The Health & Social Care Team (HASC) is pleased to share a positive outcome following recent engagement with the Ministry of Defence (MOD) regarding the treatment and management of ME/CFS within their health resources.
We were contacted by a concerned individual who highlighted potential harm caused to people with ME/CFS and outdated information in MOD materials. In response, the HASC team wrote to the Air Marshal to:
- Recommend the removal of outdated resources relating to ME/CFS
- Highlight the 2021 NICE Guideline for ME/CFS (NG206)
- Emphasise the importance of recognising post-exertional malaise (PEM) when supporting individuals to return to work
On 10 November 2025, we received a letter from the Air Marshal stating the following:
I can confirm the guidance regarding CBT and GET for ME/CFS will be removed from the next publication of Joint Service Publication (JSP) 950 Leaflet 6-7-7.
The MOD also reassured us that their current approach is guided by the 2021 NICE guidelines.
This marks an important step forward in ensuring that MOD materials reflect modern, evidence-based understanding of ME/CFS and avoid perpetuating harmful recommendations.
There may still be further correspondence needed to ensure that post-exertional malaise (PEM) is fully recognised and considered in MOD return-to-work guidance, but this is a very welcome and positive development.
Correspondence
Dear Air Marshal
I am writing on behalf of the ME Association, a national charity dedicated to providing information and supporting people affected by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and Long Covid (LC), and to ensuring that healthcare practice reflects the latest scientific evidence.
It has come to our attention that the Ministry of Defence may be relying on the 2008 Synopsis of Causation: Chronic Fatigue Syndrome (Dr Adrian Roberts) in its approach to ME/CFS. This document is now significantly outdated and no longer reflects current medical understanding or best practice. Continued reliance on it risks perpetuating misleading and potentially harmful advice, for example, it recommends Graded Exercise Therapy (GET) which is no longer advised due to clear evidence of harm (Vink & Vink-Niese, 2021).
Post-exertional malaise (PEM) is the hallmark feature of ME/CFS and unlike people who are simply deconditioned, those with ME/CFS have been shown to respond abnormally to exertion, with evidence that the condition is underpinned by a complex interaction of persistent immune activation and neuroinflammation (Nakatomi et al., 2014; VanElzakker et al., 2019), coupled with autonomic dysregulation and mitochondrial impairment in both immune cells and muscle tissue (Naviaux et al., 2016).
Recently the largest-ever genetic study of the illness identified eight genetic regions associated with increased risk of developing ME/CFS (DecodeME Study Team, 2025). This study, involving 16,000 people with ME/CFS and 250,000 population controls, provides strong biological validation for the condition and dispels beliefs around psychological or de-conditioning related models of causation.
In October 2021, the National Institute for Health and Care Excellence (NICE) published updated guideline NG206, setting out evidence-based recommendations for the diagnosis and management of ME/CFS (https://www.nice.org.uk/guidance/ng206). These explicitly advise against GET and instead emphasise energy management and pacing strategies, recognising rest as an essential component of care.
NICE NG206 identifies post-exertional malaise as the cardinal symptom for ME/CFS, alongside fatigue, unrefreshing sleep and cognitive difficulties, with GP-led investigations recommended to rule out other causes. You may find this infographic, which has been designed for health professionals in primary care, useful to share with your clinicians.
Around 30–50% of people with Long Covid also meet the diagnostic criteria for ME/CFS (Lopez-Leon et al., 2024), underscoring the need for accurate recognition and management within occupational and medical services.
In the context of occupational health, early recognition and appropriate adjustments are critical in order to reduce the risk of developing more severe forms of the illness. NICE advises that return-to-work plans must be gradual and flexible and that activities triggering post-exertional malaise should be avoided. The ME Association’s resources for clinicians and employers provide practical guidance to support these recommendations.
We respectfully urge the Ministry of Defence to withdraw the 2008 Synopsis of Causation on ME/CFS and update all internal and occupational health materials to reflect NICE NG206 (2021). We would also recommend you seek guidance from other specialist organisations such as Post Covid Society.
As part of our ongoing advocacy work, we liaise regularly with the ME/CFS All-Party Parliamentary Group (APPG) and with parliamentarians more widely to raise matters affecting patient care and policy. We would of course prefer to work with the Ministry of Defence directly to address this issue, but if necessary we can also bring it to the attention of the APPG and seek clarification through parliamentary questions to ensure alignment with current national guidance.
We would be happy to provide further clinical evidence, training resources or support to assist in this update process.
Yours sincerely,
HASC Team, The ME Association
MOD Response
Dear HASC at the ME Association
Thank you for your letter of 13 October 2025 to the Director General of Defence Medical Services (DMS) Air Marshal XXXX, regarding the Ministry of Defence (MOD) policy and treatment guidelines on Myalgic Encephalomyelitis (ME), Chronic Fatigue Syndrome(CFS) and Long Covid in relation to Graded Exercise Therapy (GET).
I appreciate the concerns you have highlighted regarding the use of Cognitive Behavioural Therapy (CBT) and GET for ME/CFS. I am grateful for the opportunity to look into this matter and share your commitment to ensuring that healthcare practice reflects the latest scientific evidence. I can confirm the lead Consultant in Rehabilitation Medicine at the Defence Medical Rehabilitation Centre, specialising in ME/CFS, and the lead in
Occupational Medicine Policy have been engaged to inform the response.
I hope I can reassure you that the clinical management of MOD patients is led by the most up-to-date NICE guidance, specifically the 2021 publication. Clinicians further draw on resources from the British Association of Clinicians in ME/CFS, ensuring care is tailored to the individual needs of each patient, and informed by the most up to date medical advice.
I can confirm the guidance regarding CBT and GET for ME/CFS will be removed from the next publication of Joint Service Publication (JSP) 950 Leaflet 6-7-7.
On return-to-work plans, the MOD individually tailors return-to-work plans to each patient, ensuring a gradual progression that is fully supported by the individuals clinical and occupational health team, and Chain of Command. The individually tailored plan remains under regular review with the occupational health teams, with the ultimate goal being a successful and healthy return to work. If appropriate, DMS assist with onward referral and
transition of care into NHS services.
Thank you once again for bringing this important matter to our attention and I trust this letter explains the Department’s position.
Yours sincerely,
HQ Defence Medical Service