The imminent royal commission report into Defence and veteran suicide will probably be quite scathing of the Department of Veterans’ Affairs and the Australian Defence Force. But the report, due to be handed down on 9 September, will probably overlook two root causes of military mental illness: the great volume of preventable work-related sickness and injury among ADF members, and the ADF’s reliance on contract civilian health staff.

Civilians who are treating sick and injured ADF members are poorly placed to promote recovery and mental health with one of the most important treatments: getting people back to work as soon as possible.

These causes reflect a longstanding, widespread yet never-tested premise that ADF members need only short-term clinical treatment and that the only reason the ADF needs uniformed health personnel is because civilians cannot deploy. This premise formed the basis of a 1996 Australian National Audit Office (ANAO) audit that found that the ADF’s per-person health costs were three times as high as for civilians treated through Medicare. The audit blamed gold-plated health services, with the result that the 1997 Defence Efficiency Review contracted out those on ADF bases.

However, the ANAO’s cost comparison was invalid, because the ADF and Medicare systems have different scopes of care. The main reason for the high cost of ADF (and the Department of Veterans’ Affairs) health services actually relates to the volume of preventable work-related illness and injury.

Although inconsistent, state and territory data suggests that an ADF member may be 12 times more likely to claim compensation for work-related injury as an average civilian and five times more likely than a manual labourer (who on average would suffer more injuries than anyone).

Furthermore, a 2016 study found that up to 90 percent of all Australian Army work-related injuries were not being reported, which suggests that the problem is even worse than this compensation data indicates. We can assume that navy and air force underreporting would be similar.

To use the metaphor in an 1895 poem by Joseph Malins, rather than ‘a fence ’round the edge of the cliff’ to stop people from falling, the ADF has instead put ‘an ambulance down in the valley’: we’re focused far more on treating avoidable harm than preventing it.

This error is compounded by the unfair expectations placed on the ADF’s contract civilian staff in assessing fitness for work. The fraction of navy personnel who were medically unfit for sea rose from 4.8 percent in 1996 to 13.8 percent in 2018, while those with at least one medical employment restriction rose from 9.4 percent to 40.2 percent in the same period. This increase is typically ascribed to lower recruitment medical standards.

But another explanation is that the ADF now employs civilian doctors who lack experience in dealing with work-related injuries, compared to doctors whose military experiences give them a better understanding of the demands of ADF employment.

And absence from work is itself a psychological as well as a medical problem. As the Royal Australasian College of Physicians has explained, it leads to avoidable mental health issues, because:

—Absence from work leads to poorer health;

—Resting while waiting for recovery actually delays recovery;

—The longer people are off work, the less likely they will ever return to work;

—Most common health conditions are not cured with clinical treatment alone; and

—Useful work is itself a therapeutic intervention and therefore part of the treatment.

There are at least three possible reasons why we’re not getting injured and sick people back to work as fast as we should. One is that contract health staff lack the ADF workplace experience that uniformed health medical people can use in judging what work a patient can and can’t do.

Also, contract health staff tend to take a stronger, possibly misapplied, approach patient advocacy, often by recommending more time off work than needed.

Finally, no doctor can get a patient back to work if veterans groups, with commendable intentions but often regrettable results, are meanwhile ensuring that patients know how to maximise the compensation benefits to which they are legally entitled. Compensation payments for ADF members appear to be about twice as high as those for civilians.

Arthur Graham Butler, a Gallipoli veteran and author of the official Australian medical history of World War I, explained that military health services have two purposes beyond immediate casualty treatment: facilitating the operations of their patients’ commanders, and helping the injured and sick eventually to return to civilian life. Both mean getting as many service personnel back to gainful work as soon as possible.

But the current ADF health services are designed only to provide treatment.

The commission ought to recommend greater emphasis on prevention of injury and illness and, for those who do need medical services, hastening their recovery by returning them to their ADF duties or civilian employment as soon as possible.

We’ll take a big step towards achieving that if we recruit more uniformed medical staff.