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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 655-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE defence committee
MEDICAL CARE FOR THE ARMED FORCES
Tuesday 12 JUNE 2007
MS SAMMIE CRANE, COMMODORE TOBY ELLIOTT RN, AIR COMMODORE EDWARD JARRON, MS SUE FREETH Evidence heard in Public Questions 1 - 104
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Defence Committee on Tuesday 12 June 2007 Members present Mr James Arbuthnot, in the Chair Mr David Crausby Linda Gilroy Mr Adam Holloway Mr Bernard Jenkin Mr Brian Jenkins Robert Key Willie Rennie John Smith ________________
Memoranda submitted by the Ex-Services Mental Welfare Society, The Royal British Legion and the Soldiers, Sailors, Airmen and Families Association
Examination of Witnesses Witnesses: Ms Sammie Crane, Chief Executive, Army Families Federation (AFF), Commodore Toby Elliott RN, Chief Executive, Ex-Services Mental Welfare Society (Combat Stress), Air Commodore Edward Jarron, Secretary-General, Royal Air Forces Association (RAFA), Ms Sue Freeth, Director Welfare, The Royal British Legion, and Mrs Elizabeth Sheldon, Project Manager, Soldiers, Sailors, Airmen and Families Association (SSAFA), gave evidence. Q1 Chairman: We welcome our witnesses. We are about to begin the first evidence session of our inquiry into medical care for the Armed Forces. We intend to hold several evidence sessions on this matter and make several visits. We are also in the course of doing a web forum and have just extended that forum. One of the ongoing threads in that web forum is criticism that it is stopping discussion. If you would encourage people to take part in the web forum it would be very helpful. Even if they want to have a go at me it would be a very good idea for people to get involved in the web forum. It is the modern way to find out things. We hope to publish a report towards the end of the year because this is an extremely important subject. Perhaps you would begin by introducing yourselves and saying what your organisation does and your role in it. Ms Crane: My name is Sammie Crane, chief executive of the Army Families Federation. The federation works to make sure that army families are treated fairly, secure a fair deal and are represented in the decision-making process on policy and legislation. Commodore Elliott: I am Commodore Toby Elliott, chief executive of Combat Stress, more properly known as the Ex-Services Mental Welfare Society. My charity looks after veterans of all three Services and the merchant navy who suffer psychological injuries as a result of service. Air Commodore Jarron: I am Air Commodore Edward Jarron, chief executive of the RAF Association. That is a membership association which offers comradeship and welfare. Approximately 10 per cent of its turnover is spent on comradeship and 90 per cent on welfare support for the Royal Air Force. Ms Freeth: My name is Sue Freeth, director of welfare of The Royal British Legion. I am sure that many of you know of the work we do. The three pillars of our provision are: comradeship, remembrance and welfare. We provide a wide range of welfare activities for both the serving and ex-serving community. Mrs Sheldon: I am Liz Sheldon, project director for in-service support at SSAFA. We provide a broad range of social welfare support for in and ex-service people and their families. We look after and help 50,000 people a year. Chairman: I want to run briefly through the structure of the areas that I hope we will cover this morning so that if there is a particular subject that you want to deal with we will get to it at some stage. If there is not a particular subject that you want to deal with you can pop it into one or two of your other answers. We will deal with the following: medical care for operational casualties; rehabilitation for service personnel; healthcare for service families; care of service personnel after discharge; mental health; and the general role of the voluntary sector. It may well be that you believe you have something to add to what another witness has already said. Because there are five of you there is no need to come in on every question unless you want to add a nuance or give a different experience of the answer to that question. Let us begin with medical care for operational casualties. Q2 Mr Crausby: The treatment of service personnel, especially those injured in operations in Iraq and Afghanistan, has been a matter of considerable public concern and debate particularly in the media. Turning first to the Royal Centre for Defence Medicine in Birmingham, can you tell us whether you believe that the principle of having a single receiving centre for casualties in an NHS acute hospital is the best way to deal with them? Ms Crane: The feedback I have had is that the clinical care at Selly Oak is so good it could not be replicated elsewhere and therefore that is the correct place to which serious casualties should be taken. Mrs Sheldon: I have been to Selly Oak two or three times and involved in projects to set up family accommodation there. I agree that clinical standards there are very good, but perhaps it may be useful for the Committee to broaden the discussion to consider the way in which welfare is delivered more holistically in terms of looking after the emotional needs of patients and their families not only at Selly Oak but onwards. Q3 Chairman: We will come to the care of service personnel after discharge. Mrs Sheldon: This is in-service care. Commodore Elliott: One cannot refute the priority that casualties must be given the best that is available in this country. If the surgeon general says that he cannot do it with his Defence Medical Services then we have no argument about from where it should come. If Selly Oak can provide it that is fantastic. Ms Freeth: We have made two trips there in the past three months. I reiterate other comments here. We are very satisfied with the medical care being provided there. I believe that the therapeutic value of being in a military-managed environment is absolutely critical to the improvement and rehabilitation process and the care when casualties are evacuated. The interface with health and personal care for individuals whilst there is perhaps the point where further improvement needs to be made. At the moment healthcare is extremely good, but support for people who visit and for the individuals whilst there in terms of providing basic essentials is currently provided by charity which some of suggest is perhaps not appropriate. These are essential things like toiletries and clothing for people who have been separated from their possessions and travel assistance for visiting families. It is particularly difficult for single personnel. I think that those are areas where we encourage further consideration. Q4 Mr Holloway: Do families not get rail warrants to visit injured soldiers? Mrs Sheldon: They do. There are regulations which give help with transport and accommodation for seven days when the patient is either seriously ill or very seriously ill. Once the patient moves off that list public funding stops. One can imagine that it is very difficult for families travelling from one end of the country to the other, or from overseas, to visit patients. One has foreign and commonwealth families. Fijian and South African families come over and suddenly find themselves stranded in the UK because funding has stopped. That is where the charities are stepping in because public funding has stopped. Air Commodore Jarron: I agree with the broad point that in order to provide the level of medical expertise that is required for battle casualties being part of a teaching hospital is the way to go. I do not think any of us would disagree with that. In terms of support for families, the Royal Air Force Association is at the beginning of that process. We have been largely a veterans organisations and we are now focusing far more on current Royal Air Force support. Like The Royal British Legion, we are looking at ways to support people who often have been hauled off the battlefield, treated in theatre and then sent straight back. Little items like toiletry packs are things that we are starting to put in place. Ms Crane: As to travel, the travel allowance that is given to families is supposedly for seven days initially. It can be and frequently is extended. It applies when someone is seriously or very seriously ill and once the individual is no longer on that list the amount of travel assistance available reduces. Q5 Mr Crausby: Therefore, it relates to serious illness, not the seven days? Ms Crane: The amount of travel assistance for families applies whilst service personnel are seriously ill or very seriously ill. Q6 Mr Holloway: If someone who has not seen his family for ages gets hurt in Afghanistan and may die assistance is available for seven days, but if he gets better and is there for a month or two and is not in danger the family end up paying for it? Ms Crane: Yes. Q7 Mr Holloway: That is incredible, and it should be all over the press. Ms Crane: I should like more clarification about when it does and does not, because when I have talked to them they have said they have extended the allowance whenever it has been requested. Ms Freeth: Clearly, there are lots of people involved in advising individuals. For some people what is available in principle and what they hear about and are able to access therefore is too variable. Q8 Chairman: Did you say that the allowance had been extended whenever the request had been made? Ms Crane: Yes. Q9 Chairman: So, people are not aware that they should be making the request to extend the allowance? Ms Crane: That is my point. I have asked that there is more information about how families request that additional grant. The feedback we have had is that quite often people are very proud; they feel that they are asking for charity and it is not at the top of their mind. There ought to be a pamphlet or something giving that information. Mrs Sheldon: There is quite a lot of confusion and a number of people are involved in trying to address the issue. But people at Selly Oak are pretty hard pressed in trying to see if they can extend people's stay there. They could be looking at all sorts of different channels to get funding and assistance from the charitable sector, or perhaps welfare funding within the MoD. For the people who are trying to deliver the service, let alone families, it is very confusing. Q10 Mr Jenkin: I am somewhat astonished by this. I always imagined that when a serviceman was injured and shipped back home there would be a single point of contact for the family. Whether or not it be home representation of the unit, there would be somebody who was the point of reference for that family and the red carpet would be rolled out. What is missing from that? Ms Freeth: The CO is responsible. Q11 Mr Jenkin: COs are usually pretty busy in theatre so that is not viable. Ms Freeth: When a casualty occurs the provision for the family is exceptional. People are found everywhere and brought to wherever that soldier goes, whether it is to Germany - Ramstein - or Selly Oak. That is very successful, and heaven and earth are moved to make sure that the family gets to the soldier. What we are talking about here are days, weeks and months later when the soldier is not in such a critical condition and then the travel allowances reduce and confusion arises, but the initial stage is very good. Q12 Linda Gilroy: Ms Crane, have you dealt with individual cases of that kind? Are you able to give us more precise examples of what you have said? Ms Crane: I can access them and have been told about them. Very few families have contacted us to complain about their treatment at Selly Oak. Q13 Linda Gilroy: One of the difficulties facing the Committee is that it hears about cases and it fully understand why people may be reluctant to come forward. But it would help us enormously if through your organisations people can contact us with examples of these things rather than just hearsay. Ms Crane: What I am saying is that it is positive. Q14 Chairman: You may be able to give us a case study, perhaps with the names removed if people wanted to remain anonymous. Ms Freeth: Most of the cases we have seen are those involving single soldiers. They do not have those family arrangements. Those are the individuals in respect or whom we have been approached to help finance travel allowances. We have done that in a number or cases and I am sure we can provide details on those individuals. Q15 Chairman: I want to come back to the issue referred to by Sammie Crane. She said that if there was a request the allowance would be extended. Have you been aware of that? If so, presumably you would say to the individual soldier that he should ask for an extension of the allowance. Ms Freeth: That is not always understood in terms of the individuals. The unit welfare officer is dealing with the individual concerned. Inevitably, we send people back to challenge whether there is already something available for them, but they come back and are told it is not there. Maybe there is not enough information. The people who are assisting people in the whole process are not always the best informed, perhaps not for want of trying, and so it is still very variable. Q16 Chairman: Therefore, the unit welfare officers are not aware that they should be extending the allowances? Ms Freeth: In some cases I believe so. Mrs Sheldon: One of the issues here is that from Selly Oak to Headley Court is not just a straight patient pathway; people dip into and out of specialist units and go backwards and forwards maybe from Selly Oak. It could take some time for them to reach Headley Court, if at all. It is very confusing for all the people who are trying to manage the process and communications and get clarity about entitlements and allowances. We have helped in instances where people, both single soldiers and families, have been sent to other specialist units and have needed help with transport, so we can supply information. Q17 Mr Holloway: To go back to the point about people receiving this benefit if they are told about it, are we really saying that the main mechanism for looking after people when they are no longer critically ill is the dead wood in the rear party? Ms Freeth: The unit welfare officer under the new SAM system is responsible for ensuring that local contact is maintained with the individual on his or her return, deployment or discharge. That will depend very much on the experience they have had. I do not know how much training they have received. Q18 Mr Holloway: There is no quality control whatever. Ms Freeth: I believe that the new SAM system for local control and involvement has been in place for less than 12 months, so perhaps it is a little early to challenge it, but it certainly needs scrutiny. Q19 Mr Holloway: But not for families. Ms Crane: I think it is slightly unfair to call them "dead wood". Mr Holloway: I was in the Army and I know that sometimes among the people who do those jobs there is dead wood. Chairman: I entirely agree with Ms Crane that to talk about dead wood in the rear party is pejorative. Q20 John Smith: I think we should stick to accurate and factual information. Ms Crane: I am sideswiped by it because I rely so heavily on unit welfare officers. The SAM system is now in place and it is the CO who is responsible. Whether or not that works and is effective is a really important factor in looking after sick and wounded troops. It is critical that the resources and manpower are put in to support it so there is focus. It is true that we must have more focus on where individuals are. Interestingly enough, the reserves are doing it very well. They have a track and trace from Selly Oak on all their troops who are not fit for discharge. That has been very successful. I hope that the SAM system will produce a better method for families. We have discussed Selly Oak, but to my mind the area that we really ought to be looking at is discharge from that establishment before rehabilitation at Headley Court. That is the area of concern for most of us here. Commodore Elliott: I sit on the defence medical discharge policy committee as the ex‑service representative. I have watched the Army roll in the new sickness and absent management system. By comparison with the Y list that went before it, this is a fantastic step forward. I think it is too early to judge whether it is just a success or a great success, but it is a major change in the way things are going. Q21 Mr Jenkins: I want to go back about 15 minutes to the discussion on the central unit. We decided to use a central unit for bringing back personnel. We know that teaching hospitals in London are fully occupied. Birmingham is approximately the centre of the country and Selly Oak is conveniently there. On reflection, do you think that the Selly Oak unit is the best location for the siting of that facility? Ms Crane: It is the closest to the main recruiting areas and I think that is a major point for families. It also has good communication to and from it. Possibly the only weakness is the lack of military units nearby and therefore support to begin with has been confused, but I believe that has been taken on board by them. Q22 Mr Jenkins: We do not want to base our garrisons in the south of England where we do not recruit anyone. We have had that argument. I fully agree with you. We need a garrison in the Midlands and more personnel there. Ms Crane: Which you now have with Stafford which is very close to Birmingham. Ms Freeth: In terms of relevant medical expertise Selly Oak has a great deal to offer. I think that the foundation trust is in the process of building new facilities and some of the shortcomings and future improvements could be taken into account in that redevelopment. An area that we are particularly concerned about is accommodation and recognition that some families and visitors will have to stay there for considerable amounts of time needs to be built in. At the moment I think that investment for that facility relies almost exclusively on charitable support. If this is to become a future centre of excellence and one point of contact for people returning it ought to receive government funding. Q23 Mr Jenkins: The Government has put a tremendous amount of money into the NHS. If anyone says that we do not have the money for this service believe me he is using a different hymn sheet. I want to come to the MoD's contribution later. Let us look at the facts rather than run off at a tangent. You say that Selly Oak is the right place to be? Ms Crane: I do not think that could be argued on the clinical side, but we need to look at what facilities are available for patients and families beyond the clinical aspects. We have been very closely involved in setting up temporary accommodation at Selly Oak and working with the MoD on leased flats on the hospital grounds that were originally very grotty hostels for doctors and nurses. We have paid for temporary refurbishment of those flats. It would be fantastic if public funding could set up accommodation within the new PFI build, but in the meantime - over the next five or six years - what will happen? This is where you can say that, yes, public funding should step in and try to find a better interim solution, but equally more use should be made of the agility of the charities to step in and help. Q24 Mr Jenkins: When injured personnel come back what has been the process? Has the management at Selly Oak been able to deal with those casualties? How has it intermeshed them with its everyday work? Have you had any complaints about the reception and processing of injured personnel in Selly Oak? Ms Crane: To begin with it was confused and shameful for a period of time. The way people were managed was poor. I am reassured by what has been put in place in the past six months, specifically the introduction of a senior officer in the hospital to liaise directly with the hospital and put chain-of-command control into what is happening there and how we work with the hospital. It is critical that we work very well with Selly Oak. Q25 Mr Jenkins: So, has the military-managed wing been an improvement? Ms Crane: Yes. Q26 Mr Jenkins: Has that been a big step forward? Ms Freeth: Yes. To sustain that will need continuous commitment. After all, that unit is a very small proportion of the overall Selly Oak budget. Q27 Mr Jenkins: What concerns me and I believe one or two other Members of the Committee is the constant media coverage. Disgraceful stories have been run. When probed it has been found that the situation described has not happened and does not exist. It has a demoralising effect on the staff at Selly Oak. The NHS does not want the press to be critical of it. We have to fight our own media to get the truth out. Are these stories in accordance with what you have heard? How do some of these stories affect you as individual organisations? Ms Freeth: I should like to encourage more openness and transparency about when these reported incidents come to light. We know that they are investigated. I think there needs to be more openness about what comes out of those investigations, namely that when there are mistakes we are told what has been done about them and, when they have been looked at and found to be erroneous, we make sure that it is better understood. As organisations we are trying very hard to educate our own membership and the people with whom we have contact to make sure that the true story is told, but individuals and the press are particularly keen to highlight failures in this area. In the past 12 months a number of us who have talked to the press have tried to focus their attention on other areas where we believe there are difficulties. They have been much less interested in drawing attention to that, which is disappointing. Q28 Mr Jenkins: Therefore, when "The Daily Blurb" runs a story about a soldier being insulted and it is found to be fabricated and has no essence of truth do you believe that its front page story the following day will be "Sorry, we got it wrong. We lied to you again"? Do you think that will ever happen? Ms Crane: No. In April we conducted a short-term survey asking families their views of the provision for wounded soldiers. The vast majority were concerned but 71 per cent said that their concern came from media reporting. That gives us a very graphic explanation. Q29 Mr Jenkins: That is the struggle. We have to get it over on our website that people who complain about Selly Oak have never been there; they have read about it in the media. Imagine the effect that has on the families of injured personnel. There is a slanted story in the media. With the best will in the world, how do we overturn it? We conduct an inquiry and say that the story is untrue. That is not printed. Mrs Sheldon: One wonders whether some of this could be ameliorated if there was clarity about support for patients and families, not just immediately but beyond. People's perceptions can change. I am sure that initially people are so damned grateful to be in a safe bed and being looked after but as they start to recover and look around and rebuild their lives they begin to ask what else they can do. What can be done for them and how are their families coping? It is a matter of starting to think about getting the systems of support in place and it is clearly communicated. If they are not in place it will cloud people's perceptions, rightly or wrongly. I believe that that is an extremely important matter that needs to be dealt with. Ms Freeth: Individual expectations are very high. If they do not receive what they have been led to expect the disappointment factor hits very quickly, particularly if they have lost a career that they have wanted for many years and in which they have been successful. This is why we have to aim for 100 per cent because it is expected. Q30 Willie Rennie: The military-managed wards are not just for military personnel. Although they are managed by the military they are mixed wards, are they not? Is that an issue for some servicemen? As I have heard from various health professionals and the military, do they prefer to be treated in wards with only their colleagues because only they understand what they have been through? Do you hear that as an issue among service personnel? Ms Crane: There are two issues here: one is perception. The guys out in Iraq and Afghanistan want to believe that when they come back they will be treated in an ethos with which they are familiar. That has a very powerful influence here and on morale in operations, and it is one that should not be overlooked. Strangely, I have had feedback both for and against having other types of patients in the ward with the patient concerned. Some patients quite like not being just military, but I think the majority would rather be military. I think the advantage of having a closed-off area, which is S4 ward that is purely military, far outweighs any other consideration. Q31 Willie Rennie: How would one get into that closed-off area? Would it be through personal choice or would it be a medical matter? Ms Crane: As long as the wound is skeletal or orthopaedic in nature the patient would go there. Selly Oak comprises five hospitals, so one must have the right kind of wound to be in that ward. There is no point in putting someone with burns, blindness or brain injuries into S4 ward because it would not be the best clinical care for that patient. Ms Freeth: It is part of a larger orthopaedic ward. Individuals will go to a range of other beds in the whole complex depending on what treatment they need at any one time. The only part that is military-managed is that section. In terms of casualty numbers, so long as they continue as they have been for efficiency it would probably be quite difficult to have anything very different from what is currently in place. Q32 Willie Rennie: I am not quite sure I understand the last bit. Does one go into the military-only section by personal choice or is it determined medically? Mrs Sheldon: It is based on clinical need Ms Crane: The priority must be the saving of life; that is what we all want. Any other consideration comes after that and therefore one must go for the best clinical care. But the majority of injuries will be in the orthopaedic ward. That is where the majority of casualties go and if they go into that ward they go into S4. Commodore Elliott: As a serviceman, I have been to a military hospital where there have been civilian NHS patients. The experience of being on a ward with demented old ladies in adjoining beds is horrific. It was undignifying for them. I was terribly embarrassed about it. I experienced that in one of the Birmingham hospitals when I became a civilian. There comes a stage for every casualty when he or she is well enough and needs to be recovered into the military environment where he or she sits or lies alongside other veterans of the particular campaign and feels comfortable about that. They should not be with civilians at that stage unless they want to be. There is also the scandal of mixed-sex wards. I do not know whether it happens at Selly Oak, but that practice is still prevalent in the NHS. I hope that our servicemen are not experiencing that if they go to other wards. Q33 Mr Jenkins: Can we kill this myth again? The Government has put a lot of money into stopping the practice of mixed-sex wards. We have not dealt with it fully, but it is not true that it is prevalent. Commodore Elliott: I am not saying that, Mr Jenkins. I am saying that I have experienced being on a mixed-sex ward as a patient. It was undignifying for the civilian old ladies there, let alone what I felt about it. Q34 Mr Jenkins: Was it last year? Commodore Elliott: It was about four years ago. Ms Crane: Do not forget that we have female wounded personnel. Q35 Chairman: Ms Crane, earlier you said that 71 per cent of the complaints you were talking about were induced by the media. The Ministry of Defence says that it has received only one formal complaint, but if 71 per cent of the complaints you have talked about come from the media it implies that 29 per cent are based on something other than that. Can you rectify these different figures? Ms Crane: I said that we ran what we call a short-term survey before the welfare conference held in April. We went out and asked families four simple questions. The first one was: "Are you concerned about the medical care provided for wounded and injured soldiers? Yes or no." The majority, 84 per cent, said that they were worried, but when we asked why they were worried 71 per cent said that their concern came from media reporting. I am not talking about complaints but families' perception of care. Q36 Chairman: Where did the other 29 per cent come from? Ms Crane: Fourteen per cent said that it came from information from friends and 15 per cent from experience. Q37 Chairman: But there has been only one formal complaint? Ms Crane: We have not had formal complaints. Q38 Chairman: The Ministry of Defence says that it has had only one formal complaint. Can you explain that? Ms Crane: I believe that there have been failings and early on particularly shameful ones, but a lot of the delivery has been successful. Selly Oak has saved a lot of lives. It is the post-operative period and the time after discharge that has caused the most upset for families. Q39 Mr Holloway: How many of the witnesses think the media has been helpful? My impression is that people like Mark Nichol in the Mail on Sunday have been almost valiant in standing up for these guys. Ms Crane: I think we needed more focus on it. Media attention does help, but it has been very difficult for the morale of families and troops. Q40 Mr Holloway: Has the media attention led to improvements? Ms Freeth: I believe it has focused attention where necessary and as a result of some of it there have been improvements. Q41 Mr Holloway: So, that has been largely helpful? Ms Crane: I deny that. I believe there was an internal battle in the MoD which was already tackling this and I am not as convinced. Q42 Chairman: Mrs Sheldon, you said that you felt the media were concentrating on the wrong things. Mrs Sheldon: I think that it ought to concentrate on the aftercare and onward management and support of patients and their families. There has been an awful lot of attention on Selly Oak and improvements have been made, but the focus should be on gaps in public funding to support families of patients for onward rehabilitation, not necessarily by the media but it is hoped by decision-makers. Ms Freeth: I think that dislocation and disaffection start once they have left. The support they are able to receive at Selly Oak and access to services back in their own NHS areas is extremely variable. The individuals who are in contact with them and the ability to enjoy the support from colleagues - those with whom they are familiar and who understand them - is a major factor. How that is addressed is a real challenge. There is an expectation that the NHS can just pick it all up. To work that out will be a major challenge for the MoD and the NHS. Mrs Sheldon: It is a risk because families will, if they are feeling unhappy and disaffected, go to the media. Recently, a family which had a high expectation that their son would go on to Headley Court but who landed up in a specialist unit were very disappointed and felt let down. One cannot talk about the rights and wrongs of that, but certainly expectations have been mismanaged, or they have failed to understand what would happen. As a result, they went to the press. Q43 Linda Gilroy: Commodore Elliott mentioned his work on the discharge medical policy committee and some new arrangements. Commodore Elliott: This is the Army's sickness and absence management system. Q44 Linda Gilroy: That is very new. Will it address the sorts of issues we have just heard, or do other things need to be taken on board to improve that? Commodore Elliott: There is a stage where the wounded casualty will be discharged back to his home whilst he waits to become fit to go back into service or awaits the medical discharge procedure. That is a very dangerous period. Under the old Y list system soldiers were lost to the system; they were forgotten and felt neglected. We have on our books veterans who have been through the Y list and have developed severe and enduring mental health problems which have been caused by being lost in the system. The sickness and absence management system is designed to prevent that happening and I applaud it. I am quite convinced that if it is made to work and the right resources are allocated to it the system will stop a lot of this happening. Having listened to what Mrs Sheldon has said, I believe there is a stage beyond service that we need to consider more than we have so far. Quite recently, we heard from the director of the Army Welfare Service about additional people who had been allocated to look after very seriously damaged people who have been discharged from hospital. They have run their cases until they are back in their own homes, wherever they happen to be, and when they come up to medical discharge. He also talks about looking after them as veterans, but when you challenge him he says that normally the service looks after veterans until two months after discharge and the absolute maximum is about two years. I think there is a lot of work that ex-service charities need to do together with in‑service people to look at life beyond those two months. Frankly, he will not have the resources to manage these cases for the rest of their lives. There is a wonderful challenge there for all of us to work together. I believe this is something that the service community, including the ex-service community, should do. We can look after our own; we have a lot of resources that can help do that. Q45 Chairman: Commodore Elliott, am I right in thinking that people present to Combat Stress on average about 15 years after they have been discharged from hospital? Commodore Elliott: Last year we had nearly 1,000 cases. The average length of service was 11 years. We have a lot of very experienced and battle-hardened veterans coming to us, but, sadly, they are not being attracted to us until on average 13 years after discharge. Therein lies a real challenge in service as well as after it to try to pick up these men and women much earlier, because the earlier they are picked up the more effective the help we can give. Air Commodore Jarron: One area that we are looking at now is how we can give better support to those who are about to be medically discharged. They have had treatment and then go home; they are split from their unit and have no local support. The medical discharge process can take anything up to six months. There is a long void when there is no support whatsoever and it is an area that we are picking up increasingly. Chairman: Perhaps we may come to that in a few minutes. That is a crucial area on which we want to concentrate. Mr Jenkins: The difficulty is that we started to shut down the defence hospital units and put them into the NHS. We have now had some experience of this, albeit an unwanted one in view of the number of people coming back wounded. Given that choice and your experience, was it the right decision to put the provision into the NHS? The turnover of clientele and the level of experience can never be matched by defence hospitals. If it was the right decision, can you now see a future for others as well, which is important? What mistakes were made? Is there a catalogue of mistakes? We are trying to find out the truth rather than urban myths. Some people run around with gloom and doom. There are good things and bad things. Let us make sure we get rid of the things that are not good before we extend this programme anywhere else. I want to find out whether it is getting better. Can we have military-managed wards? We may have only one severe burn victim but four beds. It may be impossible to deal with it unless we have four. A smaller number means that given the specialist set of clinical skills we will never get them in, but as soon as we can get them together we will have a ward for military personnel and we can manage that ward. What lessons if any can you offer us? We will go to Selly Oak and ask about their experience. If you have any facts with which you can supply us we would be very grateful. What lessons have we learnt? Q46 Chairman: Could that be split into two questions? The first question is: was it the right decision to go to Selly Oak with the gloss of military-managed units? The second question is: what lessons should we have learnt from it? First, was it the right decision? Mrs Sheldon: I do not think it was the right decision at the time because nobody could foresee or build into the planning assumption the number of operations that would be carried out. Let us not forget that Selly Oak started off as a teaching hospital for military medics. They have worked very hard to improve it. That was a big mistake, but the good thing is that the clinical resources are now centred on the need. That is the right decision but it has come about in an unfortunate way. Q47 Chairman: It was a wrong decision but it should not now be overturned? Mrs Sheldon: Yes, absolutely. Ms Freeth: I believe that it is the right way to go. We do not have access to all the figures. Will one centre there be enough? Air Commodore Jarron: Clinically and financially, it is very hard to criticise the decision to go there. There is a big emotional issue here. Servicemen like their own things; they love their own regiments and comradeship is very much part of what service is about. Interestingly, at this year's annual conference there was a resolution moved by a veteran that we should approach government to re‑establish our military hospitals in support of our men. It failed because practical arguments were put forward. Nevertheless, there is a very big issue about the emotional wellbeing of these people. It is exactly the right business decision, but what we have to do is make sure that we do not throw out the baby with the bathwater and lose the emotional support that is so important. Commodore Elliott: We are rather too far down track to go back. I think we have shut the last military hospital. It is interesting that we are about the only country in the western world that has a system where we rely on the NHS to look after our servicemen and women and veterans. The alternative model seems very attractive to me because you end up with a quasi-military environment which is so good for both in-service people and veterans who in the old days went into the military hospitals when there was enough room for them. They gained a huge amount from that. That is not available to us. I suspect that if we look back at what happened over the past couple of years at Selly Oak we were caught out, but I believe that this is a question for the surgeon general and defence medical services rather than us. We have gone forward quite a bit since being caught out, and from what I have been told I am quite convinced that Selly Oak will be good news in future. Ms Crane: I agree with what Ms Sheldon said earlier, but this goes wider than just the treatment of those who suffer wounds from operations. A big complaint that comes in all the time is access to medical care for those now serving in the Army who need minor operations to get fit to go back on exercise. That is where the draw-down of the military hospitals is having greatest impact. That applies also to those who are discharged from Selly Oak having had a high level of clinical care and need somewhere to convalesce before they can go on to Headley Court. Q48 Chairman: Let us turn to the second question about the lessons learnt. Mrs Sheldon: One thing I have picked up - this is purely anecdotal - is the strain and stress of military and NHS staff at Selly Oak in becoming used to each other's working practices. For some NHS staff the sight of some of the casualties who have been dealt with has been pretty horrific and traumatising. Taking things forward, one needs to think about the way they are supported. Turning to patients and their families and taking it forward, the question is how best they can be supported emotionally through the journey back to full recovery, or perhaps into a new life in the civilian community, making sure it is properly supported throughout. One can say that the SAM system is a great improvement, but it is also a matter of making sure there are people who are able to help these families in a personal way. The numbers are not particularly big, but, by golly, the problems they have in coming to terms with it are tremendous. Therefore, I think it is absolutely critical to make sure they have someone who almost helps them along that journey. Ms Freeth: I do not believe one can separate health and social care particularly at Selly Oak. People need all of the information to travel with them right the way through their journey from Selly Oak and on to where they are being referred. That is not happening. We need to learn a lot from that. We need to design in the fact that this is a special place and there is a need for training and support for staff. We also need unusual things one would not expect to have elsewhere that must be planned in for the future rather than thought about afterwards, because they create unnecessary unpleasantness and difficulties for everybody involved. We need to continue independently to evaluate the quality of the service there. Air Commodore Jarron: It has largely all been said. Fighting the war and winning is relatively easy; what matters is what comes behind it. We have found that elsewhere. It is the long-term recovery process that needs our attention. Commodore Elliott: I agree with that, but I also pick up Ms Crane's point about the other injured and ill servicemen who await treatment in the NHS. I have attended a naval medical board of survey. Two of the five case I heard whilst there indicated that these people had waited a huge amount of time to get treatment in the NHS. I suggest that the Committee could take evidence from the MoD about how much down time there is among servicemen awaiting treatment in the NHS which they would not have had in the service hospitals. Q49 Mr Holloway: You said that people presented 13 years afterwards. I believe that following the Falklands there were 300 suicides and numerous suicides among special forces from Gulf War 1. My understanding was that if you had a bad day it was best to get people back with military people as soon as possible. Do you think that the separation of people from the system and their unit is storing up further problems for us in future? Commodore Elliott: Most certainly, in the context of mental health we are very interested in whether or not we should be bringing serving soldiers, who are in the sickness and absence system, into the society's work to prevent the bad day you are talking about. As to the suicides which have been quoted in the press in the past few days, it needs to bottom out. We do not really know how many of the Falklands war veterans have committed suicide since. Q50 Mr Holloway: Is that not part of the point? Commodore Elliott: I am keen to do this if no one else is. We need to create a roll of names to be provided by the veterans themselves so we can say whether or not this is true. Veterans are quite upset that the system does not seem to believe them. Ms Freeth: Suicide research is going on at the moment and we need to learn quite a bit from it. At the moment evidence about the causes is inconclusive. Q51 Mr Holloway: This is not about verification but about our responsibility to these people who have experienced these things. There have been numerous wars in the past few years. It sounds to me as if we will have a big problem 13 or more years down the line if we carry on in this particular vein. We are not thinking ahead, are we? Ms Freeth: We can certainly see a growth in people presenting for a whole series of different reasons. All of the charities provide an opportunity which we see benefiting people when they come back into contact with others; they have some direct experience. That familiarity is absolutely critical, but it is not always possible to provide the best care close to the unit. Q52 Mr Jenkin: We have spoken at length about Selly Oak. The Committee will visit Headley Court and Selly Oak in due course. What is your experience of other Ministry of Defence hospital units? Do you have anything important to say about them? Commodore Elliott: There are not any. Mrs Sheldon: Are you talking about overseas? Q53 Mr Jenkin: Cyprus, for example. Mrs Sheldon: My report would be based purely on the family perspective of care for families overseas and what is happening there. Do you want that to come into this discussion? Q54 Chairman: Yes. Mrs Sheldon: Suitable pay for civilian medical and dental practitioners is an issue for families, particularly in Germany where recruitment has been difficult. That leads to lack of continuity for family medical care which is the MoD responsibility overseas. The same goes for dental care overseas. Those are the kinds of issues of which we have experience at the moment. Q55 Chairman: We are also talking about units at places like Frimley Park. Are there any comments on other military units in hospitals? Mrs Sheldon: I should like to pick up the question of healthcare provision for families overseas. Chairman: Let us leave the question of families overseas. What about other military units? Q56 Mr Jenkin: What about Northallerton and Peterborough? Ms Freeth: In terms of the NHS services for which there are contracts for service healthcare, one bit of feedback is that some people have to travel a long way to access that care. I believe that there are six contracts in place at the moment in NHS services specifically for serving people. There do not appear to be enough of those to enable people to have easy access. It does not appear that the ability to receive sensible treatment that will get people better as quickly as possible is delivered under the current six contracts. Q57 Mr Jenkin: I think we have already covered this question, but, in case there is anything that you want to add, do you have any concerns about the care that service casualties receive in theatre and during evacuation? Ms Crane: I think that it is far more successful now than in the past, and well done on delivering it. Q58 Mr Holloway: Obviously, all the witnesses agree that rehabilitation care has improved over recent years. Where do you think we are with that now, and what further improvements can be made? Mrs Sheldon: I think that Headley Court is doing a fantastic job, but again the wider, holistic issue is to make sure that patients can support each other and keep family units together at a very important time in their lives. That is something which up until now has not really been properly looked at. At Headley Court there is limited temporary accommodation in the grounds. There are refurbished family quarters which will happily house one family but perhaps not two or three. Sometimes they have to squeeze in people. There is also a small house in the grounds which has a dozen rooms suitable for single person accommodation where service people have generally gone to practise their skills on new equipment and so on. At Headley Court it is really important to have the families with the patients to help them rebuild their lives. That sort of infrastructure is not in place. Again, where necessary we provide charitable funding to help them set up accommodation nearby, but ideally that is something which public funding should provide. Ms Freeth: There is a short supply of medium-term rehabilitation for people with complex injuries who will need assistance for 18 months or possibly two years and who will not stay at Selly Oak but, it is hoped, go back to their locality. As a service provider of homes we have been approached and over the past five years have taken in some four or five individuals who have stayed with us two or three years. One of our homes specialises in being able to provide support, because we have physio and occupational therapy on site. Were larger numbers of individuals to come through - that looks like a possibility - it would be difficult to find the resources to cater for those people certainly together. It is likely that they will go off to a unit that may have no military input or connection with, or little experience of, long-term military rehabilitation. Looking at the numbers, we do not have enough information as to whether this perhaps should be a new service, but medium and long-term rehabilitation is in short supply. In the NHS it is difficult to get access to day rehabilitation services. Q59 Linda Gilroy: In terms of the provision of medical care, how well do you think service families are looked after when they return to the UK from overseas postings? Ms Crane: For most families returning from overseas and moving round the UK the biggest issue is dental care. It is an issue for the whole country. Government tells us that it should improve within the two-year timescale of the new contracts, but for us it is a much bigger issue. We move every two years, so by the time we have found an NHS dentist and are on that waiting list and perhaps are getting close to some sort of care we are moved again and have to start from scratch. It is not a list that is transferred from one practice to another. An additional issue - I do not have a lot of evidence to support it - appears to be that if there are two serving parents, of which there are an increasing number, their dental care is with the MoD and dentists will not sign on children without a parent in a dental practice. That group has a specific issue. Families do not have a problem accessing NHS doctors; we have not picked up an issue in that regard. Sometimes it takes a while to work out where you are when you have just moved, but we believe that a lot of NHS doctors are rather bemused by us. I have had conversations on it. They see us as a rather vulnerable group living in isolated locations. We are not necessarily the same as the rest of the population during this period of high operational tempo. We believe there is a high rate of antidepressant prescribing which arguably takes place quite quickly rather than after careful consideration. We have considered doing more research on it, but it is a very difficult area to delve into. I certainly do not suggest that all army spouses are manic depressives; we are a very strong bunch. Q60 Chairman: You are a fascinating and very difficult combination of great vulnerability and self-sufficiency. Ms Crane: And where we are located has a big impact on it. We reflect in urban areas the number of families that can drive. We have a lot of families living in isolated locations that cannot drive. They are supposedly married but are single parents and therefore have problems accessing medical care in some cases. Unit welfare officers, who are my heroes, often----- Mr Holloway: I was not criticising all of them but just making the point that a guy who does not tell someone that he is entitled to a travel allowance is dead wood. Q61 Chairman: I think we have gone into that enough. Ms Crane: But they do help and during operational deployments they organise assistance for families. At the end of last year I was at a coffee morning and I asked a spouse what she had been doing during the deployment. She said that it had been a difficult pregnancy and she had to get the bus to Salisbury three times a week but it took seven hours. She was only in Larkhill and so was fairly close. I told her that the unit would have helped her and she said that she thought she had to do it. Some of it is our own fault, but how doctors perceive us is a problem. Medical notes also do not follow us very quickly; we do not have access to them. We do not seem to have much of a problem in transferring from one waiting list to another for operations, but it is more of an issue for therapies and specialists. Again, there is a national shortage and that means that by the time we have reached the top of the list people see that we shall move quite quickly and therefore are reluctant to start expensive care or do not take it seriously. IVF is a major problem for families. As far as concern waiting lists, we have the most cases. We would like families to have retention of quarter, which means they can stay in the house where they are presently situated until they get to the end of their IVF treatment. It is a postcode lottery and expectations can be raised. If one is Shropshire one can get two cycles; if one is in Wiltshire one can get only one. Some may argue that to move from Wiltshire to Shropshire is an advantage, but it is a difficult stage. We are a young community. We have a high proportion of young families and it is additionally difficult if you are a couple that wants to have children and is trying to get IVF treatment. Q62 Robert Key: I have experience of a number of cases in Salisbury. The Ministry of Defence has always argued that if you are starting a cycle in Salisbury and are then posted, overseas, for example to Germany or Cyprus, it will fly the wife back to complete the cycle. Is that not the case? Ms Crane: I think that is the case. The MoD is helpful in those circumstances. The majority of moves are within the United Kingdom. Remember that we are way off the scale compared with the national average for moving outside a local health authority area. Chairman: You are talking about many of the same issues that came up during our inquiry into the education of service children. Q63 Linda Gilroy: I believe that my colleague Mr Key will return to the issue of dentistry which is probably highest among the issues that you have mentioned. Do you have any good examples of primary care trusts that have taken particular interest in any of the transitional issues you have mentioned? Ms Crane: I am ashamed to say that I would probably hear the least where it is most successful. I do not hear an enormous amount about this issue. We are here to discuss it and therefore I will tell you what I know, but generally I think it is working relatively well other than in the dental area and in specialisms such as IVF. Ms Freeth: One concern is that the families of former commonwealth soldiers, who are now some six per cent of the force, are entitled to medical care when they are here, but not to other statutory support in the same way. We find an increasing number of complex cases where everyone around them has been unable to assist. That is certainly a group of people we need to look out for to provide better support for them. Mrs Sheldon: I should like to broaden the discussion to the emotional side and the impact that all of these issues can have on relationships. It is a matter of making sure that families have access to professional and independent counselling support which has continuity to help them through some emotional aspects associated with service life which has its own distinct pressures. These things are very complex and cannot always be solved within a two-year posting. Q64 John Smith: I want to return to IVF. How big a problem is access to IVF for service families? What about access when one is posted overseas, not when one has started treatment and comes back to continue it? Is it a problem? Ms Crane: I would have enormous difficulty giving you the scale of it because I can go on only those who report it to me. I presume that IVF rates in army families are comparable with the rest of the population. I would have to look back at those statistics. Obviously, where it does not work it is emotive and is a problem. It is a matter on which families approach us. I know that hospitals overseas have provided it as and when they can and generally quite successfully. Q65 John Smith: Is there any evidence that access to IVF treatment is causing particular difficulties for service families and results in either the break-up of families or the premature termination of service in order to access these medical services? Ms Crane: I think that it is ongoing treatment that is important. Let us assume one has decided that one wants IVF treatment. Quite a long process is involved. It may be that an area does not want to take on the case because it knows one is moving; it may be that one starts and there is a posting and one cannot finish the treatment. I do not think that the problem lies so much in initial access; the issue is one of ongoing access. Q66 John Smith: Is there any evidence that there is a difference in access to services, not just IVF but other therapies, as between commissioned officers and other ranks? Are commissioned officers turning more to private treatments because they may be in a financial position to do that because of inadequate access to therapies such as IVF, including dentistry? Is there any such evidence coming through to service family associations and other organisations? Ms Crane: I have no evidence that that is so other than in the case of dentistry. I know that a high proportion of officers have sought private dental treatment. Q67 Robert Key: It is perfectly clear that a lot depends on where the service family ends up living. Sometimes one may find oneself in a very large military garrison like Tidworth or Catterick where defence medical services, for example GP services, may be available, but that is quite rare, is it not? Do you think there should be special arrangements - fast-track facilities - for service men and women and their families to access NHS physicians and dentists? Ms Crane: I would like to see some way in which families can access - never mind a fast track - dentists and specialist therapists on moving, especially those with special needs who have an additional difficulty in this area. Q68 Robert Key: Given there is no question that there is a huge shortage of NHS dentists, particularly in areas around Salisbury Plain garrison which I know best, do you think it would be a good idea to explore the Ministry of Defence helping to fund private dental treatment, which after all is what most of the population has been forced to do under this Government? Ms Crane: I think it would be wonderful. Ms Freeth: We would support that. Obviously, we see veterans. One of the difficulties is the huge mismatch between what people are entitled to when serving, and certainly when they are injured, and what they are entitled to when they leave and become veterans. That difference creates some of the dissonance. We would like to see those services being extended at least for some period whilst individuals are veterans. Q69 Robert Key: I want to ask about wider health provision for families. Health is not just about sore toes or tonsillitis; it extends into areas of family health including education where there are services children in local primary schools with, for example, ADHT and also to social service support where you have a large number of broken families and marriages and the care of children, the burden of which falls on local authorities across the country. Is that a particular problem on which you have views? Ms Freeth: Those are not areas in which we have had problems brought to us and on which we can report. Commodore Elliott: I have noticed that in our work we receive more and more calls from carers of soldiers who are extremely worried about their husbands and need quite a lot of advice from us because they are frightened to go to the in-service provision that has been made for them, normally because it is the soldier who does not want to indicate to the authority that there is a problem caused by his psychological injury. We are just rolling out a new service, which we will fund ourselves, to help families of our veterans and that will open up the service to in-service people even though it is not strictly speaking our bailiwick. Mrs Sheldon: This is one of the areas in which we are very heavily engaged in providing professional social work support to families in Germany, the UK and across the world. We are receiving a lot more calls for help from families that have a lot of pressure because of relationship and emotional problems. It is not just a problem affecting the spouse or partner; it affects the children. There are very serious issues in terms of child care and also mental health problems. Ms Freeth: In other countries health monitoring of families is available and used. Certainly, I think this is an area that should be considered. Obviously, it is a difficult area but it is important to be able to catch these sorts of issues as early as possible and to respond to them. We know that according to the King's Fund study of individuals that is being done there is an alarming dependency on alcohol, not necessarily understandably. That also has an effect on family life. Health monitoring is critical. At the moment all we have is a commitment to a short-term piece of work that has been extended, but I believe that it should be a permanent part of the bailiwick. Mrs Sheldon: This is where a close relationship between the specialist agencies and the unit welfare officer and units on the ground is essential. A unit welfare officer is not trained to spot the symptoms of big problems that arise. Although secondary care within Great Britain is provided by the Army Welfare Service there is still a need to turn to specialist agencies that can help. It is absolutely critical to have people who are trained and are agile enough to spot where problems arise sooner rather than later. There is patchy provision across the MoD in the sense that the RAF has its own way of providing supporting, using professional social workers. There must be a holistic approach. One must be very careful that one moves initially from the command as the point of contact to the specialist agencies so there is consistency. Q70 Robert Key: Perhaps we may turn to the provision of health services for families abroad. SSAFA has given us evidence that growth in the defence medical services has been less than half that in the National Health Service as a whole. There has been an increase but it is not as great. Another way of putting it is that it is falling behind. Has that impacted on service families abroad? What is your perception of the provision of healthcare to families posted abroad? Ms Crane: I touched on this earlier. There is at the moment a real problem about the provision of doctors and dentists overseas. It all comes back to parity funding. Because the MoD is not signed up with the NHS and the funding comes through the ministry there is no obligation or capability of providing the same facilities overseas as in this country. Much of the facilities overseas are really good, and I have had experience of them in several countries. I have been very grateful for that very familiar and close-knit arrangement, but the lack of doctors means that there is not that continuity of care or empathy from one person. The employment of locums has an effect on the local budget which makes it even more difficult to provide services. That is one of the big issues I raise. Mrs Sheldon: I support Ms Crane. Obviously, what one does is try to provide a service that matches the standards of the NHS. There is an obligation to meet those standards, namely that an adequate number of people are there to provide that service but within ever-dwindling funding. Ms Crane: When I accompany my husband I sign off from my local doctor and then sign on when I go overseas. Why does not my NHS funding go with me? Why does it stop? Q71 Robert Key: The answer is that in this country local primary care trusts are funded per capita to include military personnel and their dependents, but that does not happen overseas. Ms Crane: But not military personnel because they are not part of NHS funding. Robert Key: It does include military personnel because it has been a bone of contention for many years between the Ministry of Defence and the Department of Health who now seem to agree that primary care trusts and other trusts receive funding to include military personnel, but that is a technical point. Q72 Mr Jenkins: Before we go too far, that is exactly the point I want to raise. My local community, which has expanded over recent years, has always missed the boat. We were being paid for 50,000 although we had a population of 55,000. By the time we got the next settlement we got money for 55,000 but had a population of 60,000. Two or three years ago we managed to move ahead because we got paid for 75,000 although there were only 33,000 there. The PCT now has the money. I expect that in a garrison town with 15,000 to 20,000 young and fairly fit and active individuals there will not be the same strains on the services as there will be with a mixed population that includes a good number of old people and pensioners who cost the NHS and PCT a lot more money. If one has all this money in a PCT where does it go? Why are you not asking them to bring in dentists and sign contracts for GPs and specialist facilities? You do not have a big demand but what is there is not being met by the PCT. Ms Crane: One would then pay the medical professionals the equivalent of what they are paid within the PCT and one would attract more people to those jobs. That is the main issue. Q73 Mr Jenkins: I am referring to the actual provision within the community in mainland Britain? Ms Crane: I thought we were comparing it with overseas. Mr Jenkins: The overseas argument is a different one. But in locations in Britain the PCT has a duty and responsibility to provide GPs, dentists and so on. They have been very successful in managing to fund extra dentists in my area, so we do not have a problem with NHS dentistry. Why can they not do the same here? It is a matter for the PCTs; they are the ones who put the contracts in place. Therefore, if your PCT is not doing it someone should start asking why not. Q74 Mr Jenkin: Ms Crane, you have raised a very interesting question. Should not the Ministry of Defence have its own PCT and ring-fenced NHS funding to spend on servicemen and women and their families wherever they may be, whether they be at home or abroad? Then we would not have the problem of competition. By placing so much emphasis on the National Health Service as it is we have put servicemen and women and their families in competition with all the other resources in the NHS. I think that most of the public regard that as unacceptable. Do you agree? Ms Crane: It sounds very interesting and I would love to look at it. Ms Freeth: Certainly, with the devolution of spending in particular areas it is very difficult to lobby PCT or authorities to address the needs of their service communities. They are not willing to do that. We need a national arrangement to make sure everybody gets the same quality of support, because at the moment it is very difficult. Each of us would have to lobby individual parts of all of the PCTs and all local authorities and that is simply not something of which we are capable to make sure things are delivered. Q75 Robert Key: When a family hears that it will be posted overseas, are there some places in respect of which it says, "Great! They have wonderful medical services"? If so, which are those places? Do they sometimes groan and say that they do not want to take their families there? If so, name them, please. Ms Crane: That is a bit unfair out of the blue because some of my information is rather old. A lot of families that go to Germany will say, "This is great." That is why the reduction in the number of medics there has been so difficult for people. The level of delivery of the Army Medical Service in Germany and Cyprus has been very good. I had experience in Brunei. I had babies in Brunei, Hong Kong and places like that and it was great. Q76 Robert Key: Which are the places that give rise to a groan? The defence medical services overseas are all wonderful, are they? Ms Crane: I think it depends on what you want. I do not have a lot of evidence about the Falkands, Belize, Batus, Brunei, Nepal and Naples. I do not know the detail of each one. Q77 Willie Rennie: What is the view of health services for military personnel in Scotland? Do you have any evidence of differences between England and Scotland or even Wales? Commodore Elliott: I have an opinion about Scotland with regard to veterans and mental health. Of all the administrations the Scottish Executive is the most forward thinking in dealing with mental health in the community, including veterans with mental heath problems. I get most excited about the discussions that we are having at the moment with the Scottish Executive. In Wales the head of the mental health policy unit believes that veterans should be treated the same as everyone else; in other words, there is no difference. The same is true of Northern Ireland where because of security issues there are problems to which home service veterans are very sensitive. We are going through a process of work in partnership with the MoD during which the funding arrangements for the work we do with veterans will be transferred from the MoD, where under the service pension order we get some of our war pensioners treatment funded - that system avoids a postcode lottery; it is exactly the same for a veteran regardless of where he comes from in the United Kingdom - to one where we will be funded by the NHS. I am extremely concerned by the fact that we will have to deal with PCTs and individual veterans, which means we will have a contracts department that is larger than the whole of my staff put together. Undoubtedly, there will be a postcode lottery and differences in opinion between the administrations as to what they want us to provide. I am extremely nervous about going down that route. I quite like Mr Jenkin's idea that it should be applied to the work of my charity. I would like to have a top slice and my own budget which avoids all of these difficulties and can get on with our work, which is to look after veterans who are very ill and in desperate need of help without having to worry about that. Q78 Mr Jenkin: We are coming on to ex-servicemen and women. At the moment, what responsibility does the Ministry of Defence demonstrate for the health and welfare of ex‑servicemen and women? Commodore Elliott: I have sat on the Confederation of British Service and Ex-Service Organisations (COBSEO) ever since the Prime Minister announced that there would be a minister for veterans within the MoD. I have watched the whole process grow. We have been talking about having a minister for veterans for the past 60 years and now we have one. It is still early days, because unfortunately ministers change every five minutes. When the first minister, now Lord Moonie, met with us he said that government believed there were certain things that the ex‑service organisations did better than government and it wanted them to go on doing that. I think it is absolutely terrific that we should be working in partnership for the benefit of our veterans. We have a huge role to play in this because of our history. The ex‑service organisations were founded because there was nothing for veterans after the First World War or, even earlier, after the Crimean War. There is a huge amount we can do together. I think that the Government is embarrassed by some of the things that are emerging at the moment. As we all know, at the moment mental health is a particular issue. Some of what has been reported is very accurate. The articles in the Sunday Times were fairly accurate, but there were one or two minor points of details. I think they are beginning to grasp that this is an issue where we have to do better, but I want us to do better together in partnership. Ms Freeth: The charities play an increasing role in supporting the welfare of veterans from the oldest to the youngest. We wonder whether or not that is sustainable largely because of the present prioritisation of social support in the community. If you are not at serious risk you cannot access many of the social services that are available to you and welfare organisations are being drawn more into service provision. We do not and cannot provide health support to veterans which is a critical area for us. Under our charitable objects none of us is able to provide health support other than in Commodore Elliott's case. Therefore, we are frustrated by the difficulty that veterans experience in terms of accessing health support for areas that are the result of, or are exacerbated by, service-related injuries. Q79 Chairman: Perhaps I can bring you back to the precise question asked by Mr Jenkin. What role does the Ministry of Defence demonstrate in looking after ex-servicemen? Ms Freeth: Its role is to provide a pension and information service. It does not provide services to veterans in terms of health and social support. Q80 Mr Jenkin: Has the presence of a minister for veterans made any difference? Commodore Elliott: Going back to my experience of sitting on a veterans' forum - which was chaired by the Minister for Veterans on Friday - he meets with veterans' representatives, that is, the executive of COBSEO and one or two others and representatives of other responsible government departments and those for Wales, Scotland and Northern Ireland. There are civil servant representatives of the ministers. There is something called the Minister for Veterans task force which seems to have fallen into disarray, or it is not meeting very regularly. I think that the Minister for Veterans is finding it very difficult to get the other government departments to engage to the extent he would like in a co‑ordinating role to ensure that veterans get the visibility they need. Q81 Mr Jenkin: What role should the Ministry of Defence have in providing healthcare for veterans? Commodore Elliott: Healthcare? Q82 Mr Jenkin: We are talking particularly about healthcare in this inquiry, but if you want to make a broader point do so. Commodore Elliott: The answer is that the Ministry of Defence has made it quite clear for many years that veterans' healthcare is provided by the National Health Service. It is absolutely adamant about it and we cannot move the department on that. There is very little that it can do. It has made some arrangements for TA casualties with mental health problems to go to the defence medical services for an assessment and maybe a little bit of treatment, but that is about it. Ms Freeth: The minister has pressed for the delivery of priority treatment for war pensioners by the NHS, but the ability to leverage that systematically and consistently across the country does not appear to be possible. The legion would like to see the minister ensuring that veterans do get the treatment to which they are entitled and were promised. Q83 Mr Holloway: Fifteen years ago for a television programme I spent three months living homeless in London. There were a lot of ex-servicemen, admittedly some of the national service generation. How much evidence is there that there are large numbers, or any, homeless ex-servicemen now? Commodore Elliott: About 10 years ago an ex-service action group on homelessness did a study and found that one in four of those sleeping rough in London were ex-servicemen. A study which is about to report indicates that that is down to six per cent, which is a pretty good achievement. The MoD has played a large part in providing housing for single ex‑servicemen who leave the Services and have nowhere to go. The ex-service organisations also help in this regard. I believe that six per cent is the lowest we will ever get. Q84 Mr Holloway: What about temporary accommodation? I have a guy in my constituency who was injured in Iraq. He is staying with his girlfriend's parents because he cannot get any sort of council housing. What is the situation there? Ms Freeth: There have been improvements. A number of new projects have assisted, but more accommodation is needed and is in the process of being provided around the country. There are two new projects, one in Catterick and one in Yorkshire, that will take place in the next two or three years, but in the meantime housing is a problem. There is a need for short and medium-term housing particularly for the most vulnerable, that is, early service leavers who are not entitled to any of the support that people get if they stay for four years. In both health and social care the biggest group of people with difficulties are the early service leavers who are not entitled to the kind of support that is available once four or five years have been served. Commodore Elliott: You raise a very important issue. There are people camping out with friends who are invisible to us. That is an area where we must do our best. Ms Freeth: Work is being done by the minister to try to get the local connection system back in place for individuals so they get priority treatment. Ex-servicemen and women and those who support them still do not know enough about how to access housing provision in their areas through local government. Q85 Mr Jenkins: When servicemen leave the Services the employer has a duty of care. What does the employer put in place to ensure that when someone leaves he does not have his medical records put in his hand and is simply told to look after himself, but that when he is settled down his medical records will be accessed and sent speedily to the GP of his choice and this is the support he requires, etc? At the practical sharp end we may just have some influence on the MoD to bring about an improvement in that area rather than the provision of housing 15 years down the line. Do they give them that linkage? They cannot give them their medical records because they might lose them, but do they make sure the linkage is there and the records follow ex‑service personnel? Commodore Elliott: The procedures for medical discharge involve handing the patient across to the National Health Service, and the medical records go with the patient into the NHS. All too frequently the problem is that the Services do not know where that patient will end up. He has nowhere to go. A lot of servicemen who are being discharged will not contact their local GPs and all the services that they should connect up to until they are in trouble, and therein lies a huge problem. In fairness to the Ministry of Defence, I think it is an extremely responsible employer in this regard. The resettlement process is probably second to none. I do not think anyone else does resettlement in this country for people who leave their employment. The servicemen themselves have a role to play in all this, inasmuch as they are responsible for doing all the things that need to be done, except in the case of very damaged people where special arrangements are made to make sure local NHS services are provided. I do not think that we should be too worried about this, apart from being aware that some servicemen, whatever we try to do, will not do what they are advised to do. Ms Freeth: At the moment a lot of information is given to people at the point of departure and when they come to medical discharge they have all the other problems that go along with that. I believe that there is too heavy a reliance on information on paper that is given to people, which they probably do not read and certainly do not digest. There is just too much of it. We need a more personalised approach to service departure. The new personnel system which the Royal Navy has started and is about to be adopted by all the Services will be an automated one where people terminate themselves. They will go online and their termination papers will be processed electronically. I can understand why that is a perfectly sensible and efficient way to complete the paperwork, but there is a real danger that part of the process of personal preparation will disappear when we should be increasing it rather than diminishing it. Air Commodore Jarron: One of the problems we have is making contact with veterans because of data protection. Once they have gone there is no way to track them and the MoD is not allowed to pass to us the names and addresses of people who have left. Very often we end up with a huge pile of paper. I think I still have mine from when I left a few years ago. Very often is not immediately after you have left that the problems set in; it is three, four or five years down the track when things are not quite working out as you would have liked. We have no way to go out to these people other than through our network of local welfare officers who hopefully keep a finger on the pulse. It would be extremely helpful to have some way to access veterans. Ms Freeth: A paper system has been introduced and SSAFA, ourselves and the regimental associations are taking part in this. I think it has been in place since April. There is a piece of paper in the termination pack for people to complete and send on to us. I do not know how many people have left, but every single one has been offered this in the past two months. We have not received one. Air Commodore Jarron: That is exactly the point I make. A piece of paper in a pile that high will still be lying there two years later. Q86 Mr Jenkin: Ms Freeth, in your memorandum you describe the lack of a seamless transition from Ministry of Defence care to the NHS, but should not the ministry maintain responsibility particularly for the people who have been on active service, whether or not they have been injured? Should not responsibility for those people be maintained by the Ministry of Defence so that they keep the records, keep track of them and maintain responsibility for making sure that care is delivered? Is that not what the British people would expect for these people who have made such big sacrifices for their country? Ms Freeth: I suspect that was expected from the creation of a new veterans minister. The ministry has done a great deal in terms of repositioning and valuing the veteran and his contribution to society through public commemoration, but in terms of improving the quality of what is provided for the individual I do not think there has been a huge improvement, which is disappointing. I suspect we may well have felt that we had more leverage when we did not have a minister. We have to go through him to press other government departments. There seems to be almost less influence over those departments than there was when we did not have a veterans minister. Q87 Mr Jenkin: Do you think that a lot of ex-servicemen, particularly those who have suffered injury and perhaps are unable to work, feel dumped by the system? Commodore Elliott: Yes, they do. Ms Freeth: Certainly, the people who come to us do feel that. Clearly, we are the people who have the most difficulty. We will know about the exceptions, if you like. Q88 Mr Jenkin: How widespread is that problem? Ms Freeth: It is not a massive problem but it is growing. There is a concern about unexpected and increasing injuries, particularly the increased mental health presentations, and something needs to be done to provide better and more joined-up support. Q89 Linda Gilroy: Some of the witnesses made a remark to the effect that the way in which their organisations are set up prevent them from doing certain things, unlike the RFA. In the wider community there is a move to get the third sector to act as partners to take on services. Is that something that you would want to look at as organisations? You have a long tradition of providing services particularly for veterans. I would have thought that on the whole veterans would prefer to turn to organisations which they feel are of their own rather than necessarily a government service as such. Commodore Elliott: This is exactly the process of which we are trying to take advantage. All too often the funds that one is after are disaggregated down to local level. For a UK-wide operation like Combat Stress that creates a huge problem. I am absolutely convinced that Combat Stress provides exactly what veterans' mental health problems need, as long as they are not too extreme. It is a case of finding a way to get a nice block of ₤10 million to provide this service seamlessly for veterans across the United Kingdom using the principle of the third sector that is funded to do the Government's work. I do not mind; I think we should be doing the Government's work. Q90 Linda Gilroy: A number of remarks have been made to the effect that it would be good if government funded this but not necessarily directly. Commodore Elliott: We cannot raise the money charitably to do all of the work that we need to do. We fund about 40 per cent of what we do from charitable income at the moment and we think we are asking as much as we dare from the hugely generous public who keep on saying, "Why ask us to fund you to do the Government's work?" I do not think there is now an issue about the third sector doing the Government's work. We are delighted to do it; we have a huge and proud tradition going back nearly 90 years and we think we can do it in partnership with the NHS, the Ministry of Defence and everyone else. It is just a case of sorting out the funding. Ms Freeth: A number of us have been looking at the individual payments programme and have been briefed on that. The ability to be partners locally, however, is not something for which local government is willing to select us because we can provide a service only for our community. Our charitable objects restrict us to working with our community, unlike other organisations that have a broader remit. I think that is unfortunate. In some of the pilot areas for individual payments we would have liked to be part-players, but under the current criteria we are not permitted to be because we cannot provide a general service. Q91 Mr Holloway: There are very large numbers of ex-servicemen in Iraq working in the private security industry. Will this compound your problems in the future? Ms Crane: Yes. Commodore Elliott: When these chaps come home they are referred to us for treatment. We are very concerned about the fact that they go back afterwards. I think they are being rather stupid, but in those cases treatment is funded by their insurance companies, so it makes it much easier to provide what they need. Q92 Willie Rennie: We have covered the general structure of health services. What about mental health services, in particular the Chilwell Centre for the TA, the Priory Group and its services and the other structures within the services? How is it operating? Commodore Elliott: It has been very interesting because they have gone through major restructuring. We are talking of in-service mental health provision. They have gone for a community-based mental health service where the community health centres are based in garrison towns, naval towns and so on. I have to say that, based on anecdotal evidence from the soldiers and sailors who have come onto our books, and the fact that we have a very good relationship with many community health practitioners who are serving the Royal Army Medical Corps, naval people and so on, this seems to be very good. It is a great improvement on the past. As to the Priory Group, this is designed for short doses of treatment for very difficult patients. We have no evidence as yet - I do not know whether the MoD has any - about how effectively all this money is spent in terms of treatment outcome. I am not sure how it is being measured, but we will have to wait and see. Q93 Willie Rennie: Do you have concerns about value for money? Commodore Elliott: I have a question about it, because I would not mind having the money and contract myself as part and parcel of a service that I believe would be more appropriate, which is to provide a service like that to in-service patients as well as veterans. This is an aspiration. Q94 Willie Rennie: I have heard contrasting figures of ₤500 a day to get Priory Group services compared with ₤200 for the service that you provide. Commodore Elliott: We are looking for ₤247 in this year's settlement, but we are not doing what the Priory Group does; we do not have as many doctors as they do and so on, so we are not comparing like with like. They do acute work; we do chronic work. To go back to in service, I think it is much better. Another matter that is so important is that education must be in place so that people understand what it is that is beginning to get to them if they start to suffer the psychological effects of trauma. That is getting much better. For about eight years the Royal Marines have had a system called TRIM - trauma reduction management system - which is a command-led rather than doctor-led scheme. That has been trialled in the Royal Navy, successfully I understand, and at a defence welfare and aftercare conference the other day where I spoke the chief of general staff said that he wanted TRIM for the British Army now. My message is that an occupational hazard of being a serviceman is that you are more likely to end up with psychological wounding than physical wounding. We need to be just as grown up about psychological wounding rather than treating it as something shameful and stigmatising and deal with it on the battlefield and in recovery, just as we do with our physically wounded people where battlefield procedures are second to none, as we know from the people who come home. That message is getting across. We need to be grown up and treat these people in the same honourable way as we do the physically wounded. Ms Freeth: The ongoing research of the King's Fund demonstrates that the operational tempo is having an impact on top of what Commodore Elliott describes. We can already see that, so we should be preparing for how to respond to it rather than wait until those research reports emerge in two years' time. Commodore Elliott: If one turns to Chilwell, it was the society who reported first that we were seeing TA soldiers coming to us very soon after returning from active service being discharged into the NHS and not getting what they needed there. They came to us. Subsequently, Professor Wesley produced a study which showed that for psychological casualties from Iraq the figures were four per cent for the TA and two per cent for regulars. He has reported very recently that the TA figure has gone up to six per cent and for the regulars it is four per cent. The society believes that those figures probably hide another couple of percentage points; there are casualties there who do not present because of stigma and the military ethos issue, among other things; or it may be that as soon as the soldier gets back from active service he discharges himself into the community and becomes one of the vulnerable service leavers. They go outside into the community in the hope that these terrible nightmares and flashbacks will go away but they do not and they start to deteriorate. But I want to be quite positive about what I have seen in service. Mrs Sheldon: As I understand it, we are looking at the service person but there is also the family. Parents and families are very seriously affected by emotional trauma. Sometimes it is very hard to understand that the person who has come back is completely different from the person who went away. Again, they should be brought within the umbrella of whatever mental health care is offered to make sure their concerns and worries are also taken into account. Perhaps we have a narrow definition here and we ignore this at our peril. At the end of the day, if these issues are not addressed the whole relationship breaks down in the family and that has an impact on the person in either returning to service life or being able to rebuild a new life outside. Q95 Chairman: Are we ignoring it currently? Mrs Sheldon: All of us have evidence of cases where it is being ignored. Again, I think it is due to a breakdown in the systematic tracking of families and picking up the symptoms as soon as possible. It is a matter of making sure that professional help is easily and quickly available, not putting barriers in the way that the process is handled both within the service and externally. It is a matter of making sure that within service when people are helped to make the transition to the outside it is understood that the whole family needs to be embraced in the concept, not just the service person. Commodore Elliott: I could not agree more. The society's constitution is such that it is supposed to look after only veterans, but that has been broadened. We are now starting to roll out services for veterans' families and adolescent children. Adolescent children are very badly damaged by the experience of having a father who comes back a changed man and behaves in a really frightening and horrible way. Earlier I spoke about evidence that families in service did not resort to what was available and came to us instead. This is of great concern to us. Ms Crane: I was at a camp in Cyprus where decompression for units coming out of Iraq takes place. I met a padre there who said that TRIM was being delivered to TELEC 10 that had just returned. The problem with families is that a lot of us are trying to raise awareness about the psychological effect of multiple deployments and operational tempo. Among lots of spouses and children at schools overseas there is increased awareness. People know that this happens and it is not something one should be so ashamed of and there are people who can help. I think it is the more remote families, partners and parents who are particularly vulnerable and we do not see. Unless service people want us to talk to them there is no way we can contact them. Another factor that has a big impact is public opinion and sometimes media pressure. If it is an unpopular deployment that has an additional effect on how people feel. Chairman: You mentioned padres. It is often the padres and commanding officers who bear the brunt of this. They are expected to be the long stops and themselves have no one with whom they can talk these things through. Q96 Willie Rennie: Returning to the veterans' service which we have covered at various points during the session, the age profile has changed. It is a much younger group of people who now come to you. First, what impact does that have on your service? Second, what waiting list do you have? You have referred to funding difficulties. How difficult is funding? Third, from where do most of your referrals come? Is it from community GPs or elsewhere? Commodore Elliott: As to age profile, we have made a deliberate change in policy and we "outed" this issue about eight years ago. At the same time, we have started a major revision in our clinical uplift for treatment. Whilst we still have a large number of World War II veterans on our books who benefit most from the respite and convalescent aspects of being in a treatment centre, there are a lot of much young veterans. Over the past four years, partly because a lot of the Word War II chaps have got beyond the age when they are able to come in for treatment, the age profile has dropped from an average age of 61 to 51. That is a huge decrease in age for those people who understand how data works. At the same time, we have had a very large increase in the number of referrals. In the past three years we have had a 27 per cent increase, or nearly 1,000 referrals a year. For a small organisation like ours that is causing us a great deal of overstretch. I am prepared to use that term. I also use it when speaking to the secretary of state and the veterans minister whenever I possibly can. That has been accepted. I am really pleased that the Minister for Veterans is about to announce a 46 per cent increase in the funding that he is to provide for remedial treatment which will help us to a large extent to increase the number of clinicians and skill mixes that we have in our treatment centres. Q97 Willie Rennie: Do you think that the increase in referrals is due to the fact that people are more aware of your service or a change in the number of people who suffer from these conditions? Commodore Elliott: All I can say is that there are far more people out there than we know about. Far more of them and their families are more aware of the issue and understand it. Quite often it is the wife or carer who brings Fred to our front door and says, "Take this man; otherwise, I am going to walk out on him." It may sound amusing but it is not; it is very sad, and it is good that we have found him. From where do referrals come? About 10 per cent come from the National Health Service and social services; about 30 per cent come from our fellow ex-service organisations, for example The Royal British Legion, SSAFA and regimental associations working with us in partnership, which is very important. We are increasing our capability to work in partnership, not only in terms of finding partners but also in terms of the services that we can provide to them. The remaining 50 to 60 per cent come by way of self-referral. We are not exactly certain whether the guy has called a helpline and been told to go to Combat Stress or he has found us on the Internet, or his mates, carer or whatever have told him about us, but that is a group which is really growing. We convert about 65 per cent of these people to active clients, as we call them, so each year we have about 600 new cases where we provide treatment and welfare support. As to funding, we rely heavily on income from the veterans agency and the war pension treatment and travel allowance that we get for providing treatment for up to six weeks a year to war pensioners, but only two per cent of last year's intake who arrived at our front door because of mental health issues had a war pension. We do not turn them away; we worry about them first and how the hell we are to fund what we are doing for them comes second. In that area we are working very hard with the minister and the secretary of state who understand our problem, which is our need to find funding for that 40 per cent of the work we do. As to the clinical priority, far more of the newer guys than the older veterans need to come in and get what we can provide. The challenge we have at the moment is that we cannot afford to open up the beds for them because we need the money to keep all the beds open. We need to have a clinical priority for admission rather than the funny balance that we have at the moment. Ms Freeth: One of the difficulties we have is that not everyone can be referred to the services that Combat Stress can provide. The charities support other people who perhaps do not have direct or provable combat-related needs but still are veterans with health needs. There are two groups, one of which we want to provide for and direct to local services that we cannot access; the other are people with other difficulties, for example problems with addiction. Commodore Elliott's service is not able to take those people. These are people in very extreme circumstances. For these people there is a shortage of service provision. In our case the problem is particularly alcohol abuse. We have small numbers of people who are drug addicts. This is a group of people - I am sure SSAFA would say the same thing - for whom we need new services. At the moment, those services really exist only in London and are not in adequate supply. Q98 Willie Rennie: Why is it necessary for those to be military-based services or services related to each Service? Why cannot the community not fund them? I know that mental health and addiction services are pretty poor relations, but why does it have to be in the military? Commodore Elliott: If I may answer that, this is my specialist area. The truth of the matter is that the National Health Service tries to provide for these people. Veterans go to the NHS and get a very good service. They are happy with that and we do not see them, but the veterans we see say that when they go to the NHS they will be referred to, say, a PTSD support group. They will sit in the group with people who have had terrible car accidents, traumatic child births and all the rest of it. He will be one soldier who has worn his best mate's brains down the front of his uniform and seen terrible things in Kosovo and so on. When it comes for him to talk about his experience, which is part of the process, either he bottles out and leaves the group straight away or reduces the group, including the therapist, to tears. He traumatises the group. They just do not fit in. The worst thing is that they feel they cannot say anything and so they get no benefit whatsoever from it and leave treatment. Ms Freeth: There are two groups: there are people who want to receive therapy as a group of veterans and individuals who do not want to do that. We need services for both categories but there simply are not enough in the community generally for people who need drug and alcohol treatment. We need more of them. Our community seems to need a greater supply of that than perhaps other parts of society. Q99 Willie Rennie: We return to Mr Jenkin's earlier point about the responsibility of the MoD for ex-servicemen. If there is such a difference in their needs the ministry should have a greater responsibility. I am pleased that you will be getting extra funding, but do you think there is sufficient funding for addiction as well as all the other services? Commodore Elliott: The answer is no. It is very difficult to deal with drug and alcohol addiction. Seventy-five per cent of the chaps on our books have major alcohol and drug problems. We do all we can to encourage them to detox and all the rest of it. We manage to get some of them to sign a no alcohol contract so that whilst they are with us they can benefit from the treatment we provide which includes working on alcohol problems. This is a really difficult group. I am sure that you have all heard of Dr Alan Jones and T Guinn. There are some really hard cases. They want to help half of the time; for the other half they want to do their own thing. They are incredibly difficult to deal with. At the moment we have a committee on which sits some ex-service rough-sleeping units. That is looking at the issue of whether or not it is possible to contain and provide these men with what they need in the sort of environment that many of us want to sustain. They can become very difficult to cope with; they can disrupt the whole unit, destroy the therapeutic environment that we need to do our work and be very dangerous both to themselves and the staff. That is not to say we do not try to identify how we may do this, but the sad thing is that for a lot of them the only time they get what they need is when they are in prison, and even then they do not get it all. Q100 Chairman: I want to draw this session to a close because it has been going on for a long time this morning. Commodore Elliott, we are very much looking forward to seeing you in Combat Stress. You may not be aware of this. Commodore Elliott: We were waiting to hear whether you would come. Q101 Chairman: We would very much like to see you after visiting Headley Court on Thursday. When we visit can you possibly have considered the point that apparently some research was published in the Lancet that it is not necessarily a good thing to leap in very early when somebody suffers psychological stress; sometimes it is best to leave the individual for a period of time to allow his or her own resilience and curing mechanisms to kick in. Perhaps we can ask you about that on Thursday. Commodore Elliott: With pleasure. Q102 Chairman: I should like a quick yes or no answer to the final question which is to do with the role of the voluntary sector as a whole. My impression from what you have been saying this morning is that you believe the voluntary sector has a very important role to play in these areas; that you very much appreciated Lord Moonie's comment that you had a huge role as ex-service organisations and government wanted you to go on doing it; that you could be more agile as organisations than the vast Ministry of Defence could ever be but that you need to be properly funded for the work that you do. Is that a fair summary of your views on the role of the voluntary sector? Mrs Sheldon: Absolutely. Ms Freeth: Yes. Air Commodore Jarron: Yes. Commodore Elliott: Yes. Ms Crane: You are looking at me but I am not ex-service. Q103 Chairman: But from your experience do you agree with that? Ms Crane: Yes, most definitely. Often people want something that is not part of the system to be available in garrisons around the world, so I do support it. Q104 Chairman: And not part of the Chain of Command? Ms Crane: No. Commodore Elliott: There is a nice mix. We want to work with the Chain of Command. We have been to 3 Para, the padre you talked about and the commanding officer. We already have a very good relationship. It is not so much for their benefit although talking to them helps them; it is to ensure that those soldiers who discharge themselves early post the amazing tour they have just had in Afghanistan know about us and will come to us. Ms Freeth: There are some good services that we would like to see extended. We have been pressing for the Chilwell reservist programme to be extended. Those are things that could be provided within the resources of the MoD. Mrs Sheldon: We would give a definite "yes" to that, but we also need to make sure that this includes in service. Charities have a huge part to play in partnership with the MoD in service. I have found a huge amount of willingness and interest in setting up family accommodation at Headley Court and Selly Oak, but I think there is a certain amount of embarrassment among people in the MoD that this is not publicly funded. They feel perhaps a little awkward sometimes when they work with charities and know that they can move and help people much more quickly. For us and the MoD it is important to encourage that maturity in partnership working. We would like the MoD to see all of us as very much part of the fabric by which services are delivered. Chairman: I thank all of you for this very valuable session. Mr Jenkin: Chairman, can we record the thanks of Members of the Committee for the work done by all of these organisations? That work is of tremendous value The fact that the quality of your evidence this morning has been of such high value to us underlines what an immensely important role you play in the welfare of our armed servicemen and women, veterans and their families. Chairman: That is entirely right. |