Scoping Review: A Needs Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and their Families in Scotland

SECTION 3: Provision of Healthcare and Welfare Support

3.1 Preface

The following section is predominantly dedicated to establishing the current status of health and welfare support provision for the UK Armed Forces community in terms of its organisation and delivery. In so doing, key factors have been addressed that have led to substantive shifts in strategic thinking with regards to the development, organisation, and delivery of health and welfare support services and which have consequently been influential in shaping current service provision. Particular consideration has been given to those factors associated with the risk of social exclusion in vulnerable subgroups of the ex-Service population given the wider political agenda as highlighted in the previous section.

3.2 DEFENCE HEALTHCARE

3.2.1 Military Medical Care Policy and Strategy

• The 1991 Gulf war has been advanced by Wessely and Dandeker (KCMHR, 2006) as "…perhaps the most important driver" (p.5) of the increasing interest in the health of Service personnel in the UK Armed Forces. In response to the concerns and controversies of the so-called "Gulf War Syndrome" The MoD set up the Gulf Veterans Medical Assessment Programme (GVMAP) to investigate claims of ill health among Gulf War Veterans, which began to emerge in the 1990s. The remit of the GVMAP was subsequently extended to former Porton Down volunteers and to Veterans of Operation TELIC (the 2003 Iraqi campaign). Its role is to diagnose presenting conditions, recommend appropriate management, and collate data for research purposes to identify trends.
• Two fundamental principles underpin the Defence Health Strategy as specified in "The Armed Forces Overarching Personnel Strategy" (MoD, 2002/2003). The first pertains to the fact that a prerequisite of military service is the maintenance of an effective operational force comprising Service personnel who are "fit for task" to ensure that the UK Government can fulfil its most important responsibility of providing security for the nation and for its citizens^[43]. To sustain morale and physical capability however requires contemporary and effective medical support. Thus, a fundamental element of the UK's military capabilities is the availability of medical personnel who are suitably trained in accordance with the requirements of the relevant professional bodies and whose clinical skills can be maintained to the requisite standard^[44]. The second is associated with the Military Covenant and pertains to the need for recognition of the exceptional demands of military service. As such, Service personnel also have a right to expect the MoD to fulfil its "duty of care" in order to mitigate the inherent risk to life and health and the stresses associated with the special circumstances encountered by Service families (as discussed in Section 2).
• The vehicle for the delivery of the Health Strategy is the Defence Health Programme (DHP) 2007-2011. It comprises a statement of intent to continue to improve the quality of medical provision by the Defence Medical Services (DMS) "…to improve the operational capability of the Armed Forces and the confidence in healthcare, by promotion, provision and maintenance of all elements that impact on the health of Service Personnel and, where appropriate, their dependent families." By working through the chain of command, the DHP seeks to minimise those risks to health and to provide a holistic treatment capability that includes rehabilitation and aftercare services. This includes the effective collection of data and information flow processes to improve "through life" patient outcomes, which have been facilitated since 2007 by the rollout of the Defence Medical Capability Programme (DMCP).

3.2.2 Responsibility for the Delivery of UK Armed Forces Medical Care

• The DMS is responsible for providing healthcare to approximately 258,000 Service personnel (serving in the UK and overseas), their family dependants, and entitled civilians. It includes primary healthcare, dental care, hospital care, rehabilitation, occupational medicine, community mental healthcare, and specialist medical care. The DMS therefore provide healthcare in a wide range of facilities including regional rehabilitation units and field hospitals. The cost of medical care provision as a result of military operations was recently estimated to be £71 million in 2008-2009 (National Audit Office, HC294, 10 February, 2010).
• Each of the three Services has an individual responsibility for delivering primary healthcare and the requisite medical support whilst on operations. The Surgeon-General and the Deputy Chief of the Defence Staff (Health) determine medical policy for the three Services^[45] and jointly oversee the work of the following three organisations.
  • The Defence Medical Services Department (DMSD) - the administrative headquarters of the DMS responsible for strategy.
  • The Defence Medical Education and Training Agency (DMETA)^[46] - a tri-Service organisation responsible for: (i) providing personnel to meet the secondary care requirements of operational deployments, and (ii) education and training of medical personnel.
  • Defence Dental Services (DDS) - a tri-Service organisation responsible for the provision of dental services in the UK and on operations.
• The relationship between the DMS and the National Health Service^[47] is founded on a Concordat^[48] between the Department of Health^[49] (DoH) and the MoD to confirm their joint intention to renew and strengthen the partnership between the defence and the civil healthcare services at national level. As a crosscutting partnership its fundamental aims are to:
  • enable the DMS and NHS to collaborate with and support each other;
  • provide value for money for the taxpayer;
  • maintain high standards of care for patients, and
  • promote the effective defence of the nation.
• The NHS/ MoD Partnership Board is responsible for overseeing the Concordat at official levels and to identify innovative methods of delivering healthcare to both civilian and military patients.

3.2.3 Trauma Care Provision for Severe Operational Injuries

• DMS personnel are employed on operations on a tri-Service basis to deliver medical care in theatre such as Operation TELIC (Iraq)^[50] and Operation HERRICK (Afghanistan)^[51]. Between October 2001 and October 2009, a total of 522 personnel have been seriously injured^[52] as a result of deployment on both of these operations (National Audit Office, HC294, 10 February, 2010). The Reserve Forces (which comprise both Volunteer^[53] and Regular Reservists^[54]) provides a fundamental contribution to the treatment of operational casualties^[55], in particular with regards to deployed hospital care and specialist roles. Delivery of treatment is undertaken by medical staff designated to either: (i) Incident Response Teams (IRTs),^[56] (ii) Deployed Rehabilitation Teams (DRTs), or (iii) Deployed Mental Health Teams (DMHTs).^[57]
• Typically, casualties^[58] defined as "seriously injured" are initially treated and stabilised by medical personnel in theatre prior to being aeromedically evacuated^[59] (i.e., transported by air under medical supervision) to appropriate facilities in the UK^[60]. A total of 6,900 personnel have been aeromedically evacuated back to the UK from Iraq and Afghanistan since 2003 for serious injuries as well as for a range of other medical conditions (National Audit Office, HC294, 10 February, 2010).
• Since 2001, the main receiving unit for such casualties has been the Royal Centre for Defence Medicine (RCDM) located at the University of Hospital Birmingham Foundation Trust^[61] (UHBFT) which includes five specialist hospitals including Selly Oak Hospital (the main treatment facility for the more common types of injuries sustained due to polytrauma). Forty eight per cent of evacuated personnel receive their first treatment in a secondary care facility at either the RCDM or the five MOD Hospital Units embedded in NHS hospitals (National Audit Office, HC294, 10 February, 2010).
• According to the Medical Care for the Armed Forces 7^th Report of Session 2007-08, the decision taken by the MoD to use the UHBFT as a centre for treating operational casualties derived from the MoD's view that "…the medical needs of the Armed Forces are best served through access to facilities and training in a busy acute care hospital that is managing severe trauma on a daily basis." In addition, treatment is further facilitated by a good link between Selly Oak Hospital and RAF Brize Norton, which is the main point of arrival for operational casualties.
• The RCDM has introduced measures to promote a military atmosphere in response to meeting the needs of those Service personnel who feel the loss of a military environment, which include the following.
  • Most Service personnel are treated together in the same trauma ward (depending on the type of treatment required).
  • Military liaison officers provide regular visits to deal with day-to-day needs of Service personnel and to maintain links with the patients' units.
• In recognition of the fact that arrangements for the provision of NHS care were not originally set up to accommodate the casualties of war, the "Joint Casualty Reporting and Reception Plan" (JCRRP) was devised to enable the NHS to become involved in the treatment of mass casualties. In 2002, the JCRRP was subsequently refined and is now known as the "Reception Arrangements of Military Personnel" (RAMP). According to the findings of the recent National Audit Office Report (HC 294, 10 February 2010), the increase in casualty numbers arising from military operations however inevitably impacted on the demand for services provided by Selly Oak. When military casualties peaked in July 2009, a third of the 90 trauma and orthopaedic ward beds were occupied as a result, and 80% capacity was reached in respect of the military-managed ward.
• In June 2010, the new £545 million Queen Elizabeth Hospital (QEH) Birmingham brought further improvements to the care of military patients. Situated in the Edgbaston area of Birmingham, this NHS hospital has replaced the previous Queen Elizabeth Hospital and Selly Oak Hospital. It has 1,213 patient beds, 30 operating theatres, and has the largest single-floor critical care unit in the world, with 100 beds. UK Armed Forces personnel are treated in single rooms or four-bed bays in a 32-bed trauma and orthopaedics ward in order to cater for their specific requirements and to help create a military environment conducive to their recovery. It has more staff (both military and civilian) than a normal NHS ward, a quiet room for relatives and a communal space for patients to gather. A dedicated physiotherapy suite is available close to the ward for military patients. University Hospitals Birmingham has also become the home of a £20 million national trauma research centre, which brings together military and civilian trauma surgeons and scientists to share medical innovations and advances in battlefield treatment and will play a key role in gathering scientific evidence from injuries sustained in both military and civilian environments.

3.2.4 Illnesses and Non Battlefield Injury (NBI)

• A significant number of Service personnel require treatment for illnesses such as gastrointestinal disorders and for injuries caused by non-conflict related military events (e.g., road traffic incidents or training). Since 2006, Service personnel deployed on Operations Helic and Telic have attended medical facilities in theatre a total of 125,000 times for minor injury and illness. Rates in Afghanistan have almost doubled from 4% to 7% of deployed personnel per week between 2006 and 2009 (particularly around the six-monthly rotations of deployed units), which represents a cost of £0.7million and a small reduction in operational capability of 6,700 days lost. Should these rates continue to increase, there is the potential risk that operational capability will be further reduced. Factors attributed to this increase have been identified in the recent National Audit Office report of "Treating Injury and Illness arising on Military Operations" (HC294, 10 February 2010) as:
  • basic living conditions at some forward operating bases
  • operational intensity
  • improved reporting

3.2.5 MoD Hospital Units: Secondary Care and Training

• Following the 1990 review of Defence secondary care in the UK as part of "Options for Change"^[62], a number of "stand-alone" military hospitals were closed due to insufficient numbers of patients. Moreover, the small number of clinical cases seen imposed severe restrictions on opportunities for adequate training and maintenance of medical skills of staff. In an endeavour to address these issues, the MoD took the decision to establish MoD Hospital Units (MDHUs) within host NHS facilities. In so doing, the MoD held the view that this would not only facilitate the maintenance of training and skills for Defence medical staff by working alongside their civilian clinical counterparts, but it would also enable some secondary care provision for Service personnel in an environment with a military milieu.
• Currently there are five MDHUs in England that are tri-Service in composition and are embedded in host NHS Acute Trusts^[63], viz, Portsmouth, South Tees, Frimley Park, Plymouth and Peterborough. Their primary function is to be fully integrated throughout each host NHS Trust for the dual benefit of assisting Service personnel with the development and maintenance of their medical skills whilst making a contribution to overall NHS capacity and capability. In addition, they serve a key purpose in ensuring the provision of personnel who are at "full readiness for deployment" as required including a substantial number of Reserve medical personnel (Medical Care for the Armed Forces (7^th Report of Session 2007-08), House of Commons Defence Committee 18^th February 2008). Whilst the potential benefits of this arrangement cannot be disputed in principle, in practice there are a number of issues which have surfaced following the realignment of medical care, a summary of which will be provided in Section 5 as part of the commentary on the evaluation of progress made since the implementation of the Veterans Initiative in March 2001.
• The priority of treatment of injured Service personnel is intended to return them as quickly as possible to operational effectiveness. The DMS employs two mechanisms to fulfil this objective, viz, "fast track programming" and "accelerated access". The former pertains to the system whereby Service personnel can receive fast access to treatment (in the main for musculo-skeletal disorders) that extends beyond the arrangements with the MHDUs. As such fast track treatment is provided either in the MHDU host Trusts, in other NHS Trusts, or in the independent sector. "Accelerated access" refers to treatment that Service personnel receive within MHDUs.

3.2.6 Rehabilitation and Aftercare

• To meet the Defence strategic intent on health, the provision of effective rehabilitation and aftercare constitutes another major element of the work undertaken by the DMS under the aegis of the Defence Rehabilitation Plan (DRP). The DRP is based on a tiered approach comprising three elements (see Appendix E). In order to fulfil the aim of restoring function as efficiently and effectively as possible (particularly in respect of enabling a return to active military duties), the approach taken by the DMS with regards to the treatment of musculo-skeletal injuries incorporates the following underlying principles.
  • Local provision of care (where possible)
  • Best use of physiotherapy and rehabilitation (as opposed to surgical intervention)
  • Reduction of waiting time for assessment and treatment
• In the same way that capacity at Selly Oak was challenged due to increasing levels of military casualties, the Defence Medical Rehabilitation Centre (DMRC) at Headley Court faces similar pressures in meeting the rehabilitation needs of Service personnel. On average, seriously injured patients receive four periods of rehabilitation at Headley Court, a figure which equates to 89 days in rehabilitation over a 187 day period. Thus rehabilitation is an ongoing process for most patients. Since 2006, the number of complex trauma patients has increased two fold although the number of neurological patients has remained constant. Between 2006 and 2008, the number of staff increased by 23% and ward beds by 83% in 2007 to 2008. Over the course of 2009, the number of operational patients at Headley Court exceeded the 28 beds originally dedicated to complex trauma (although this was not the case in terms of overall bed numbers).
• In the event that casualties from Afghanistan persist at the 2009 level, analysis undertaken by the National Audit Office (HC294, 10 February 2010) suggests that seriously injured patients will occupy 86% of all ward beds by April 2010. To this end capacity at Headley Court will be exceeded unless other categories of ward patients reduce or alternative treatment facilities are identified. In currently reviewing its contingency plan with the DoH, the MoD intends to expand the provision of rehabilitation for seriously injured personnel by providing Headley Court-led services in other existing rehabilitation centres and building additional ward space (National Audit Office Report, HC 294, 10 February 2010).

3.2.7 Mental Healthcare for Service Personnel

• The mental healthcare provision for Service personnel underwent a reconfiguration based on the outcome of the Medical Quinquennial Review, which was published by the MoD in 2002. This constituted the delivery of an occupational mental health and community-based service through 20 Departments of Community Mental Health (DCMHs)^[64]. Together with primary care the DCMHs provide most of the mental health service delivery to military personnel in the UK and abroad^[65]. By virtue of the MoD's principal aim to provide out-patient treatment for the majority (where possible), the DCMHs are staffed by multidisciplinary mental health teams^[66] accordingly. For Service personnel who are on operations abroad, Field Mental Health Teams (FMHTs) comprising mental health professionals visit all operations to liaise with unit commanders and to attend to those in need of mental health support. Since, 2006, a total of 1,700 Service personnel have attended a medical facility during recent operations in Iraq and Afghanistan due to a mental health condition (National Audit Office, HC294, 10 February, 2010). A much smaller percentage however are referred for treatment by the FMHTs while on operations. Between 2008 and 2009, 0.2% of those deployed in Afghanistan and 0.8% of those deployed in Iraq received referrals.
• The provision of in-patient mental healthcare has also been subject to changes following the closure of the Duchess of Kent Psychiatric Hospital at Catterick in April 2003. This led to an interim arrangement being signed with the Priory Group commencing in December 2003 for the delivery of inpatient services on the grounds that it would permit patients to receive treatment at closer proximity to their parent units than was previously possible. The Priory Group subsequently became the default provider of in-service mental health provision when the full contract with the MoD was signed on the 1^st April 2004. Due to increasing concerns^[67], however, about the extent to which the quality of inpatient care provided by the Priory Group was being compromised the contract was subjected to a review, the outcome of which resulted in it being duly terminated.
• On the 18^th November 2008, the Under Secretary of State for Defence (Rt Hon Kevan Jones MP) announced that the MoD had awarded a contract to provide in-patient mental health care to Service personnel across the UK to a partnership comprising an initial network of seven NHS trusts^[68], the lead for which is the South Staffordshire and Shropshire Healthcare NHS Foundation Trust (SSSFT). All seven trusts were selected because of their Healthcare Commission ratings for clinical quality and resource management in addition to their geographical proximity to the 15 Departments of Community Mental Health (DCMH) located within the UK. Thus, this new scheme ensures that treatment is offered close to the patient's home or parent unit by using the facilities at each of the participating trusts to ensure national coverage and to build on MoD's partnership with the NHS. Moreover, the development of a network of NHS hospitals to provide care on this basis has been heralded as a first for the NHS.
• As stated in its Annual Report 2009/10, the vision of this unique NHS Inpatient Network is to:
  • improve clinical outcomes;
  • minimise inpatient stay in accordance with clinical need;
  • align the Network to the cultural needs of the MoD;
  • provide culturally sensitive, evidence-based high quality mental health care;
  • ensure services are dedicated to returning individuals to return to work as soon as is clinically possible, refine services to enhance patient experience;
  • provide services in response to the developing requirements of the MoD;
  • audit all aspects of the service;
  • promote education, training and conference events across the Network and in partnership with the MoD, and
  • refine services to enhance patient experience.
• Since the contract commenced on 12 January 2009 with SSSFT and subsequently the other partners on the 9 February 2009, NHS Greater Glasgow and Clyde was incorporated into the Network with a specific remit to provide services to DCMH Faslane thereby resulting in a total of eight NHS mental health providers and the second one to be based in Scotland along with NHS Grampian. In addition, the Inpatient Network increased its core bed capacity in three Trusts (Hampshire, Somerset and Tees, Esk and Wear Valleys), resulting in an overall increase of 14% with 25 beds available across the Network. Two per cent of those Service personnel who are aeromedically evacuated from Iraq and Afghanistan receive their first treatment at either the inpatient care provided by the this network of NHS Mental Health Trusts or outpatient care provided by the 15 DCMHs (National Audit Office Report, HC 294, 10 February 2010).
• On 31^st May 2011, SSSFT hosted an Academic Seminar entitled "Military Mental Health & Associated Issues" at St George's Hospital, Stafford. MoD inpatient performance and activity figures reported at that seminar from 1^st January 2009 to 27^th May 2011 included the following.
  • Total number of referrals received (n=559)
  • Total internal Network transfers (n=3)
  • Total re-admissions within the Network (n=80)
  • Total number of admissions for NHS Grampian (n=21; 3.76%)
  • Total number of admissions for NHS Greater Glasgow and Clyde (n=13; 2.33%)
  • Total number of referrals by Service:
    • Army (n=370; 66.19%)
    • RAF (n=92; 16.46%)
    • Royal Marines (n=16; 2.86%)
    • Royal Navy (n=79; 14.31%)
    • TA (n=2; 0.36%)
  • The number of admissions per year per service has decreased.
  • In 2011, the average length of stay for NHS Grampian was 28 days compared with 43 days for NHS Greater Glasgow and Clyde.
  • The rank order of the top 10 diagnostic codes over the contract period was:
    • alcohol dependence (28.77%)
    • adjustment disorder (23.65%)
    • moderate depressive episode (21.65%)
    • post traumatic stress disorder (9.69%)
    • severe depressive episode without psychotic symptoms (4.94%)
    • acute stress reaction (3.13%)
    • severe depressive episode with psychotic symptoms (3.13%)
    • adjustment reaction (2.56%)
    • harmful use (1.12%)
    • paranoid schizophrenia (1.14%)

3.3 Operational stress management policy and strategy

• The judgement handed down by Lord Owen in May 2003 in respect of the 2002/03 PTSD class action (Mr Justice Owen - Multiple Claimants v. MoD, 2003) highlighted the need for the MoD to address their failure to provide Service personnel employed on operational duty with adequate training and support, and to detect and treat those suffering from operational stress.^[69] In December 2003, the Service Personnel Board (SPB) agreed to address the actions identified in their initial paper (SPB 21/03 dated 16^th December 2003). This was followed by a second paper (SPB 22/03 dated 22^nd December 2003), which sought to principally endorse the Terms of Reference for an Overarching Review of Operational Stress Management.
• In February 2004, a Steering Group comprising both general and medical staff (including psychological experts) was established to undertake the necessary action. This included the implementation of a tri-Service review to ensure that Service personnel (and MoD employed civilians) are protected (as far as possible) against the effects of operationally induced stress. It comprised two phases. The first phase was dedicated to devising a tri-Service policy for the management of operational stress (SPEG paper 19/04 dated 29^th September 2004). The second phase pertained to proposing a strategy for: (i) training commanders in the delivery of the policy, and (ii) communicating the policy across Services. A key message to be conveyed in communicating the policy was that the effects of operationally induced stress are uncommon, unpredictable, but amenable to treatment (in the same way as a physical injury).
• Development of the second phase strategies was reported in "Over-Arching Review of Operational Stress Management - Phase 2 Training and Communication Strategies" (28^th April 2005) in the form of nine recommendations. In summary their purpose was identified as being to:
  • focus on existing training and communication initiatives to deal with operational stress,
  • review existing training measures to identify gaps in provision which need to be addressed to improve the mental wellbeing of those exposed to stress on operational duty, and
  • review the communications strategy to deliver advice on operational stress management and to make sure that action is taken to resolve any deficiencies.

3.4 Prevention and management of psychological trauma

3.4.1 Screening

• Lord Owen's judgement on the PTSD Class Action (Mr Justice Owen - Multiple Claimants v. MoD, 2003) proclaimed that pre-deployment screening, with current levels of knowledge, would offer no significant protection against the development of PTSD occasioned by combat.
• Much of that knowledge derives from the King's Centre for Military Health Research (KCMHR) and is based on evaluations of the practical implications of mental health screening in the context of the Iraq deployment. Jones and Wessely (2005) highlight the extent to which screening out those who may be particularly vulnerable to the stresses of combat is fraught with difficulty. Moreover, papers by Rona et al (2005) and Gilbody et al (2006) outline the reasons as to why screening post-deployment does not provide an effective means to reduce trauma-related psychopathology either in the military or the civilian sectors. On the basis of the conclusion reached by KCMHR that screening is not an effective preventative measure, the DCMHs do not routinely screen personnel on return from operations. Consequently, there is a considerable reliance on personnel themselves seeking help and the non-medical stress management processes introduced by the MoD for Service personnel both during and after deployment such as Trauma Risk Management (TRiM) and the "decompression" technique, both of which are described below.
• According to the recent National Audit Office report (HC 294, 10 February 2010) this situation is further aggravated by the inconsistent access to non-medical stress management programmes on return to the UK for Reserve Forces personnel (who typically deploy individually rather than as part of a unit) and those Service personnel who move units following deployment. The MoD is currently developing its stress management programme to address this issue.

3.4.2 Trauma Risk Management (TRiM)

• This is a relatively new approach pioneered by the Royal Marines as an alternative to the previously espoused Critical Incident Stress Debriefing (CISD)^[70], which is now being adopted by the three Services. TRiM is conducted by trained military personnel within the unit itself rather than by mental health professionals (e.g., psychiatrists or counsellors).
• It therefore builds on the peer support and "buddy system" which has long standing favour with the military (Keller et al, 2005) to ensure a better "fit" with military culture.
• TRiM practitioners are peers and colleagues from each unit who receive brief training to:
  • offer a point of contact and support (particularly in the aftermath of a traumatic event),
  • identify those at risk, and
  • arrange for further help in accordance with individual need.
• TRiM formalises the unit's responsibility to routinely check on those who have experienced a traumatic incident at one, three, and six months intervals. In line with the UK Armed Force's mental well-being policy, the work of TRiM is also intended to reduce stigma in the military by seeking to change military culture in order to encourage those with mental health problems to seek help without fear of discrimination.
• In making it more acceptable for Service personnel to report experiencing psychological distress without fear of discrimination and reprisals (e.g., losing their job), it is also intended that this will also help to increase treatment compliance (KCMHR, 2006, 2010).
• KCMHR conducted a randomised controlled trial (RCT) to evaluate the effectiveness of TRiM as a means of providing immediate intervention. Whilst there was no evidence to suggest that TRiM reduced traumatic stress, it has since been rolled out across the three Services by virtue of the fact that it has not shown to cause harm, it encourages military personnel to talk about problems experienced as a result of exposure to traumatic stress, and it is perceived as being helpful (Greenberg et al, 2010).

3.4.3 Decompression

• This is a technique used to help Service personnel who are returning from front-line duty to recover from their experience and to facilitate their return home. It involves a unit spending approximately 36 hours together between leaving the combat zone and heading home. Given that the time required to reach and return from combat zones has been substantially reduced from what was previously the case, decompression is intended to provide the opportunity to reflect on and talk about their experiences should individuals wish to do so in a relaxing military environment.
• Since 2006, all Service personnel returning from operations spend 36 hours in Cyprus on their way home (Deahl et al, 2011). A recent study by Jones et al (2011) reported that only 50% of Service personnel want to undergo decompression compared with 90% who report finding it helpful having experienced it, although further research is required to determine how best to facilitate adjustment on return home from operational duty (Hacker Hughes et al, 2008).

3.4.4 Medical Assessment Programme (MAP)

• This programme was established in 1994 by the MoD on a national basis to offer expert mental health assessments to any Veteran with operationally induced mental health problems who has been deployed on operations since 1982 (including the Falkland's conflict).
• Based at Guys and St Thomas Hospital in London, MAP is run by Professor Ian Palmer (a Consultant Psychiatrist and a Professor of Military Psychiatry who served in the Army for 25 years).
• Veterans can either be referred through their NHS General Practitioner (GP) or can contact MAP directly. Furthermore, carers of Veterans who have concerns about their mental health can also contact MAP.
• The assessment (which comprises a review of NHS and service medical records followed by a consultation with the Veteran) results in a diagnosis, treatment plan, and liaison with the medical and mental health team involved in the Veteran's care. In addition, the Veteran is provided with a written document outlining his/her situation.

3.4.5 Reservists Mental Health Programme (RMHP)

• In response to concerns raised about the mental health of members of Reservists who had been deployed on military operations (e.g., National Audit Office, HC 964 Session 2005-2006, 31 March 2006) and the empirical evidence to support those concerns (e.g., Hotopf et al, 2006), the MoD announced its intention in November 2006 to initiate the RMHP to meet the mental health needs of Reserve personnel.
• The DMS in partnership with the NHS subsequently launched the RMHP to offer assessment and out-patient treatment (where appropriate) by DMS personnel to eligible Reservists^[71] for mental health problems associated with operational deployment. Eighty one patients were seen between December 2006-2008, of whom 70% were diagnosed with a combat-related mental health problem.
• Although GP referral is considered to be the predominant mechanism by which individuals gain access to the RMHP, according to the recent National Audit Office report (HC 294, 10 February 2010) only 12% accessed the programme through their GP in 2008.
• Referrals from civilian psychiatric services are also accepted (subject to the GP being kept informed). In exceptional circumstances self-referral is accepted for an initial assessment.
• The assessment conducted by DMS mental health practitioners' results in out-patient treatment being provided only for those who have suffered from an operationally related mental health problem that is amenable to that which is available through the RMHP. In the event that acute care is required, the DMS provides access to NHS in-patient treatment.
• On completion of the RMHP treatment patients are referred back to their GP for further care. Re-referral for further assessment (if required) is available providing a minimum of six months has elapsed since the previous discharge.
• Regardless of whether or not the individual is eligible for treatment under the aegis of the RMHP, all those assessed are provided with a personal management plan which details the nature of their key problems and how these might be addressed.

3.4.6 Evidence-Based Treatment for Combat-Related Disorders

• A relatively small number of Service personnel require treatment for combat-related psychiatric disorders (although these may not surface until many years after they have left the military).
• Although PTSD commonly adopts centre stage (a myth commonly fuelled by the media), as a condition it is neither the sole psychopathology to emerge post-trauma nor does it most commonly occur in isolation from other co-morbid conditions (e.g., anxiety, depression and substance abuse) (Klein & Alexander, 2009).
• The National Institute for Clinical Excellence^[72] (NICE) 2005 guidelines state that individuals suffering from psychological conditions should be offered an evidence-based psychological therapy as the first line of treatment rather than pharmacological treatments. For example, based on the outcome of a systematic review of clinical treatment trials for PTSD, the NICE guidelines (2005) recommend two psychological treatments, viz, Trauma-Focused Cognitive Behavioural Therapy (TM-CBT) and Eye Movement Desensitisation and Reprocessing (EMDR). The use of medication is also acknowledged as an appropriate treatment, particularly when there are legitimate reasons for not pursuing a psychological approach.^[73] Two antidepressants, namely, paroxetine and mirtazapine are recommended for use by non mental health specialists (e.g., GPs), and amitriptyline and phenelzine are recommended for use by mental health specialists.

3.5 Medical discharge

• All Service leavers who leave the UK Armed Forces through medical discharge are required to attend a Medical Board.
• It is the responsibility of the Medical Board to make the decision about whether an individual is medically unfit for any form of military service.
• Not all those who appear before the Medical Board will be recommended for medical discharge as it depends on which of the following medical grades is received as shown in Table 4.

Table 4. Medical Discharge Grades and Fitness Levels

Medical Grade	Fitness Level
P2	Fit for combat
P3	Fit for light duties (applied in the case of a medical condition which would prevent the individual from undertaking the full range of military duties, but is capable of performing useful duties in barracks)
P4	Pregnancy/maternity
P7	Fit for limited duties (applied when an individual can perform useful duties within the limits of his/her disabilities. This may also require the provision of regular, continued medical care or supervision, and may require regular long-term medication)
P8	Medically unfit for any form of military service
P0	Unfit for duty but under medical care (a return to duty is likely within a total period of 12 months)

• Referral to the Medical Board is made by either the individual's doctor, unit, or the Sickness Absence Management team (SAM). In the Army, typically the Medical Board comprises three experienced Army or ex-Army doctors and the chairman is a consultant in occupational medicine. Their assessment of each individual's case comprises a:
  • review of medical notes,
  • discussion with the individual about his/her presenting medical condition, and
  • physical examination (if required).

Allocation of the medical grade will also take into consideration the views of the unit chain of command in respect of future Service employment.

• The findings of the Medical Board can take up to two weeks. There is a possibility, however, that the SO1 Occupational Medicine Army Personnel Centre (APC) will not accept the conclusion reached by the Medical Board. For this reason, individuals who are found by the Medical Board to be medically unfit for any form of military service in the Army are advised to make provision for this pending confirmation from their unit or the APC Medical Discharge Cell before committing themselves to any future arrangements. Confirmation of a P8 grading indicates that the individual has fallen below retention standard and is either medically discharged or medically retired, the effects of which vary according to military status and whether or not the individual is trained or in training as a new recruit.
• The medical discharge procedures are complicated and require the individual to complete a number of administrative activities with the appropriate departments. Medical documents should be automatically forwarded to the Service Personnel and Veterans Agency (SPVA) for assessment to determine eligibility for pension/ compensation. Whilst the case is being assessed, it is left up to the individual to keep the SPVA informed of any change of address within the first few months after discharge. The Veterans Welfare Service (VWS) is notified of all medical discharges, and a letter is sent to all those who are medically discharged to inform them of VWS services. Further details about the roles of the SPVA and the VWS are provided later on in this section under the heading of "Welfare".
• Medical discharge data is compiled from two sources, viz, FMED23 (Medical Board Report) and pay and personnel systems. Although they are subject to quality and completeness checks, it is important to be aware that statistics based on medical discharges do not represent measures of true morbidity or pathology. Within a medical and occupational health context their purpose is to provide an employability recommendation, which is subsequently translated into a chain of command decision on manning requirements. At best they indicate a "minimum burden" of ill health in the UK Armed Forces. In addition, the number and diversity of processes involved with administering a medical discharge introduce a series of time lags, as well as impact on the quality of data recorded.
• The UK National Statistics 2009 present the medical discharges for all three Service personnel by Service, year and the principal cause leading to discharge between 2004 and 2008 (i.e., the period for which the Defence Analytical Services Agency [DASA] have validated the data). The International Classification of Diseases and Related Health Problems Version 10 (ICD 10) is used to classify the primary cause leading to medical discharge. A summary of the causes of medical discharge for each of the three Services in relation to musculo-skeletal disorders, mental behavioural disorders, and nervous system diseases is provided in Table 5. However, in interpreting these data it is important to note that comparisons between the single Service statistics are not valid because medical discharge rates differ in each Service to meet specific requirements in respect of the:
  • fitness level required by each Service
  • employment policy of each Service
• Whilst the medical discharge rates for mental and behavioural disorders have decreased over the five year period for Regular UK RAF personnel and Regular UK Naval Service personnel, there has been an increase for Regular Army UK personnel. Whereas in 2004, mental and behavioural disorders were recorded as the primary cause of medical discharge for 121 Regular Army UK personnel, in 2008 there were 137 cases despite a decrease of cases in 2007 to 114. Overall, however, the most prevalent primary cause of medical discharge for all three Services pertains to physical disorders rather than mental disorders.

Table 5. Medical Discharges for Tri-Services

Cause of Medical Discharge	Regular UK Army Personnel		Regular UK RAF Personnel		Regular UK Naval Service Personnel
	N	%*	n	%*	n	%*
Musculo-skeletal disorders	3,109	65	413	44	974	63
Mental and behavioural disorders	602	13	271	29	185	12
Nervous system diseases	192	4	74	8	92	6

Note: * Percentage of all cause coded medical discharges during the five year period
Source: DASA (Health Information)

3.6 Service family healthcare provision

• In addition to its responsibility for meeting the healthcare needs of its Service personnel, the MoD is also required to deliver healthcare to those Service families who are posted overseas. Should it be the case that there are insufficient MoD resources available to fulfil that requirement this is met by contracts with local healthcare providers in the host country as well as UK-based NHS Trust hospitals.
• Although the healthcare of Service families in the UK is the responsibility of the NHS, the MoD has a role to play in supporting Service families following the termination of an overseas posting to facilitate the transition to NHS healthcare provision (Medical Care for the Armed Forces (7^th Report of Session 2007-08), House of Commons Defence Committee 18^th February 2008).

3.7 Veteran healthcare policy and strategy

• In terms of meeting Veterans' health needs, the SPCP outlined a commitment to:
  • improve information about how Veterans' health needs differ from those of the general population,
  • establish whether more has to be done to assess the healthcare needs of Veterans, and
  • raise awareness among healthcare professionals about the healthcare needs of Veterans.
• In meeting that commitment, however, two different problems have been identified with regards to assessing the healthcare needs of Veterans.
  • The first problem pertains to obtaining a clear understanding of the nature, extent and distribution of physical and mental injury among Veterans in the UK. Although some of the needs of Veterans who have sustained physical injury are well recognised (e.g., with regards to the long term management and rehabilitation of amputees), controversy remains in respect of health needs where the diagnosis of certain conditions has been subject to dispute (e.g., Gulf War Syndrome). Furthermore, to define the special mental health needs of Veterans is problematic due to the diverse nature of psychological injury.
  • The second problem is concerned with assessing the availability and quality of current health service provision for Veterans to establish whether the healthcare needs of Veterans are being met effectively. Anecdotal reports suggest that some Veterans perceive their health care needs to be qualitatively different to civilian patients and that to receive treatment alongside them in the NHS is unsatisfactory. The validity of these claims, and the implications for future healthcare provision, require an empirically based evaluation.
• Two papers presented to the Partnership Board formed the basis of the discussion as to how the evidence base could be amalgamated effectively to inform commissioners of the healthcare needs of Veterans. The first paper was prepared by MoD/DoH officials and entitled "Veterans' Health Needs Assessment - Options for a Way Ahead". The second paper entitled "Veterans' Health and Healthcare Needs" was prepared by John Newton (RDPH South Central, Department of Health) for presentation to the Working Group 2: Policy, Strategy and Veterans dated the 26 September 2008. Both of these papers highlighted the importance of identifying and building on the existing and emerging evidence. In respect of the latter, the second paper suggested an approach to achieve this requirement, an outline of which is provided in Table 6.

Table 6. Outline of Partnership Board Approach

Approach	Purpose	Proposed methods
Conduct of a formal epidemiological needs assessment	To obtain qualitative data on: frequency of specific conditions risk factors lifestyle and behaviour patterns	Case-control studies (Veterans vs non-Veterans) based on representative groups and appropriate controls. Large scale prospective cohort study based on a clearly defined target population
Assessment of the quality of service provision for Veterans	To obtain qualitative data on the NHS treatment experiences of Veterans and their families	Interviews Focus groups
Identification of factors to enable Service improvement	A pragmatic approach to identify current strengths and weaknesses of a service from referral to the completion of an initial course of treatment	Experience-based Design Model Formulation of Stakeholder Group (including Veterans) to provide a source of external advice on service improvement

• In order to take further this approach, it was proposed that the Partnership Board should request the DH Policy Research Programme to commission a suitable academic group to: (i) conduct a literature review of existing evidence on the physical and mental health needs of Veterans, and (ii) use the outcome of that literature review along with other relevant sources of information to develop a robust research proposal for one or more studies. By this means, it was proposed that additional qualitative and quantitative data on the healthcare needs of "recent" Veterans in the UK (including prognostic indicators of health risk) could be generated. It was also proposed that the NHS Institute for Innovation and Improvement should be invited to support the Experience-based Design work using a selection of NHS services that provide healthcare to Veterans (e.g., inpatient facilities at Selly Oak) at an estimated £20,000 per unit for a six month project.

• A subsequent Discussion Paper for the MoD/UK Departments of Health Partnership Board meeting on 10 February 2009 entitled "Assessing Whether More Needs to be Done to Assess the Healthcare Needs of Veterans" provided an update on progress towards meeting this particular commitment of the SPCP. It endorsed further the importance of obtaining robust epidemiological data that would provide the necessary evidence to determine whether Veterans' healthcare needs differ from the general population. In addition, it highlighted the need for commissioners to identify the numbers of Veterans within their region as part of their local needs assessment, particularly in view of the increasing number of younger Veterans who have been deployed on more recent operations (e.g., the Gulf War, the Balkan conflict, Iraq, and Afghanistan). The paper also proposed a "staged approach" to meeting this commitment, which would incorporate five stages to:

(i) identify current knowledge and practice relating to the healthcare needs of Veterans;
(ii) identify research already in progress;
(iii) synthesise the outcome of (i) and (ii) to identify gaps;
(iv) commission projects to address gaps in service provision, and
(v) produce guidance for commissioners subject to requirements.

• In addition to addressing the first two stages (which will be included in Section 5), this paper also proposed an approach for undertaking the other three stages. In terms of stage (iii), the Partnership Board was asked to approve a proposal to commission a scoping review to inform further work on "assessing the healthcare needs of recent forces Veterans", which was subsequently awarded to KCMHR. The specification of that review will be considered in Section 5. In considering what more might be done to meet this commitment, the paper proposed the need for further research to:
  • obtain more in-depth and robust data on Veterans' experience of and satisfaction with NHS services.
  • ascertain whether the help-seeking behaviour of Veterans is different when compared to the general population.
• Finally, it suggested that the MoD investigate the extent to which the data obtained on medical discharges by DASA on the previous 10 years could be analysed for future benefit.
• Most recently, the Coalition Government commissioned Dr Andrew Murrison MP to examine the relationship between the MoD and the NHS in respect of addressing mental health problems (Murrison, 2010). The report entitled "Fighting Fit" included the following four key recommendations.

(i) Examination of the MoDs current systems of assessment for and evaluation of mental health problems.
(ii) Increase in the numbers of mental health professionals to enhance outreach provision for Veterans.
(iii) Introduction of a Veteran's Information Service (VIS) for access 12 months post-service.
(iv) Pilot of an online early intervention service for Serving and ex-Service personnel.

3.8 current organisation and delivery of Veteran healthcare

• On leaving the UK Armed Forces, the healthcare of Service personnel transfers from the military to the NHS. To facilitate the transition of care all departing Service personnel have a discharge medical, the purpose of which is to:
  • provide an opportunity to document any harm that has occurred and that could be attributable to service (e.g., high-tone hearing loss in gunners),
  • ensure that there are no outstanding matters to be addressed, and
  • prepare a summary^[74] for the NHS GP along with instructions on where service medical records^[75] can be obtained.
• It is the responsibility of the individual to register with an NHS GP practice and handover the summary as soon as possible on discharge. The NHS GP practice can subsequently apply to the relevant Service repository to obtain a copy of the Veteran's full medical record (with his/her written consent). This applies whether or not the Veteran has left service because of a medical discharge. Because some GPs, however, have reported problems in accessing past service records for discharged members of the UK Armed Forces, the Partnership Board, DMCP and Connecting for Health are currently working together to develop a range of proposals to ensure better connectivity between the MoD and the NHS. These include:
  • improving the transfer of records between the MoD and the NHS
  • making referrals into the NHS by means of Choose and Book
  • accessing summary care information

As an interim measure, a DoH guidance letter was issued to SHA Chief Executives in June 2008 to notify GPs of contact points for accessing records should any difficulty be encountered. In addition, the standard Family Doctor Services Registration Form (GMS1) used by NHS GP practices now asks individuals who are registering with a GP practice to declare whether they have left military service and, if so, to provide their: (i) address prior to enlisting, (ii) service or personnel number, and (iii) date of enlistment.

• For Service personnel discharged with significant health problems, the MoD typically liaises with the local Primary Care Trusts^[76] (PCTs) and affiliated providers of health and social care in the event of ongoing health needs. A military social worker provides support for up to 12 months to enable access to the appropriate NHS services. Responsible Commissioner Guidance covers issues associated with continuity of care for those leaving the UK Armed Forces.
• In 1953, hospitals run by the Ministry of Pensions for the treatment of war pensioners^[77] was transferred to the NHS. The UK Government gave an undertaking that there should be priority out-patient and in-patient examination and treatment for war pensioners in NHS hospitals for the condition or conditions for which war pensioners received a pension or gratuity unless there was an emergency case or another case which demanded clinical priority (Priority Treatment for War Pensioners, HSG(97)31, dated 18^thJune 1997). Current guidance on this is set out in Priority Treatment for War Pensioners - HDL (2006) 16 which states that GPs and NHS Hospitals should give priority treatment to war pensioners (both in-patient and out-patient), for examination or treatment which relates to the condition(s) for which they receive a pension or gratuity, unless there is an emergency case or another case demands clinical priority. Veterans should not be given priority treatment for conditions unrelated to service in the UK Armed Forces.
• Updated DoH guidance^[78] for access to health services for military Veterans issued on the 12 September 2007 (HSG) extended the guidance of HSG(97)31 based on that implemented by Hull Teaching PCT whereby priority access to the NHS was made available to all military Veterans for Service-related conditions^[79]. In addition, entitlement of priority access to NHS treatment based on clinical need is no longer contingent on eligibility to receive a war pension. (By the same token, Veterans who are eligible to receive priority treatment does not necessarily mean that they are entitled to a war pension.) Although it is for clinicians to decide whether it is likely that a condition is related to service, this updated guidance states that "…it is not appropriate for secondary care staff systematically to ask patients where they are Veterans suffering from a condition that they believe is related to their military service". Thus, it is solely dependent on Veterans to be willing and to take the initiative to inform clinical staff accordingly that priority access may be forthcoming (should the clinician decide that it is appropriate). The Service-related conditions identified as being most likely to benefit from priority treatment provision were:
  • hearing loss,
  • orthopaedic injuries, and
  • mental health conditions.
• As of 1 January 2008^[80], GPs were requested to implement the extension of priority treatment in making new^[81] referrals for diagnosis or treatment. In the event that the GP considers that severe disability has resulted from a condition due to service, then he/she "could suggest" to the Veteran to apply for a war pension given that they may also be entitled to claim a pension or gratuity or receive benefits (e.g., a free prescription).^[82] As is the case with war pensioners, all Veterans have use of the NHS complaints system should they encounter any problems in respect of access to priority treatment. The updated guidance also highlighted the implications for service provision (particularly in the future) resulting from anticipated changes in the profile of the UK Armed Forces. Due to increasing recognition by the UK Armed Forces of the need for active equal opportunity policies^[83], the proportion of women as well as those from the ethnic minorities who join the military service is likely to increase. To this end the healthcare needs of Veterans will also change accordingly.
• On the 13 February 2008, the Healthcare Policy and Strategy Directorate (Scottish Government) also provided updated and extended guidance on HDL (2006) 16. From 29 February 2008, all Veterans (including those who have served as Reservists) should receive priority access to NHS primary, secondary and tertiary care for any conditions likely to be Service-related. This also applied to those Veterans who are not in receipt of a war pension. NHS Boards were tasked with the responsibility to ensure that GPs, heads of service in secondary care, and all relevant hospital staff were aware of the current priority treatment provisions. Recipients of CEL 8 (2008) were also advised that monitoring arrangements would be required to evaluate impact on those services that are most likely to be accessed by Service personnel (e.g., mental health, audiology, and orthopaedic services). To minimise any potential confusion that may arise when Veterans interpret "priority treatment" as "preferential treatment" the Scottish Government and the MoD have worked together in providing Veterans organisation in Scotland and CAS with information to clarify this issue. Finally, CEL 8 (2008) outlined the process involved in obtaining the medical history of Service personnel on their release from the UK Armed Forces.

3.9 Development of a community-based mental health service for Veterans

• From 1948 successive governments have intended that the NHS should be the main provider of mental healthcare for Veterans. In addition to the NHS, the MoD also relies on the services of Combat Stress^[84] to supplement the provision of mental healthcare available to Veterans on a UK-wide basis including Scotland. As an independent charity founded in 1919, it has a long-standing reputation for its work with Veterans, the original focus of which pertained to the occupational rehabilitation for Great War Veterans who returned from hospitals such as Craiglockhart. In more recent times, their charitable work has been dedicated to providing residential care for Veterans with mental health problems at one of their three treatment centres^[85] run by the Society. In addition to providing a rehabilitative function, Combat Stress provides its clients with social opportunities within a "secure military haven" which also facilitates the re-establishment of contact with old acquaintances ("A Community Based Mental Health Service for Veterans: a Core Briefing Paper", MoD & SPVA, 2008). A network of Regional Welfare Officers (RWOs) operates to offer support within client's homes and to instigate the process of assessment for Veterans who would potentially benefit from a residential stay at one of the Combat Stress centres. In addition, Combat Stress operates a national network of Community Outreach teams comprising RWOs, Community Psychiatric Nurses (CPNs), Mental Health Practitioners (MHPs) and Administration Support Officers (ASOs).
• The RWO is usually the first face-to-face contact a Veteran will have with a member of Combat Stress. Together the team can provide a wide range of practical support and advice in the Veterans own home, as well as community-based clinical care provided by the CPN and MHP.
• With the emergence of NICE-recommended treatments for mental health conditions, there has been increasing focus on the need for mental health service providers to ensure the provision of effective treatments for those who require them. To this end, the MoD co-operates with the DoH and Combat Stress accordingly. Changes to NHS procedures and commissioning arrangements, along with concerns expressed about the prevailing milieu within the Combat Stress treatment centres, resulted in agreement being sought from Combat Stress in 2004 to undertake an independent review of its work^[86].
• In spring 2005, a review was conducted by the Health and Social Care Advisory Service (HASCAS)^[87] to evaluate the treatment programmes provided by Combat Stress in respect of clinical arrangements (including staffing, training, and cost effectiveness). Whilst confirming the enthusiasm, commitment and motivation of the Combat Stress staff, it highlighted areas of improvement to ensure that the programme incorporated best practice^[88]. Furthermore, it called for wider improvements in mental health service provision which extended beyond that already provided by Combat Stress in order to meet the mental healthcare needs of all Veterans in the community (i.e., not just war pensioners). On this basis, a key feature of the HASCAS Review pertained to work (that commenced in the autumn of 2006) to develop this new community based model for mental health services for Veterans, which placed NHS Primary Care services and GP services at its core. Officials from the MoD, the four UK Health Departments, Combat Stress, and the HASCAS were instrumental in devising the framework for the structure of this new initiative, which also incorporated the advice of leading UK clinicians (including the UK Trauma Group).
• In January 2007, the outline of that service model and the proposed pilot projects was presented in a HASCAS briefing paper ("A Community Based Mental Health Service for Veterans: Outline of Service Model and Pilot Projects"). This was followed in April 2007^[89] by the core briefing paper ("A Community Based Mental Health Service for Veterans: A Core Briefing Paper"), a primary objective of which was to present the firm proposals upon which the model would be based. These were as follows.
  • As an NHS led service it would reflect NHS best practice and procedure.
  • Access to the service would be predominantly client and GP centred.
  • Cases would be managed by means of an evidence-based step care approach as encouraged by NHS policy.
  • Evidence-based treatment would be provided in accordance with the condition-specific guidance issued by NICE.
  • In seeking to identify the specific clinical and social needs of Veterans, the service would also be in line with the 1999 National Service Framework for Adult Mental Health (NSFAMH).
  • Regionally based clinical networks comprising NHS clinicians, mental health specialists from the DCMHs, academic and UK Trauma Trust^[90] clinicians in order to facilitate the conjoint sharing of training, information and expertise.
• A total of eight service elements were identified with a view to ensuring the provision of:
  • general and specific information regarding local "Veteran-sensitive" and accessible services - for both Veterans and agencies;
  • clinical guidance for primary care - to encourage early presentation, case identification and assessment;
  • access to a "Veterans Champion" at PCT level - to assist and support the retention of Veterans in primary care services by assuring them of an understanding of the military;
  • parallel welfare support and advocacy for Veterans - to address their needs and concerns regarding a broad range of matters;
  • local Veterans' mental health clinical networks - to promote and facilitate the sharing of knowledge, skills, and expertise;
  • access to a "Community Veterans Mental Health Therapist" at Mental Health Trust level - to improve the assessment, treatment, and support of Veterans with identified Service-related severe or complex mental health needs;
  • identification of key workers for at-risk Veterans who may require intervention - to ensure a co-ordinated approach by all agencies concerned, and
  • appropriate residential settings - to enable the: (i) provision of respite care, (ii) stabilisation of severely disturbed Veterans, and (iii) delivery of evidence-based interventions.
• Responsibility for the provision of a local enhanced service varied according to the nature of the service element. For example, the MoD would be responsible for ensuring the standard provision of general information on a national basis, whereas it would fall to the local services to ensure that Veterans and relevant agencies were furnished with the information about local "Veteran-sensitive" and accessible services. In terms of commissioning the mental health services for Veterans, the provision of specialist treatment for the small number of "vulnerable" Veterans were intended to be accommodated within the existing NHS arrangements for commissioning specialised services.
• The underlying rationale for accommodating Veterans healthcare needs within existing NHS services derives from the view that a Veteran-dedicated service model would not be:
  • in line with the long established UK social welfare arrangements,
  • justified due to insufficient demand (particularly as the Second World War generation diminishes), and
  • supportive of social inclusion.
• The military and the Veterans' community, however, have expressed concerns about the accessibility and acceptability of a community-based mental health service. In particular, these concerns derive from the view that Veterans' exposure to military culture and related experience means that they have different healthcare needs to those of the civilian population that cannot be met satisfactorily in an NHS setting with civilian medical staff. Proposed barriers to obtaining appropriate and timely help for Veterans include the:
  • stigma attached to mental health problems. (Although this is not unique to the military, this issue may be compounded when Service personnel are exposed to a culture that reflects machismo ideals and which commends those individuals who are resilient, stoic, and self-sufficient in the face of adversity.)
  • configuration of NHS mental health services to prioritise severe enduring mental illness.
  • problems for Veterans in engaging with treatment services that have little understanding of military culture or combat-related psychological trauma.
• Whilst most of these concerns are based on anecdotal reports rather than empirical evidence, there is evidence to suggest that Veterans frequently present to mental health services for treatment many years after they have experienced combat (Creamer & Forbes, 2004). This is further substantiated by reports from Combat Stress that, on average, the time between discharge from service and first contact with Combat Stress is 14.1 years (Fletcher, 2007; Busuttil, 2010). However, the ongoing rise in the number of referrals to Combat Stress resulting from the most recent operations, viz, Op TELIC and Op HERRICK suggests that delayed help-seeking is more likely in older Veterans than the younger ones. Hart & Lyons (2007) state that the time between discharge and referral of nine months for the 167 referrals received from Op TELIC is substantially less compared to that of the Combat Stress-wide average delay of 13 years^[91]. To establish whether there is a causal link however between the accessibility and acceptability of service provision (particularly with regards to the mental health services) and a delay in seeking appropriate help has yet to be established.
• In addition, the HASCAS Review brought to the fore two key factors widely considered as sine qua non when planning a new service^[92]. The first factor is concerned with ensuring that there is likely to be a demand for the proposed service. Evidence for that demand should be informed by robust epidemiological data to confirm the range of needs to be met and the extent of the conditions that require intervention (as indicated by their prevalence^[93] and incidence^[94] rates). The second factor is concerned with ensuring the availability of sufficient resources to fulfil requirements (both in terms of the extent of the problem and the range of needs identified).
• As evidenced by their December 2006 paper ("Piloting the Implementation of a Community Mental Health Service for Veterans")^[95], however, the absence of robust epidemiological data on the incidence and prevalence rates pertaining to Veterans with significant mental health problems substantially undermined the extent to which it was possible to adequately address these two factors. Moreover, there were no data available to inform the extent to which the needs of this target population were being met by the NHS and affiliated civilian agencies, particularly with regards to "vulnerable" subgroups^[96] with concomitant social problems (thereby increasing substantially their risk of social exclusion).

3.10 Piloting the implementation of a community-BASED mental health service for Veterans

• In an endeavour to obtain the necessary epidemiological data to inform the UK wide roll-out of the community based mental health service for Veterans, the MoD and the DoH announced in 2007 that six pilot schemes would be conducted predominantly over a two year period in the following sites:
  • London (based in Camden & Islington)
  • Shropshire & Stafford
  • Cardiff
  • St Austell (based in Bodmin)
  • Newcastle upon Tyne
  • Edinburgh
• Other active partners in these projects are the long-standing service for Veterans in Hull^[97], the RMHP programme at Chilwell (Nottinghamshire), and Combat Stress. Service developments in Northern Ireland are included as part of this initiative with involvement from the Police Rehabilitation Training Trust (PRTT), which was originally established in 1999 to assist retired RUC officers and those planning to leave service. As the primary provider of psychological services to serving officers and police staff on referral from the Police Service of Northern Ireland (PSNI) Occupational Health and Welfare Unit, it has since expanded to provide a service to Service personnel from the Irish Regiments.
• Intended as one aspect of improving mental health services for Veterans across the UK, the structure of the pilot schemes has been designed to be consistent with current NHS policies, structures and procedures, including that of quality assurance. A Clinical Expert Group has produced guidance on referral criteria, the design of person assessment, the range of interventions to be provided, a service specification, and information on core staff training. The "Mental Health Services for Veterans: A Proposed Service Model" paper presented a three dimensional scheme to classify the mental health problems of participants as follows.
  • Dimension 1: severity (mild/moderate/severe)
  • Dimension 2: complexity (simple/complex)
  • Dimension 3: relationship to military service (not at all/to some extent/ considerably)
• As the purpose of these pilot schemes is to: (i) encourage early presentation; (ii) offer appropriate interventions in the community to those who would potentially benefit, and (iii) involve existing and new cases (although priority would be for new referrals), all six sites are co-terminous with the catchment area of a Mental Health Provider Trust or equivalent (e.g., a Care Trust or PCT). In addition, sites were chosen to permit comparisons based on the following factors.
  • Sites which include a Combat Stress Treatment Centre (e.g., Stafford) and those which do not (e.g., St Austell)
  • Sites based in England (e.g., London) with those based in another home nation (e.g., Cardiff and Edinburgh)
  • Comparator sites where there is no change of service (i.e., the RMHP, Combat Stress, the Hull Psychological Trauma Service and the PRTT).
• In the December 2006, the HASCAS paper ("Piloting the Implementation of a Community Mental Health Service for Veterans") estimated that the total costs for the pilot schemes would range from £470,000 to £582,000. The implementation of the pilot schemes started from late 2007 in Camden & Islington, Shropshire & Stafford, and Cardiff. The Edinburgh based pilot scheme known as "Veterans First Point" (VIP) was launched in April 2009 to run over three years. VIP was developed by a Veterans Advisory Group, which was established by the Rivers Centre for Traumatic Stress (Royal Edinburgh Hospital) and which included Veterans and representatives from a wide range of Veteran organisations. Funded by the MoD (£70,000), NHS Lothian (£220,000), and the Scottish Government (£640,000), VIP was officially opened by the Public Health Minister, Shona Robinson. Staffed by peer support workers with military backgrounds, it provides a dedicated "one-stop-shop" service to offer information and advice on a wide range of health and welfare support services. At a meeting of the Scottish Parliament Cross Party Group on Supporting Veterans (held at Whitefoord House on 28 April 2009), it was noted that the Scottish pilot scheme was different to the other pilot projects currently underway in England and Wales although the evaluation of all projects would be used to inform subsequent decisions on the roll-out of a community-based mental health service for Veterans in Scotland.
• In addition to the implementation of an audit protocol, comprising specified outcome measures, an integral part of these pilot projects is the conduct of a full independent evaluation, the tender for which was awarded to Professor Michael Barkham (Director of the Centre for Psychological Services Research [CPSR]^[98], University of Sheffield). A key aspect in determining the nature of that evaluation was reaching agreement on a minimum core data set by the Expert Group. In April 2008, the paper entitled "Veterans Mental Health Project: A Minimum Data Set for Community Based Mental Health Services for Veterans" led to an agreement that the minimum data set should comprise two categories of core information comprising: (i) routine clinical data and (ii) pilot specific data based on patient descriptor information (including details on the client, service history, and medical/ social history) and the administration of two standardised measures (Patient Health Questionnaire [PHQ9] and the Work & Social Adjustment Scale [WASAS]) for completion on every occasion the service user attended. Other clinical measures were also used where clinically appropriate, and other facets of the services were captured by interviews with service users in accordance with the NHS Ethical Protocol Agreement.
• The outcome of the pilot scheme evaluation intended to: (i) generate data that would inform the provision of local services within the designated pilot regions, and (ii) establish whether the community-based model for mental health services for Veterans would be sufficiently robust to warrant its implementation across the UK. The findings from the evaluation of the Edinburgh pilot scheme were presented to a selected audience on the 21 April 2010 at a conference organised by VIP. The evidence from the Final Report "An evaluation of six Community Mental Health Pilots for Veterans of the Armed Forces" (CTLBC-405, 15 December 2010) is summarised in Section 5.

3.11 Improving access to psychological therapies (IAPT)

• An important aspect of conducting the pilot studies is to link these in with the IAPT programme to access psychological therapies in common mental health conditions. The goal of the IAPT programme is to deliver a new state-of-the-art psychological therapy service in the UK which would "…not only demonstrate a paradigm shift in meeting the health needs of a large group of people, but also show that the NHS can deliver innovative new services valued by the wider population". On securing additional targeted funding in the Comprehensive Spending Review (CSR07), the national roll-out of the IAPT programme commenced in order to enable PCTs to implement the NICE guidelines for people suffering from depression and/ or anxiety disorders. Publication in February 2008 of the policy document entitled "Improving Access to Psychological Therapies. Implementation Plan: National Guidelines for Regional Delivery" (Gateway Ref: 9427) provided Strategic Health Authorities (SHAs), PCTs, training providers and service providers with clarity about the form and nature of the services to be established and an overview of training^[99] and commissioning requirements for the implementation of IAPT. The NHS Operating Framework 2008/09 highlighted the need for PCTs to conduct a needs assessment of their local population as the first step in planning how they will implement a stepped-care psychological therapies service.
• Guidance on performance indicators, service standards and outcomes monitoring was subsequently provided in the IAPT Outcomes Framework 2008/09. The standard set of performance indicators developed by SHAs to support regional performance monitoring^[100] of each IAPT service are collated nationally to produce averages which are published to permit benchmarking (subject to Review of Central Returns [ROCR] approval). Service-level performance indicators are based on an outcomes framework. Subject to discussions with the SHAs and ROCR, outcomes are monitored in respect of the following performance areas:
  • accessibility - to ensure that waiting times and the range of interventions provided across the stepped care model are appropriate;
  • equity of access - to ensure access to all members of the community (established by means of a local equality impact assessment);
  • population coverage - to demonstrate improvements in those receiving psychological therapies;
  • effectiveness - to: (i) obtain pre- and post-treatment health and wellbeing outcome data (for at least 90% of those treated), (ii) demonstrate symptom reduction, and (iii) demonstrate social inclusion and employment status, and
  • acceptability and quality - to monitor: (i) satisfaction and choice of IAPT service users' and (ii) supervision of trainees and experienced staff.
• In March 2009, the Veterans Positive Practice Guide on IAPT (DoH, 2009) highlighted the need for commissioners to:
  • understand the demographic profile of their local populations (including Veterans) to provide IAPT services that are appropriate;
  • include Veterans as part of needs assessment;
  • ensure the effectiveness of IAPT services for Veterans from a range of circumstances (particularly those who present with complex and problems distinct from the general population given their vulnerability to social exclusion);
  • improve access as a way to remove barriers which prevent Veterans from accessing psychological therapy services);
  • engage with Veterans' organisations and groups and those with existing expertise in working with Veterans [e.g., MAP, Combat Stress, UK Trauma Group]);
  • encourage Veterans to engage with services by providing a conducive location that provides some form of anonymity;
  • recruit, develop and retain a workforce that delivers high quality services to meet all needs including those of Veterans, and
  • understand military culture.
• An approach has also been made to see whether Veteran mental health can be part of work undertaken by NICE to provide additional guidance for specific at-risk groups.

3.12 Healthcare provision for Veterans who encounter the Criminal Justice System

• The NHS is responsible with the Prison Service for providing healthcare to those Veterans who are in prisons along with their civilian counterparts. It is the aim of the Prison Healthcare Policy Unit at the NHS^[101] to provide the same quality of health service to prisoners as it does for the general public.
• Evidence that the prison population in the UK suffers from a relatively high rate of mental health problems^[102] has been instrumental in informing UK Government policy^[103] to improve mental health services for prisoners. In line with that policy, "Changing the Outlook: A Strategy for Modernising Mental Health Services in Prisons" proposed how a multidisciplinary health team system could provide In-reach services in order to ensure that all prisoners with severe and enduring mental health illness (including Veterans) could receive comprehensive care. To this end, the first Mental Health In-reach Services were commissioned from local Mental Health NHS Trusts in 2001-02 to offer prisoners the same type of specialist care and treatment they would receive in the community from Community Health Teams. In January 2004, an evaluation of the success of the PIR services in England and Wales commenced the details of which is presented in Section 5.
• Despite these initiatives to enhance mental healthcare provision for prisoners, there is a growing consensus that prison may not always be an appropriate environment for those with severe and enduring mental illness. Indeed, many harbour concerns that the experience of being in custody can exacerbate mental ill health, increase vulnerability and elevate the risk of self-harm and suicide. Furthermore, in light of substantial increases in the prison population^[104], there has been an imperative to address this issue at a time when the UK Government contemplates the need for larger capacity prisons as a means of alleviating the increasing pressure on the prison system. Thus, in December 2007, the Secretary of State for Justice asked Lord Bradley (former Home Office Minister) to undertake a six month^[105] independent review to determine the: extent to which offenders with mental health problems or learning disabilities can be diverted from prison to other services, and (ii) nature of the barriers which may prohibit such a diversion^[106].
• In February 2009, Lord Bradley presented the outcome of his review to the UK Government followed by the publication of "The Bradley Report" in April 2009. It proposed the implementation of a number of recommendations over varying timescales. A crucial first step in their implementation pertained to the need to establish the governance arrangements at a national, regional and local level to provide a framework as a basis for the work to progress. Consistent implementation across the country and the strategic working of key organisations to deliver the agenda was considered to be of paramount importance in developing appropriate services to meet the diverse and complex needs of the target population. Particular emphasis was placed on the existence of "good early identification" and "assessment of problems" which can inform how and where offenders are most appropriately treated to ensure their effective management. The establishment of Criminal Justice Mental Health Teams was considered to be a vital component in ensuring that prisoners can receive targeted and effective care during their custody. The momentum of the work would be contingent on measuring progress with regular reports to Parliament. By this means, the wider stakeholders and the public would be kept advised of any subsequent changes and of their effectiveness.
• Publication of the HMIP Thematic Report ("Out of Sight - Severe and Enduring Mental Health Problems in Scotland's Prisons") in December 2008 presented 20 recommendations for the Scottish Prison Service (SPS) in respect of the current arrangements and challenges for managing prisoners suffering from severe and enduring mental health problems. The inspection focussed on six specific areas relating to mental health issues in Scotland's prisons in respect of:
  • the scale of severe and enduring mental health problems in Scotland;
  • the processes involved;
  • the impact on the prison;
  • prison-based and community interventions;
  • issue for release, and
  • reasons for use of prison for people suffering from severe mental health problems.

The findings relating to each of these six areas will be presented in Section 5. However the main finding from the Thematic Inspection was that: "The use of imprisonment is inappropriate for people with severe and enduring mental health problems. Their primary need is mental health and the appropriate place to address that is hospital."

• The Howard League Scotland (HLS) has focused on problems of the Scottish courts and the legal system, liaising with and influencing Scottish Ministers, civil servants, the Judiciary and the SPS in respect of the wider criminal justice system in Scotland. It is particularly interested in the:
  • rehabilitation of offenders and the effectiveness of interventions;
  • improving prison regimes;
  • relationships between drug and alcohol abuse and crime;
  • early intervention and prevention;
  • reducing the unnecessary use of imprisonment, and
  • links between poverty and crime.

The HLS are of the opinion that it is time for criminal justice policy and systems to adopt a different direction that would rely more extensively on community approaches to reducing crime and dealing with criminality. HLS is a fully independent body that seeks to promote effective pathways to achieving this goal; the success of which would help to address the capacity issues facing the prison service across the UK.

3.13 WELFARE AND SUPPORT

3.13.1 Organisation of Welfare and Support Provision

• From the 7 April 2007 the Armed Forces Personnel Administration Agency (AFPAA) and the Veterans Agency (VA) were amalgamated into the Service Personnel and Veterans Agency (SPVA) to provide an integrated and efficient "through life" personnel service to both Serving personnel and Veterans under the new brand for services to Veterans "Veterans UK". As a single banner covering a variety of different Veterans' services provided by a range of different organisations, its purpose was to form a single point for accessing information. From 2 April 2007 a new Veterans' portal website (www.veterans-uk.info) replaced the previous VA website as a focal point for accessing information on Veterans' services provided by the MoD, other UK Government departments and voluntary agencies.
• The SPVA works in partnership with EDS (Defence) Ltd for pension payments and Atos Origen for medical support to pension awards. It also has commercial relationships with Paymaster (1836) Ltd for pension payments and Atos Origen, SPVA has responsibility for the delivery of a tri-Service administration system known as the Joint Personnel Administration (JPA); the remit of which is to harmonise and simplify personnel and pay administration across the Services to ensure a joined up service.
• The day-to-day business of the SPVA is managed at the highest level by the Agency Management Group (AMG), which comprises both MoD and EDS directors. It also has an Executive Board to complement the role of the AMG and to address commercially sensitive and funding issues for managing the Partnering Agreement. The strategic intent of the SPVA is: "Dynamic delivery of high quality comprehensive and responsive through life services to the Serving and Veterans Community". Its mission is to: "…deliver reliable, trusted and efficient personnel services to the Serving and Veterans communities".
• The core functions of the SPVA are to administer the:
  • Pay^[107] and allowances to the UK Armed Forces through the Joint Personnel Administration (JPA);
  • Armed Forces Pension Scheme (AFPS) 75 and 05;
  • AFCS and the WPS in accordance with relevant legislation, and
  • award and delivery of campaign medals and the Veterans badge.
• In addition, the SPVA provides:
  • administrative support for casualties and the repatriation of compassionate cases through the Joint Casualty and Compassionate Centre (JCCC)^[108];
  • quality welfare services and support to war disablement pensioners, war widow(er)s, their dependants and carers;
  • ex-Service beneficiaries of the AFCS;
  • a managerial role for the Ilford Park Polish Home (IPPH)^[109];
  • the ex-gratia payment scheme for former prisoners of the Japanese in World War II^[110] (in accordance with UK Government policy), and
  • administrative support to the Central Advisory Committee (CAC) on war pensions and the War Pensions Committee (WPC).
• To reflect the unified service to Veterans under Veterans-UK, the Welfare Service was also subjected to rebranding such that the War Pensioner's Welfare Service (WPWS) was given the new name of the "Veterans Welfare Service" (VWS). The main role of the VWS is to provide advice, guidance and practical assistance to war disabled pensioners and war widow(er)s. It also provides assistance to individuals who are in the process of claiming under the WPS or the AFCS. Assistance provided by the VWS is available to deal with all Veterans' concerns regardless of whether they are directly related to disablement or Service. Regional Welfare Managers throughout the UK are responsible for ensuring the welfare managers provide the services required. Administrative staff and a network of volunteer visitors provide support for each regional office. The VWS has a close working relationship with the Regimental Home Headquarters (RHQ)^[111] and all of the main ex-Service organisations to ensure that Veterans and their dependants have ready access to a wide range of advice and help on welfare issues.

3.13.2 UK Armed Forces Welfare Policy and Provision

• As part of its "duty of care", the MoD has a responsibility to secure the well-being of its Service personnel and their dependents both in the UK and overseas; a responsibility which is enshrined in the UK Armed Forces Welfare Policy (PSG 18). This policy is underpinned by seven principles that pertain to the provision of operational and non-operational welfare support as a means of meeting that responsibility.
• Although the three Services share many components of their duty of care, the welfare and support structures vary among Services and among establishments. A tri-Service review of the provision of welfare support to the greater Service community was completed in December 2005. Its purpose was to:
  • undertake a gap analysis to identify shortfalls and opportunities for rationalisation particularly with regards to the accessibility of welfare support;
  • examine the possible harmonisation of welfare provision across the three Services;
  • ensure the adoption of best practice, and
  • determine the most efficient use of welfare resources.
• Welfare fora provide the opportunity for frequent discussion on welfare issues. Units are required to provide the MoD with information on the frequency of meetings, the attendance of key figures (e.g., the Commanding Officer) and any changes in the frequency or arrangements for meetings.
• The Defence Select Committee's Report "Duty of Care" (Third Report of Session 2004-05) raised concerns about the role of Empowered Officers in providing welfare support to recruits on the grounds that "…recruits are reluctant to discuss their concerns with the chain of command. Recruits who are not comfortable talking to an NCO may be even less inclined to seek out an officer" (Paragraph 176). The recommendation was therefore made to the MoD to review the possibility of Soldiers, Sailors, Airmen and Families Association (SSAFA) Forces Help or similar qualified civilian staff providing an alternative to the Empowered Officer. By having a position equivalent to the Empowered Officer, the civilian would have direct access to the welfare services within a unit and authority to make "binding recommendations". In its subsequent response, the MoD conceded that the "…Empowered Officer concept is not working perfectly at the moment", but because it had only been in operation for a year felt that it was too early to introduce new arrangements.
• Traditionally the role of the chaplains^[112] within the UK Armed Forces has been to provide guidance and advice to Service personnel and their dependents in respect of spiritual, moral and pastoral needs. To this end, chaplains are regarded as an integral part of welfare support provision. The nature of the military chaplaincy is also proactive in the sense that chaplains are required to share the experience of Service personnel such as being on exercise and taking part in physical training. However, chaplains do not have a command role and do not assess training performance. This reflects the ethos of the welfare service provision in the UK Armed Forces, which is not under the control of the chain of command of those who seek its assistance. Its purpose is predominantly to work in partnership with the MoD in order to ensure that both the requirements of Service and the needs of serving soldiers and their families are fulfilled. Welfare Officers are mainly serving personnel who are professionally trained and equipped with the necessary skills and knowledge to provide welfare support.
• According to the Defence Select Committee's Report "Duty of Care" (Third Report of Session 2004-05) the provision of non-uniform welfare services varies considerably at different units and was subject, in part, to the Commanding Officer's support and interest. Furthermore concern was expressed about the extent to which Commanding Officers "…may be tempted to "tick the box" of welfare provision merely on the basis that an organisation is present within an establishment and not give that provision the importance it very much deserves" (Paragraph 196). In response, the MoD confirmed that the welfare review had been mapping the different services and organisations that provide welfare services to the UK Armed Forces. On this basis, the review would seek to assess the welfare contribution that each organisation provides to Commanding Officers in order to: (i) identify the nature of the gaps and overlaps in provision, and (ii) review the interface between organisations and Commanding Officers.
• A National Audit Office report on the Reserve Forces in 2006 reported that Reservists and their families make little or no use of the Defence Welfare Services until they are deployed. On this basis, it was recommended that the MoD should focus its attention and resources on those welfare services which are most used by Reservists and their families to ensure that:
  • information supplied to Reservists' families is written in plain English;
  • Reservists in all three Services have access to adequate dedicated provision of welfare support, and
  • welfare support provision is improved for families of deployed Volunteer Reservists who do not live in close proximity to the Reserve Unit with which they train and those Regular Reservists who have no unit.
• In 2009, the Report on the Strategic Review of Reserves (MoD) presented seven recommendations with respect to providing welfare support to serving members of the Reserve Forces. These included the need for:
  • consideration of a long-term strategy for the improvement of Reservist welfare support;
  • steps to be implemented by the MoD to enhance the understanding of Reservists, viz, their entitled welfare support and benefits at all stages of service and for their dependents;
  • potential for providing a single point of entry for welfare support;
  • a review of the current provision and eligibility criteria for the Reserve Forces in each service to access all welfare provision and organisations, and
  • further research and surveys to be conducted by the MoD to ascertain attitudes towards welfare provision.

3.14 Organisation and nature of resettlement provision

• In providing a framework for all aspects of the Service personnel policy agenda, a key theme of the Armed Forces Overarching Personnel Strategy (MoD, 2002/03) is to provide Veterans and their dependants with "…a robust and effective system of resettlement provision". As part of its "whole life" strategy, this system is viewed by the MoD as "…a fundamental pillar of support and a tangible manifestation of the UK Armed Forces commitment to be an employer of first choice" (National Audit Office, Leaving the Services, 24 June 2007). Whilst it is ultimately considered the responsibility of the individual Service leaver to effect a successful return to civilian life by making good use of the MoD's resettlement provision, it is the responsibility of the MoD to ensure that military personnel are secure in their knowledge that they will receive assistance to prepare them for civilian life and future employment.
• As part of the military covenant between the MoD and its personnel the resettlement provision is dedicated to ensure:
  • access to timely and accurate resettlement advice and information to all Service personnel;
  • modern resettlement provision based on best civilian outplacement practice which would meet the needs of eligible Service personnel;
  • resettlement assistance on a graduated basis (both in terms of provision and time available according to length of service);
  • responsive and effective contracted resettlement services (including advice, workshops, training and job finding);
  • resettlement assistance to as many Service personnel as possible, and
  • appropriate resettlement allowances to assist Service leavers.
• Service leavers are typically classified into the following three categories.
  • Normal service leavers: those who are discharged from the trained strength either on: (i) completion of their engagement, (ii) having submitted their notice to leave, or (iii) having been given notice of discharge under redundancy.
  • Medically discharged service leavers: those who are discharged from the trained strength due to a medical condition which has been graded by a Medical Board as being a P8 (i.e., medically unfit for any form of military service).
  • Early Service leavers: those who are either compulsorily discharged from trained strength or untrained strength or who leave voluntarily from trained strength or untrained strength with less than four years service.
• The resettlement provision is tri-Service with a central MoD Directorate determining policy and administering the third tier of support, the Career Transition Partnership (CTP) described below. The first two tiers of support are provided by the individual Services.
  • First line unit resettlement information and administration: provided in an interview with the Unit Welfare Officer (UWO)^[113].
  • Second line educational and training services (ETS) resettlement advice: provided in an interview with the Individual Education and Resettlement Officer (IERO).
  • Third line CTP^[114] outplacement service: provided through a contract partnership that exists between MoD's Directorate of Resettlement and Right Management Ltd.
• In accordance with the Tri Service Resettlement Manual (JSP 534) resettlement from the UK Armed Forces often begins within two years of the "exit'" day when leavers officially become civilians. Since the introduction of an initiative to give support to Early Service leavers in April 2004^[115], all Service personnel have access to some assistance in making their transition from military to civilian life. The level of resettlement support provided to Service leavers is dependant upon length of service (to aid retention) and is not dependent on their rank, as follows.
  • All Service personnel: Entitled to access resettlement advice via their respective single Service Resettlement Advisers (including finance, housing briefs) at any stage of their career.
  • Early Service leavers: Generally have no access to CTP services, but receive a mandatory resettlement brief and interview by a suitably qualified interviewer prior to discharge.
  • Service leavers who have completed a minimum of four years: Entitled to access a range of services provided by the CTP including the Employment Support Programme (ESP).^[116]
  • Service leavers who have completed a minimum of six years (five years if enlisted prior to September 2002): Entitled to the CTP Full Resettlement Programme (FRP).^[117]
  • Service leavers who have been medically discharged: Entitled to the FRP.
• For normal and medically discharged Service leavers resettlement is received under the terms of Graduated Resettlement Time (GRT), which aims to reward length of service and provides full flexibility in how pre-release settlement time is spent. Hence, those who have less than one year of service and are medically discharged are entitled to FRP but are restricted to 10 working days GRT, whereas those who have more than 16 years of service are entitled to FRP and 35 working days GRT.
• Resettlement arrangements are designed to be sufficiently flexible to permit both deferred and transferred resettlement. The full rules governing these arrangements are laid down in JSP 534. For those entitled to the FRP, the CTP delivers support from the start of the resettlement up to two years post-discharge. In addition, these personnel are entitled to claim an Individual Resettlement Training Costs (IRTC) Grant to assist with the cost of training with external civilian college or firms. Civilian Training Attachments (CTAs) and CTP sponsored courses can be supported by IRTC. With the exception of Service personnel whose service is terminated prematurely for misconduct, all other personnel are also granted terminal leave on completion of their commission of engagement to assist with their resettlement, based on one day's terminal leave for each completed month of service. The maximum allocation is 20 working days.
• JSP 752 Tri Service Regulation for Allowances specifies the entitlement of Final Tour of Duty Provision (FToD) for normal and medically discharged Service leavers. The purpose of FToD is to assist personnel in their final tour to resettle themselves and their family in the area of the UK in which they intend to retire should the Service be unable to assign them to a duty station within 50 miles of their chosen retirement location. It includes the following:
  • Removal expenses and disturbance allowance (REDA): Provided at public expense under FToD provision,
  • Insurance allowance (IA): To meet the average cost of transit insurance purchased by Service personnel when they are required to move their personal effects, but are not entitled to claim REDA, and
  • Continuity of education allowance (CEA): Concessions available for those who are medically retired/ discharged.
• For the purpose of informing Service personnel of their entitlement on discharge the MoD provides an abundance of information in the form of booklets, manuals, and websites. The "Transition to Civilian Life. A Welfare Guide" (dated 21 January 2008) was developed specifically for issue to those leaving the Army who intend to settle in the UK^[118]. Its purpose is to explain some of the procedures and actions that those Service leavers are required to take in effecting their transition from the military to civilian life. Comprising 14 sections, it covers resettlement, housing, leave and pensions as well as explaining the related administrative procedures.
• In recognition that those not eligible for FRP may be at risk of social exclusion, and as a consequence may encounter health and welfare problems on leaving the UK Armed Forces, further initiatives have been undertaken to identify how best to help vulnerable Service leavers. This now includes the pilot of a "voluntary light touch mentoring scheme" which was sponsored by Pensions and Veterans and provided by the VWS and volunteers from the SSAFA Forces Help. Based at Catterick Garrison, the focus of this telephone-based service was on signposting clients to appropriate sources of support. Clients were followed-up for a six month period after which a brief evaluation was undertaken on housing arrangements, employment, alcohol use and relationships. Initially, the pilot evaluated Service leavers undergoing training with subsequent recruitment of Early Service leavers (i.e., with less than four years service) who recently returned from deployment. However, the provision of additional assistance by means of this system proved to be ineffective, predominantly due to low take-up rates and the conclusion that current welfare assistance provision (e.g., JobCentre Plus) was sufficient (Braidwood & Williams, 2009). Fossey (2010) suggests that such an outcome may in part be due to "maturity, stigma or ignorance, especially if mental health problems had not been identified at the time of discharge" p.15.

3.15 Pensions provision

• All Service personnel automatically become a member of the Armed Forces Pension Scheme (AFPS) on joining the UK Armed Forces. As an occupational pension scheme, it provides pension and invaliding benefits to members. Although it is based on a non-contributory scheme pension benefits are taken into consideration with regards to pay assessments. Within the Army there are three pension schemes (AFPS 75, AFPS 05, and the Reserve Forces Pension Scheme [RFPS]). Under current arrangements, all Service leavers should receive a Service Leaver's Pack from the Termination Cell, Service Personnel and Veterans Agency (G) approximately nine months prior to their termination date or as soon as possible after the notification of discharge (if less than nine months). Its purpose is to provide guidance and advice before and after leaving Regular service. To avoid a delay in receiving their Termination benefits and pension, eligible Service personnel are required to complete an SPVA Pension Form 1 (no earlier than six months and no later than six weeks before last day of service). Completion of this form is a legal requirement.
• The End of Service Benefits and Pensions Policy contained within the Armed Forces Overarching Personnel Strategy (MoD, 2002/03) refers to a package that comprises pensions and ill health, injury and death benefits, the award of which is subject to revision by virtue of developing manning requirements. In particular, this policy is designed to support the career patterns of Service personnel and to maximise retention rates at particular stages.

3.15.1 War Pensions Provision

• Any disablement arising from a Service-related cause can lead to the award of a war pension, the administration of which has been subject to a number of changes. In June 2001, the War Pensions Agency (WPA) became an Executive Agency of the MoD following the reorganisation of the Department of Social Security (DSS)^[119] into the Department for Work and Pensions (DWP)^[120]. The WPA subsequently changed its name in 2003 to the Veterans Agency (VA) to provide a single point of contact within the MoD for providing information, help and advice on a wide range of subjects including benefits and welfare issues, pensions and benefits by means of a free Helpline, welfare service and website. Its core functions were to administer the:
  • War Pensions Scheme (WPS) which provided financial support to war pensioners and war widow(er)s living in over 100 countries worldwide (although most were resident in the UK), and
  • Armed Forces Compensation Scheme (AFCS).
• On 6 April 2005, the AFCS replaced the arrangements for compensation paid under the WPS and the Armed Forces Pension and Research Attributable Benefit Schemes (AFPRABS). The AFCS covered all Regular (Gurkhas included), ex-Regular, Reserve and ex-Reserve personnel whose significant injury, illness or death by service occurred on or after the 6 April 2005. It is no-fault, non-contributory and separate from compensation for common law claims. Benefits included a tax-free lump sum awarded for pain or suffering. The AFCS was particularly significant in that, for the first time, it permitted injured Service personnel (men and women) to claim compensation whilst still in Service. A tariff system comprising 15 levels was used to determine the amount of the award based on severity of injury.^[121] In addition, since its inception the AFCS ensured that those who sustained the more serious injuries (i.e., tariff levels 1 to 11) received compensation for life on leaving the Services by means of regular tax-free and index-linked payments known as the Guaranteed Income Payment (GIP). The purpose of GIP was to make up for the deficit in pensions and earnings due to a decrease in the amounts such personnel were likely to earn post-injury. A total of seven principles underpinned the AFCS, which were: (i) fairness; (ii) simplicity; (iii) modernity; (iv) security; (v) employability; (vi) human rights, and (vii) affordability.
• In July 2007, the Under Secretary for State for Defence and Minister for Veterans (Rt Hon Derek Twigg MP) commissioned a review of the AFCS to assess whether the rules relating to multiple injuries arising from one incident continued to meet the Scheme's original intent of focussing on the most severely injured. Having taken into consideration the comments received during the consultation undertaken between October and November 2007, the review concluded in January 2008. It recognised that a specific rule in the Scheme that calculates the lump sum award where more than one injury is sustained in one incident was not originally intended for the type of serious multiple injuries being sustained in contemporary conflicts. Far more of those who sustain such injuries survive because of significant advances in the medical care provided in theatre. Measures duly implemented in respect of this review included an increase in the lump sum payment for Service personnel with the most serious injuries to £570,000 and provide an increase for all awards ranging from 10% to 100%. Furthermore, these increases were applied to all claimants of the AFCS since 2005. The amending Statutory Instrument was laid on the 16 January 2008 and the changes came into force on 8 February 2008 ("Armed Forces and Reserve Forces Compensation Scheme: The Ministry of Defence's Proposals for Changes to the Rules on More than One Injury Sustained in One Incident. Summary of Responses", February 2008, MoD: London).
• Originally it was intended that a full review of the AFCS would not be conducted until after five years of operation in order to allow sufficient cases to support any evidence-based analysis. On 29 July 2009, however, the Secretary of State for Defence (Rt Hon Bob Ainsworth MP) brought forward the planned review of the AFCS to 2010 to ensure further that Service personnel were not being disadvantaged by inadequate compensation for injuries sustained in Service. Members of the public and Service personnel were invited to submit their views on the AFCS during the public and service engagement period from the 22 October to 19 November 2009. The terms of reference ("Armed Forces Compensation Scheme Review" [Hansard Column 66 WS, 22 October 2009]) for the review was to consider the AFCS in its entirety with regards to:
  • establishing the validity of underlying principles,
  • evaluating the effectiveness of the AFCS (in its current form) in effecting these principles, and
  • making recommendations on the need for modifications to ensure that the AFCS is "fit for purpose".
• Under the aegis of the MoD, the Admiral the Lord Boyce led the review as independent chairman with support from:
  • a MoD team comprising both military and civilian members
  • an Independent Scrutiny Group (ISG) which included:
    • medical and legal experts in injury^[122] and compensation issues.
    • representatives from the Confederation of British Service and ex-Service Organisations (COBSEO), the Royal British Legion (RBL), Service Family Federations, War Widows and an injured soldier who had received compensation from the AFCS.
• In undertaking the review, comments were obtained from over 200 individuals and groups and the Review Team undertook visits to serving personnel of all three Services in their bases and at Headley Court. The Admiral the Lord Boyce also conversed with Ministers, the Chief of the Defence Staff and the heads of the three Services and the judiciary.
• In February 2010, the Secretary of State for Defence presented to Parliament the outcome of Admiral the Lord Boyce's Review, which comprised findings in respect of eight areas related to the terms of reference above. Although the underlying principles were considered by the Review Team to remain "broadly right", they recommended changes to the wording in order to enhance comprehensibility and to effectively convey how the: (i) tariff system operates in terms of level of award, and (ii) compensation scheme links in with the availability of other UK Government welfare support. It also acknowledged that the AFCS enhanced the provision of compensation awards compared with its predecessor, the WPS. Recommendations were made however to improve certain aspects of the AFCS, the implementation of which received full approval from Defence Ministers. On this basis, the AFCS will be revised to increase the:
  • GIP - to reflect the enduring effects of more severe injuries on potential for promotion and the ability to continue in work to the age of 65 years;
  • tariffs levels 3 to 15 by 50%;
  • maximum award for mental illness, and
  • time limits for claims and appeals.
• Improvements were also recommended in respect of the:
  • burden of proof arrangements for claimants who have poorly maintained clinical records, and
  • communicating effectively to Service personnel and their families the:
    • nature of the scheme,
    • entitlement to payments, and
    • rationale for the calculations on which payments are determined.
• New additions to the AFCS pertained to the:
• formation of an expert medical body to advise on compensation regarding specific illnesses and injuries (e.g., mental health, injury to genitalia, loss of hearing).
• introduction of a rapid interim payment prior to the full award to assist those who have been injured.
• "The Review of the Armed Forces Compensation Scheme - One Year On" (MOD, February 2011) describes the progress which took place over the past year. For example, the creation of the recommended Independent Medical Group (IMEG) to advise Ministers on the medical aspects of the Scheme was established in early 2010 and comprised senior consultants from relevant specialties including trauma, orthopaedics, neurology, occupational medicine, and mental health. IMEG also had three lay members to represent the Services and ex-Service organisations. The initial brief was for IMEG to consider specific topics from the Lord Boyce Review, viz, the compensation for mental disorders and hearing loss. In addition, consideration was given to a number of potential anomalies identified in the Review which meant that the Scheme was not delivering the horizontal and vertical equity on which it was founded. These included: loss of the use of a limb, injury to genitalia, spinal cord injury and brain injury. Due to the complexity of these topics and the diversity of opinion, more time has been given to enable in-depth consideration. In September 2010, the Minister for Defence Personnel, Welfare and Veterans extended IMEG in its present form to March 2012, with a review of its future in September 2011 to enable further work in this domain. Thus, some of the recommendations have been more complex to implement than others because of the need for detailed analysis and legislative work. However, all of the recommended legislative changes to the Scheme have now been undertaken and the new legislation was laid before Parliament on 28 February 2011.

3.15.2 Benefits Provision

• The impact of Service life can adversely impact on the ability of:
  • spouses and civil partners to obtain paid employment and maintain a National Insurance contribution record the implication of which may be twofold. First, it may adversely affect their contribution record for basic State Pension along with their access to contribution-based working-age benefits. Second, it may result in unfair treatment in respect of the assessment for eligibility to certain entitlements in the UK, and
  • accompanying family members to obtain paid employment by virtue of the mobility requirement.
• To tackle any disadvantages associated with entitlement to benefits, the UK-side commitment sought to implement a number of measures which included use of the Service medical board evidence in place of the face-to-face medical assessment by the DWP to establish eligibility for Employment and Support Allowance (which replaced Incapacity Benefit as of October 2008). This allowance is paid weekly to sick and disabled people under State Pension age who are unable to work.
• Benefits in respect of transport concessions for Service personnel and Veterans who were seriously injured in Service and entitlements for severely disabled Veterans have also been addressed as part of a UK-wide commitment. The measures undertaken in Scotland are outlined in Appendix C, and the progress made since their implementation in July 2008 is summarised in Appendix D.

3.16 Housing provision

• When a Service occupant of Service Family Accommodation (SFA) is due to leave the UK Armed Forces on discharge, it is the responsibility of the individual's administrative unit to inform DE Ops (Housing) Housing Information Centre (HIC) four months pre-discharge. Thereafter, HIC issues a period of notice to individuals to vacate SFA subject to the nature of their exit from Service, as follows.
  • Normal discharge/ Premature Voluntary Release (PVR): 93 days Notice to Vacate timed to expire on the last day of service.
  • Medical discharge: 93 days continued use and occupancy of the SFA after the date of discharge. Thereafter, extensions of up to 93 days may be granted on compassionate grounds^[123].
  • Compulsorily discharge: A minimum of 28 days notice is given in cases of discharge on disciplinary grounds or misconduct.
• A crucial element to enable Service personnel to effect a smooth transition from military to civilian life is the provision of advice on and assistance with housing. The July 2008 SPCP contained 10 housing-related commitments which sought to remove any housing disadvantage that the UK Armed Forces community may suffer as a result of:
  • the mobility requirements of service (nationally and internationally), and
  • injury sustained in service.
• Measures were proposed to redress the potential disadvantage that Service personnel face in terms of not being able to get on the housing ladder because of their obligation to be mobile throughout service. These included the following.
  • Affordable homes: The Key Worker status will be extended to enable Service leavers to access the Key Worker Living scheme 12 months after discharge. Scottish Ministers agreed to extend access to their affordable housing schemes to Service leavers 12 months after discharge. (paragraph 2.13)
  • Adaptable affordable homes: Low cost initiative for First Time buyers in Scotland may also be eligible for a grant from the Local Authority (LAs) to cover the cost of any necessary adaptations. (paragraph 2.16)
• Similarly, measures were proposed to assist seriously injured ex-Service personnel in obtaining suitable accommodation. These were as follows.
  • Adapted social housing: In view of the fact that seriously injured service personnel can face delays in obtaining suitable adapted housing where they are not given sufficient priority, it was proposed that seriously injured personnel in England and Wales should be given "additional preference" (i.e., high priority for social housing). Scottish Ministers were required to remind landlords of existing high priority that seriously injured personnel in Scotland receive for adapted social housing. (paragraph 2.15)
  • Disabled Facilities Grant Means Test: AFCS and WPS payments for most seriously disabled were to be disregarded in the means test for DFG in England and Wales. In Scotland this means test was to be considered for discontinuation. (paragraph 2.17)
• The allocation issues identified as part of the Scottish Government's commitment to support Veterans and Service personnel living in Scotland were addressed in "Paper 3 - Veterans" for discussion at a meeting of the Allocations Policy Review Advisory Group on 27 February 2009. The paper was prepared at the request of Scottish Ministers as part of the wider review of social housing allocations policy. The paper first referred to the legislative context within which this policy operates to highlight the following.
  • On leaving the UK Armed Forces, ex-Service personnel have the same rights to social housing as any other civilian.
  • The Housing (Scotland) Act 1987^[124] states that anyone who is 16 years or older must be admitted to a housing list.
  • Social landlords^[125] must act in accordance with those factors specified by the Housing (Scotland) Act 1987 that determine the allocation of social housing. Beyond that which is specified, social landlords have discretion to develop allocations and letting policies in line with local priorities.
  • Because social landlords are legally bound to allocate their houses in accordance with housing need, seriously injured ex-Service personnel should already be considered as a high priority in this regard.
• Paper 3 also outlined the steps taken to implement the Scottish Government commitment on seriously injured Service personnel. These included the production of a revised Housing Circular on housing for people leaving the UK Armed Forces by the Scottish Government in consultation with Convention of Scottish Local Authorities (CoSLA) and the MoD. The key aspects highlighted in respect of meeting the housing needs of seriously injured ex-Service personnel in Scotland are as follows.
  • Access to adapted social housing - to accommodate the nature of the injury and/or disability sustained.
  • Special consideration by social landlords of housing applications pertaining to ex-Service personnel who left service under medical discharge.^[126]
  • Rapid assessment of housing applications - to minimise delays in the allocation and arrangements of suitably adapted accommodation.
  • Social landlords to liaise with other relevant housing and service providers (including Veterans' services) - to ensure that all aspects of need are considered and appropriate support (including housing) is provided.
• In order to establish what has been achieved to date in terms of meeting the housing needs of the UK Armed Forces community in Scotland, Appendix D provides an overview of the specific measures undertaken as part of the Scottish Government commitment in relation to housing and the progress that has since been achieved.

3.17 Homelessness initiatives

• As part of its obligation to the UK Armed Forces community, the MoD has sought to tackle homelessness^[127] by putting preventative measures in place for "vulnerable" Veterans who are at risk of experiencing social exclusion. For example, in the financial year 2002-03, the MoD committed £285,000^[128] to preventative programmes to assist with the re-housing of ex-Service personnel. In recognition of the need to measure the impact of these programmes in order to provide evidence for future policy decisions in respect of homelessness, the MoD together with the Office of the Deputy Prime Minister, the Devolved Administrations and the Ex-Service Action Group (ESAG)^[129] commissioned KCMHR to conduct a feasibility study of the extent, causes, impact and costs of rough sleeping and homelessness amongst Veterans in a sample of Local Authorities in England. The findings of this study and the recommendations that derived therefrom will be addressed in Section 5 along with the other research studies that have been conducted in this domain.
• In July 2008, the UK Government pledged a further £400,000 to provide new supported housing for Service leavers in England to enable them to make a successful transition to civilian life. This initiative was to be delivered by the Department for Communities and Local Government (CLG) in collaboration with the Housing Corporation with support from MoD gifted land. Opportunities were to be explored with Scottish Ministers and ex-Service charities on housing ventures that would meet the accommodation needs of Veterans in Scotland.

3.17.1 Homelessness Legislation, Policy and Strategy in Scotland

• A number of steps have also been taken to improve homelessness legislation in Scotland which derives originally from the Housing (Homeless Persons) Act 1977 (consolidated in the Housing [Scotland] Act 1987. As such it was the first act to place specific and comprehensive duties on the 32 Local Authorities (LAs) for dealing with homelessness in their area. It was limited in scope, however, by virtue of the fact that a number of hurdles needed to be overcome even if an applicant was found to be homeless. These hurdles were:
  • "priority need" - to ensure that where supply of LA accommodation was limited, families with children and the most vulnerable would have priority access.
  • "intentionality" - to counter the concerns that households would deliberately give up their homes in the belief that the homelessness route would lead to superior accommodation.
  • "local connection^[130]" - to prevent "magnet cities" from becoming inundated with homeless people from outwith the area.
• The appointment of the Homelessness Task Force (HTF) by the Scottish Executive in August 1999 provided the catalyst for initiating a homelessness action plan with the following terms of reference:

"To review the causes and nature of homelessness in Scotland; to examine current practice in dealing with cases of homelessness; and to make recommendations on how homelessness in Scotland can best be prevented and, where it does occur, tackled effectively" (p.1. Scottish Executive, 2002).

• The first report of the HTF, published in April 2000, focused on amendments to the homelessness legislation. It formed the basis for what was enacted by the Scottish Parliament as Section 1 of the Housing (Scotland) Act 2001, which required LAs to carry out an assessment of homelessness in their area and to prepare and submit a strategy for preventing and alleviating homelessness in their area by 1 April 2003. The production of a homelessness strategy is designed to enable LAs to adopt a holistic approach to tackling and preventing homelessness (including rough sleeping), which requires the LAs engaging in partnerships with housing associations, health boards, voluntary organisations and employability/training organisations to enable the development of sustainable solutions to homelessness, with the individual at the core. In taking this approach, concomitant problems, which may serve to exacerbate the likelihood of repeat homelessness are dealt with such as health service access to address substance misuse problems. In addition, the LAs homelessness strategies should also identify actions to facilitate early and effective interventions to support those at risk of becoming homeless, which may include:
  • arrangements for the early identification of individuals experiencing housing difficulties across the full range of tenures and landlords,
  • access to advice and support for at risk individuals, and
  • availability and access to the appropriate services to tackle specific issues (e.g., family and relationship counselling, mediation, and debt advisors).
• It is the legal duty of LAs to secure some form of temporary accommodation. Those accepted as homeless should automatically be placed on the housing register (or waiting list), which would entitle a "reasonable preference" (i.e., priority) for a permanent tenancy. A recently revised Code of Guidance on Homelessness provides LAs with guidance on how to operate their homelessness functions. Whilst all LAs must "have regard to" the Code in their policies and practice according to the Scottish Council for Single Homeless (SCSH) its implementation is variable across Scotland. Moreover, whilst families with children and certain categories of vulnerability (e.g., old age) are well addressed by the legislation, it is not clear to what extent other groups (including vulnerable ex-Service personnel) face different policies in different parts of Scotland. Communities Scotland is the organisation responsible for regulating LAs homeless functions and was established by the Housing (Scotland) Act 2001 to ensure that LAs implement their homelessness duties correctly.
• In February 2002, the HTF final report^[131] made a further 59 recommendations for improving the legislative framework which were endorsed by the Scottish Parliament on 7 March 2002. In respect of Service leavers who either return to or who were already residing in Scotland, the HTF in its final report made the following recommendations.
  • LAs should take full account of the needs of those leaving the UK Armed Forces for whatever reason (including dependents) as part of their homelessness strategies. To this end, LAs should engage with Veterans' organisations, and their strategies should incorporate the findings of the Resettlement Working Group of the Veterans Task Force.
  • Guidance to LAs should emphasise that Service leavers should be classified as threatened with homelessness in the event of cases where their licence to occupy Service accommodation is due to expire and no other accommodation is available.
  • LAs and other bodies (including the Scottish Prison Service) who may encounter individuals who are homeless or at risk of homelessness should have procedures in place to identify Veterans and to sign post the support services available to them.
• The Homelessness Monitoring Group (HMG) was established in 2002 to oversee the implementation of the HTF recommendations^[132], and the Homelessness etc. (Scotland) Act 2003 provides the necessary legislation to take them forward. HTF regard their implementation as being fundamental to defining the rights of those affected by homelessness (including Veterans) and the duties and obligations, which LAs and others have towards them^[133]. Following the commencement of section 1 of the Homelessness etc. (Scotland) Act 2003, the definition of priority need has been expanded. From 30 January 2004, LAs have a legal duty to assist a member of a household who is vulnerable as a result of having been discharged from the Regular UK Armed Forces^[134]. By means of the Homelessness etc. (Scotland) Act 2003, however, it is intended that the requirement to establishment "priority need" will be phased out over a 10 year period, the law will be updated, and the "local connection" provision will be suspended.
• The benefits system is also considered by the HTF as having an important role to play in helping individuals through the crisis of homelessness given that the most significant aspect of the social security system is the SCSH benefit system. As it is means tested, housing benefit can meet up to 100% of the rent. However, it cannot be used to provide a deposit on a rented property and housing benefit for privately rented accommodation is subject to restrictions. The administration of housing benefit has become increasingly complex and some LAs may take longer that 14 days^[135] to process a claim. Although there are other benefits such as the Social Fund (which offers further financial assistance) and Community Care Grants^[136], in Scotland benefit matters are reserved and therefore outwith the scope of the Scottish Parliament and Government. Moreover, a main limitation of all of these funds is that they are cash limited (i.e., once the budget allocated to a specific area has been used up there is no further financial assistance available) and their implementation is subject to geographical variation. For this reason the HTF highlighted the general need for more information about the operation of the benefits system in Scotland and for research into the impact of benefits policy on homeless people in Scotland including Veterans.

3.18 Welfare provision for Veterans who encounter the Criminal Justice System

• The link between homelessness and offending and imprisonment is well established. In Scotland, approximately 3,000 ex-prisoners submit homelessness applications each year (Pawson, Davidson & Netto, 2007). Once imprisoned, individuals are at an increased risk of losing any accommodation that they might have previously had due to a number of mitigating factors including housing benefit restrictions and a lack of information regarding how to retain their tenancies (McIvor & Taylor, 2000). There is the suggestion that private landlords may discriminate against those with criminal convictions who are trying to access accommodation. Furthermore, because family bonds may be weakened by periods of imprisonment, this can mean that ex-prisoners are unable to return to and remain in their original family home (Hickey, 2002). Scottish prison statistics suggest that between 3,600 and 8,550 individuals may have encountered homelessness following release from prison in 2006 (Scottish Executive, 2006).
• Concern has been expressed over a number of years by those voluntary organisations that help ex-Service personnel to adjust to civilian life that a number may end up in the Criminal Justice System. In an endeavour to improve in-reach prison services, the MoD leads a working group that brings together Government, the Prison Services and organisations from the voluntary sector. As a non-executive body, it helps to ensure a partnership approach to undertaking in-reach activities. Prison-In-Reach (PIR) is an initiative that aims to ensure all Veterans that are prisoners or probation offenders and their families as well as those responsible for resettlement services are fully informed of the types of support available to them from the SPVA^[137] and ex-Service charities^[138]. This includes both pre- and post-discharge welfare provision. The work of PIR is designed to contribute to the wider UK Government goals of reducing the risk of re-offending.
• In Scotland, the MoD has been working in partnership with the Scottish Prison Service, Families Outside, and a number of Scottish ex-Service organisations to improve knowledge and support available to ex-Service prisoners and their families. In 2006, a PIR pilot was undertaken in HMP Edinburgh, which aimed to raise awareness among resettlement and welfare staff as well as other voluntary organisations. This work was supported with a poster, leaflet and advice wallet that contained contact details of those providing advice, guidance and practical assistance. Following evaluation, the PIR project was rolled out to all 17 prisons in Scotland.
• Discussions have also taken place with Safeguarding Communities and Reducing Offending (SACRO)^[139] with the aim of ensuring project partners become closely involved in the services offered through its developing Community Links Centre (aims to provide advice, guidance, and assistance to prisoners and discharged prisoners including the extensive support that can be provided by ex-Service organisations for Veterans in prison).

3.19 Education and skills training provision

• While Service personnel can enjoy a long and fulfilling career in the UK Armed Forces, the majority leave service at least 25 years before the national retirement age. For most this requires the need to pursue a second career on leaving service (National Audit Office, HC 618 Session 2006-2007, 27 July 2007). Many who join the UK Armed Forces do so at a young age (particularly those who are recruited by the Army), and typically commit to a military career before taking advantage of any opportunities in further and higher education. Indeed, this is one of the reasons why the MoD is reluctant to raise the recruitment age of all three Services to 18 years.
• Once individuals attain that age of 18 years, they are more likely to have continued in academic study to pursue other career aspirations not related to the military thereby making it more difficult to attract them to a career in the UK Armed Forces (Cm6620, July 2005). To address this potential disadvantage, however, the SPCP pledged a commitment to put measures in place which would assist those Veterans who wish to pursue further education and training. Appendix C provides an overview of the specific measures undertaken as part of the Scottish Government commitment in relation to education and skills training and the progress that has since been achieved. (It also provides a summary of the measures implemented to address the potential educational disadvantage experienced by Service children due to the mobility requirement.)

3.20 Employment provision

• In accordance with the UK-wide commitment to help Veterans to enhance their chances of success in obtaining employment in civilian life, the Scottish Government pledged to implement five specific measures as summarised in Appendix C. On the basis of the first annual report, as provided in Appendix D, the following measures have since been implemented.
  • Improved signposting in respect of the availability of public sector jobs.
  • Statement of Employer Support issued by SaBRE (Supporting Britain's Reservists and Employers) has been endorsed by the First Minister.
  • Establishment of standards and outcomes as part of the Supported Employment Framework for those who encounter particular difficulty in gaining access to the labour market. (A package of support tailored to meet specific needs in this regard will be provided to facilitate employment prospects.)
• Obtaining and retaining suitable employment is a challenge for those with mental health problems. The Social Exclusion Unit project sought to establish: (i) how best to assist Veterans with mental health problems to enter and retain employment, and (ii) what more can be done to provide them with opportunities for social participation and access to services. Links were also established with the DWP and the Pathways to Work team to conduct a series of rehabilitation pilot schemes to address employment skills and attitudes. The Welfare to Work Strategy is founded on the premise that work is good for health and that everyone (including those with disabilities) should have the opportunity to work.
• Following a 12 month pilot scheme conducted in London, Project Compass was established by the MoD along with a number of partner organisations^[140] to help ex-Service personnel who: (i) want to be employed; (ii) have no current substance misuse or mental health problems; (iii) have been living a relatively stable life in the previous 6 months, and (iv) are homeless or at risk of homelessness. In order to help Veterans obtain suitable training, experience and the opportunity to secure sustained employment in their chosen career, it provides:
  • bespoke training, careers advice and employment support;
  • two day Ready for Work pre-employment training programmes to enhance self-esteem and communication skills;
  • two week work placements with companies^[141];
  • job coaches, and
  • referrals to other support agencies (including Combat Stress).