DR CHRISTOPHER FREEMAN

11 OCTOBER 2007

  Q210 Chairman: I would like to say welcome to everyone. This is the third session of our inquiry into Medical Care for the Armed Forces. It is a particular pleasure for us to be able to come to Scotland to take evidence on this. We are grateful to our hosts at the Scottish Parliament for making these facilities available to us. We will be taking further evidence during the next few months from ministers at the Ministry of Defence, from ministers at the Department of Health and we expect, and hope, to publish a report some time in the New Year. This afternoon we have evidence from the Royal College of Psychiatrists, from the Board of the St John and Red Cross and also from officials from NHS Scotland. If I may begin by setting out the timetable for that. Dr Freeman, thank you very much indeed for coming. We will be hearing from you between now and about ten to two. We will then hear from the Red Cross and at about ten past two we will move on to NHS Scotland and the way that defence medical care interacts with them. We expect to finish at about 3.15, 3.20, so that gives us a timetable of how much we have got to get through in the time. With you, Dr Freeman, we have just over half an hour. I wonder if you could very briefly introduce yourself and say what you do and why you do it.

  Dr Freeman: Yes. I am Dr Chris Freeman. I am a consultant psychiatrist and psychotherapist working in the Lothian Edinburgh area. I have been a general psychiatrist and more recently, over the last ten or 15 years, a specialist in the treatment of traumatic stress reactions. I run a traumatic stress treatment centre called the River Centre which offers a service for the whole of Scotland, but mainly for the south-east of Scotland, and we treat asylum seekers, refugees, civilian accident victims, Service personnel, Fire Service, Police, a wide range of patients suffering from post-trauma psychological reactions. Just by chance, because most other services across the whole of the UK are very, very small, we are by far the biggest service anywhere in the UK with about ten or 12 full-time staff working in this area. It is a credit to Lothian Health Board that they have funded that. I am also Chair of what is called the UK Trauma Group, which is a managed clinical network of all the trauma services in the UK, both in the independent sector and in the NHS sector, including Combat Stress and military psychiatrists and psychologists as well. We meet once or twice a year to exchange ideas, discuss policies, give advice, etc. That has been going on now for about ten years. I am really here with three different hats on, and if I give three different answers I apologise for that. I am here as a general psychiatrist to try and give you a picture of what it would be like in routine clinical practice were a veteran referred; I am here as a specialist in traumatic stress to say what could be done in specialist centres; and I am here representing the Royal College of Psychiatrists to give an overview of psychiatry. I have to say those are three quite different perspectives, there is not a single answer to most questions.

  Q211  Chairman: Okay. Thank you very much. Can we look first at ex-Service personnel with mental health needs? Could you tell us briefly how well you think the NHS deals with ex-Service personnel?

  Dr Freeman: It hardly deals with them at all. I speak now with my general psychiatry hat on, what it would be like if I was working in Fife or Argyll or Glasgow and a man, usually a man, with a Service history was referred to us. It would be no different were he a postman, a painter, a squaddie in the Army, a colonel in the Army, in his history there would be a note that he was a soldier rather than a postman. It would be as basic as that. There is no specialist service. Most general psychiatrists would not be very much aware of the war pensions scheme, would not be aware of Combat Stress and the role it plays in Hollybush House, would have a vague idea that there had been a lot of debate around about Gulf War Syndrome, chronic fatigue, perhaps overemphasising the role of PTSD, but it would be no more than that. They would get treated for their depression, their alcohol or drug addiction, just like any other person. They would not be aware that a circular goes round to chief executives from the Health Department regularly saying that veterans should have priority because that would never filter down to your average general psychiatrist. They probably would not have any concept of what Army or Service life is like and what the particular stresses or strains of being a veteran would be. They would get the same treatment as anybody else, but not specialist tailored treatment if they were referred in that sort of way.

  Q212  Chairman: Do you have a view about whether Ministry of Defence as opposed to the NHS should maintain some sort of responsibility for veterans after they leave the Service? Do you think the arrangements that we have got at the moment are satisfactory? From what you say it sounds as though you do not.

  Dr Freeman: No, I do not think that. Things have improved. There was a time seven or eight years ago when if you referred a Serviceman you could hardly get access to his Service medical records, it was difficult to contact a doctor in the military to find out what had happened, but that has improved a lot. Of course, there was this very odd practice that the Army had of the man's Commanding Officer writing him a letter of recommendation on his discharge saying, "This man is a credit to the Service. He would be fully well-employed in any job you would care to offer him", without any mention of what difficulties he might have been through or what traumas he had had in Service practice. Men were discharged from the Services with, understandably, a big pat on the back for the service they had offered but were given a clear message: "You're going to be okay. Go out there into civilian life and get on with things". Of course, one of the big messages I want to get across is how difficult it is for these men to seek help. That is one of the really important things that we have to change. Even for Combat Stress it is many, many years before a lot of these people come forward for help. They are ashamed of having psychological problems, they use drink and alcohol to cover up their symptoms, and it is really hard for them to consider going to their GP and saying, "I'm breaking down. My marriage has gone wrong. I'm having dreams and nightmares", etc. I do not know that the Ministry of Defence can do much about that. There could be an argument for saying that there should be some sort of post-discharge screening, that one or two years after discharge you should see someone and at least have your mental health checked out, but my guess is that many of these men would not go back for that, they would be avoidant of it. I think it has to be within the NHS and the primary target has to be alerting GPs to the particular problems of veterans and having them sensitive to doing that. These men do go with physical problems. The GP is the main point of contact and they do go with their excess drinking, etc. It is raising awareness amongst primary care teams that the NHS has to do.

  Q213  Mr Jones: I agree with the need for perhaps more awareness among GPs of the general things you are talking about, but do you not think we could invent a system to at least track these people either through the NHS, the MoD or some veterans' agency and at least we would know where they were? One of the things that comes over all the time, which is exactly what you are saying, Dr Freeman, is people do not know where they are and they only present when they have problems or perhaps they do not know they have problems?

  Dr Freeman: As I am sure you will know, a lot of these arguments were argued out in what was called the PTSD case in the High Court a few years ago where several thousand soldiers were suing the MoD for not being looked after in terms of their psychological needs, both during their Service and post-Service. That was one of the areas that was debated and it was certainly something that the men put forward, that in some way a letter could go from the Army Medical Service to their GP on discharge simply saying, "This man served in Northern Ireland, two tours of service in Iraq" etc., flagging up that there would be certain people who would be at high risk, but that was rejected by the MoD at that stage. There are a few who fall through the net and drift around the country and do not register with GPs, but most of them do have a GP and when they go to their GP two years after discharge they do not say, "I am a soldier", or "I'm an ex-soldier", they just go in as someone who is working as a painter, a postman or whatever. So if the GP did have some little starred note saying, "Look, this man actually saw active service in three different theatres of war and was exposed to X, Y and Z" that would alert them, I think.

  Q214  Mr Borrow: Moving on to serving personnel, to what extent do you think the MoD provides adequate support for the mental health services for serving personnel?

  Dr Freeman: Again, it has waxed and waned. If you go back 20 years it was at a very low ebb. There was then a large number of community psychiatric nurses appointed in the Service and we had four or five working at Redford Barracks at one time. I happened to run a cognitive therapy, psychotherapy training course and those CPNs came on that course, so there was high quality psychological treatment for these people. Sadly, most of those personnel seem to have disappeared and Catterick has closed, which was a place that you could go for inpatient treatment. I think they do an okay job but not a great job. The psychiatric services are stretched. They do pretty good assessments and monitoring but getting high quality psychological treatment is certainly as difficult in the Army as it is in the NHS, given that these are a high risk group of people. The thing that the MoD has done over the last few years is there is a large research unit at King's College run by Simon Wessely, they have put a lot of money and effort into that, and they are taking post-deployment screening seriously, they are following people up more during Service, but there is always this tension, you think of yourself as the soldier, "How much do I want to disclose about my mental health problems? Does that mean I am going to be gently eased out of the Army?" It is a very difficult tension. I feel that bit has not changed yet, there still needs to be more acceptance of psychological problems in serving Service personnel and the aim should be to treat and rehabilitate these people to keep them in the Services. They are often very, very good soldiers who are very, very loyal to the Army, particularly, and they want to stay. They are terrified of going to the medical officer and saying, "Look, I'm depressed, I'm having nightmares, I can't sleep and my marriage is going wrong" in case that has an impact on their Service career.

  Q215  Mr Borrow: You mentioned the closure of Catterick, but to what extent do you think the restructuring of mental health services has improved things or made them worse?

  Dr Freeman: I am certainly concerned about the use of the Priory private independent hospitals for the inpatient services. I do not think when that was commissioned that the Priory were experts in this area. Many of these men say that what is important to them is being treated by someone who has some knowledge of the system in the Forces, they need to feel the person understands what life in the Army is like, so I am not sure that was a good idea. The problem with contracting to the private sector is that the private sector makes its money by keeping people in beds, the longer someone is in hospital, the more money they get, and that is a tension between the NHS and the private sector, I think.

  Q216  Mr Borrow: To what extent is your view coloured by the actual work you do in the sense that within serving personnel there will be displayed a whole range of mental health difficulties, not simply those that are related to the trauma of being in theatre? Obviously that will be part of it but there will be the whole range of mental health needs that a civilian population would show as well.

  Dr Freeman: I think that is a very fair point and something I would want to emphasise. Even if you take post-trauma psychological reactions we have slipped into a very easy way of thinking that horrible events happen to you, therefore the psychological reaction you get is post-traumatic stress disorder, and that is just not true. There are some good follow-up studies. If you take 100 people, military or civilian, who have been severely traumatised psychologically because of exposure to warfare, rape, torture or whatever, the commonest reaction they will get is depressive illness. The second commonest is some sort of anxiety disorder, panic disorder, agoraphobia, generalised anxiety disorder. The third is PTSD. Even in those who have been traumatised PTSD is not what you would expect to happen. I fully agree it is really important that we do not narrow this argument down to thinking of psychological trauma, therefore PTSD, therefore services for PTSD. Depression, alcohol and drug misuse, anxiety disorders, they get just the same range of psychological problems as people in the general population and, therefore, they need that range of treatments.

  Q217  Mr Borrow: Is there anything the MoD could do to actually improve the preventative health services in the mental health area? In other words, what could be done to make it less likely that serving personnel have mental health problems either while they are serving or after they have left the Service?

  Dr Freeman: Again, this was very fully debated in that MoD case and there were examples given of could we screen entrants into the Services better. I think the answer is probably no, the evidence is that screening is not a sensitive enough tool and who would you actually screen out because sometimes someone who has had a very disadvantaged background, who may have had adolescent problems from the backstreets of Glasgow, becomes a really good soldier when they are embraced into the Army and supported and given an experience they never had in their civilian life, and you might screen out some very good soldiers. Apart from screening for very severe mental illness problems, which I think the Army would feel they already do—schizophrenia, bipolar disorder, excessive drug misuse—I do not think screening at the beginning would do. As you know, they have what is called the PULHEEMS System for rating people regularly during their Service and that does not pay enough attention to psychological and social factors. In-Service monitoring is something that I think could be done. The Israeli Army, as you will know, has very detailed pre-deployment preparation and there is this big debate about how do you prepare soldiers for warfare. Do you do traditionally what the British Army has done and said, "We're a great fighting force, you should be proud to be a British soldier. We expect you to behave with valour and gallantry", whereas the Israeli Army says, "You will be scared shitless. You will never feel fear like you will feel in the battle force and you need to know how your body responds to that. In training we are going to put you through that now so you are prepared for how you respond in very, very stressful situations". It is quite a different message. They would claim they get lower rates of post-psychological breakdown but I think the evidence is not that strong, to be honest.

  The acronym "PULHEEMS" is derived from the first letters of the qualities assessed when a medical examination is carried out. The PULHEEMS qualities are P (Physical Capacity), U (Upper Limbs), L (Locomotion), H (Hearing), EE (Eyesight), M (Mental Capacity), and S (Stability, reflecting the member's psychiatric stability in the military environment).

  Q218 Willie Rennie: In general do you think that the mental health services within the Armed Forces are getting better or getting worse?

  Dr Freeman: I think they are getting better. Although that big court case was "won" by the MoD rather than by the men, and many of the men were very disappointed in the outcome, it certainly focused the MoD on the fact that they had to do things better. There is some very good research going on. They are taking this seriously now. I am not sure it has been fully translated into treatment services but in terms of understanding what they can do in terms of post-deployment defusing and those sorts of things, the project that the Marines have, I think they are really trying hard.

  Q219  Willie Rennie: Okay. Just going back to ex-Servicemen, do you think ex-Servicemen suffer a disproportionately higher level of mental health problems than the general population?

  Dr Freeman: Yes. It is not uniform across the Services, the Air Force and the Navy have much lower rates than the Army. That may be about the nature of deployment and all sorts of factors may be involved in that. Of course, you have to say that the population that the Army recruits from is often a very disadvantaged population so they may have had problems anyway. The big issue is that for many of these men their time in the Army was the best time of their life. They had their needs met, the comradeship, etc., and accommodating to civilian life after that can be very difficult for them and that is why many go in the TA and stay involved. I see many patients who are furious with what they regard as the bad deal they got in the Army in terms of medical care but if they could turn the clock back they would go back in and still serve.