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Memorandum submitted by Dr D Alun Jones (CBPS 25) MD BSc DPM FRCPsych Seiciatrydd Ymgynghorol Consultant Psychiatrist
Post Traumatic Stress Disorder Cross-Border Issues.
1) My evidence is based principally on my experience with traumatised ex-Servicemen and the problems arising with treatment for them. Much of this was on a cross-border basis throughout the U.K.
2) My work with ex-Servicemen began in 1981 when a patient was referred to me by his General Practitioner at my clinic in Dolgellau. The referral was for depression and alcoholism in a man who had been pensioned out from a family firm in Lancashire and retired to the Cardigan coast. As part of my normal clinical assessment it emerged that at the age of 18 he had been shot down whilst on a night mission over Holland. He was the only survivor. He made his way across France almost to the Pyrenees but was captured and had a horrific time.
3) This was before DSM and Post Traumatic Stress Disorder, but clinically I thought he showed a state which had been continuous throughout since that experience.
4) At that time I only knew vaguely of the War Pensions Agency but thought there should be some benefit for him. He was much too anxious to deal directly himself and I wrote with my report asking that correspondence should come to me.
5) I received a very helpful reply from Dr W.R.O.Eggington, Senior Medical Officer at War Pensions Agency, Norcross dated 2nd December 1981. A copy of this letter is attached as Appendix 1.
6) I had also directed him to his then local MP for advice, Dafydd Elis Thomas, now Lord Elis Thomas Presiding Officer of the Welsh Assembly. A copy of his letter dated 24th February 1982, which is in Welsh, is attached as Appendix 2.
7) Shortly after that I was approached by a field officer of Combat Stress on another case and mentioned this gentleman. I was then asked to act as Honorary Consultant for Combat Stress and did so for many years.
8) I found myself being asked to report on increasing numbers, many from outside North Wales. Many were travelling great distance. Most were referred by Combat Stress for help with War Pension Claims. I saw them at my clinic in Chester. Many were travelling from the Manchester area and in collaboration with the Combat Stress office in Manchester I established a clinic there. I was then asked by the Field Officers of Combat Stress whether I would help "the other side of the Pennines" and I started a clinic in Leeds. Cases were coming from as far as Hull and I started work there. This process continued until I was holding ex-Service clinics in most parts of the U.K.
9) The connection in Scotland began at a meeting in Manchester when a young Gulf Veteran from Scotland pleaded for a help there and I agreed to hold a clinic in a Glasgow area if they found a venue. This later led to another clinic at Perth.
10) I still have about 26 locations across the U.K. (Appendix 3) and was visiting on a cycle of about two months. Over the years I have seen around 2,500 ex-Service men and women.
11) With my retirement from the Health Service in 1995 I continued and expanded this work which was then funded by part of the Ty Gwyn fees.
12) With the closure of Ty Gwyn there was no funding from any source and I have been trying to maintain the contact as best as I can.
13) When consultant contracts and sessions were reviewed in the 1980's my Health Authority recognised the work as a special clinical interest and allowed sessional time for it. I do not know of any other Health Authority in the UK which designated clinical sessions for a civilian NHS consultant psychiatrist to deal specifically with traumatised ex-Servicemen.
14) Consultant Colleagues became aware of my interest and made referrals. Over the years many General Practitioners became aware and referred ex-Servicemen. Other agencies referred from all over the U.K. - SSAFA, RAFA, Army Benevolent, British Legion, NGVFA, Probation Service, Prison Medical Officers, the Courts and others. Ty Gwyn was registered under the Mental Health Act 1983 and was able to take patients from the Courts and from prison for treatment or assessment.
15) Overall the outcome at Ty Gwyn was very good. Marriages were preserved; social disruption and offending behaviour was prevented and quality of life greatly improved for many who came.
16) Because of the isolation that many felt and the lack of treatment facilities in the UK inevitably many ex-Servicemen came by word of mouth on introduction by ex-Service comrades with whom they remained close.
17) I noticed that each conflict tended to produce its own characteristic reactions. Knowing this was often a key to establishing rapport with men who had rarely spoken to anyone of their experiences. Appendix 4 lists the campaigns from which I have seen ex-Servicemen.
18) In addition I found myself dealing with trauma cases from the other emergency services: Police, Fire Service and Ambulance.
19) In 1988 I was invited to give a paper at a psychiatric symposium at the Royal Army Medical College on long term effects of trauma in ex-Service personnel.
20) In 1990 at the Annual Meeting of the Royal College of Psychiatrists I gave a paper on "Long-term Effects of Service Trauma in General Psychiatric Practice".
21) In 1997 I presented a paper at a joint meeting of the Welsh Psychiatric Society and the Societe de Neuropsychiatrie de l'Ouest describing the first 170 Gulf War Illness cases I had seen by then.
22) I presented a paper at the European Conference on Traumatic Stress in Berlin in May 2003. This described the series of 440 Gulf War Illness cases that I had seen up to that time. The number is now about 500.
23) The veterans of the first Gulf War certainly impressed me as different. They give a different impression of illness, a common malaise; sallow young men walking with sticks.
24) In 2004 I gave evidence to the Independent Enquiry into Gulf War Illnesses conducted by Lord Lloyd of Berwick. I attach a copy of this report as Appendix 7.
25) The mode of leaving the Forces was striking. Although these men and women were clearly unwell, very few were medically discharged. Many left by PVR or SNLR where the underlying ill health was a significant causal factor.
26) Although a surprisingly high proportion of the ex-Servicemen I have seen had had psychiatric contact in the Forces, very few engaged with any civilian psychiatric services. This despite the clear priority in the NHS directed by statute for War Pensioners [ Appendix 5.].
27) My involvement with psychiatry in North Wales began as a Junior Doctor at the North Wales Hospital, Denbigh in October 1958.
28) I then spent three years from 1959 to 1962 on a Epidemiological Research Project with Dr Gwilym Wynne Griffith, MoH of Anglesey, on mental disorder and mental health needs in Anglesey. This served as the basis for much of my subsequent work.
29) I then spent a year and a half at the Bethlem and Maudsley Hospitals for further training then returned as Consultant to the North Wales Hospital in Denbigh.
30) There were about sixteen hundred patients in the hospital at that time and I as Consultant had responsibility of the whole of the female side with about nine hundred patients.
31) Within three years that hospital population was reduced to about six hundred and a number of new special units were established with the resources released. Most of those units have survived the closure of the hospital and continue elsewhere as existing services.
32) These initiatives are reflected in my work with ex-Servicemen suffering Post Traumatic Stress Disorder.
33) Many ex-Servicemen suffering Post Traumatic Stress Disorder have alcohol or drug problems.
34) In the 1980's I had established an Alcohol Treatment Unit and later a Drugs Treatment Unit at the North Wales Hospital, Denbigh. At the same time, and with much community support, I established CAIS, now the biggest Drug and Alcohol Charity in Wales.
35) After the closure of Denbigh the drug and alcohol beds were relocated in 1997 to Hafan Wen, a new 25 bed purpose built unit on the Wrexham NHS District General Hospital site, where CAIS provides this service to Welsh patients under contract to the Welsh Assembly Government through the Local Health Boards .
36) Because of recent reduced commissioning in Wales CAIS has had to look to commissioners over the border and paradoxically a significant part of the work at Hafan Wen is now done with English patients.
37) With the recent reduction in commissioned Welsh beds there are now three Welsh patients waiting for each bed and CAIS is making urgent representations to the Assembly on the matter.
38) Many traumatised ex-Servicemen suffer personality and behavioural effects.
39) I established at Denbigh a Treatment Unit for disturbed young people with personality disorders which took many youngsters, particularly from the Courts and the Probation Service but this was lost with the closure of North Wales Hospital, Denbigh.
40) I drew on the therapeutic structure and the mode of treatment however in the therapeutic unit that I established for ex-Servicemen in Llandudno.
41) Shortly after the 1990 NHS Act I initiated an in-patient facility at Ty Gwyn in Llandudno, exclusively for traumatised ex-Servicemen. I agreed with the management the resources that I would require, and that it should accept only NHS funded patients through the ECR system (Extra Contractual Referral). I insisted that a bed should cost no more than a bed in my local psychiatric hospital at Denbigh where I had established a number of special units. Ty Gwyn worked solely on funding from the Health Service with some minimal charity contribution from the Army Benevolent Fund.
42) NHS funding became increasingly difficult and barely one in five applications were approved. It was a matter of great distress to those patients who were refused and great professional distress to myself that I was unable to treat them.
43) The table below shows the number of patients listed at each of my clinic venues at the time of the closure of Ty Gwyn in October 2005 and the number of patients then waiting for approval for treatment.
44) Traumatised ex-Servicemen do not generally settle in civilian treatment units. They can be very frightening and intimidating to other patients but they also feel ill at ease in an environment where they do not identify and where they feel that their experiences are not known or understood.
45) A considerable number were in fact ex-Servicemen who had been admitted to one of the Combat Stress establishments but had consumed alcohol or transgressed in an unacceptable way and had been excluded.
46) I felt that Ty Gwyn complemented the broader work of Combat Stress and I would have been very happy to collaborate all the more closely, as indeed would the management of Ty Gwyn.
47) Colonel Simon Brewis of the Army Benevolent Fund wrote when Ty Gwyn was closing: 'Combat Stress provides a service in providing respite treatment at its 3 centres and welfare care in the community, but it does not have the facilities to take on patients who suffer from chronic PTSD and who have associated disruptive, alcohol and drug problems. Ty Gwyn will take on all these categories.'
48) At the time of closure in October 2005 Ty Gwyn had treated over 600 cases. The majority of admissions to Ty Gwyn were from outside Wales but they enabled the unit to function well and to provide treatment for those in Wales.
49) Many local ex-servicemen who could not be funded and who could not be admitted made contact and looked to Ty Gwyn for continuing support which was always given. Likewise a substantial number of other ex-Servicemen who were rootless and homeless settled in the Llandudno area after treatment in Ty Gwyn and still remain there.
50) They looked to Ty Gwyn for continuing support and many still maintain contact with former Ty Gwyn staff and with myself. They have been able to lead much enhanced lives; reducing much of their social conflict.
51) At the present time there is no specialised treatment for traumatised ex-servicemen with severe challenging problems or with alcohol or drug problems anywhere in the U.K.
52) With the closure of Ty Gwyn the then Chief Executive of CAIS said that this was a service that CAIS would be willing to provide. They have staff trained in PTSD and most of this patient group have drug and alcohol problems for which CAIS is recognised as a leading UK provider of treatment.
53) I was delighted with this suggestion; I still chair CAIS; and I saw this as a way to achieve stability for the service and to draw in younger consultants to carry on the work.
54) CAIS identified premises and prepared clinical and business proposals and submitted these to the Assembly and to the local Health Boards but regrettably to no avail and was unable to proceed.
55) CAIS still holds an interest in this and if offered collaboration from the Welsh Assembly could reinstate the service and would look also to the Department of Health in England and corresponding body in Scotland.
56) Barely a third of the ex-Servicemen known to me are employed. This raises the possibility of European Convergence funding for treatment and rehabilitation and CAIS would pursue this.
57) CAIS has been designated by 12 of its colleague Drug and Alcohol Treatment Agencies in Wales to lead on the submission of a major bid being submitted in the next 14 days under the European Convergence and Competiveness programmes.
58) The Ty Gwyn unit before it closed was an example of a cross border service where a unique facility in Wales was drawing funded referrals from all parts of England and Scotland to their benefit, and to the benefit of patients in Wales for whom there would otherwise have been no service, as now occurs.
59) It is doubly ironic that that cross border service has gone and that the excellent drug and alcohol and detox facility provided by CAIS at Hafan Wen in Wrexham is now serving a significant number of cross border referrals from England to the detriment of service to Welsh patients.
60) To answer specifically the questions put to me "in the field of post traumatic stress disorder".
61) My answers relate to my special interest in traumatised ex-Servicemen.
Question 1 The extent to which cross-border health and social care services are currently funded for and accessed by the Welsh population.
Answer 1: Patients suffering from post traumatic stress disorder (PTSD) have very limited access to treatment facilities. Combat Stress provide respite care in their several units in England and Scotland but no specialist provision exists anywhere in the UK for patients suffering from severe PTSD with associated active drug and alcohol problems.
Question 2 The arrangements currently in place to co-ordinate cross-border service provision.
Answer 2: I have extensive experience in the treatment of PTSD particularly in ex-service personnel and many patients seek my assistance. I no longer have anywhere in the UK to refer these patients.
Question 3 Commissioning, funding and quality of cross-border services.
Answer 3: The Welsh Assembly Government and many Local Health Boards satisfy themselves with a modest arrangement with Combat Stress, but again no service exists for severely traumatised ex-service personnel with associated drug and alcohol problems, and no place for transfer from police custody or prison.
Question 4 The extent to which health and social care policy has diverged across the UK since the introduction of devolution and the impact that this has had.
Answer 4: It would appear to me that devolution has had little impact in the area of PTSD and commissioning in Wales follows the pre-devolution pattern.
Question 5 The extent to which mechanisms are in place for identifying and resolving cross-border deficiencies.
Answer 5: Welsh Assembly Government, Local Health Boards and statutory commissioners seem to have little understanding of this group of the most severely traumatised ex-service personnel. These people almost invariably have associated major drug and alcohol substance misuse problems. There is now nowhere in the UK where this severely traumatised group can access meaningful treatment.
62) In summary: the cross-border flow now remains of Welsh patients to the Combat Stress homes, but this does not provide for those with challenging or offending behaviour or alcohol and drug problems that was provided at Ty Gwyn.
63) I attach my C.V. as Appendix 6.
Dr D Alun Jones Consultant Psychiatrist.
18 March 2008
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Total ex-Service cases approx 2500 These included most spheres of WW2.
Campaigns and postings post WW2
• Aden 1960's • Afghanistan • Bangladesh flood relief • Beira blockade S Rhodesia • Belize • Borneo • Bosnia • Canada Training • Christmas Island • Colombia • DERA • Falklands • Gulf War 1 • GULF WAR 2 • Hong Kong • Iceland cod war • Ireland • Kenya • Korea • Lockerbie • Malaya1950's • Namibia • Oman • Sierra Leone
Appendix 5
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