2008-The war veteran`s medical assistance in the United Kingdom

- Eduardo C. Gerding  -

Boletín del Centro Naval Nº 822- Oct/Dic 2008
 

Foreword
 

In order to understand the medical assistance to the British War Veterans it´s of the utmost importance to get acquainted with the United Kingdom demography and the National Health Service (NHS). The population of the United Kingdom is about 60 million inhabitants and growing 400,000 per year which constitutes one the main issues in the political agenda. In 2006 the UK's total fertility rate (TFR) was 1.86 children per woman, below the replacement rate of 2.1.Today boys have a life expectancy of 77.2 years and women 81.5 years. The number of people granted citizenship during 2006 was 154,095, 5% fewer than in 2005. The largest groups of people granted British citizenship were from India, Pakistan, Somalia and the Philippines. 21.9% of babies born in the UK in 2005 were born to foreign-born mothers, according to official statistics released in 2007 that also show the highest birth rates in Britain for 26 years.In 2002 there was an estimated £27bn ($43bn) savings gap - the difference between what people need to save for a comfortable retirement, and the amount they were actually saving (BBC News, Pensions in Crisis- 10 December, 2002 ). The United Kingdom Total Health Expenditure in 2003 was U$S 2,317 . The war veteran´s health system must be understood in this context.

The British Military Hospitals
 

British troops wounded in Iraq and Afghanistan are probably not receiving proper care in British hospitals. According to Sue Freeth, welfare director for the Royal British Legion, which represents 450,000 service members and veterans, many soldiers are waiting 18 months or longer for critical mental health care services, which she called "a national disgrace¨.(Kevin Sullivan, Washington Post Foreign Service-Care for injured British troops is faulted, March 12, 2007). The United Kingdom started closing their military hospitals in 1990.

The Royal Hospital Haslar which dates back to 1753, is the last military hospital in the UK and will be closed in 2009. In 2009 the 200 military personnel remaining at Haslar will move to the new Ministry of Defence Hospital Unit (MDHU) at Queen Alexandra Hospital in Cosham, Portsmouth, which was opened in 2005. A military-managed ward at Birmingham's Selly Oak Hospital has been set up in the wake of criticism of the treatment of service personnel on civilian wards..(BBC News, Military Hospitals marks closure, 30 March 2007 ).

Selly Oak Hospital is one of two hospitals which form the University Hospital Birmingham NHS Foundation Trust, the other being the Queen Elizabeth Hospital in the Selly Oak area of Birmingham, England.The hospital in its current state is likely to close in 2010 upon completion of the "Birmingham Super Hospital".In March 2007 the Hospital was alleged of mistreating Iraq war veterans (BBC 11 March 2007) 

The National Health Service ( NHS )
 
The National Health Service (NHS) is the publicly funded health care system in the United Kingdom. Each of the four constituent countries of the UK (England, Scotland, Wales, Northern Ireland) have their own NHS. It works very much like the Argentine Instituto Nacional de Servicios Sociales para Jubilados y Pensionados (INSSJP). The NHS provides the
majority of healthcare in England, including primary care (such as general practitioners), in-patient care, long-term healthcare, ophthalmology and dentistry.Scottish Dr. Archibald Joseph Cronin, author of the novel, The Citadel, published in 1937 provided innovative ideas which were essential to the conception of the NHS and probably contributed too to the Labour Party´s victory in 1945. The NHS in England is controlled by the UK government through the Department of Health.As of March 2005, the NHS has 1.3 million workers, and is variously the third or fifth largest workforce in the world, after the Chinese Army, Indian Railways ,Wal-Mart and the United States Department of Defense. The BBC quotes an alternative workforce of 1.33 million people in 2004.The NHS is the largest employer in Europe. It employs approximately 1.3 million staff and provides an enormous range of services to over 57 million people.

Notwithstanding, the number of people working in the NHS fell by more than 17,000 between 2005 and 2006.( The Independent .Alarm at significant drop in number of NHS workers,27 April 2007 ). The NHS is to receive an increased budget from £90 billion this year to £110 billion by 2010-11, an increase of 4 percent (HealthInsider-10 Oct 2007 ). 70 percentof the NHS costs are wages.

Continued staff shortages mean that wages will have to rise well above inflation in order to recruit and retain staff.

Two-thirds of health spending goes on people over 60 with an increasingly heavy demand. Medical equipment is getting more high-tech and the public demanding all the expensive new drugs. ( Adam Smith Institute- Three quarters of NHS cash 'is needed just to stay still' says think-tank )

The structure of the NHS

The National Service Frameworks (NSFs)

The NSFs are long term strategies for improving specific areas of care. The NSF for coronary heart disease was launched in March 2000 and sets 12 standards for improved prevention, diagnosis and treatment, and goals to secure fair access to high quality services. The standards are to be implemented over a 10-year period. Each NSF is developed with the assistance of an external reference group (ERG) which brings together health professionals, service users and carers, health service managers, partner agencies, and other advocates.

Strategic Health Authorities (SHAs)
 
The SHAs are part of the NHS in England and are responsible for enacting the directives and implementing fiscal policy dictated by the Department of Health at a regional level. Each SHA contains various NHS trusts which take the responsibility for running local NHS services. On April 12, 2006, Patricia Hewitt, Secretary of State for Health announced that SHAs were to be reorganized reducing to ten in number.

The National Institute for Health and Clinical Excellence (NICE) NICE is a apecial health authority of the NHS which publishes clinical appraisals of wether particular treatments should be considered worthwhile by the NHS based on cost-effectiveness.

Kindly submitted by Commodore (Ret)Toby Elliott

Trusts
 
Primary Care Trusts
 
The PCTs administer primary care and public health. In 1 October 2006 the number of PCTs were reduced from 303 to 152. These oversee 29,000 GPs and 18,000 NHS dentists. PCTs control 80 per cent of the total NHS budget.

NHS Ambulance Services Trusts
 
290 organisations administer hospitals, treatment centres and specialist care in about 1,600 NHS hospitals.

NHS Care Trusts
 
The NHS Care Trusts are organizations that work in both health and social care. They carry out a range of services such as social care, mental health services and primary care. There are a small number of Care Trusts in England and none in Scotland.

NHS Mental Health Services Trusts
 
The NHS Mental Health Service Trusts provide mental health service within the NHS buy they are not related to the Stress Centers. Oxfordshire & Buckinghamshire Mental Health Partnership NHS Trust provides specialist mental health services to people in Oxfordshire, Buckinghamshire and the surrounding counties and highly specialist services to patients from across the UK.

NHS Foundation Trusts
 
The NHS Foundation Trust is an important part of the UK Government's programme to create a "patient-led" NHS. Whilst their stated purpose is to devolve decision-making from a centralised NHS to local communities in an effort to be more responsive to their needs and wishes, others however see the change towards semi-independent hospital boards as a move towards privatisation of the health service. There are currently 70 Foundation Trusts and it is the government's intention that all trusts will move to Foundation Trust status by 2008. UNISON ( Trade Union for
people delivering public services ) believes Foundation Trust status undermine the principles of the national health service.

Monitor (Independent Regulator of NHS Foundation Trusts)
 
Monitor regulates NHS foundation trusts, making sure they are wellmanaged and financially strong so that they can deliver excellent healthcare for patients. They are autonomous organizations, free from central Government control. They decide how to improve their services and can retain any surpluses they generate or borrow money to support these investments.

Criticism to the NHS
 
1. Access controls
 
The patients that fall outside the rules must seek and pay for private treatment of go without.
 
2. Politicisation
 
As BMJ editor Fiona Godlee has said (Editor's choice, 1 April 2006), the NHS needs a system that replaces political dogma with clinically driven decisions, confrontation with consensus, unaccountability with democracy, and short term decision making with long term stability. The NHS is too complex and too vital to our future prosperity to be governed by the self interest of any specific party. The continuing use of the NHS as a theatre for experimentation in management is wasteful. ( BMJ 2006;332:1518 - 24 June )

3. Paying Twice
 

Sometimes patients opt for private health care usually to get treated more quickly. Thus they are opting to pay twice for their health care, once for the NHS through taxes, which they don´t use and again for the private care.

4.Waiting lists
 

According to the Daily Telegraph, The Health Department admitted that around 500,000 people in England are experiencing waiting times of a year or more. The worst performing primary care trusts are concentrated in London, on the south coast and in the east of England. The Government´s target is that no one should wait longer than 18 weeks from referral to treatment by the end of 2008. (Daily Mail-500,000 wait over a year for NHS treatment-7th June 2007 )
 

5. Superbugs
 

The high levels of antibiotic-resistant bacteria (¨superbugs¨) such as Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile in hospitals are probably the result of poor hygiene standards in many NHS hospitals. Deaths linked with these two common hospitalacquired infections have risen by 59 per cent in a year. The superbugs MRSA and Clostridium difficile claimed more than 5,400 live is in 2005, up 2,000 on the previous year, according to figures published by the Office for National Statistics (ONS) yesterday. The sharpest rise was in C. difficile, with a 69 per cent increase in cases where the infection was mentioned on
death certificates. Deaths involving MRSA rose 39 per cent. . (The Independent- Targets blamed as hospital infection deaths rise 59%- February 23, 2007)

5. Computerization

A large organization such as the NHS should easily afford the overhead costs of developing and maintaining computarization systems.


6. Dentistry

There has been a decreasing availability of NHS dentistry in some areas and a trend towards dentists accepting private patients only. .(BNN Online-March 1,2006)
 
7. Coverage
 
The lack of availability of some treatments due to their perceived poor-cost effectiveness sometimes lead to what has been termed a ¨postcode lottery¨
 
8. Deficits
 
Some hospitals and trusts are running a financial deficit and getting into debt. A complete inform on charges at the NHS may be found at BNN Online-NHS charges a complete mess -18 July 2006 .

9. Scandals
 
a) The Alder Hey organs scandal
In December 1999 an Inquiry Panel was appointed to investigate the removal, retention and disposal of human organs and tissues following post mortem examination at The Royal Liverpool Children's Hospital NHS Trust.
b) The Bristol Heart scandal
An inquiry was made about the management of the care of 29
children receiving complex cardiac surgical services who died at the Bristol Royal Infirmary between 1984 and 1995.

The General Practioner (GP)
 
A general practitioner (GP), family physician or family practitioner (FP) is a medical doctor who provides primary care. A GP/FP treats acute and chronic illnesses, provides preventive care and health education for all ages and both sexes The word physician is largely reserved for certain other types of medical specialists, notably in internal medicine. Traditionally, GPs may care for hospitalized patients; where they have hospital privileges, they may perform minor surgery and/or obstetrics. In the United Kingdom, doctors wishing to become GPs take at least 4 years training after medical school, which is usually an undergraduate course of five to six years (or a graduate course of four to six years) leading to the degrees of Bachelor of Medicine and Bachelor of Surgery (MB ChB/BS).

According to the OECD ( Organization for Economic Co-operation and Development ) Health Data 2007 the number of doctors in OECD countries has increased by 35 per cent over the past fifteen years to 2.8 million. In most countries, this growth was driven largely by rising number of specialists up nearly 50 per cent between 1990 and 2005 compared with the 20 per cent increase in GPs.

According to the Irish Health System Primary care should be the first point of contact that people have with the health and personal social services. The role of the primary care services as the provider of the majority of all care requirements and the gatekeeper of specialist services will be strengthened. This will involve a team-based approach to service provision, which will help to build capacity in primary care. (Department of Health and Children-An roinn Slainte Agus Leanal- Primary Care Model: A description)

London's Chelsea and Westminster Hospital has just become the first NHS establishment in the country to treat patients online. Some UK websites fail to abide by the stringent rules set out by the General Medical Council and the Medicines and Healthcare Products Regulatory Agency. And even though all private online healthcare providers in the UK are required be law to be registered with the Healthcare Commission, most are not (The Independent-Sick? Click: NHS to launch the virtual GP-02 October 2007 ) 

Dentists
 
An Executive report on the future of dental practices found that Scotland is short of more than 100 dentists this year and will fail to reach the target for another six years. (BNN, Targets for dentistry will not be met- Friday, 30 June 2006). In 2006, about 2,000 NHS dentists across England refused to sign a new contract introduced by the Government. Under such contract, dentists would no longer be paid for each NHS treatment they carry out but instead they will get a guaranteed income, estimated to be about £ 80,000 a year for three years.

The lowest charge will be £15 for an examination and report, an increase of nearly £10, but the highest charge will be £189, almost £200 less than the current top charge. The middle charge of £40 will cover one to six fillings, previously priced at £10 to £12 each.(BNN Dentists ditch NHS-8 April 2006)

The RN
 
Nursing in the United Kingdom has a long history, but in its current form probably dates back to the era of Florence Nightingale. The Nursing & Midwifery Council (NMC) is the UK regulator for two professions, Nursing and Midwifery. The number of nurses and midwives on the register as of 31st March 2006 exceeded 682,000, making the NMC the largest healthcare regulator in the UK. Nearly 400,000 nurses in the United Kingdom work for the National Health Service (NHS), which is the vast majority of nurses registered with the Nursing and Midwifery Council (NMC). The Royal College of Nursing (RCN) is a membership organisation with over 395,000 members in the United Kingdom. It was founded in 1916, receiving its Royal Charter in 1928, Queen Elizabeth II is the patron.
 
Most members are registered nurses but student nurses and healthcare assistants are also admitted.The RCN describes its mission as representing nurses and nursing, promoting excellence in practice and shaping health policies. To practice lawfully as a registered nurse in the United Kingdom, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council. The title "registered nurse" can only be granted to those holding such registration, this protected title is laid down in the Nurses, Midwives and Health Visitors Act, 1997. First level nurses make up the bulk of the registered nurses in the UK. 

They were previously known by titles such as RGN (registered general nurse), RSCN (registered sick children's nurse), RMN (registered mental nurse) and SRN (state registered nurse) etc. The majority of first level nurses are employed as staff nurses with the minority in management and specialised roles.

Specialist Nurses
 

1. Nurse Practitioners: They perform roles similar to GP and commonly Work in primary care or A&E Departments.
2. Specialist Community Public Health Nurses: Traditionally District Nurses and Health Visitors. Now includes many School Nurses and Occupational Health Nurses.
3. Clinical Nurse Specialists: Provide clinical leadership and education for the staff nurses.
4. Nurse consultants: They are similar to the Clinical Nurse specialist but at a higher level.
5. Lecturer-Practitioners: These nurses work both in the NHS and the Universities. A Lecturer-Practitioner in Clinical care may teach on a Masters degree in critical care nursing.
6. Lecturers: These nurses are not employed by the NHS. They work Full time in universities.
7.  Managers: They have left clinical nursing and joined the ranks of the NHS management. With the advent of specialist nursing roles this has become a less atractive option. Other choose to stay closer to their clinical roots becoming Clinical Nurse Managers or modern matrons.

Mental health nursing (RMN) :
 
RMN is the specialty of nursing that cares for people of all ages with mental illness or mental distress, such as psychosis, depression or dementia. Nurses in this area receive additional training in psychological therapies, building a therapeutic alliance, dealing with challenging behavior, and the administration of psychiatric medication. In the UK, RMN undergo a 3-4 year training programme at either diploma or degree level, in common with other nurses. However, most of their training is specific to caring for clients with mental health issues.

In the Health Sector Reform Programme of Trinidad & Tobago the mental health nurse will manage a caseload of patients with chronic and continuing mental health problems, preventing avoidable breakdown or unnecessary admissions to secondary services for either the chronically ill or those suffering from episodes of acute illness. This will include preventive programmes/group work, e.g. with depressed mothers.
 
RN Nurses and economic problems
 
Nurses, policemen, teachers, ambulance workers and firemen can no longer afford to buy an average priced house in 65% of towns, compared with just 24% five years ago. (BNN Online-Key workers are priced out of homes-29 July 2006 ).Justine Whitaker (37) , is leaving her job as a specialist clinical nurse in the treatment of lymphoedema. She is quitting her hospital just eight months after being made Nurse of the Year, because of the strain that constant health reform is placing on frontline staff. (The Independent 17 October 2007). According to the Royal College of Nursing (RCN)22,000 jobs have been lost in 2007. (The Independent, April 15, 2007 )

Prescriptions
 
Oncologic prescriptions have posed a heavy load on the NHS. Such has been the case of the trastuzumab (Herceptin™). NICE recommends Herceptin™ for women with early stage HER2-positive breast cancer, except where there are concerns about the woman's cardiac function.Rheumatoid arthritis affects 400,000 people in the UK (BBC News21 August 2007).As a result of this the National Institute for Health and Clinical Excellence (NICE) has approved the so-called "smart drug" MabThera™ for prescription in England and Wales. The drug works by specifically targeting one of the key immune system cells involved in rheumatoid arthritis. It comes after a similar drug, abatacept ( Orencia™ ), was ruled out for prescription. Orencia™ which costs ₤ 9.333/year/patient could potentially benefit 12,000 people in the UK alone. (BBC News, 2 August 2007). 

NHS costs and exemptions
 
Entitlement to help with health costs (NHS prescription and dental charges, optical and hospital travel costs) is based on the principle that those who can afford to contribute should do so, while those who are likely to have difficulty in paying should be protected. New charges for NHS prescriptions, surgical supplies and dental and optical services were announced in a Written Ministerial Statement by Rosie Winterton, Minister
of State for Health Services, on 2 March 2007. There will be help with NHS prescription and dental charges, optical fees and hospital travel costs, for people on benefits, tax credits or low incomes.

People who have to pay prescription charges can buy a prepaymentcertificate, which offers considerable savings to those who need regular prescriptions.

(Department of Health http://www.dh.gov.uk/en/Policyandguidance/Medicinespharmacyandindustry/Prescriptions/NHScosts/index.htm )
 
The Stress Centers
 
The importance of mental disorders
 
An international alliance of specialists in mental health is launching a campaign today to shift the focus of the world's attention from disorders of the body to disorders of the mind.  Some 30 per cent of the world's population suffer some form of mental disorder each year, yet at least twothirds receive inadequate or no treatment, even in countries with the best resources, such as the UK. (The Independent , 4 November 2007 ). 

A report led by a group of leading academics warned that only a quarter of the people suffering from depression or chronic anxiety are receiving any treatment at all. A course of cognitive behavioural therapy, which enables people to tackle their depression and think more positively, costs £ 750 and would pay for itself in money saved on incapacity benefits and lost tax receipts, according to the London School of Economics team. In the UK one in six people suffers from depression or chronic anxiety, and that this affects one in three of all families. In most parts of Britain, you will have to wait at least nine months for a course of CBT, despite the fact that it has proved to be just as effective as medication. (BNN -Therapy on NHS 'must be increased'- 18 June 2006). 

A study, carried out by researchers (1988 to 2000) from Oxford University's department of psychiatry and Sweden's Karolinska Institute, claim that people with severe mental illness are responsible for one in 20 violent crimes. They found there were 45 violent crimes committed per 1,000 inhabitants. Of these, 2.4 were attributable to patients with severe mental illness. This means that 5.2% of all violent crimes over the period
were committed by people with severe mental illness. When the figures were broken down, it was also found that 15.7% of arsons were committed by people with such illnesses, as were 7.5% of threats and harassment. (BNN- One in 20 violent crimes committed by mentally ill- 29 July 2006 )

The impact on the military
 
A group of 64 Falklands veterans who were still serving in the British Army were studied and compared with a group of matched controls. Half  the veterans reported some symptoms of PTSD and 22% were rated as
having the complete PTSD syndrome. Presence of the symptoms was associated with intensity of combat experience and the retrospective report of emotional difficulties in the intial period on return from the war (British Journal of Psychiatry (1991), 159, 135-141)

Military veterans who say they were not adequately treated for posttraumatic stress disorder (PTSD) have filed suit against the British Ministry of Defense. The case involves more than 250 former combatants who were involved in the Falklands war, policing Northern Ireland, the civil war in Bosnia, the Gulf War and other conflicts. Another 1600 veterans were considering similar actions. According to the South Atlantic Medal Association which represents these soldiers, 256 British soldiers were killed during that conflict and since then 264 veterans have committed suicide. (CMAJ-Suicide claiming more British Falkland veterans than fighting did-May 28, 2002).

According to Roger Gabriel and Leigh A. Neal of the Gulf War Medical Assessment Programme at St Thomas Hospital ( London ), PTSD diagnosis is not difficult and its initial recognition is within the ability of all GP who later may confirm this with consultant psychiatrists.(BMJ –Vol 324 -9 February 2002).

 

The Abandoned Soldier Statue

The statue was named The Abandoned Soldier and this original art work can be seen at the care home of Combat Stress which is a charity that supports soldiers who are physically and mentally scared by the effects of war. The sculptor of The Abandoned Soldier statue was artist James Napier. He also produced a bronze statue of The Abandoned Soldier which he hopes to erect permanently somewhere in London The sculptor of the Abandoned Soldier was modelled on Daniel Twiddy who was wounded in Basra by friendly fire in 2003 and sustained many injuries including facial wounds from shrapnel.

Kindly submitted by Commodore (Ret) Toby Elliott

Combat Stress 

(Ex Services Welfare Society)
 

Founded in 1919, Combat Stress is the only UK charity to provide specialist help for the ex-Service men and women who have been profoundly traumatized whilst on active duty. This ranges from clinical depression, raised anxiety states, phobic disorders, obsessional compulsive disorders through to PTSD. It is a nationwide welfare operation delivered through a network of 13 Regional Welfare Officers across UK and Ireland.

It has a considerable expertise in specialist field based on 86 years of service. Over 85,000 veterans and their families have been helped and 8,0000 veterans are registered with the Society.

The Regional Welfare Officers and Welfare Support Teams

Short-stay treatment (6 weeks per year) is provided at three specialists centres: Hollybush House, Ayr (Scotland and Ireland) 25 beds , Audley Court, Newport, Shropshire (England and Wales North) 27 beds , and Tyrwitt House , Leatherhead, Surrey (England and Wales South ) 30 beds.

Kindly submitted by Commodore (Ret) Toby Elliott

The Management Team
 
There is a President, a Management Committee and a Chief Executive. This last is Commodore Toby Elliott OBE RN who took part in the International Colloquium in November 2006 at the University of Nottingham. From the Chief Executive depend: Director of Clinical Services (a retired military psychiatrist ) , Director of Finance and Administration (a civilian accountant ) , a Director of Welfare Services and a Director of Fundraising and Appeals. The Director of Clinical Services manages the Clinical Managers of Hollybush House, Tyrwitt House and Audley Court. There are 15 RN and two Health Assistants.
 
Patients´ admissions
 
The data obtained from 996 new referrals made to Combat Stress during the course of 2007 showed an average age of 44 years, on average these men and women have 11 years service, and on average it has been 13 years since they were discharged.35 per cent of those who apply are not admitted because their alcohol or drug addiction is too severe to be able to help  them.  According to 2006 data the patients belonged to the Army (80%), RAF ( 8,7% ), Royal Navy ( 8 % ), Royal Marines ( 2,7% ) and Merchant Navy (0,6%).
 
Reference Sources
 
The Stress Centers ´ referral sources are: NHS & Department of Health (10%), Services Charities, Welfare etc ( 36%), Self, friends and family (46%), other (7%).
 
The Whole Person Care Plan
 
The Whole Person Care Plan include: Cognitive Behaviour Therapy (CBT) Eye Movement Desensitization and Reprocessing ( EMDR ), Counselling, Post Traumatic Stress Education, Anxiety Management, Anger Management, Creative Therapies, Relaxation, Solution Focussed Therapy, Sleep Hygiene, Occupation Therapy and Social Skills.

Stress Centers´ financial support
 
The Ministry of Defense, The Robertson Truce, Seafarers UK, The Scottish Executive, The Officers´Association Scotland, The Corporation of Trinity House, The royal Army Chaplains Department, The Boughton Trust, Payroll Givers, Queen Mary´s Roehampton Trust, 51st Highland Division and Ross Bequest Trust, The Far East Prisoner-of-War Association, The Wates Foundation y J. P. Getty Jr. Charitable Association. A day in a Stress Center costs ₤ 264. 27 per cent of such treatments could be given as a result of contributions. On March 31, 2007 the Stress Center received ₤ 2.732.000.

Authorities who provided funds for bedrooms, games and furnishing at Audley Court.
Kindly submitted by Commodore (Ret) Toby Elliott

Residential Treatment Centre at Tyrwhitt House, Leatherhead , Surrey
It provides a safe therapeutic environment in which Veterans, treated
alongside their peers, find that they are able to engage with the clinical
and welfare teams who are able to make a full assessment of what is
required to met their needs, and then to find the appropriate solutions.
Photograph: Dr EC Gerding

From right to left: Chief Executive Toby Elliott OBE RN, Claire Evans
Head of Clinical Services and Dr. Eduardo C. Gerding at Audley Court.
Photograph:Dr EC Gerding

The personal file
 
Each war veteran has his own file which contains a) Medical record according to the information provided by his GP and the psychiatrist ,b) A detailed report of real war veteran´s role while in combat described by an officer in charge and c) The final report made by the Welfare Service officer. Files marked with a blue dot represent new admissions.

A neat bedrom at Audly Court. War veterans are generally reluctant to
share their room with someone else. Photograph: Dr EC Gerding

Leisure activities at Audley Court - War veterans have holistic therapies such as
reflexology, relaxation and Tai Chi, Cooking session, Computer Programming, Indoor
bowling, exercise bike, cross trainer, multi gym/weights, table tennis, darts etc. On the
right corner Mr. Jim Banks Head Nurse. Photograph: Dr EC Gerding

This picture was made by a Malvinas war veteran assisted in Audley Court who received a shot which shattered his jaw. The image depicts the intense pain suffered which couldn´t be expressed in words. This constitutes part of the Occupational Therapy. According to the American Occupational Therapy Association (AOTA), in addition to dealing with an individual's physical well-being, OT practitioners address psychological, social, and environmental factors that may hinder an individual's functioning in different ways. War veterans may express themselves all their inner feelings too through poetry (Arthur Lerner Ph.D (Ed)-Poetry in the Therapeutic Experience,2nd edition ) Photograph Dr EC Gerding

An special bathtub for disabled patients-Photograph: Dr EC Gerding

 
War Pensions
 
War pensions are paid only to disabled war veterans, widows/widowers and orphans. War Disablement Pension can be claimed under the War Pensions Scheme if the war veteran is no longer Serving in HM Armed Forces and the disablement claim arose before 6 April 2005. The Armed Forces Compensation Scheme is the compensation package for members of the Armed Forces. It is designed to provide compensation, irrespective of fault, across the full range of circumstances in which illness, injury or death may arise as a result of service. The legislation replaced the previous arrangements under the War Pensions Scheme.


War Pensions Scheme
 
Unlike the AFCS scheme, there is no prescribed set of conditions and tariffs . Instead, a medical adviser at the Agency will look at the evidence on the claim and make an individual assessment of the level of disablement. This could be from nil to 100%. If the assessment is less than 20% (i.e. in the three bands 1-5, 6-14 or 15-19%) a lump sum will be paid.
If the assessment is 20% or more, a regular pension will be paid according to the level of assessment (assessments increase in 10% increments – 20, 30, 40% etc). Therefore, someone loosing a foot could be in any assessment band depending on the level of disablement suffered by the individual – but it is likely to be one of the higher assessments. Each case is unique under the WPS though.

Armed Forces Compensation Scheme (AFCS)
 
The Scheme covers all Regular (including Gurkhas) and Reserve personnel whose injury, ill health or death is caused by service on or after 6 April 2005. The Armed Forces Compensation Scheme provides modern, fair and simple arrangements with more generous benefits for the more severely disabled. It provides compensation for significant injuries, illness and death that are caused by service including when they result from warlike incidents or terrorism. It is a 'no fault' scheme which means that individuals still have the option to sue the MoD for negligence although compensation provided by the AFCS would be considered if a court directed that damages were to be paid. Under the terms of the scheme a lump sum is payable to Service or ex-Service personnel based on a 15-level tariff which is graduated according to the seriousness of the condition. A Guaranteed Income Payment (GIP), payable for life, will also be paid to those who could be expected to experience a significant loss of earning capacity. A GIP will also be paid to surviving partners (including unmarried and same sex partners) where the service person's death was caused by service and in the case of unmarried partners a substantial relationship can be demonstrated.



How the tariffs work at the AFCS
 
The tariff levels are graded 1-15 dependant on the degree of severity. Level 1 gives the highest payment covering the most severe conditions. Level 15 covers less severe injuries such as minor burns or a dislocated knee. For those on levels 1 to 11 of the tariff, a GIP will be awarded. The GIP is calculated by multiplying the pensionable pay of the Service person by a factor which depends on age at last birthday - the younger the person the higher the factor because there will be longer to normal retirement age. 

The final amount of GIP payable is a percentage dependent on the tariff level of the condition for which an award is made. Awards made in tariff levels 12 to 15 do not attract a GIP. The percentages are in four bands as follows:
 
Band A    Tariff levels 1 to 4    100%
Band B    Tariff levels 5 to 6      75%
Band C    Tariff levels 7 to 8      50%
Band D    Tariff levels 9 to 11    30%
 
Example :
 
A man aged 23 is invalided out of the Armed Forces having lost a foot as a result of service. He was receiving a salary of £20,000. The appropriate factor is applied for a person his age. The factor is 0.878. The full annual GIP is calculated as: Salary x GIP factor, ie £20,000 x 0.878 = £17,560. As the injury is in tariff level 8 the person will receive 50% of the full GIP, so he will be entitled to £8,780 per year. This is tax free.


The Gurkhas case
 
Lance Corporal Gyanendra Rai (a Gurkha seriously wounded by Argentine artillery at Bluff Cove, in the Malvinas Islands in 1982). British Visa Officers say that Rai (and other brave Gurkhas) don´t have "strong ties" to the United Kingdom. Rai was finally discharged from the Army with only a payment of (GBP) £2,000 from the South Atlantic Fund and no pension.

He had only served for 13 years – not the full 15 years which gives him pension rights. Gurkhas who retired before 1997 have no automatic right to live in the UK. Tul Bahadur Pun, 84, who has a Victoria Cross and was recently allowed a visa, called for justice for his comrades. ( BBC , 1 August 2007)- www.cchero.co.uk (Kindly submitted by Mike Seear)

Gyandendra Rai
had part of his back blown out

 Acknowledgments  

• Jim Banks – Head Nurse (Combat Stress- Audley Court)
• Sally Blake-( Library and Information Manager-Royal College of Psychiatrists, London.)
• Malcolm Bellwood- (Combat Stress -Director Service Quality ) 
• Toby Elliott Commodore OBE RN (Combat Stress- Executive Director ) 
• Claire Evans Head of Clinical Services (Combat Stress-Audley Court) 
• David Johnson (Veterans Media and Communication Manager, Service Personnel & Veterans Agency) 
• Jim Plato ( Medical Assessment Programme-MoD) 
• Mike Seear (Operations and Training Officer, 1st Bn, 7th Gurkha Rifles in the war. Author of With the Gurkhas in the Falklands. A War Journal. )
• Alan Warsap Brigadier- Former Regimental Medical Officer, 2nd Bn, Scots
  Guards- Director Army General Practice.)