|
UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 620-iv House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE DEFENCE COMMITTEE
WEDNESDAY 7 JULY 2004 PROFESSOR K HAWTON and PROFESSOR S WESSELY MS S CALDWELL and MS E GYNGELL Evidence heard in Public Questions 402-535
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Defence Committee on Wednesday 7 July 2004 Members present Mr James Cran Mike Gapes Mr Mike Hancock Mr Kevan Jones
In the absence of the Chairman, Mike Gapes was called to the Chair ________________
Memorandum submitted by Professor Simon Wessely
Examination of Witnesses
Witnesses: Professor Keith Hawton, Director, Centre for Suicide Research and Professor of Psychiatry, Oxford University. and Professor Simon Wessely, Director, King's Centre for Military Health Research and Professor of Psychiatry, King's College London, examined. Q402 Mike Gapes: Good afternoon everybody. This is the fourth evidence session in our duty of care inquiry. The aim of the inquiry is to examine how the armed forces look after their people at the very beginning of their service, recruits in Phase 1 training establishments and trainees in Phase 2 training establishments. I should like to welcome Professor Hawton and Professor Wessely this afternoon, who are two eminent psychiatrists and then at half past four we are going to hear from the Health and Safety Executive. I should like to thank you for coming to give evidence to us and also for your written submission. Would you like to introduce yourselves before we get into questions? Professor Hawton: I am Keith Hawton. I am Professor of Psychiatry at Oxford, a director of the Centre for Suicide Research at the university and I am also a consultant psychiatrist. Professor Wessely: I am Simon Wessely. I am Professor of Psychiatry at King's and Maudsley and I am also a Director of the King's Centre for Military Health Research and an advisor in psychiatry for the Army. Q403 Mike Gapes: Could I begin with a general question? On the basis of what psychiatrists know about young people in general and the young recruits who have harmed themselves in particular, is it possible or even helpful to consider constructing profiles of vulnerability? Professor Hawton: Perhaps I might say first of all a little bit about the nature of suicide and then come onto the question of profiling. One important point is to recognise that suicide rarely results from a single event; it is often a complex process where a series of factors over time may lead to suicide, although there may be a precipitant. A wide range of factors can be relevant. I will go through these briefly, if that is okay. First of all, starting with the family and family history of mental illness, and we do know that a family history of suicide is more common amongst people who commit suicide or self-harm, various types of life stresses are going to be relevant in young people, particularly broken relationships, bereavements, abuse, bullying, work problems, loss of status through work or in society and so on. We know that psychiatric disorder is very common in people who either self-harm or commit suicide. The vast majority have a diagnosable psychiatric problem, although it is often only diagnosed in retrospect rather than being known at the time. This can be particularly depression, anxiety disorders and, less commonly, manic depressive illness, schizophrenia and alcohol and drug problems are also important contributory factors and drug abuse is becoming an increasingly common factor in suicide in young people. We know that certain personality types may be more vulnerable and the sorts of characteristics which seem to be particularly relevant here are a tendency towards being aggressive, acting impulsively and generally having poor coping skills or poor resiliency. Various psychological processes may be relevant to someone getting into a suicidal crisis, such as feelings of hopelessness, pessimism that nothing will change in the future, feeling trapped in a situation and feeling powerless to do anything about it or to escape from it, loss of self-esteem, shame, isolation, which may either be in reality, in the sense of being actually isolated from people around, or feeling isolated in a psychological sense and, for whatever reason, being unwilling to share problems with other people or approach other people for help. Probably less relevant to young people, but not entirely so, is physical illness which can be a contributory factor, particularly where it is life-threatening or involves chronic pain. Another important factor which we have become increasingly aware of is that awareness of suicidal behaviour in other people may be very important; so exposure to suicidal behaviour, such as through a family suicide but also amongst one's peers. This can lead to clusters of suicidal acts which it is well recognised can occur in young people. We also know that there is good evidence that exposure to suicidal behaviour in the media may in certain circumstances also be a vulnerability factor. Then, crucially, there is the availability of methods for suicidal behaviour and awareness and knowledge of them and how to use them. It is not by chance that the highest occupational groups for suicide in the United Kingdom are all ones where there is access to means. They are: farmers and vets with obvious access to firearms; female doctors, dentists, pharmacists, all having access to drugs and anaesthetics in the case of anaesthetists who are particularly high in this group. We know less about what protects people against suicide, so-called protective factors, having close, supportive relationships, having good coping skills or resiliency as it is increasingly termed and being willing to use sources of help. So a wide range of factors can actually contribute to suicidal behaviour and it is important to recognise that and in any one individual there is likely to be more than one of these factors which is going to be relevant. Q404 Mike Gapes: Professor Wessely, do you want to add anything to that? Professor Wessely: No, you have the world authority on the subject next to me, so I am not going to add to that. Q405 Mike Gapes: That is very useful. There are many strands there which we shall no doubt take up. I asked you specifically whether we needed to construct a profile. If you had a profile which could include all those different categories that is very, very wide, is it not? Professor Hawton: Yes. Q406 Mike Gapes: It could be a very large cohort of the population. Professor Hawton: Absolutely. Q407 Mike Gapes: How could you narrow that down to focus on vulnerable young recruits? Professor Hawton: I think this is very difficult. If we are addressing the question of whether you can screen people at the point of application to join the force or as they enter the force, to pick out those who are really likely to engage in a suicidal act, fatal or otherwise, it is difficult, if not verging on impossible, or at least has the potential for very serious consequences. What one is talking about here is trying to predict what is a very rare event, at least in the case of suicide; self-harm of course is much more common. Trying to predict something which is going to happen months or years in the future is the first problem; predicting something which is rare. I have been through all these factors, but in terms of what we call their specificity for projecting suicide, they are all very crude. They are also, as you were hinting, relatively common in the population generally. I can give you an example. A history of deliberate self-harm is the best predictor of suicide and yet we know on the basis of a study we conducted recently of 6,000 schoolchildren in England, that over 13 per cent of them reported an act of self-harm at some time, most of which had not come to medical attention incidentally. In the girls it was 22 per cent and the boys around six per cent. So you are talking about something which is relatively common and yet very few of these will go on to commit suicide. In terms of how specific that factor is, it is clearly not. The other thing was that as I went through those factors it was obvious that some of the factors are environmental and unpredictable; for example, broken relationships and bullying. If you are screening somebody at one particular point, how do you predict? You cannot predict that they are going to experience these things. Another important point, particularly in young people, is that you are talking about the period when all the major mental health problems are most likely to develop, to have their onset. Very often there will not be any precursors to those illnesses which you can pick up. It is another important point to recognise that it is a dynamic situation. An additional factor is many people who die by suicide will actually not have these clear risk factors which you can detect at a certain point. The result of all this is that if you screen out people using the sort of factors I went through earlier, if you take those out of your population within the force, you are going to lose many, many individuals who will not develop problems, some who will, a minority of whom will actually go on to develop problems and you will also be losing a lot of people who may make a significant, positive contribution to the aims and responsibilities of the force. This is not just speculation. There have been numerous studies of risk factors for suicidal behaviour where people have tried to look at what does predict it within a population and these have all produced disappointing results without exception. There were large numbers of false positives, in other words people who showed the characteristics which are risk factors, but who did not go on to show the behaviour you were trying to detect and large numbers of false negatives, in other words people who appeared to be okay when you screened them, but subsequently carried out a suicidal act. Overall, I personally would not favour this approach of screening at a certain point; there is a different question about what happens over time subsequently. Professor Wessely: We have done quite a lot of work for screening on psychological vulnerability in the military and if you look at the criteria used for establishing a screening programme in the NHS, there is no shadow of doubt whatsoever that this particular instance would fail on every single one of the criteria which the NHS use. There is really complete unanimity of opinion there, that screening for vulnerability to mental disorders is ineffective and counter-productive. That is in the general population. It becomes even worse in the military. If you just take simple risk factors, for example coming from a broken home, and if you say no-one can join the military who comes from a broken home, that would eliminate nearly the entire Army; 70 per cent on the figures you have. It would not matter to the RAF so much, but it would certainly affect the Army and that is just on one factor. All these factors are very common anyway; they are particularly common in the population the Army traditionally recruits from and each of them is rather weak. You could construct a profile which would eliminate everything Keith has said and you would just be left with the Chief of the Defence Staff and no-one else and I am not so sure about even that. The statistics really do work like that and of course that would eliminate the problem. However, you also have the other side, which I am very, very keen on, which is that a lot of these people, who are quite clearly risky - you meet them and you know these are customers with somewhat dubious backgrounds - who can be a bit scary to the average psychiatrist, nevertheless the research we are doing at the moment shows that the vast majority of them seem to do well and the military actually does very well by them and there are winners from that game as well as losers. You would lose completely that kind of social aspect. I know that is not the purpose of the Army, but it is a side effect of the Army; it does address a socially excluded group which very few other people can tackle. They would go at a shot. Q408 Mr Hancock: I am interested in the profile you can get and whether or not people grow out of the profile and how that emerges. Once you are in it and you fit the criteria you have built up, is it possible for someone to grow out of it or are they always a potential risk? The key issue is that nothing has ever taken them over the edge. Professor Hawton: May I take self-harm as an example, going back to this school study I talked about. What we know is that only a minority of these people who report self-harm will go on to serious suicidal behaviour later on in life. Maybe this is trivialising it, but for many this will represent almost a developmental phase, a way of coping with difficulties at a certain phase in their life. Having said that, once somebody has crossed that boundary into harming themselves, they will always carry some potential, increased risk. That is the current state of knowledge. However, for some it will be an incredibly low risk and they would have to be faced by certain overwhelming circumstances for them to resort to this behaviour again. For a small minority, it is a serious omen in terms of subsequent risk, but it is the small minority; that is the crucial point. Q409 Mr Hancock: If you were looking at a group of young people at school, fifteen-year-olds at school and you recognised in that cohort of youngsters some who met your profile of people who were potentially self-harming, who were actually self-harming, would they, according to your recollection of the youngsters you have met like this, be the type who would want to join the armed forces? That is the other issue, is it not? Do people who meet these criteria, somebody who self-harms, actually want to put themselves deliberately in harm's way? Professor Hawton: This is a very good question. I think the honest answer to that is that I do not think we know, but, it leads really onto a complex question: are the factors which are associated with risk of self-harm also associated with an increased likelihood of wanting to join the armed forces? In that case I would say yes, partly because of the associations with self-harm, maybe with some difficulties in following certain occupational routes and the Army or forces might be more available to people of that kind. I should be loath to say that people would want to put themselves at risk because they had had a tendency to self-harm. I think that is highly unlikely; there may be a very, very rare case. Professor Wessely: There is good evidence that that association you described does exist, through risk-taking behaviour. For example, the studies we have done after a war show you have an increase both in suicide, a transient increase, and in accidental injury. The predictors of both are almost the same; they are rather similar. Sometimes I have been involved in looking at individual cases and it is very hard to know whether or not that was suicide or it was just a completely stupid piece of driving or risky behaviour which went hideously wrong. I think you are right that there is an overlap between those characteristics of danger-seeking, excitement-seeking and risk-taking. Q410 Mr Hancock: I read that paper, but it was based on the American experience, was it not? Professor Wessely: No, it was our paper; it was very British. Q411 Mr Hancock: Is there a suggestion that is something which is a pattern among young soldiers in the UK? Professor Wessely: We do not know. The study we are doing at the moment will hopefully be able to look at issues, but we do not know. We do know about the coming together of self-harming behaviour and risky behaviour in general and we know that both go up in the military after deployments. The final bit of the jigsaw is that we do not specifically know for the UK. I suspect that it will probably hang true, but you are right, we do not yet know it. The paper we were describing is a UK birth cohort, which includes very few, hardly any military people. Q412 Mr Jones: You mentioned that the reasons for suicide are wide-ranging and there is no one reason and in some cases there might be several reasons for suicide. Is there anything either of you have actually seen in terms of military training which is likely to exacerbate those problems or lead to problems which people bring in from civvy street being exacerbated by the way the training is done in any of the services? Professor Wessely: The obvious one is guns, access to firearms, which is major issue which is clearly military specific. That is the immediate response to that. Professor Hawton: I suppose the fact that the very young people are away from their family situation and if they are then involved in adverse experiences like bullying, the impact of that may be more damaging for them when they do not have a family. They may feel far more insecure under those circumstances than someone who experiences bullying under other circumstances but has their family support or their usual friends around. In that way, these young people may be more vulnerable. Professor Wessely: Yes, I would agree with that. Q413 Mr Hancock: I just want to go back to the profile and your experiences of people who fitted into this profile going potentially from self-harm to suicide or maybe even to harming others. Is it your experience that the ultimate, the suicide or the harming of somebody else in their lives, occurred while they were relatively young or is it something which is liable to appear at any age? The issue we have here is that we are dealing with very young people who have come from maybe the sort of home lives you have talked about into a service environment, many of them in the first year of their service lives and they are still under 20 years old in the main. Would you recognise that that is the potential risk time for them? Professor Hawton: One of the issues is that in the general population that is a time of particular risk, particularly non-fatal suicidal behaviour, self-harming behaviour. Having said that, suicidal behaviour can appear at any stage throughout the lifecycle, although the risk becomes less as people get older, particularly for self-harm, not so much for suicide. So the suicide risk is something which does not change greatly. There has been a big change in the United Kingdom in the last few years in that suicide rates have come down in older people and gone up in younger people, so that now, what was the traditional pattern of suicide risk increasing with age, is no longer the case, particularly in males. Across the lifecycle you see suicidal behaviour occurring and quite often with no previous suicidal acts. Q414 Mr Hancock: How effective would it be for the armed forces in the UK to develop from your profile of young people into an effective screening mechanism, not at the training stage, but at the recruiting stage, so that there was an effective measure for the armed forces to be able to exercise some form of --- Professor Wessely: I go back to the previous question. I do not think that is possible. It has been tried occasionally and it has failed. It is just not possible. You would eliminate too many people who would make good members of the armed forces for the small number you would not recruit in. The disadvantages for those people you have removed who would have done perfectly well are profound. You label them as being mentally unstable, vulnerable, etcetera and someone's constituent had that problem, but I cannot remember who it was. When the Americans did that in the Second World War, that was repeated on a vast scale and there is lots of evidence of people who were denied the chance of military service whose lives were stigmatised ever after. When later in the war they were recruited into the military because the Americans had run out of people, most of them made perfectly good soldiers. The negative consequences for the people who are falsely labelled are enormous. Q415 Mr Hancock: If you cannot do it at the initial recruiting stage, how soon into the training phase could you do it? Professor Wessely: In terms of screening, you have a higher respect for psychiatry and its powers of prediction than we do. Q416 Mr Hancock: Let us not say "screening" then. Let us say identifying the vulnerable person in training. Professor Wessely: Spotting the people in trouble is a very different strategy. That is not screening, that is where you are observant for the signs of people in trouble. Neither of us is expert on military training, but it is their policy that they know their people and they spot people in trouble. That is a perfectly reasonable strategy. The question of how good they are at it is a different question. Q417 Mr Hancock: But that is only good if they are good at spotting them, is it not, and people are trained? Professor Wessely: Sure. Q418 Mr Hancock: The evidence we have is that the average life of a trainer is a two-year deployment, somebody who is coming out of a unit, is sent as a trainer with very little educational support for the initial stage or developmental work during his or her time as a trainer. Professor Wessely: As a strategy I quite agree with you. My experience there is certainly that knowledge of behavioural characteristics and of the issues we are talking about could be increased. That would be a strategy which would not impact in the way that screening would impact on people who are not at risk and are falsely labelled. I suspect strongly that could be improved, particularly if the situation is as you say it is. Neither of us is expert in how the military train people. Q419 Mr Hancock: Have the military ever asked either of you for advice about how they should maybe give a bit more support to NCOs or junior officers who will be in charge, maybe not of training units but of actual fighting units? Professor Wessely: Yes, I have been specifically asked for advice on spotting post-traumatic stress in Iraq, for example, and other conflict situations. Yes, they do ask for that kind of advice. The curriculum taught to officers is changing and is kept up to date. They do not always listen to what I say. Why should they? However, they do ask for advice on that. I have not specifically on this particular issue, no, but on other issues, yes. Q420 Mr Hancock: Are you then both surprised, being eminent in your field, that the military have not made greater use of the sort of expertise which is out there, both to help them during the initial recruiting stage and definitely in the training stages, not you two in particular but your colleagues? Professor Hawton: They have not approached me, but I do not know whether they have approached colleagues; I just do not know. Professor Wessely: All I can say is what I have done, which has not been on this particular issue. I have, however, done a lot with the military on other issues of psychological relevance. Q421 Mr Cran: You may have answered this question. I might have fallen asleep when you did, so I am going to re-state it. It is simply this. I am unclear in my mind whether the incidence of self-harm and suicide is any different in the general population than any other population and in this case we are speaking about the population of the armed services. In that regard I think you, Professor Wessely said this. Where you said it, I do not know, but it is in quotation marks, so I am entitled to quote it. You said "... suicide during military service is, thankfully, very rare, and like all rare events, almost impossible to predict". Professor Wessely: Yes. In general suicide rates in both the US and the UK armed forces are lower than in the rest of the population in general and there are many reasons for that. The particular exception we know from the UK is young men in the Army, where the rate is higher. Those are the DASA statistics. That might be explained by the fact that they take more dodgy people and it might be the fact that they take people with higher risk factors. Q422 Mr Cran: That is the Army as distinct from the Air Force or the Navy. Professor Wessely: That is the Army. For the Air Force and Navy it is lower overall. On deliberate self-harm there is no reliable data at all within the armed forces. Keith is making an attempt. My training is epidemiology and we should love to have that kind of data. It is very hard to get and at the moment there is no data. Professor Hawton: One of the problems, particularly as people move further on in their Army careers, is that they are more likely to go to civilian hospitals if they commit a self-harm act and we do not have a national network for collecting information in any case, let alone collecting it on Army personnel. There is a real issue about collecting accurate data which you can then compare with accurately collected data in the general population which is available. Professor Wessely: Whenever we have mentioned it even simple data protection and confidentiality issues make you weep. Q423 Mr Hancock: It is a very serious issue, is it not? Professor Wessely: It is very serious; absolutely. Q424 Mr Hancock: If you have a young man or woman who can readily avail themselves of a weapon with live ammunition, who has been having some sort of treatment in a civilian hospital or even from their own GP and the armed forces are not told about it, that must be an error somewhere in the system and it must be something we ought to write in our report, because it must be seen as something where we are very vulnerable. Professor Wessely: It is such a difficult area. As a researcher, I would love to have that data, of course. On the other hand, if I were that young man who had chosen to take myself to a civilian hospital because I did not want specifically the Army to know that I was having trouble at home and I had just taken an overdose, I would be completely opposed to what you have just said. One of the papers I have sent to you was when we did work on screening with the military and how many of them said exactly that thing, that they did not want details of their mental health ... They were perfectly happy to tell the military about their dodgy knees, but they absolutely did not want sensitive data, and this is sensitive data, to get back to the chain of command or to the military medical service. Q425 Mr Hancock: My last question was going to be on screening again, but both of you have convinced me that is not an easy option and is not a viable one for the armed forces. My question therefore really relates to whether it is possible to look at some of the cases that we have been asked to look at, not just on this Committee, but this Parliament has been asked to look at, of the 100 or so young men and women who have died over the last years and to see whether you can glean from the information which is available on young men and women, whether or not there was anything in what had happened prior to the incident which took their lives, which might have signalled a warning to people. Have you been asked to do that? Professor Wessely: No. Professor Hawton: I have not been asked. Q426 Mr Hancock: Would it be possible? Professor Wessely: It is the kind of thing we do. Professor Hawton: It is the sort of thing we do. We are well versed in conducting what are called psychological autopsy studies, which have been mentioned in some of the official papers, in terms of trying to reconstruct what has happened in suicide cases, but we have not been asked to do this, no. Q427 Mr Hancock: From our point of view, do you think that would be something which would be worth requesting the MoD to invest some money in? Professor Hawton: It might well be. If one were going to go down that route, I would suggest investing the money as well or perhaps instead in investigating what I would call failed suicides, in other words acts which were clearly, as far as one could gather, intended to be suicide and did not result in death, because then you can talk to the individuals and glean a lot more information from it. That approach, perhaps combined with looking at the actual cases where death has occurred, would be the most valuable approach. Professor Wessely: I should say in defence of the Army that there is such a study going on. It is not being done by us and it is on deliberate self-harm not suicide but is being done at Imperial. That is just within the Army. Q428 Mr Cran: If I understood the answers to my question, you said that the incidence of suicide in the armed forces population is lower than that in the general population. Professor Wessely: Correct. Q429 Mr Cran: But that the incidence of suicide in the Army is higher than the other two services. Professor Wessely: In the Army in young males. Q430 Mr Cran: I just want to be clear about these statistics. Is the incidence in the Army higher than in the general population? Professor Wessely: No. Q431 Mr Cran: It is still lower. Professor Wessely: It is still lower, with the exception of that particular sub-group. That change is significant, but it is based on very small numbers, not big numbers. You are going to ask me what the numbers are and I have forgotten. Q432 Mr Cran: Are they statistically significant? Professor Wessely: Yes, they are significantly increased in young Army males, though it is still based on a small sample size but a significant one. Mike Gapes: Perhaps you could send us the statistics. Sorry, I am told we have them already. Q433 Mr Cran: If I understood you, Professor Wessely, you said that there are many reasons why the incidence of suicide is lower in the armed services than in the general population. Professor Wessely: Yes. Q434 Mr Cran: I should just like you to canter over some of them. Professor Wessely: One of the things we are looking at very much is the protective effect of military life. We are looking at the winners as well as the losers. Sometimes, for example, they select, they screen, but they screen on certain variables like IQ, major mental illnesses, physical disabilities, all of which are risk factors. That is the first thing. Secondly, for some people who are at risk the Army, the military environment, is actually very protective. People do well under that kind of institutional care. Some people do not, but many people do. Then there is the employment aspect. This is a job, this is giving people education, trade, and adult literacy, all of these things. So there are many, many positive aspects which might further reduce the suicide rate, particularly if you took account of the risk profile. One of the most important things we are doing at the moment, which we should really like to continue, is looking at this issue of exactly what the risk profiles are of people when they come into the armed forces. We do not do that; the Americans do, we do not. How does that play out during people's military careers and indeed when they exit into civilian life? Can you spot the winners and losers at an earlier stage? If you just take the crude statistics, they are very misleading. I am sorry to harp on the point, but you have to bear in mind that the Army is not a random sample of the UK adult population and it is skewed towards difficult people. I should not say that on the record, should I, but it is true? Q435 Mike Gapes: Following on from what you have just said, is there any evidence to suggest that suicide rates decline in the Army as an individual's length of service extends? Professor Wessely: I do not know. I am sorry, I do not know. Q436 Mike Gapes: Is there any correlation between suicide rates and frequency of operations for people in the armed forces? Professor Wessely: Suicide rates are such a rare event that I do not think you could ever do that statistically. If you can, our study will eventually give you that information. I suspect it is too rare an event and they deploy so often that you would find that very hard. The only other point I would make on that is that evidence we do have is that a certain number of deployments is good for mental health. Too many is bad, but having no deployments at all is very bad for mental health. We have evidence from the Iraq war to show that mental health actually improved for those deployed during the Iraq campaign compared with those who stayed behind. Some deployment is good. Q437 Mike Gapes: Would you be able to say that greater stability and job satisfaction and personal success for young people within the armed services are actually positive factors? Professor Wessely: I am making that as a generalisation. I hope, as our work continues, we will be able to be more definitive on that, but I should be really surprised if that is not the case. That is very much what we are doing at the moment. Q438 Mr Hancock: Then you raise a very interesting issue. One of the things we discovered was that in between training there was a very significant down period and it was during that period that most of the incidents that we have knowledge of occurred. Professor Wessely: Yes; between Phase 1 and Phase 2. Yes, I am aware of that. Q439 Mr Hancock: What is the significance there? You talked about the state of the mental health of people on deployment improving, they are better off; with people not on deployment it goes down. This is a critical time for these young people, is it not? Professor Wessely: Yes. We do not have specific evidence on that, except to say that what you say sounds highly plausible from the psychological point of view and fits in with what are the benefits of military service, why it helps you. Therefore the point you have just made would say that is a risky period. It is when they hang around bases and really have not much to do. I cannot give you any figures on that except to say that seems very plausible. Q440 Mr Jones: Can I turn to training? Professor Hawton already mentioned that 16- to 18-year-olds face certain issues or problems in their lives which make them more prone to self-harm than suicide and I should be interested if you could just run through some of those. On a general point, what should the Army be doing in terms of support once people are into training, monitoring people's mental health but also reacting to issues, particularly in this group of 16- to 18-year-olds which you have already identified as a vulnerable group in society and in the Army? Professor Hawton: The first thing is that I do not have first-hand knowledge of what attitudes towards mental health are generally in the armed forces in the UK. Going back to this notion of a population approach to trying to do something about this problem rather than trying to screen out people, one of the crucial things is whether mental health problems can be less stigmatised - and I am talking about emotional problems in general and not just major mental illness - whether there can be a sense that helping people who are getting into such difficulties is everybody's business within the Army, not just that of psychiatrists or medics. Just taking the example of the US Air Force suicide prevention programme, which I assume the Committee has been made aware of, the key elements in that seem to be the whole attitude change which comes through the programme starting from the top, from the highest in command, saying they had to do something about mental health, mental health had to be their concern, saying we know people at this age develop mental health problems, we cannot pretend it is an unfortunate occurrence which we would rather did not happen because it does happen, making it everyone's concern, particularly trainers and supervisors of young people. That then leads on to ensuring that they are getting good training, recognising the point which was made earlier about the rapid turnover which is of course an issue, which means that in any case such training would have to be repeated to ensure that people kept their skills level up, generally getting over to people that we do care what happens about emotional issues and so on, getting help early, making it less stigmatising to get help. Again I realise there are issues here, because if you are going to take help-seeking away from the line of command of an individual, which is desirable, you also have the conflict with what we talked about earlier, of people who may be at risk to themselves also being risky in other ways. There is that issue about confidentiality and yet maintaining safety within the force. I think the approach to it has to be a really general one in terms of how you approach mental health issues and concerns for people's mental health, repeating what we have said several times, not the idea that you screen people out, and you recognise that it is a dynamic situation. People can develop problems at any stage, so the idea of cross-sectional screening, even later on during people's training or forces career, is not a particularly good one. I think it is all about vigilance, awareness, knowledge, compassion and making people feel safer about seeking help when they are getting into difficulties. Professor Wessely: I would certainly agree with that. First of all you have to say stigma of mental disorder, emotional matters, is a very general problem. In my career I have looked after two of your colleagues who were extremely insistent that nobody knew that was the case. So this is not just a thing for the military, it is a thing for everyone. Secondly, it is true though, if you spend time with the military, that their particular culture is more stigmatising of emotional weakness and vulnerability and unfortunately, unlike Keith, I do see problems there, because I do think that is the nature of their job. They are not like middle-aged academics or Maudsley social workers. They are somewhat tough people and they are to do a different job of fighting, not emoting. Part of that is that they learn to repress emotions and fear. It is a subtle thing that we want to do here. We definitely do want to increase people's willingness to admit to emotional distress and come forward, but in a way which is compatible with their overall purpose and culture. It is not an easy thing to do. It is not a simple thing which putting up posters around the barracks is going to achieve. It is a difficult one. Professor Hawton: Although I do think there is a difference between resilience in the face of the stresses of military combat and dealing with emotional problems, I do feel you can have separation between those two objectives. Professor Wessely: There are specific things. Our research has shown that people are very reluctant indeed to come and talk to RMOs, who are officers. There are only five psychiatrists in the Army anyway, so most people are not ever going to see a psychiatrist. Community psychiatric nurses (CPNs) have a somewhat different reputation and the Army do have quite a few CPNs. I cannot see any reason why CPNs should not be attached to training units and I do not think they are at the moment. They are much closer and less stigmatising and they are not officers. I think if you were going to present, you would be more likely to go to see a CPN than you would a medical officer. Professor Hawton: They are likely to be closer in age as well. Professor Wessely: Yes, they are likely to be closer in age. The other thing is that the Army do have quite a few of them, whereas the situation with doctors is very bad. Q441 Mr Cran: Could we get back to the question you have both spoken to us about and that is the question of a strategy that an organisation should have for the prevention of suicide, for identifying it and all the rest of it. As far as I can see, and we have gone around the armed forces fairly exhaustively, there is a strategy, but it is quite a loose strategy. It depends upon the corporal noticing if the behaviour of the individual, the recruit, is rather different, if performance is falling off and all of that. Then there is encouragement to go to see the padre and then sometimes, as far as I can see quite often it, stops there because of the confidentiality. Only in extremis does it happen to be the case that the individual in question is signposted to the doctor, not a psychiatrist but a doctor, who then, as far as I can see, might be able to push the individual in one direction or another, perhaps to a psychiatrist. It all seems to me to be quite loose. Do either of you have any knowledge to confirm or deny that? Professor Wessely: You are right. First of all, if you just took away the word "Army" that is a description of how mental health services work anyway. They are very loose things, people have to present, they have to be spotted by the GP and they have to be referred on. In many respects the Army, in a somewhat closed environment, knows people better than an average GP would. If you want a strategic approach, what the evidence says is very much what Professor Hawton has just been saying, then favour the population based strategy of doing things which addresses everyone. For example, increase the training ratios, increase the education in spotting emotional disorders in the NCOs, which would then apply across the board to everyone, as opposed to targeting individuals. That would be a general strategy. It is sometimes called the population approach as opposed to the high risk approach. I am sorry, I have gone completely incoherent and forgotten what your question was. Q442 Mr Cran: I was saying that I thought the strategy the armed forces have was quite loose. Whether loose or not, it may actually be effective. I do not know. The question is: should they have a tighter strategy. Professor Wessely: There is nothing wrong with a loose strategy, so long as they do have regular checks to make sure that it has been working. Personally I should like to see them as strong on these issues and as robust as they are on issues such as racism or bullying, which have a much higher priority and which I know, from personal experience, commanding officers' careers can end on. It is not just the strategy, it is, as you have just said, that there is nothing particularly wrong with their strategy. It is a question of how much importance is put on it and how much effort is put into actually changing attitudes which are difficult. The US Air Force has done a good job on that, but it is a difficult process. We are both against simple, glib solutions to this problem. It is a problem which requires years and absolutely, unquestionably, requires leadership from the top in the way that the military does show that kind of leadership on issues which desperately matter to them. Professor Hawton: There has to be a commitment to a clear philosophy about mental health and putting this as a priority, not the priority, recognising that mental health problems will occur with young people, that there are particular factors which in some ways may make it more difficult for people with mental health problems, because of fear of stigma, fear of being discharged from the force and so on, which may make it particularly difficult for them to seek help. One can draw an analogy with what happens in the general population, but there are particular issues within the forces situation which also need to be addressed. The underlying one is having this as a priority. Q443 Mr Cran: May I put the question the other way? Is it the professional view of both of you that we should adopt what the US Army has, the US Army suicide prevention programme? It is pretty comprehensive, is it not? All officers to identify mental illness and all the rest. Pretty comprehensive. Should we do this? Professor Wessely: It is. No, I do not think we should because there are other elements of it which I do not think are effective and I do not think are suitable for the British culture and the British military culture. I would say that it should be reviewed and there are elements of that programme which are very good and there are other elements, for example the use of critical incident stress debriefing which we are completely opposed to and we think makes you worse. Flooding the Army with trained counsellors every time they have an accident would be complete anathema. That is the American policy. Bits of it certainly; the whole thing, no. Professor Hawton: The common theme of it is right, which is very much along the lines of what we have been talking about. I do feel that lessons can be learned from it and one can select out those things which seem most appropriate for the British situation. Q444 Mr Cran: I do not know about you, Chairman, but I think it would benefit the Committee if you could possibly take the time to tell us what the US Army does that would benefit us; not all of it, but tell us the things you think would really benefit the UK's armed forces. Professor Wessely: We will both need to read that documentation. Professor Hawton: I know at the present time they are following up the initial study to try to look at which bases implemented the programme, to what degrees, what components of the programme and where they appeared to get greater effectiveness. There are going to be problems about numbers, even though obviously it is a huge organisation. I know they are trying to evaluate which might be the most effective components of that programme. We could have a look and say what we think would be most useful, but there may be some more information coming. Q445 Mr Cran: It would be immensely useful for us if you could do that. Professor Wessely: Certainly. Just two caveats. The general answer to your point is that the bits which I think are most effective are the bits which involve education and training. The bits which are least effective are the responsive counselling interventions. Secondly, just to say, and it is the US Air Force rather than the US Army which has published most on this, that you still have to set this in the context of suicide rates falling anyway in America when they implemented their programme. Even though much of it sounds very plausible, we still do not know that it made a difference. We simply do not know that. The fall in the US Air Force suicide rate was pretty much the same as what was happening outside in the population anyway. Q446 Mr Cran: Just so I am clear, even with those caveats, you might have a look at it and give us the benefit of your advice. Professor Wessely: Certainly; yes. Professor Hawton: It is worth also highlighting the fact that other outcomes were found to change with the programme, including domestic violence and indeed accidents. Maybe again that was a general trend which was happening. The more outcomes you see a change in, the more likely it was to have been effective, particularly that it was a general approach rather than a specifically targeted approach to one problem. Q447 Mr Cran: I just want to be clear about two other things. I was very interested in what you said about the fact that the incidence of suicide is lower in the armed forces than in the general population. I know one death by suicide is one too many, we just have to accept that is too many and whatever we can do has to be done but it is a question of what can be done. I am unclear what an organisation can actually do, apart from the things you both mentioned, to prevent suicide, that is people getting through the net. That is what seems to happen. I too have the view that the armed forces seem to be quite good at spotting somebody who is going off the rails, for all the reasons you have given, and I am unclear what more they could do to prevent the few suicides that there are. Professor Wessely: In a way I would feel more comfortable talking about what they could do to reduce deliberate self-harm, because suicide is such a rare event. It is like murder in that it is difficult to do. Q448 Mr Cran: Self-harm then. Professor Wessely: My own general view, having dealt with them for some years, is that with most of the incidents I have heard about or dealt with where there has been a really bad outcome there is nothing wrong with the policies; it has been local factors on the ground which have gone wrong, usually to do with supervision or simply having too many people and not enough trainers. Q449 Mr Cran: And differences I see of practice; very different as between establishments. Professor Wessely: Yes. They are different between services as of necessity, but there is also tremendous variation within the services as well. I should have thought that it was more about knowing the right things and them not actually happening on the ground. I am just talking anecdotally now. Where I have been asked to comment on adverse incidents, I usually find that it is just local factors which have happened, as it is in most organisations really. Q450 Mr Cran: What are you recommending in terms of self-harm? Professor Wessely: I am very supportive of Keith's approach on the population base. I think that better training of trainers, increased supervision ratios, better access to CPNs and continuing to try to restore the morale and faith in the Army medical services, which are very low, and particularly the issues of trust and confidentiality. One of the papers we have given you identifies that as a major problem. Whether fair or not, it does not really matter: it is the perception that the system is leaky which does not help people to come forward. Q451 Mr Cran: That leads me to my last question. So far as I can see and we have been told, there has to be a management plan set out for vulnerable people, wherever they are, in this cases in the armed forces, for what is going to happen. How do we get the individual in question better? As I can see it, because of confidentiality, there is a great reluctance to put anything down on paper, a plan seems to me quite often to be very, very informal indeed and not formal and I just worry about all of that. I am not an expert, you two are. Is this a worry to you? Professor Wessely: I come back to the point that it is very hard to come up with glib solutions. I should be worried, for example, about a system which was more formal. I should be very, very worried about a system in which individuals are identified because they are from a broken home, they are at risk, they are given a different uniform. I am exaggerating, but if in some way they were targeted and being seen differently I could see that backfiring in an horrendous way and it could well make things worse. I am less against informal measures of care, so long as they are effective, whereas I can see that formal measures of care, in which it is known that Private Smith has these problems, could quite easily lead to Private Smith having a worse deal rather than a better deal, as opposed to general issues across the whole of that unit. Professor Hawton: On the other hand there does need to be a clearly planned response to self-harm episodes. Okay, we lack sufficient evidence about the best way of managing self-harm in the general population, but there are general principles about how self-harm should be managed and those principles should be used within the Army as well. If I am answering your question correctly, there should be attempts to use the approaches for which there is best evidence. Incidentally, it is of interest that NICE, the National Institute of Clinical Excellence, is about to publish an evidence-based guideline on self-harm. It is coming out at the end of this month. It may be that there will be approaches within that which can be adopted within the Army, if they are not being used currently. Mr Cran: We will look for the NICE report, but in the interim, and because we are passing on to another question, it would be rather useful for the Committee to know what these principles are. If you could possibly tell us, I for one should be very interested and I should like to be able to test whether the armed forces are using these. Q452 Mr Jones: In terms of self-harm, suicide is pretty self-evident, somebody kills themselves. However, with self-harm, there must be a whole range of different things. How easy is it for someone who is supervising youngsters to spot that? Can you give some examples of what the range is for self-harm? Professor Hawton: It can range from suicide at one extreme to someone - you may well disagree or not whether this should be called self-harm - battering themselves in a fit of anger and expressing anger through bashing a wall, perhaps even fracturing a finger or whatever. We recognise that the motivation or intention behind self-harm can vary greatly from tension relief, which may be served by self-battery or whatever, some people do this through cutting themselves, which seems to relieve tension, to communicating distress to others, to wanting to block things out temporarily, which is getting closer to suicide, where you are actually trying to escape from a situation in terms of becoming unconscious. There is a whole range of motivations. One of the crucial things does seem to be about the availability of method, which is terribly important. Just taking the situation in the USA in general, where firearms are very available in many households, we know that the availability of a firearm in a household increases the risk of suicide in young people in particular. One has to think about that component of it as well as the person's intention. We also know that people who survive very serious attempts quite often say that they did not really want to die. Studies have been done of people who have survived self-inflicted firearm wounds where, when they say what went on, it appears to have been very impulsive, often a reaction to an interpersonal event combined with alcohol consumption and the fact that the firearm was available led to a near fatal outcome. Q453 Mr Hancock: Could I take you back to what you said about the ability of the military to come to terms with mental illness and the possibility that someone could recover from mental illness and still be able to serve in the armed forces? Do you think it is a serious possibility that the military could cope with that? They might in certain trades, but in enlisted personnel? Professor Hawton: It depends what mental illness one is talking about. Taking an extreme case, severe schizophrenia, I would personally not feel very comfortable about someone proceeding in the forces if they developed a disorder like that. Less severe or of a similar severity is manic depressive illness. We know that can be very well controlled and treated. We know that most people recover from depressive illness with treatment, although it is an illness which we increasingly recognise recurs and there are now strategies to prevent recurrence; not entirely effective, but pretty effective. I should be very disappointed if people were being excluded if they developed a depressive illness, for example, because it is so common. The proportion of the population of this sort of age which develops depressive illness, particularly females, is extremely high and you are going to be losing a lot of people, many of whom may be very talented. Professor Wessely: They do not exclude people just because they have had an episode of depression. The prevalence of depression in the armed forces is somewhere between eight and 12 per cent, depending how you measure it. Clearly they are not excluding them. I have been involved in numerous cases of people who have been treated and returned to full duty. Q454 Mr Hancock: If that is the case, why is it such a problem for young people who have a problem to seek help in the armed forces? The evidence I read was that if you had been in the forces for some time you were certainly more confident that you could cope with that. Certainly my own personal experience of a serving member of the armed forces who went through very traumatic problems and had a serious drink problem is that was tolerated. It was as though it was tolerated because of what he had gone through, but they did not recognise the other problems he had, which manifested themselves much more when he left the military. Professor Wessely: There are two answers to that. The first one is that anyone who deals with adolescents anyway knows that it is very difficult for adolescents to seek help. This is a general problem in the whole of mental illness. Professor Hawton: Particularly males. Professor Wessely: Particularly males. Again it is not a specifically military problem. The reasons would be a) thinking it is not a mental health problem anyway and about one third of people we have seen just do not accept that this is a mental health problem; b) the next big one is clearly stigma, quite obviously, and shame; c) believing this will impact on their career. It is all of those three factors. Q455 Mr Hancock: What advice would you two give us in the way of helping the armed forces come to terms with the problems young people are facing? What advice would you give us? Professor Wessely: To continue to develop their community-based services, which they have been doing. As you know, 16 new community mental health centres have been created, which is a very, very welcome development, but there are still staffing problems across the whole of the defence medical services. I think that is in keeping with what has happened in the rest of society: to try to bring as many services as you can down onto the level where they are needed and to continue that trend. It is happening, but probably not as much as one would like. Professor Hawton: While the history of mental health promotion and educational activities is not awfully good, particularly based on school programmes, nonetheless one can think about imparting certain very simple information to trainees as part of their induction about how to recognise when they might be getting into difficulties and, more importantly, when to recognise that your peer may be in difficulties. That is probably important, although the evidence from school-based programmes is that these sorts of approaches only work when there is an institutional change as well, in other words the whole atmosphere and attitude towards mental health problems shows some sort of shift, such that it is worthwhile recognising these things, because people recognise that there are people out there taking an interest and want to help them. Q456 Mr Hancock: My last question relates to the older serviceman who might be the instructor or the trainer, who develops an interest in the elements of bullying or trying to take advantage of a female recruit. We were told last week that in one unit there were 15 incidents where trainers were suspended for having some sort of relationship with recruits; 15 in one unit at one time. This is a phenomenal figure. Is that something which you would say was part of a mental illness which the NCO has, the trainer who goes down that road of trying to manipulate young recruits for their sexual pleasure or just bullying them? Professor Hawton: It may or may not be. It could be. Professor Wessely: Sometimes; it could be. It sounds more like an organisational failure, but yes, it could be. I would not say in general that is a symptom of mental illness, no. Q457 Mr Hancock: Would you say that all instructors of young personnel in the armed forces ought to be subjected to proper psychological examination before they are given control and command of young people? Professor Wessely: No, I definitely would not say that. That is coming back to a general view and that suggests again that psychiatrists or psychologists know what makes a good trainer and we do not. Professor Hawton: Having a situation of zero tolerance in that sort of situation is probably the crucial thing. Professor Wessely: That is not a matter for psychiatrists; I agree completely that that is not a matter for psychiatrists. Q458 Mr Jones: Could I ask about training in terms of supervising? You have already stated that trainers should not be psychologically assessed, but how easy is it for someone, whose job it is to train somebody in PT or other subjects which do not involve mental health, to spot things which you as professionals or psychiatric nurses can spot? How easy is it for the untrained eye to spot some of these things? Professor Wessely: I would like to say that it is not that easy, or that would do us out of a job. Actually in general to know that something is wrong is the Clapham Omnibus test and that is very easy. I should like to think we have a bit more knowledge and expertise to know exactly why, what and where. There is nothing clever about psychiatry when spotting that something is wrong, that somebody is drinking too much, is crying all the time, has become more violent, is socially withdrawn; if you know about it, because it might be happening at home. I really do not think it requires massive expertise to spot that. Professor Hawton: No, it is not rocket science. Q459 Mr Jones: Could you suggest anything in the training which could be improved? Professor Wessely: That is where the US programme is very nice. They have some very nice training material, very simple, straightforward, aimed particularly at NCO ranks. It is very neat and very quick. Most of these things are just reminding people that their own commonsense judgments are actually quite accurate. Professor Hawton: I have to say that I have looked through that training material briefly. I should like to see it backed up a little bit with real-life examples rather than checklists of things to look out for. What would be useful might be to have young actors role-playing the sorts of things to look for. Q460 Mr Jones: We saw some of that a few weeks ago at RAF Halton where they are doing that training with a very good actress. Professor Hawton: You remember these things much better than when you just see a checklist of items. Q461 Mr Jones: The armed forces suggested to us that awareness training could sometimes be counter-productive for junior personnel. What is your experience? Professor Wessely: It depends what you mean. If we are talking about other ranks, teaching people the symptoms of post-traumatic stress disorder or depression for themselves I have to say I share that view. It is not something I favour. What we are talking about here is teaching people who have to spot, who have the duty of care, to recognise those signs and symptoms. I am certainly absolutely not in favour of giving every recruit a briefing on suicide; I am definitely absolutely not in favour of that. I could see that being very counter-productive. Professor Hawton: We may have some disagreement here. I agree with your last point, but I think being aware of some of the basic symptoms, things to look out for, to know whether or not you or someone else is becoming depressed, is different. That is worthwhile. It is such a common problem. As we have said, people often do not recognise it, particularly young males. I personally would favour trying to have that as something which is in their consciousness, that young people do sometimes develop these problems and these are the common things which we know signify this is happening. Q462 Mr Jones: How do you get a recruit to realise that they are suffering from depression and it is not just an off day, which we all have, do we not? Professor Wessely: We do. Q463 Mr Jones: What is the difference between the off-day and actual depression? Professor Hawton: It is persistence, is it not? Persistence and depth of feeling and how it affects your functioning. Professor Wessely: It is not just feeling sad, it is actually being sad and not being able to go to work. Because there is a disagreement on that one issue between us, I would make a strong plea that that therefore suggests we really do not know and it would be a research question. There are many things, for example psychological debriefing, which we thought was a terribly good thing and only when we actually did proper controlled trials, did we actually show it did more harm than good. This is another area where we genuinely have uncertainty. It would be nice if that could be subject to proper research, because we do not know. That is the truth. If we cannot agree, we probably do not know. Q464 Mike Gapes: Professor Hawton and Professor Wessely, this has been an extremely valuable session. Before we conclude, may I ask whether there is anything we have not touched on that you would like to add to what you have said? Professor Hawton: There is one specific point which we briefly touched on which goes back to suicide and to the availability of firearms - I understand that all four cases from Deepcut involved firearms - and this question of how that specific risk might be reduced. Professor Wessely: You have probably come to this conclusion anyway, but suicide is a solitary activity and I do not particularly like the idea of 16-year-olds on their own with guns. Suicide is a solitary activity and it very rarely happens in company. That is generally true, is it not? Professor Hawton: Absolutely; yes. Q465 Mike Gapes: What about the question of whether we put too much pressure or push new recruits too far? Is that an issue which needs to be looked at? Does that involve risk? Professor Wessely: We are not experts on military training, so we do not know. A training which was completely without stress would not be a training. It is not medical school. I was told by one officer very genuinely that on the whole, nevertheless, if you are going to have a breakdown it is better you have it on a base in England than in Basra. That is probably a legitimate point. Other than saying that it has to have some elements of stress in it, because war is a stressful business and you might as well come prepared, after that it is a technical question which we are not really qualified to address. Q466 Mike Gapes: You mentioned very early on that one of the risk factors was drug abuse and you said that was increasing. Is there any evidence that - this gets us into very controversial areas -smoking cannabis has an effect on people years later, and given the rising incidence, this has led to possible mental health problems? Professor Hawton: Professor Wessely can comment because he has done research on that, but I do not know of any evidence linking cannabis with long-term risk of suicide, although there may be, because of the associations we know with long-term risk of psychosis, for which there is now clear evidence. Professor Wessely: We are pretty convinced that it does increase risk of psychosis, which is not really a problem within the military. We have not done research on drug abuse in the armed forces for the reasons that we would not believe the answers people gave us and in order to get the trust of the research that is just a no-go area for us. They tell us about alcohol, no problem, but I am afraid we cannot help you on drugs, we just do not touch it. Q467 Mr Cran: I just want to be clear about what you were saying. You were saying that mixing of guns and so on with people who were possibly going to exhibit mental illness in the future --- Professor Wessely: No, I was making a general point that successful policies to reduce suicide have almost invariably been about means. Those are the things which have worked. Clearly you cannot have armed forces without guns, but opportunity. From analysis of those cases, and it might be that the psychological autopsy shows that even more, these happened in private. I would have thought, looking at where people are alone with guns --- Q468 Mr Jones: Then I did understand your answer; it was just that I articulated my question rather badly. My observation of the thing is that recruits' access to live ammunition is very strictly controlled; I mean very strictly controlled. I was just wondering whether you had any information or had a view that the strictness was not strict enough. Professor Wessely: That is well beyond our knowledge. I do not know. They know much more about firearms than we do. Mike Gapes: Gentlemen, may I thank you very much for coming. We are very appreciative. Memorandum submitted by Health and Safety Executive Examination of Witnesses
Witnesses: Ms Sandra Caldwell, Director, Field Operations Directorate and Ms Elizabeth Gyngell, Head of Division, Better Working Environment Directorate, Health and Safety Executive (HSE), examined. Q469 Mike Gapes: May I first of all welcome our witnesses from the Health and Safety Executive, Sandra Caldwell and Elizabeth Gyngell. As you are aware, we are carrying out an inquiry into duty of care. This is our fifth evidence session and the aim of the inquiry is to examine how the armed forces look after their people at the very beginning of their service, recruits in Phase 1 training establishments and trainees in Phase 2 training establishments. Ms Caldwell and Ms Gyngell, would you like to introduce yourselves and say a few words? Ms Caldwell: I shall kick off. I am Sandra Caldwell. I am HSE's director for field operations and basically to put that into context HSE has four operating directorates: the nuclear inspectorate, the railway inspectorate and what we call our hazardous industries inspectorate which deals with onshore and offshore chemical works. Anything else for which HSE has responsibility comes into my area: the public service, construction, agriculture through to hospitals, schools, self-employed builders. We cover the whole of that spectrum. I have with me today Elizabeth Gyngell. I asked Elizabeth to come along. She will introduce herself, but she works in our policy group. She has particular responsibility for psycho-social issues which include stress, bullying and violence at work. We just picked up from reading the Surrey police's final report, that these were possibly areas which you might want to explore. I shall hand you over to Elizabeth to give a bit more of an introduction. Ms Gyngell: My name is Elizabeth Gyngell. I am the HSE's priority programme manager for our stress work. That does cover a range of areas, but basically it is policy development and working out what we then do with that. Q470 Mike Gapes: Can you enlarge a little on HSE's specific responsibility for health and safety at armed forces' initial training establishments and how you fulfil that responsibility? Ms Caldwell: I shall start by explaining the application of the law and then drill down to your question. I hope that puts it into context for you. In the UK, the Health and Safety at Work etc Act 1974 applies to all armed forces, so it covers all activities of armed forces. The Health and Safety Executive is the enforcing authority for the Health and Safety at Work Act. We have the responsibility of inspecting MoD and its activities. In saying that the Health and Safety at Work Act applies to all of MoD activities, I have to say that is in respect of work activities. So what it would not cover would be a recruit who was off duty, on leave, away from the barracks. It is focusing on the work activity aspect. We also do not have a remit for industrial relations or, in a sense, for pastoral care. It is strictly for work related activity. Sometimes that is very clear; if a soldier is on guard duty it is very clear that would come within the Health and Safety at Work Act and we would be the enforcing authority for those types of activities. There may be some grey areas which we would have to have a look at, depending on the individual circumstance. That is no different from any other work place where somebody has access to a work place and might be using the work place for their own private activity and they are not at work. Q471 Mike Gapes: Does that mean you cover all MoD facilities in the United Kingdom? Ms Caldwell: Yes. Q472 Mike Gapes: Do you also have responsibility for UK facilities outside the United Kingdom? Ms Caldwell: No, the Act only applies to the United Kingdom. It does not apply, for example, if there are troops in Germany. It does not extend. Q473 Mike Gapes: So training which was going on in Canada or Norway or Germany would not come under your remit. Ms Caldwell: Would not come under our remit. Q474 Mike Gapes: That is helpful. Would there be any facilities in the UK which, for national security reasons, you would not be able to visit? Ms Caldwell: No, but there would be special procedures, in particular vetting procedures and security procedures. For example, our nuclear inspectorate deals with a lot of such areas. Q475 Mike Gapes: How many staff do you have who are actually responsible for health and safety in the Ministry of Defence? Ms Caldwell: I am going to give you an answer which you will probably say sounds as though I am trying to avoid the question. In total the number of staff in my division is something like 1,600 and they are regionally based. We have two types of interaction with the MoD. One is central approaches and we have what we call a public services sector. They are staff who make the central approaches to the Ministry of Defence's central health and safety areas, they will look at the systems and procedures, some of the discussions on some of the grey areas on the application of the law. We then regionally have inspectors who at any one time may or may not be inspecting the activities of the Ministry of Defence. We do not have a dedicated cadre of inspectors just looking at Ministry of Defence activities. They will be looking at the activities of the police or the fire brigades as well. They are not just dedicated to the Ministry of Defence. Q476 Mike Gapes: Could you then easily evaluate how much time your staff would spend on MoD-related matters? Ms Caldwell: I could not. It would not be particularly high to be honest. Q477 Mike Gapes: Could you give me some idea? Roughly how many days a year do you spend inspecting MoD facilities? Ms Caldwell: At the moment, because we are working to the strategy set by the Commission which sets our priorities, we would be mainly dealing with the MoD on a site visit basis, purely on a reactive basis, looking at the investigation of incidents. Q478 Mike Gapes: You do not initiate these yourself? Ms Caldwell: There are some areas where one of the regions may take an initiative because they may have investigated an incident which has led to some concerns about a particular activity and so they would go much wider. Q479 Mike Gapes: So normally it is reactive rather than proactive. Ms Caldwell: Normally it is reactive. May I paint a picture for you? When we are dealing with large public sector bodies such as the National Health Service, the MoD, our approach would always be of looking at safety management systems and an audit type of approach. We would first be looking at the senior commitment and what the policies are, organisation, arrangements and procedures and then audit against those via site activities. For example, the Health Service is a particular priority for us. Last year we carried out something of the order of 30 in-depth audit activities of the health services, but because MoD is not a priority area for us, we have the central approach, looking at the procedures and systems and a reactive way of inspecting by selecting certain accidents and incidents to investigate. That is how we work. Q480 Mike Gapes: If you did 30 in the NHS, how many did you do in the MoD? Ms Caldwell: Last year we would not have done any audits. The combination in respect of the MoD is of a central approach and reacting to complaints or incident investigation. Q481 Mr Hancock: Do they give you a hard time? Do they say they do not need you because they have a good track record and they look after their own health and safety? Ms Caldwell: No. To be honest, when the Health and Safety at Work Act first came in, which was in the late 1970s, there was a real concern about the application of health and safety legislation to the MoD. There was a real concern that we would get in the way of the defence imperative. We have worked to establish that Parliament has decreed that the Act should apply and we have a responsibility to ensure that what the Health and Safety at Work Act requires is being done in the MoD. We now have a relationship which enables us to do that. In some of the areas we do have difficulty in the sense that under the Act there is a whole set of regulations and some of those regulations disapply some of the requirements. For example, in the reporting of incidents, diseases and dangerous occurrences regulations, the regulations apply, but the reporting elements of them are qualified by the fact that there is no requirement to report accidents which occur on duty. What has happened is that in a sense we have lived with that; we now have relationships with the MoD such that they do report work-related fatal accidents to us and serious accidents to us and we do investigate them. In the areas where we have investigated incidents and made recommendations, those recommendations have been followed up. Obviously we sometimes have robust discussions, but I have had robust discussions on construction sites as well. Do they ever invite you when they are planning a new establishment, for example, which is going to be predominantly for the training of young recruits, to give some advice about how they should set up certain procedures on this site? Is that something you have ever come across? Ms Caldwell: Not that exact example, but they do come to us when they are going to introduce new systems and ask whether they can discuss the systems with us: they have these procedures and can they discuss the procedures with us? We will also look at their procedures and if we have areas or issues we will take them up with them as well. Q482 Mr Hancock: Do you have a specific officer within your organisation who is the linkage between the HSE and the particular element of the military? Ms Caldwell: Yes; we have two. They work in what I call our central area. Q483 Mr Hancock: You have two link officers, do you? Ms Caldwell: Yes. Q484 Mr Hancock: Do they ever get involved in, say, some of the incidents we are investigating where young people have been killed in incidents or there have been accidents? Have you been involved in that type of investigation? Ms Caldwell: We will investigate all fatal accidents which are work related. Q485 Mr Hancock: So a soldier on guard duty who died through --- Ms Caldwell: Even though it is not reportable to us, the MoD does report it to us and we will investigate. Q486 Mr Hancock: Would they report it to you at the stage where there would still be hot evidence to judge whether or not what they were telling you was correct, like the same day, the next day, the next week? Would it be after the MoD police had been involved, the military police or indeed the civilian police? Where do you fit in the hierarchy of people who need to know? Ms Caldwell: On "fatals" we would be alerted on the day. On serious accidents, it may take a few days longer to report to us. Q487 Mr Hancock: Do you have fairly accurate records of the incidents where you have had that reported to you? I should be interested to know whether your tally of incidents matches the number of incidents and the timing that we have been given. Ms Caldwell: I can provide you with whatever data we have, if that would be helpful to you? Q488 Mr Hancock: Yes, it would be. Ms Caldwell: The point I want to come back to is always that for our involvement we would be looking for the work-related link. Issues such as suicide --- Q489 Mr Hancock: But we would not know it was suicide, would we? It would be a young soldier, found dead, middle of the night, on guard duty alone, dead, shot. We can maybe guess it was suicide, but nobody at that time could say for sure whether it was suicide. What would they say to you? There has been a non-accidental death, please come and have a look to see what you can make of it? Ms Caldwell: Up until recently we have probably indicated to the MoD that if the issue is a matter of suicide or possibly murder that is the situation. Q490 Mr Hancock: But you do not know that, do you? Ms Caldwell: I know, but I am just saying that we do make it quite clear in other work-related deaths, when we are dealing with the police for example, because we will investigate other work "fatals" in conjunction with the police. What we try to do is get enough information and the police are usually able to indicate to us whether they believe it is a suicide or work related. I am coming to your point. In the past, if we believed, or the information we had received pointed to suicide, we would leave it to the police with the MoD to explore that issue, as we did in the Deepcut area. We were not involved in those. Q491 Mr Hancock: You did not investigate any of the Deepcut incidents. Ms Caldwell: We did not investigate. Q492 Mr Hancock: But you were informed on the day of the incidents, were you? Ms Caldwell: I would have to check that for you. Q493 Mr Hancock: It would be interesting to know. If, for example, there was a death from a bullet wound, but you would not know, nor would the military know, that it might have been a malfunction of the weapon, for example, I am interested to know what your role is whether or not you would be involved in something like that, where the weapons were not adequately maintained. That must be a health and safety issue. Ms Caldwell: That would be a health and safety issue. Q494 Mr Hancock: I find it difficult to understand where your role is. If the military have an obligation to inform you --- Ms Caldwell: They do not. Legally they do not. That is what I was saying. Strictly legally, if it happened on duty, the regulations do not require the military to report that to us. What has happened over recent years has been that they have reported fatal accidents to us. Legally they do not have to, if the incident happened when the individual was on duty. Q495 Mr Hancock: Would you be involved in the procedures for young recruits or Phase 2 trainees who had done their first phase or in between phases of recruit training, predominantly 17- or 18-year-olds? Would you be asked by the Army whether it was good practice in health and safety terms that such young people be given live ammunition? Would you be asked to suggest to them good practice for the way in which those weapons were accounted for or the ammunition was issued? Would that all be something the Army would take on board themselves? Do you set them standards which they have to maintain? Ms Caldwell: We would look at the standards which they have actually developed. For example, when we have investigated accidents involving shooting, we would look at the standards, the systems and procedures. To be honest, in the shooting incidents I am aware of where we have investigated, what has normally been the situation is that the systems and procedures are adequate. It is the application of those systems and procedures which has failed. Q496 Mr Cran: I just want to be clear in my mind about this, because I am finding this extremely confusing. As I understand it, you said that the armed services were under no obligation to consult or involve you in those cases where a serviceman was on duty. Ms Caldwell: That is the wording of the current set of regulations on reporting. Q497 Mr Cran: You did go on to say that they do nonetheless not observe that and they do inform you. Ms Caldwell: They do inform us. Q498 Mr Cran: Could you be clear about why that is? Ms Caldwell: Because in a sense we have built up this relationship and they recognise that we have a genuine and a proper interest in investigating those incidents, to investigate them with them, for us to learn the lessons as well as for them to learn the lessons to ensure that information can be fed back into ensuring the right procedures are in place or getting the right understanding from the command of the importance of applying proper procedures. Q499 Mr Cran: Fine. I have got us to where at least I want us to be. I think the question then must be: do you consider that to be adequate? I would myself worry about a situation where the armed forces were not obliged but merely through good practice consulted you. Until somebody tells me why it should not be, I should like to see this on a statutory basis. Ms Caldwell: I shall widen it even further and then I will answer your question. I said that the Health and Safety at Work Act applies to all MoD activities, but they are a Crown body and they have Crown immunity. As a consequence, we are unable legally to use our usual enforcement powers. That is in relation to the Act. What we have built up over the years are equivalent administrative arrangements to deal with that. I can explain the equivalents. Even in the Act, although we have the responsibility and we carry out our regulatory work, Crown immunity disapplies our enforcement ability there. In respect of the reporting of accidents, again there is that difficulty. Both the Health and Safety Commission and the Health and Safety Executive have publicly said that we would support the removal of Crown immunity and it would go not only on the Act, but also we are going to be reviewing the regulations. We would start from the premise that those regulations should apply to all. Q500 Mike Gapes: On the question of Crown immunity, it is not just the Ministry of Defence which has Crown immunity. This place has Crown immunity. Ms Caldwell: I know. As a junior inspector, I found that out when I wanted to stop some activity here. Q501 Mike Gapes: We will not talk about water supplies a few years ago. Is your point about Crown immunity a general point or are you specifically referring to the MoD? Ms Caldwell: It is a general point. It has been repealed in certain areas with respect to health and safety, but not generally. Q502 Mr Hancock: Have they ever in your experience used Crown immunity to prevent you having information you have asked for? Ms Caldwell: In my experience, no. Q503 Mike Gapes: How long have you been doing this job? Ms Caldwell: That was what I was going to come on to say. I took up this post in December, so that is a short time frame, but in briefing for this afternoon, nobody brought that issue up with me. Q504 Mr Hancock: Did they raise with you the issue of Crown immunity and say this was a good opportunity for you to say that Crown immunity is a problem? Do your colleagues recognise it as an impediment against them doing their job properly? Ms Caldwell: Personally, I think it should be removed, because there should be a level playing field. As an enforcer, it is unfortunate that we do not have a level playing field, that we have certain powers which we exert when we are inspecting private sector work and we do not have the same level playing field for the public sector. I personally and the Commission and the Executive would hold that particular view. Q505 Mr Cran: May I just ask a teeny question, so I get this into my head? The following proposition would be correct, would it not? The MoD do indeed try to bend over backwards to be co-operative with you but at the end of the day we cannot any of us be sure that you are indeed consulted on 100 per cent of the occasions where anybody else without Crown immunity would have to. That is correct, is it not? Ms Caldwell: That is correct. I would say that the commitment at senior level is there. Q506 Mr Cran: It is a question of what happens below that, is it not? Ms Caldwell: Yes and that is always the same in any work environment. As you say, we have the particular situation then of Crown immunity. Q507 Mr Cran: We have got there. That is fine. You said in answer to the Chairman that visits to training establishments are reactive - I took the word down. Do you think that is adequate? I know perfectly well that you, like everybody else, have resource constraints and all the rest of it. Talk me through why, if you believe it to be so, that is adequate. I like to see visits which nobody expects and you just zoom in to see what is really happening. Do I have this all wrong? Ms Caldwell: No. Let me deal with that, because that is a slightly sideways point. In most work environments, unless we are visiting to investigate accidents and incidents, our usual approach is to call uninvited so to speak, unless we are doing something like an audit which we have to set up and which requires a lot of documentation and talking to the management. Obviously, if you want to investigate an accident, you want to ensure that the right people are there. I have almost lost myself in that eloquent reply. Q508 Mr Cran: It was very eloquent. The point of my question was that as I understood it, the visits to training establishments are reactive. I asked: is that adequate? Ms Caldwell: I think you would expect that I could always do more if I had more resources. At the moment, our priorities are set by the Commission and I have to cut my coat according to the resources that I have. With respect to the MoD we do have the central approach and the reactive approach. A degree of proactivity would also be sensible. Q509 Mr Cran: I just have to know what all that means. Are you agreeing with the proposition that it is not adequate and therefore you would like to be free to go in unannounced when you felt you wanted to? Ms Caldwell: I would put it this way. Under the Health and Safety at Work Act, the responsibility for adequate arrangements lies with the duty holder, not with HSE. Our responsibility is to ensure that there is the commitment, that the procedures are in place and to police them. At the moment we do it on a reactive basis. In other areas we do it on a proactive basis because they are a priority. If we had more resources, we would be able to do more proactive work. Q510 Mr Cran: I do understand that, but I am trying to get you to give me a clear answer to my question. Do you think it would be desirable, if you had the resources at hand, to be able to make unannounced visits to Army establishments? Ms Caldwell: More resources would enable us to carry out audit activities. Q511 Mr Cran: That I understand. Ms Caldwell: I do not think we would make unannounced visits to the MoD just because of the security aspects. It is a little different. I am not trying to be clever here; we do have the arrangement that we notify so that they can check that we are who we are. Mr Cran: I understand. Q512 Mike Gapes: May I take it a step further? You referred to the regulations which give exemptions and some of them relate to diseases and other matters. Could there be a case for these exemptions applying in general to MoD establishments, but not to the initial training establishments which are a rather special place within the MoD? Is it necessary to have exemptions for the initial training establishments in the armed forces? Ms Caldwell: I think with law, if there is a will, there is always a way, is there not? To be fair to the MoD, I am not sure that they are necessarily comfortable with the particular exemption on the reporting of incidents, just by the very nature of the type of arrangements they have in place. Some of that is more historical than an actual concern. On the reporting aspects, when we revise the regulations, that would be an area where we would have discussions and I could see that developing. The Act does apply to initial training establishments and our responsibility for scrutinising or regulating them applies. So it is not disapplied from initial training establishments. The only thing which is not applied across the piece is the reporting issue. Q513 Mike Gapes: Is that not the essential point, that under Regulation 10(3) of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 reporting requirements for accidents, deaths and diseases do not apply to members of the armed forces on duty? Ms Caldwell: I would not like us to try to do it piecemeal; I should like the lot to go. Q514 Mike Gapes: Is there not an argument that armed forces on duty in combat operations are different from armed forces on duty in initial training establishments? Would there not be a case at least for you being able to have the requirements not disapplied in the initial training establishments? Ms Caldwell: You could do that; there is no reason why you could not do that. Equally, at the moment there is probably no reason why, when the regulations come up for revision, you could not start from the basis that there is no exemption at all. Mike Gapes: Thank you; that is helpful. Mr Cran: A nice seed sown there. Q515 Mr Jones: We have been talking about initial training establishments and you have a situation where young people are in an environment. What main differences do you think there are or have you come across between a military establishment and a work place with 17- or 18-year-olds? Do you think additional support could be given to those 17- or 18-year-olds and are there things happening in private industry which could be cut across to training establishments? Ms Caldwell: In all aspects of training or do you have a particular area in mind? Q516 Mr Jones: Phase 1 training for example. You have a lot of young people in a concentrated area at once. Are there health and safety issues there which you think need more regulation as opposed to 17- or 18-year-olds working on a shopfloor or a factory? Ms Caldwell: I would start from the basis that Regulation 19 of the management regulations does require all employers to look at the vulnerability of young people irrespective of the workplace they are in. A lot of that is that there is a recognition that they do not have the same life experience as established workers, they may be physically or psychologically still immature and you have to be able to match the training to their abilities. Then, in looking at initial training establishments, there probably are some other factors which one would look at in the sense that obviously it is a very disciplined environment, probably far more disciplined than other workplaces. That could be a good thing as well as a bad thing. I am not saying good or bad, but it is a difference. One of the other issues is that some of the training they are undergoing is by nature more hazardous, but that is the job they are going to be doing and they need to be trained in that activity, as firemen need to be trained in dealing with fires before they do it for real. What I would be saying is that what needs to be done is to look at those particular circumstances to see whether anything over and above what would be the norm elsewhere needs to be applied. Ms Gyngell: I would agree. The other aspect is that they are very often removed from their family support system. It is not only that condition, because they might have gone to boarding school or wherever, but it is unusual for quite a lot of the people, as I understand it. So one would be looking for that to be added to the things you would want to pay particular attention to. Ms Caldwell: They will also perhaps not yet have developed social support systems that you get in work places if you are an established worker. Q517 Mr Cran: I should be quite interested to know whether you have any role whatsoever. I would not be surprised to hear the word exemption come out very shortly. Do you have any role in terms of advising the MoD, the armed services, or auditing the armed services, in terms of things such as bullying, work related violence or excessive stress? Ms Caldwell: May I say what we are doing? We have looked at the final report of Surrey policy into the Deepcut incidents and there we are picking up that stress and bullying may be issues. We have done a number of things. We have spoken to the MoD and asked them for all their documentation on stress and bullying and we are setting up meetings to discuss this with them, really to see whether we can help improve the situation and determine whether they are looking at the right things. We have also approached them with the Adult Learning Inspectorate, whom ministers have asked to look at MoD's training. We are looking to see whether we can work with them and co-operate in looking at some of the areas; really to see whether we can join forces to see whether there are areas it would be sensible for us to look at. We have also informed the coroner that we have an interest in areas of stress and bullying, if that is an issue. We have also alerted our field force that, when we do get reports of incidents which appear at first to be a suicide, they should ask questions of the police to see whether there are any issues associated with stress and bullying. We did that at a recent death in June. Q518 Mr Cran: In the armed forces? Ms Caldwell: In the armed forces. That looks as though it was not a work related death. We are conscious that there may be evidence that stress and bullying may be an issue and we are making sure that we are looking into it. There are various reasons. Obviously we have the responsibility, but also we ourselves are developing expertise in this area. Elizabeth can tell you about the work we are doing on developing management standards and work we have been doing with DTI on bullying, really to make sure that the right standards are going to be applied and the right understanding is being developed. Q519 Mr Cran: Do I understand from that and from previous answers to questions that albeit you are doing what you have just outlined, the MoD may or may not listen? Ms Caldwell: I should be very surprised if they did not. As I have actually said to you, they are very co-operative when we make recommendations. Nothing has been brought to my attention as an issue and a real concern that the MoD did not respond. I have every expectation that they will respond. Q520 Mr Cran: I do not doubt that they are keen to respond, but I just want to know what the situation is. They do not have to respond. Ms Caldwell: Yes, because although there is Crown immunity and we are unable to use our enforcement powers, what we have set up are equivalent administrative procedures. For example, my inspectors have powers to issue what are called prohibition notices and powers to issue improvement notices. Where Crown immunity does not bite, a prohibition notice would stop work activity immediately until the issue had been put to rights and an improvement notice is a legally binding document which requires certain improvements to be made. What have been agreed across the piece with the Cabinet Office, where Crown immunity bites, and there are instructions on this, are Crown notices. We have Crown prohibition notices and we have Crown improvement notices. If we made a judgment of the nature you were indicating, that we felt our recommendations were not being taken seriously, or that we were not going down the right lines, we could issue a Crown improvement notice. Mr Cran: That is really helpful. Thank you very, very much. Q521 Mike Gapes: Where young people aged 16 or 17 are in training, in general employers must take steps to supervise them appropriately and ensure the risks have been reduced. What particular steps would you expect the armed forces to take to meet the particular needs of young recruits under the age of 18? Would it be acceptable to expose them to the same training risks and regime as recruits above the age of 18? Ms Caldwell: You would start with your selection procedures first. Are your selection procedures tailored to your needs? For example, we as an organisation obviously recruit and train inspectors and we now have selection procedures. We have given job specifications and have psychometric testing to ensure that we are getting people into our organisation that we think are going to be suitable for the task. I would expect the same thing to occur in Army training. Once you have recruited people in, what you need to be able to do during training of anybody, but even more so with young people, is to ensure that the risks in that training are reduced and that the right amount of supervision is also applied. It is also important that you not only in a sense apply selection procedures to recruits, but also to your trainers, so that you have the right trainers, with the right approach and with the right competencies. I have already mentioned that there is a legal requirement, Regulation 19 of the Managing Regulations, which does require any employer, and that would include MoD, to look at the particular training they are giving to young people, to tailor it for their physical and mental maturity and capability. Q522 Mike Gapes: So the answer to my question is that it would be different for those under 18 from that for those over 18. Ms Caldwell: Yes, in that particular element. There is that precise requirement to look at that. Q523 Mike Gapes: Does European legislation influence your work in any way? If it does, how would that affect the military training? Ms Caldwell: The answer is yes, because there are health and safety directives which have to be implemented. Those directives would be implemented in regulations under the Health and Safety at Work Act and then would apply to all work places. Unless there was an exemption, they would apply to the Ministry of Defence and training establishments. Q524 Mr Jones: May I turn to the issue of firearms? Obviously you cannot have armed forces without firearms, but you will be aware that in civilian establishments where firearms are used there are very clear regulations. From my experience at Sellafield, where they have an armed police force, there are quite tight regulations as to how firearms are carried on site and also how they interact with civilians. What measures should be taken at an armed forces training establishment to ensure that access to firearms and the use of firearms is made as safe as possible? Do you have any experience of investigating deaths where firearms have been involved? Ms Caldwell: Yes. The only guidance we have issued on firearms is on the use of shotguns by farmers. That said, because we have had occasion to, because we have investigated incidents involving shootings, we have looked at MoD's own guidance on firearms and find it very comprehensive. The incidents we have actually investigated fall into two categories: either those systems and procedures have for some reason or another not been applied, or there has been an unusual circumstance in which the individual has been injured. For example, one area we were looking at and now the MoD are looking at was the design of a safety catch. A gun went off in an environment where it would not have been expected to go off. We pursued that and the MoD are looking at the design of the safety catch. Q525 Mr Cran: You have already made it very clear to us that the HSE has powers to investigate serious accidents at MoD bases and that is correct, is it not? Ms Caldwell: Yes. Q526 Mr Cran: The Committee would be interested to know how many incidents such as these have been reported by each of the wings of the armed forces in, let us say, the last five years. Is that a set of statistics you could provide for us? Ms Caldwell: I could not provide them now, but I shall provide whatever data I can. Q527 Mr Cran: That would be very gratefully received. At the same time could you include what type of accidents they have been? Is there a theme to all of this? Are they the same type of accidents? Are they quite random? That would be helpful for us too. Ms Caldwell: Okay. Do you want accidents just to Army personnel? We also have responsibility for all the civilian workforce of MoD and we have a lot of information. Q528 Mike Gapes: As much as you can give us and we will decide what we need for our report. Ms Caldwell: Okay. Q529 Mr Cran: At the same time, it would be very helpful for us to know how many of these incidents resulted in Crown improvement notices or Crown censure notices, if any. Maybe none of them did. If they did, we should like to know. Ms Caldwell: I can also provide another piece of data. I mentioned the Crown prohibition notices and the Crown improvement notices. We also have another administrative procedure which is called a Crown censure. Crown censures are used in situations where we would normally think there was sufficient evidence for us to take a prosecution in a criminal court. If in establishments which have Crown immunity we find sufficient evidence that if Crown immunity had not been there we would have gone to court, we have a system called Crown censures. We actually bring the senior management in from whatever public body it is and lay before them our evidence and get their response to it and agreement to the recommendations we would make. The MoD will publish in their records when they have had a Crown censure, so I can also provide you with details of Crown censures over the last five years, if that would be helpful to you. Q530 Mr Cran: Superb; that is what we should like. Please. Just a general question which in a way you have answered before but it has been in the middle of all sorts of other answers and I just want to disentangle it all. Take the question of initial training establishments. I just want to get a sense from you of how the MoD have reacted to any recommendations which you may have made to them for improvements, to the systems or whatever. Ms Caldwell: In the briefing I have, but I will check for you, I cannot recollect anything which says they have not responded in a way we would expect them to. Q531 Mr Cran: Is it possible therefore for you to confirm to us how many recommendations you have made over a reasonable time period, that is one which is reasonable for you and is not going to result in undue expense and all that? Ms Caldwell: May I say that I will give you examples of the type of recommendations we have made? Is that acceptable? Mr Cran: It is not like 100 per cent, but if that is what you can give us, we will have a look and if we want more we will come back to you. Q532 Mike Gapes: May I take you back to an earlier answer you gave? In this context of European legislation and health and safety at work directives, what would happen in the case of a conflict between a European directive and MoD training policy and practice? Would Crown immunity just come in and that be the situation, or not? Ms Caldwell: We would treat it in the same way we negotiate with the MoD when we are developing any set of regulations. We start from the basis that they should be applied and that MoD need to make the case to us for an exemption to be made. I have not come across that type of conflict. Usually if it is a conflict like that, there would be a more generic conflict in other work places. Q533 Mike Gapes: Perhaps we can look at that again later. Final question I think. It has been a very long session for us as a committee and hopefully we can conclude with this one. The attitude of the armed forces to health and safety issues. You have said that they are doing things they do not actually have to do and that they are complying with things even though they have immunity. Do you have a general overview on how the services interpret and implement health and safety policy generally and how they asses and manage risk to recruits under training? Ms Caldwell: I would make a comparison really with other work places. We would say that we certainly have the commitment from the top. We would certainly say that MoD put a lot of resource into their central consultative function. On occasions, however, there will be failures of application of their systems and procedures. That is no different from any work place where you have commitment from the chief executive and the board and trying to get that same commitment in a large organisation right down to your field force is quite a challenge. It is down to ensuring that you establish the right safety culture, that those in that management command actually do take health and safety seriously and are seen to take health and safety seriously. Let us look at bullying for example. The type of thing you would be looking for would be to ensure that there is clarity on what is acceptable and unacceptable behaviour and that anybody in the command structure, seeing unacceptable behaviour, would actually act to stop it rather than just walk by. It is trying to get that in such a large organisation as the MoD which is a real challenge to them. It is a challenge which is not unique to the MoD I can assure you. Q534 Mike Gapes: Therefore what do instructors and people lower down the chain of command need to know and what training do they need in order to ensure that they are able to contribute effectively to providing a safe training environment for recruits? What should they be looking for to check that they are assessing risk appropriately and addressing issues which come up? Ms Caldwell: It comes down to the ability to carry out a risk assessment. Trainers need to understand that the risk they need to control is the risk of the activity they are trying to train people in, the risks associated with applying that training and the risks associated with the environment or the premises in which that training is taking place. A lot of that can be done by tailored risk assessments which would be used routinely, but there will be occasions when they actually need to have the ability to recognise that it is a dynamic situation and the situation has changed and they need to be able to assess that risk. This is the point about making sure that the trainers are trained themselves. Q535 Mike Gapes: Absolutely. Thank you Ms Caldwell and Ms Gyngell. Do you have anything else you would like to add that you do not think we have touched on? Ms Caldwell: The only point you might want to be aware of, because you tackled me a little bit on the issue of resources, is that the DWP Select Committee has been looking at HSE's activities. The Chairman of the Commission and the Director General of the HSE appeared before them on 11 May. You might want to have some discussions with them. I just thought that might be helpful. Mike Gapes: I am sure we will have a look at the transcript. Thank you very much and thank you for coming and giving us a most useful session this afternoon. |