. Perhaps that is not surprising, given that it was formed in 1919 and that it has helped, treated, or both, 100,000 veterans.

Combat Stress’s current active and passive lists of personnel whom they serve come from about 20 theatres of operation, ranging from Borneo, Rwanda and Burma through to much more recent conflicts. Currently, just short of 2,000 ex-Northern Ireland veterans are on its lists.

To obtain better recognition of the problem, it is worth looking at the new referrals to Combat Stress for the year 2007-08, which total 1,160 cases with an average age of 44. Interestingly, over the 90 years, the average age is decreasing. The average length of military service of victims is about 11.5 years. However, I was surprised that the interval between discharge from military service and the first contact for treatment is 14 years. That apparently is the norm and according to Combat Stress, it has not changed for a number of years. The figures are therefore a warning, particularly given the current and recent service of so many of our troops in Iraq and Afghanistan. It is not only a warning of demand to come, but a hint for early detection.

I hope that the Minister agrees that Combat Stress is the leader in the field and that it should be supported to the hilt by the NHS. It is not a respite organisation; it is an active treatment specialist for ex-service personnel with combat stress. It has 180 psychiatric clinical personnel and three centres, and specialises in getting its traumatised patients back into normal life in their communities with their families. I repeat: in that field, it is the best.

One Combat Stress treatment centre is in Ayrshire in Scotland and the other two are in Shropshire and Mole Valley. It has also developed outreach services nationwide. Huge, enormous sums have been provided by public donation, from both individuals and events. Recently, it received £3.5 million from Help for Heroes towards a building programme in Leatherhead. As the Minister will be aware, the Leatherhead Combat Stress centre is close to and linked with Headley Court.

Charitable donations amount to about 58 per cent. of running costs and the remaining 42 per cent. comes from the MOD—that is for this year. However, as the Minister will be aware, responsibility for funding is moving from the MOD to the Department of Health. There has been no problem for the Combat Stress unit in Ayrshire. The Scottish NHS has recognised the need, and has agreed full funding to come directly from a central source. Sadly, that is not the case south of the border.

I am sure that the Minister will recognise, and I hope accept, the need for full funding. The need is self-apparent, as is Combat Stress’s expertise, but it appears that there is a bureaucratic problem. The current approach for Combat Stress, as I understand it, is that it seeks funding from the primary care trust for each individual patient. That is a minefield. The cost to the charity in dealing with the bureaucracy and various foibles of so many PCTs does not bear thinking about.

There are precedents for direct central funding in such special cases, and I believe that this is one such case. I understand from quiet discussions with the relevant section in the Department of Health that it feels that that might well be the appropriate approach. The problem is that after long, drawn out discussions and negotiations, nothing has happened and no agreement has been reached. I hope—and I am sure the Minister will agree—that the need is obvious, that funding will be available and that Combat Stress’s expertise is demonstrated daily. Perhaps he could strengthen his accent and sort this out by mimicking the Scots.

I congratulate the hon. Member for Mole Valley (Sir Paul Beresford) on securing this debate. Few things can be more important than looking after the health of the brave men and women who risk their lives for us in combat, and there can be no clearer reminder of the sacrifices that they make than the moving scenes yesterday in Wootton Bassett as the bodies of eight young men were returned to their families.

Despite that tragic loss of life, it is important to remind families that the vast majority of those who see active service return home safe and well. Most ex-service people benefit enormously from their time in the armed forces and go on to lead full and productive lives after completing service, including active service in combat zones.

However, in war, there are casualties, and even those who return home physically unharmed may well have suffered severe mental trauma that can itself prove fatal, as it leads on occasion to suicide. It is important that we provide the best possible care for people who have to deal with the consequences of the difficult circumstances that they experienced in combat.

Afghanistan and Iraq are difficult, unfamiliar and extremely stressful environments. Sometimes it is hard to tell friend from foe, and there are constant threats from roadside bombs, land mines and snipers. Many may be deeply affected by their experiences. This Government believe that we need to do all that we can to give the right kind of support to those serving their country and returning to civilian life.

The most common mental health problems treated in the military are similar to those treated in the civilian population: anxiety, depression and alcohol problems. Research from Manchester university shows lower rates—

Sitting suspended for a Division in the House.

On resuming—

I was talking about the research by Manchester university that shows lower rates of suicide among armed forces leavers than among the general population. The one exception is that there is a higher rate of suicide among young, male ex-service personnel who have served for only a short period. The reasons for that are not clear. The research does not comment on whether the service is a factor. The general lower rate suggests that it is, but it is perhaps not the only factor.

The most important thing is that we get help to the people who need it, when they need it. If a serving soldier experiences a mental health problem, they can attend one of 15 community and mental health departments that have been set up by the Ministry of Defence. The Ministry of Defence also provides mental health care for those posted overseas. In the UK, soldiers also have access to NHS outpatient mental health services.

The situation is different for veterans. When service personnel leave the armed forces, they become the responsibility of the NHS. The vast majority of service veterans will access the NHS in the same way as the rest of the population. Some find it difficult to engage and need additional help in getting the treatment that they need. That is not surprising. Young men are often reluctant to ask for help when it comes to their health, and much more so when it comes to their mental health. The strong military ethos adds to that reluctance, meaning that soldiers are among the least likely to come forward. They are therefore difficult to identify as being in need of help.

In partnership with the Ministry of Defence and the devolved Administrations, we have set up pilot schemes in six NHS mental health trusts. The aim is to identify, treat and help veterans with mental health problems. We are currently evaluating the way in which the pilots have operated, what benefits there have been to the people who have come forward with mental health problems and in what ways the service needs to be improved. When the final report is published, we will roll out best practice across the NHS to ensure that ex-service personnel get the assistance that they need.

Combat Stress and other third sector organisations are fully involved with the pilots. They have worked closely with the Ministry of Defence, the Department of Health and the NHS to plan and monitor them. We want Combat Stress and the NHS to learn from each other to find the best way to help this cohort get better services than they currently receive. I am the first to say that the NHS still has to learn lessons in this area. However, I think that lessons are being learned from the pilots. When the report comes out, I hope that we will be able to find the best way of ensuring that ex-service personnel get help.

As in so many areas, providing the service that each individual needs requires statutory and non-statutory organisations. Combat Stress does good work and the hon. Member for Mole Valley rightly pays tribute to the way it assists service and ex-service personnel. Discussions are taking place between Combat Stress and the national specialist commissioning group, which will consider the application for assistance and funding once the discussions are complete. I accept his point that some of those discussions have been going on for a while and that we must draw them to a satisfactory conclusion. As far as I am concerned, a satisfactory conclusion means ensuring that the people who need help get that help. To do that, we must bring together the statutory sector and non-statutory voluntary sector to ensure that the best use is made of the services that people need.

The use of community psychiatric nurses with Territorial Army experience has been encouraging. They have common experiences and work with veterans’ organisations to identify people who are not getting the right support. Such psychiatric nurses can deliver treatment themselves or refer patients to the services that they need. We are investing unprecedented amounts of money in psychological therapies. The treatments that people need if they are suffering from depression, anxiety or post-traumatic stress disorder are important components of that investment. Those are the conditions that are most often experienced by ex-service personnel. That investment, which will rise to £173 million next year, will pay for an additional 3,600 therapists. The service personnel Command Paper commits us to raising awareness of the needs of veterans and to meeting those needs.

As part of our improving access to psychological therapies initiative, we published “Commissioning for the Whole Community”, which shows how primary care trusts can ensure that veterans get access to the mental health services that they need. In March, we issued more specific guidance on providing psychological treatment to veterans. It is for PCTs to commission services, including those from the third sector, based on an assessment of the needs of the local population. That includes veterans. We also underlined to the NHS the importance of taking account of the special needs of veterans, including possible psychological conditions, in the operating framework for the NHS.

I hear what the Minister is saying about PCTs. Although the numbers we are discussing are large as a percentage of the troops, they are not large as a percentage of a PCT’s portfolio of difficulties. Therefore, there is much to be said for centralising the arrangements so that veterans get the special treatment that they need. That could include the centralised funding of organisations such as Combat Stress.

The hon. Gentleman is right that we must identify where the services would best be provided. The general view is that services are best provided where there is a local need for them. As he has identified, this is a national problem. We must ensure that we identify how the services can best be provided and that we are not providing them just in London. We must have services for personnel who are based around the country. By and large, those will have to be local services. We might also need a national component. The discussions between Combat Stress and the various commissioning organisations must therefore be brought to fruition so that we can put in place the overall services that will best ensure that those to whom we owe a debt get the services that they need.

I thank the Minister for moving in the direction that I am trying to drive the debate. Organisations such as Combat Stress have outreach services that are linked closely to the pilots, as he said. Such services generally provide respite rather than treatment. The services should be driven from the centre, so that NHS bodies and organisations such as Combat Stress can put the diverse services into local areas without involving PCTs because of the key importance of this relatively rare and unusual problem.

It is on that point that I begin to part company with the hon. Gentleman. For each individual, we must put in place a package of services that is appropriate for them. We should not assume that a national organisation can do that without having close involvement with the local services that a person may need in Doncaster, Worcester or some other part of the country. Such an organisation should be in contact with local medical services, rather than trying to parachute in some sort of overall service nationally. Local service provision is crucial to individuals because they might not simply need one particular piece of medical help; they are more likely to need a package of help. A number of services need to be in a position to provide what an individual needs, and that requires the local PCT to be engaged in the issue.

Throughout the whole of the NHS, we are trying to make it clear that veterans’ issues are some of the key areas on which the NHS has to focus. The matter has not been dealt with in that way in the past, so it is quite a change for the NHS. I do not want to dilute the effort that is going on throughout the NHS to say to PCTs, which commission many of these services, “You have got to ensure that the services are in place for veterans where they are needed and that includes mental health services.” It is important that, where there is a need to provide some service at a national level, that can be done, but it is also important to ensure that where we have the ability to put in place local services—a package of services—to help individuals, we do so and people get the help that they need.

The pilot schemes will give us a better understanding of how we can engage nationally and locally to ensure that we provide the right type of mental health service for a diversity of people. Such services will not all be standard. People with post-traumatic stress disorder have different requirements, and it is important to respond to the particular needs of those people—for example, it might be that PTSD is exacerbated by a condition regarding homelessness or an employment or education issue. We need to make sure that a number of other local services are there to provide support. I do not claim that we have got it right. We must do much more and there is a much bigger agenda, which is why we now have a Veterans Minister in the Ministry of Defence and why we have stressed in recent years that we need to have much better services for veterans.

Earlier this afternoon, I was concerned to note that—the hon. Gentleman appears not to know about this—the Conservative party put out a statement, in which it said that it regarded the provision of mental health services for ex-service people to be a national scandal and that Britain was sitting on a time bomb. One would have thought that such rhetoric would elicit a major set of proposals, but the Conservative party made just one proposal. The single proposal—I understand that no extra money was proposed and, from the press release, I believe that no other ideas were put forward—was that there should be a telephone helpline. Well, the service charities already have helplines—the Royal British Legion has one and there is also the medical assessment unit at Guy’s and St Thomas’ NHS Foundation Trust. It is not clear what another telephone helpline would add. I am interested in the idea and will by all means look at it, but such a response—a single proposal—does not seem to justify the level of rhetoric of the press release and is somewhat inadequate.

We do not want to deal with things simply by having a telephone helpline, which to some extent already exists; we want to put in place a larger package, so that the whole of the NHS responds to the needs and concerns of services’ veterans. Responding in such a way will mean that if people have mental health problems, there is a package in place and we can provide services at a national level by working with organisations, such as Combat Stress.

We will work through the negotiations to enable the best possible package for people. I cannot guarantee the outcome of the discussions, but what I can say to the hon. Gentleman is that I will go back to those who are negotiating and say that we want the matter resolved. We must continue to improve the quality of what we do for veterans, and we still have a lot of work to do. We have put in substantial extra funding and have made the matter a massive priority in recent years, but we want to ensure that there is a broad-based improvement in the circumstances of veterans and military personnel in the coming months and years. That is the least we can do for our service personnel. We will keep working with other Departments and groups such as Combat Stress to make sure that the right service support is put in place for our Army, Navy and Air Force personnel. We owe them that.