Memorandum submitted by Combat Stress (Ex-Services Mental Welfare Society) (1 August 2001)
Thank you for your letter dated 23 July inviting me to set out the Society's views on the MoD's proposal for changes to the way in which compensation for disability and death in Service is to be assessed and awarded.
The Society has specialised in the support and remedial treatment of ex-Servicemen and women of the Armed Forces and the Merchant Navy who have suffered psychological injury since 1919. The Society currently has some 5,900 clients on its books, their ages ranging from 86 to 21, and their collective experience covering virtually every campaign since the Second World War until today.
Some 75,000 ex-Service personnel have been helped by the Society during its 82 years of operation. We therefore have considerable expertise and a detailed understanding of the needs of disabled ex-Servicemen with psychological injury and the way in which the present compensation scheme works. We have major reservations about the proposals which the Ministry of Defence has put out in its consultation document on the Joint Compensation Scheme. The Society welcomes the opportunity to put its view to the House of Commons Defence Committee in the form of a Memorandum which I enclose with this letter.
THE JOINT COMPENSATION REVIEW
The Trustees of the Ex-Services Mental Welfare Society welcome the opportunity to comment on the Joint Compensation Review. This response, made by the specialist ex-Service Charity dealing with the problem of veterans suffering from psychological injury attributable to or aggravated by service will concentrate on those areas of the consultation document where there are implications for the welfare of the group it seeks to help. Some of the comments have a wider connotation.
PSYCHOLOGICAL INJURYTHE CONTEXT
As the Gulf Veterans Medical Assessment Programme's report on the "2nd 1000" serves to demonstrate only too well, psychological injury predominates amongst the casualties of modern warfare. Most of the veterans of this campaign examined by the Society found to be suffering from this category of disability have a long-term (chronic) illness, and most were extremely young servicemen at the time of trauma. Whatever else this reports tells us, it reminds that the nature of the United Kingdom's modern military operations are such that psychiatric injury is likely to feature highly on future casualty lists. It is with this forecast in mind that the Society comments on aspects of the Compensation Scheme, as applied to the psychiatric casualty, the Society's specialist field.
Fundamental to the Government's determination to maintain morale and improve recruitment and retention in the Armed Forces must be an acknowledgement that servicemen and women are contracted to work as a matter of routine in physically demanding, often high-risk and sometimes life-threatening situations under a code of discipline which requires an obedience to orders which has no equal elsewhere in the public sector. Indeed it was the nature of this special relationship between Government and its Armed Forces that lead to the introduction of the War Pensions Scheme, the first building block of the Welfare State, so many decades ago. It is the view of the Society that nothing has changed in the nature of modern Service to alter that special relationship, and this should be recognised in the provisions made by Government for those who will sustain illness, injury or death in the course of their service. In equating Service personnel with civilians and those injured in criminal activities the scheme fails to recognise this special relationship, and it is perhaps this which has lead those involved in the review to concentrate on bringing the serviceman into line with his civilian counterpart rather than recognising that a special relationship could also justify a scheme which is different.
LUMP SUM OR INCOME STREAM?
The Society agrees that it is appropriate for a tariff-based lump sum payment to be made to provide up-front cash to enable those most severely disabled to adapt to disabled living.
However, in all other respects the Society is totally opposed to lump sum compensation for lost earnings. From bitter experience in dealing with cases where large lump payments have been granted, from the South Atlantic Fund for example, the ex-Service charities know only too well that lump sums are quickly and almost invariably wasted away, leaving the State and Charity to pick up the pieces. Those with mental disorders are particularly vulnerable to the mismanagement of their financial affairs; many of the Society's veterans require help in this areathe WPA is also involved in some cases as well. The lump sum is therefore considered an inappropriate form of compensation for loss of earnings, and the solution lies, as now, in regular income.
Therefore, it is recommended that consideration should be given to altering the scheme to pay compensation in the form of a Guaranteed Income Stream (GIS) with a grant to allow the severely disabled to adapt to disabled living, but with one-off Lump Sum compensation for the minor injuries/disabilities at the bottom end of the tariff.
THE TARIFF AND ITS RELATIONSHIP TO LOSS OF EARNINGS
The tariff-based approach may be well suited to deal with claims for physical disability, as is stated. However, it is the Society's view that the medical profession's understanding of the effects of trauma on the mental state of Servicemen and women currently lacks the precision which would suit the tariff based approach to compensation for psychological injury. This will be uncomfortable for the MoD, but in moving away from the War Pensions Scheme, it is important that the scheme recognises that, in the case of claims for psychological injury, there are clinical limitations that must be taken into account.
At the time of medical discharge the individual will frequently be fighting the diagnosis, there will often be a difference of opinion between clinicians over diagnosis, and, perhaps of the greatest significance, the prognosis can be extremely difficult to forecast correctly. Therefore, when it comes to gauging the severity of injury and to estimating the effect of that disability upon future employment potential, matters will not be so clearly definable; indeed, the clinician, if honest, will admit to the limitation. From the Society's experience in dealing with this problem, it is considered most important that the scheme recognises these limitations, and has the flexibility to correct when evidence suggests that diagnosis and prognosis needs to be revised, otherwise there is a danger that the claimant will lose out.
The level of disability at which those with psychological injury will find it difficult to either find work or to hold down a job can cut in at a far lower level than for physical disability. It is difficult to read across from the current scheme that defines degree of disability in percentage terms and the various levels in the Tariff. It is also not clear from the Exemplary Injury Tariff tables how the GIS relates to the Lump Sum in terms of rate. What do the actuarial calculations demonstrate? For instance, will an ex-Serviceman invalided with a 30 per cent psychological injury aged 20 who lives to 80 (quite likely) receive more under the current scheme or under the new scheme? This is an important question to be answered before the Society could give the new scheme its support.
TARGETING OF RESOURCES
The Society considers it to be unjust to fund the higher awards for the more severely disabled at the expense of the less disabled. For the scheme to be seen to be fair and equitable, the Tariff should ensue that those deserving of compensation should receive an award appropriate to the degree of disability, regardless of severity.
The Society notes with concern that average deterioration/improvement will be anticipated in the tariff levels, and agues that in the case of psychological injury there is often an inadequate understanding of the many factors involved for an accurate prognosis to take place at the time of an award being made. The Society believes that funding should be put towards deterioration where deterioration occurs, rather than on a notional averaging basis. It is appreciated that this proposal goes against the principle of once and for all handling of claims; however "once and for all handling of claims" is not realistic in all cases, and this should be recognised.
ARTICLE 26 PROVISIONS
The Scheme makes no mention of the discretionary powers awarded to the Secretary of State under Article 26 of the Service Pensions Order to provide funding for rehabilitative or remedial treatment and convalescence for War Pensioners. Such funding is a feature of the current scheme that is particularly important for the work of the Society.
Discretionary funding is only granted in cases where the Welfare State is unable to providefor instance an individual receiving psychiatric treatment funded by the NHS will not be funded by the War Pensions Agency to attend one of the Society's treatment centres for remedial treatment at the same time. The Society accepts that this should be the case, indeed, it also accepts that when the day comes that the NHS and Social Services are able to provide for the psychologically injured veteran then its purpose will no longer be necessary.
In the meantime, it will create a considerable difficulty for the Society if disabled veterans being discharged under the new scheme seeking help lacked this discretionary funding. The Society's financial position is such that it could not afford to provide treatment to this category of ex-servicemen or women, and this would lead to invidious comparison between old and new schemes. As such the absence of an Article 26 provision is viewed as a worsening in the new scheme. It is therefore recommended that this aspect of the scheme be reconsidered.
If there is room within the scheme, there is another aspect of providing care for the disabled that is not included in the Article 26 discretionary provision and that is respite treatment. This is something for which the Society identifies a desperate need. Many of the veterans seen by the Society create a hugely demanding burden for those who care for them. Many of the Society's veterans live in the community in isolation and often very poor circumstances; their carers suffer terribly. The Society provides an element of respite in each admission for remedial treatment, but there are cases that are currently turned away for lack of funding where the prime need is that of respite in a proper clinical environment (rather than in a holiday atmosphere).
The benefit of the individual in terms of preventing relapse and deterioration, particularly for the older veteran and those with brain damage, can be significant. The cost to the Society of providing respite in these circumstances is the same as for remedial treatment. It is recommended that consideration be given to including respite treatment in the discretionary package that the Society believes should be written into the scheme.
TIME LIMIT ON ELIGIBILITY
The Society notes that "some" psychiatric illnesses will be included in the list of exceptions to the proposed three-year qualifying time limit. It would be helpful to know what psychiatric illnesses are to be included in this list.
TIME LIMIT ON CLAIMS
The scheme argues for a time limit on claims, after the condition has been diagnosed, beyond which a claim will not be accepted. This should not cause a problem for the serviceman whose condition has been identified and diagnosed in service, and where the administrative procedures will be in place to ensure that the claim is processed. However, the Society has a real concern for the veteran with the late onset of a service caused disability who may well not realise his eligibility to make a claim, neither will the clinician necessarily be aware of the provision for a claim to be made. It is the Society's experience that stigma also has a large part to play in cases where servicemen have delayed presentation for many years after the onset of their psychiatric problem. In such cases many years may pass before the case is brought to light, perhaps through the work of an ex-Service organisation.
Time late is therefore a common feature in cases dealt with by the Society under the present scheme. An open-ended scheme may well have as a disadvantage that it would be very difficult to assess evidence where claims were submitted very late, but does have that element of flexibility that is needed if such common factors are to be taken into account. It is recommended that this aspect of the scheme be re-examined.
To a great extent the issue of ownership has been overtaken by the decision to move the War Pensions Agency from the DSS into the MoD, and with it funding and responsibility for administering the War Pensions Scheme. The Society sees advantages to be gained through this move in as much that the War Pensions Agency brings with it an in depth understanding of the veteran community including dependents, together with the clinical and administrative expertise in the field which is not found elsewhere. In addition, the War Pensions Welfare Service (WPWS) provides an excellent service to the veterans and their dependents, and connects with the DSS, the NHS and the ex-Service Charities working in the welfare and disability fields. It is believed that the WPA has the capacity to run both old and new schemes side by side. With a single agency running both schemes duplication of effort will be avoided, employee and veteran alike. It is therefore recommended that the WPA administers the new scheme for the MoD and the WPWS continues to operate in the veteran community.
There are a number of other general issues concerning the scheme, such as transitory arrangements, which have been covered in the comments made by the RBL and others, and which will not be repeated here.
SECTION 10NEXT STEPS AND KEY ISSUES
Finally, both to summarise, and to ensure that the key issue questions have been answered:
Should the existing diverse arrangements be replaced by a single new scheme? Yes, provided that the package of compensation is no worse than in the present scheme. As it stands, there are aspects of the new scheme that, in the Society's view, are worse than present arrangements.
Should the scheme be owned by MoD? Yes, with the scheme being administered by the WPA.
Are the principles guiding the review the right ones? Not all of the principles are right. In particular, the Society cannot agree that it is either fair or right that the less disabled should fund the needs of the more seriously disabled. All must be compensated according to their needs.
Is it right to base the scheme on the principle of compensating financial loss, rather than on pensions? No. The disabled ex-Serviceman needs a guaranteed Income Stream through life.
Should a greater proportion of compensation be made available through lump sums? No. A grant should be made to help the severely disabled to adapt to disabled living but that is all. All other resources should be channelled through the GIS.
Is the proposed tariff approach sensible? For physical disabilityyes. For psychological injurythe approach may not work, and there is a need to build in safeguards that recognise the problem.
Is the approach to generating a GIS sensible? Cannot tell until the rate is revealed. The Society has severe concerns about Deterioration or improvement averaging in cases of psychological injury.
Does the scheme strike the right balance in focusing compensation on the most severely disabled? Nofairness at all levels must be achieved.
Is the approach outlined for determining eligibility to claim and entitlement sensible and reasonable? In general, yes, but there is some work to be done to reconsider the issues already discussed.
In principle, it is agreed that there are benefits to be gained by replacing the DSS War Pensions Scheme and the attributable benefits of the MoD's Armed Forces Pension Scheme within a single Compensation Scheme, provided only that the new scheme does not represent a worsenment on the current provision. As it stands, the Joint Compensation Scheme, as currently laid out in the consultation document, appears to fall short of this expectation in a number of key areas.
Nevertheless, the Society welcomes the opportunity to comment on this consultative document, and would be pleased to contribute to the work that is clearly needed before this scheme can be taken forward to the Statute Book.