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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 655-iii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE DEFENCE COMMITTEE
MEDICAL CARE FOR THE ARMED FORCES
Thursday 11 October 2007 Committee Room 1, Scottish Parliament, Edinburgh
DR CHRISTOPHER FREEMAN MR DEREK FEELEY, MR GEOFF HUGGINS and DR NADINE HARRISON Evidence heard in Public Questions 210 - 371
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Defence Committee on Thursday 11 October 2007 Members present Mr James Arbuthnot, in the Chair Mr David S Borrow Mr David Hamilton Mr Brian Jenkins Mr Kevan Jones Robert Key Willie Rennie ________________ Witness: Dr Christopher Freeman, Consultant Psychotherapist, Royal Edinburgh Hospital, gave evidence. Q210 Chairman: I would like to say welcome to everyone. This is the third session of our inquiry into Medical Care for the Armed Forces. It is a particular pleasure for us to be able to come to Scotland to take evidence on this. We are grateful to our hosts at the Scottish Parliament for making these facilities available to us. We will be taking further evidence during the next few months from ministers at the Ministry of Defence, from ministers at the Department of Health and we expect, and hope, to publish a report some time in the New Year. This afternoon we have evidence from the Royal College of Psychiatrists, from the Board of the St John and Red Cross and also from officials from NHS Scotland. If I may begin by setting out the timetable for that. Dr Freeman, thank you very much indeed for coming. We will be hearing from you between now and about ten to two. We will then hear from the Red Cross and at about ten past two we will move on to NHS Scotland and the way that defence medical care interacts with them. We expect to finish at about 3.15, 3.20, so that gives us a timetable of how much we have got to get through in the time. With you, Dr Freeman, we have just over half an hour. I wonder if you could very briefly introduce yourself and say what you do and why you do it. Dr Freeman: Yes. I am Dr Chris Freeman. I am a consultant psychiatrist and psychotherapist working in the Lothian Edinburgh area. I have been a general psychiatrist and more recently, over the last ten or 15 years, a specialist in the treatment of traumatic stress reactions. I run a traumatic stress treatment centre called the River Centre which offers a service for the whole of Scotland, but mainly for the south-east of Scotland, and we treat asylum seekers, refugees, civilian accident victims, Service personnel, Fire Service, Police, a wide range of patients suffering from post-trauma psychological reactions. Just by chance, because most other services across the whole of the UK are very, very small, we are by far the biggest service anywhere in the UK with about ten or 12 full-time staff working in this area. It is a credit to Lothian Health Board that they have funded that. I am also Chair of what is called the UK Trauma Group, which is a managed clinical network of all the trauma services in the UK, both in the independent sector and in the NHS sector, including Combat Stress and military psychiatrists and psychologists as well. We meet once or twice a year to exchange ideas, discuss policies, give advice, etc. That has been going on now for about ten years. I am really here with three different hats on, and if I give three different answers I apologise for that. I am here as a general psychiatrist to try and give you a picture of what it would be like in routine clinical practice were a veteran referred; I am here as a specialist in traumatic stress to say what could be done in specialist centres; and I am here representing the Royal College of Psychiatrists to give an overview of psychiatry. I have to say those are three quite different perspectives, there is not a single answer to most questions. Q211 Chairman: Okay. Thank you very much. Can we look first at ex-Service personnel with mental health needs? Could you tell us briefly how well you think the NHS deals with ex-Service personnel? Dr Freeman: It hardly deals with them at all. I speak now with my general psychiatry hat on, what it would be like if I was working in Fife or Argyll or Glasgow and a man, usually a man, with a Service history was referred to us. It would be no different were he a postman, a painter, a squaddie in the Army, a colonel in the Army, in his history there would be a note that he was a soldier rather than a postman. It would be as basic as that. There is no specialist service. Most general psychiatrists would not be very much aware of the war pensions scheme, would not be aware of Combat Stress and the role it plays in Hollybush House, would have a vague idea that there had been a lot of debate around about Gulf War Syndrome, chronic fatigue, perhaps overemphasising the role of PTSD, but it would be no more than that. They would get treated for their depression, their alcohol or drug addiction, just like any other person. They would not be aware that a circular goes round to chief executives from the Health Department regularly saying that veterans should have priority because that would never filter down to your average general psychiatrist. They probably would not have any concept of what Army or Service life is like and what the particular stresses or strains of being a veteran would be. They would get the same treatment as anybody else, but not specialist tailored treatment if they were referred in that sort of way. Q212 Chairman: Do you have a view about whether Ministry of Defence as opposed to the NHS should maintain some sort of responsibility for veterans after they leave the Service? Do you think the arrangements that we have got at the moment are satisfactory? From what you say it sounds as though you do not. Dr Freeman: No, I do not think that. Things have improved. There was a time seven or eight years ago when if you referred a Serviceman you could hardly get access to his Service medical records, it was difficult to contact a doctor in the military to find out what had happened, but that has improved a lot. Of course, there was this very odd practice that the Army had of the man's Commanding Officer writing him a letter of recommendation on his discharge saying, "This man is a credit to the Service. He would be fully well-employed in any job you would care to offer him", without any mention of what difficulties he might have been through or what traumas he had had in Service practice. Men were discharged from the Services with, understandably, a big pat on the back for the service they had offered but were given a clear message: "You're going to be okay. Go out there into civilian life and get on with things". Of course, one of the big messages I want to get across is how difficult it is for these men to seek help. That is one of the really important things that we have to change. Even for Combat Stress it is many, many years before a lot of these people come forward for help. They are ashamed of having psychological problems, they use drink and alcohol to cover up their symptoms, and it is really hard for them to consider going to their GP and saying, "I'm breaking down. My marriage has gone wrong. I'm having dreams and nightmares", etc. I do not know that the Ministry of Defence can do much about that. There could be an argument for saying that there should be some sort of post-discharge screening, that one or two years after discharge you should see someone and at least have your mental health checked out, but my guess is that many of these men would not go back for that, they would be avoidant of it. I think it has to be within the NHS and the primary target has to be alerting GPs to the particular problems of veterans and having them sensitive to doing that. These men do go with physical problems. The GP is the main point of contact and they do go with their excess drinking, etc. It is raising awareness amongst primary care teams that the NHS has to do. Q213 Mr Jones: I agree with the need for perhaps more awareness among GPs of the general things you are talking about, but do you not think we could invent a system to at least track these people either through the NHS, the MoD or some veterans' agency and at least we would know where they were? One of the things that comes over all the time, which is exactly what you are saying, Dr Freeman, is people do not know where they are and they only present when they have problems or perhaps they do not know they have problems? Dr Freeman: As I am sure you will know, a lot of these arguments were argued out in what was called the PTSD case in the High Court a few years ago where several thousand soldiers were suing the MoD for not being looked after in terms of their psychological needs, both during their Service and post-Service. That was one of the areas that was debated and it was certainly something that the men put forward, that in some way a letter could go from the Army Medical Service to their GP on discharge simply saying, "This man served in Northern Ireland, two tours of service in Iraq" etc., flagging up that there would be certain people who would be at high risk, but that was rejected by the MoD at that stage. There are a few who fall through the net and drift around the country and do not register with GPs, but most of them do have a GP and when they go to their GP two years after discharge they do not say, "I am a soldier", or "I'm an ex-soldier", they just go in as someone who is working as a painter, a postman or whatever. So if the GP did have some little starred note saying, "Look, this man actually saw active service in three different theatres of war and was exposed to X, Y and Z" that would alert them, I think. Q214 Mr Borrow: Moving on to serving personnel, to what extent do you think the MoD provides adequate support for the mental health services for serving personnel? Dr Freeman: Again, it has waxed and waned. If you go back 20 years it was at a very low ebb. There was then a large number of community psychiatric nurses appointed in the Service and we had four or five working at Redford Barracks at one time. I happened to run a cognitive therapy, psychotherapy training course and those CPNs came on that course, so there was high quality psychological treatment for these people. Sadly, most of those personnel seem to have disappeared and Catterick has closed, which was a place that you could go for inpatient treatment. I think they do an okay job but not a great job. The psychiatric services are stretched. They do pretty good assessments and monitoring but getting high quality psychological treatment is certainly as difficult in the Army as it is in the NHS, given that these are a high risk group of people. The thing that the MoD has done over the last few years is there is a large research unit at King's College run by Simon Wesley, they have put a lot of money and effort into that, and they are taking post-deployment screening seriously, they are following people up more during Service, but there is always this tension, you think of yourself as the soldier, "How much do I want to disclose about my mental health problems? Does that mean I am going to be gently eased out of the Army?" It is a very difficult tension. I feel that bit has not changed yet, there still needs to be more acceptance of psychological problems in serving Service personnel and the aim should be to treat and rehabilitate these people to keep them in the Services. They are often very, very good soldiers who are very, very loyal to the Army, particularly, and they want to stay. They are terrified of going to the medical officer and saying, "Look, I'm depressed, I'm having nightmares, I can't sleep and my marriage is going wrong" in case that has an impact on their Service career. Q215 Mr Borrow: You mentioned the closure of Catterick, but to what extent do you think the restructuring of mental health services has improved things or made them worse? Dr Freeman: I am certainly concerned about the use of the Priory private independent hospitals for the inpatient services. I do not think when that was commissioned that the Priory were experts in this area. Many of these men say that what is important to them is being treated by someone who has some knowledge of the system in the Forces, they need to feel the person understands what life in the Army is like, so I am not sure that was a good idea. The problem with contracting to the private sector is that the private sector makes its money by keeping people in beds, the longer someone is in hospital, the more money they get, and that is a tension between the NHS and the private sector, I think. Q216 Mr Borrow: To what extent is your view coloured by the actual work you do in the sense that within serving personnel there will be displayed a whole range of mental health difficulties, not simply those that are related to the trauma of being in theatre? Obviously that will be part of it but there will be the whole range of mental health needs that a civilian population would show as well. Dr Freeman: I think that is a very fair point and something I would want to emphasise. Even if you take post-trauma psychological reactions we have slipped into a very easy way of thinking that horrible events happen to you, therefore the psychological reaction you get is post-traumatic stress disorder, and that is just not true. There are some good follow-up studies. If you take 100 people, military or civilian, who have been severely traumatised psychologically because of exposure to warfare, rape, torture or whatever, the commonest reaction they will get is depressive illness. The second commonest is some sort of anxiety disorder, panic disorder, agoraphobia, generalised anxiety disorder. The third is PTSD. Even in those who have been traumatised PTSD is not what you would expect to happen. I fully agree it is really important that we do not narrow this argument down to thinking of psychological trauma, therefore PTSD, therefore services for PTSD. Depression, alcohol and drug misuse, anxiety disorders, they get just the same range of psychological problems as people in the general population and, therefore, they need that range of treatments. Q217 Mr Borrow: Is there anything the MoD could do to actually improve the preventative health services in the mental health area? In other words, what could be done to make it less likely that serving personnel have mental health problems either while they are serving or after they have left the Service? Dr Freeman: Again, this was very fully debated in that MoD case and there were examples given of could we screen entrants into the Services better. I think the answer is probably no, the evidence is that screening is not a sensitive enough tool and who would you actually screen out because sometimes someone who has had a very disadvantaged background, who may have had adolescent problems from the backstreets of Glasgow, becomes a really good soldier when they are embraced into the Army and supported and given an experience they never had in their civilian life, and you might screen out some very good soldiers. Apart from screening for very severe mental illness problems, which I think the Army would feel they already do - schizophrenia, bipolar disorder, excessive drug misuse - I do not think screening at the beginning would do. As you know, they have what is called the Pulliam(?) System for rating people regularly during their Service and that does not pay enough attention to psychological and social factors. In-Service monitoring is something that I think could be done. The Israeli Army, as you will know, has very detailed pre-deployment preparation and there is this big debate about how do you prepare soldiers for warfare. Do you do traditionally what the British Army has done and said, "We're a great fighting force, you should be proud to be a British soldier. We expect you to behave with valour and gallantry", whereas the Israeli Army says, "You will be scared shitless. You will never feel fear like you will feel in the battle force and you need to know how your body responds to that. In training we are going to put you through that now so you are prepared for how you respond in very, very stressful situations". It is quite a different message. They would claim they get lower rates of post-psychological breakdown but I think the evidence is not that strong, to be honest. Q218 Willie Rennie: In general do you think that the mental health services within the Armed Forces are getting better or getting worse? Dr Freeman: I think they are getting better. Although that big court case was "won" by the MoD rather than by the men, and many of the men were very disappointed in the outcome, it certainly focused the MoD on the fact that they had to do things better. There is some very good research going on. They are taking this seriously now. I am not sure it has been fully translated into treatment services but in terms of understanding what they can do in terms of post-deployment defusing and those sorts of things, the project that the Marines have, I think they are really trying hard. Q219 Willie Rennie: Okay. Just going back to ex-Servicemen, do you think ex-Servicemen suffer a disproportionately higher level of mental health problems than the general population? Dr Freeman: Yes. It is not uniform across the Services, the Air Force and the Navy have much lower rates than the Army. That may be about the nature of deployment and all sorts of factors may be involved in that. Of course, you have to say that the population that the Army recruits from is often a very disadvantaged population so they may have had problems anyway. The big issue is that for many of these men their time in the Army was the best time of their life. They had their needs met, the comradeship, etc., and accommodating to civilian life after that can be very difficult for them and that is why many go in the TA and stay involved. I see many patients who are furious with what they regard as the bad deal they got in the Army in terms of medical care but if they could turn the clock back they would go back in and still serve. Q220 Willie Rennie: Does the actual Armed Forces make them have more mental health problems or is it because they go in like that in the first place? Dr Freeman: There is clear evidence that deployment in certain theatres of war causes a wide range of psychological problems and if you compare different theatres of war the rates are different. These are higher rates than those people who did not get deployed at all. There are some paradoxes in that, in that within those who were deployed, if you look at those who served on the frontline compared with those who were in support services, paradoxically those in the support services sometimes have higher rates of psychological breakdown. You cannot make a clear link between exposure to frontline warfare and psychological breakdown, but exposure to deployment overseas in certain theatres of war increases your risk. Q221 Willie Rennie: I would just like to come to serving soldiers and other Armed Forces. You said they would benefit from having a separate service where they are treated together. Would that apply also to ex-Servicemen? Dr Freeman: I certainly do not think we should go, and I do not think there are plans to, down the route of the Americans' veteran system. There are all sorts of problems with that which we probably cannot go into. It is very expensive and it supports illness rather than getting well because people live in the VA system and feel secure there. I do not think we could possibly have a veterans system in the UK that separately treated people for depression, alcoholism, anxiety disorders, PTSD, we would need a whole new branch of the NHS. I think what we do need is a really good monitoring system, a central point of referral so that these men who find it very difficult to seek help can have walk-in shop front clinics where they can go, where they can see other veterans working as volunteers, where they can have an assessment triage for their appropriate treatment. After that stage, and they may well still link in with that shop front service for many years, they would go for their specialist treatment, getting psychotherapy or drug addiction treatment or whatever. It is the point of entry we need to manage better. It would cost hardly any money to have a triage system like that, an assessment service for veterans. Mr Jenkins: I just want to labour a point with regard to ex-Servicemen and that they have more mental health problems. As you said correctly, the Army does but not the Air Force or the Navy, which is rather a funny way of putting it because they are ex-Servicemen. There must be a rational reason why they do not suffer the same problems. Then you said it is because of the recruitment base we take the Army from. I am suggesting that you might be right at some point because almost every weekend in this country three or four of our young people get killed in road accidents and these are the very adventurous, risk-taking group that we recruit from in the Army anyway. Probably if we did not recruit them there would be more dead in our country as civilians than there are Armed Forces, but that is not the problem. The problem is --- Chairman: What is the question? Mr Jenkins: I am trying to make a statement here, Chairman. I think it is important we actually put this ground right. Chairman: I know. Q222 Mr Jenkins: The difficulty I have got is I have not got a control group to say, "This is what would happen to them if they did not join up" and "This is what would to them if they did join up". We are in the realms of speculation, are we not, because we do not have enough records on these individuals to prove the result? We have not got any records on the probability of an individual suffering harm from his Service career. Dr Freeman: I think that is partly true because, of course, even if you compare those who are deployed versus those who are not deployed the soldier has some choice in that. When they sign up, they sign up to be a cook or a technicians officer rather than a frontline soldier and there is some choice in that. It would be a great disservice to our serving men to think that being exposed to frontline warfare has no effect on them. What would that say about humankind if that were so? Chairman: Thank you. We have ten minutes more. Q223 Robert Key: Dr Freeman, could you help me understand what I perceive to be mixed messages here. On the one hand, I think we are being told that psychiatry thinks it is better if people with mental health needs are treated in the community together in the round rather than singled out; on the other hand, the Chief Executive of Combat Stress said it could be damaging to put veterans into those circumstances with everybody else because they could disrupt everybody else with their terrible stories and it would not be a very helpful thing to do. Can you explain how I should reconcile those two statements? Dr Freeman: I think the issue is that Combat Stress has a residential programme. As you know, it has three centres around the UK and there is no doubt that many men find that two week stay once a year extremely beneficial. It recreates for them something of what they get in their Service career and they meet colleagues and comrades. I have no problem with that. I think the issue is that most people can be treated on an outpatient basis. I would fully agree if I had a soldier with severe depression and was having nightmares and flashbacks and had a horrific trauma story and I felt they were so disrupted that they needed to be made safe and admitted somewhere I would rather they went to Hollybush in Ayr than they went into my general psychiatric ward, but that is a tiny proportion of the total. For each one like that I would have 15 or 20 more I could treat on an outpatient basis coming up once a week offering them home-based assessment. I do not think there is a tension really. I have no problem with the inpatient services being around a particular specialist area but you cannot travel to Hollybush from Inverness once a week for your outpatient treatment, you need to have distributed community-based services for the majority of these men. We need to work in partnership with Combat Stress, and it needs to be something where the triage could be done jointly between the NHS and Combat Stress, most of the outpatient treatment could be done in NHS services, because Combat Stress has difficulty in treating people with drug and alcohol problems, which is a big part of that, but if we wanted inpatient treatment then a specialist unit would be fine. Robert Key: Thank you. Q224 Chairman: We seem to be giving you the third degree. Dr Freeman: It is okay, the sun is going down. Q225 Mr Jones: Can I just follow up because you made a point, Dr Freeman, about the Priory. I think you just reinforced what we were told this morning, that you are actually dealing with very small numbers of people each year who do need inpatient care. In Civvy Street that is the case as well. In my PCT, for example, one hospital has closed and has been replaced with a smaller unit because that is the way the service has gone. It is not the fact that the Priory care contract is not in the NHS, it is the fact if they are keeping them in longer than they should or they cannot provide what you say they should do, that is actually about the contract rather than the actual --- Dr Freeman: Yes. Obviously it is not something that is unique to the veterans contract, it happens across the UK with patients with eating disorders. Q226 Mr Jones: So it does not make it wrong that is in the private sector? Dr Freeman: No. Q227 Mr Jones: In terms of the Lancet evidence we received recently, it said that it could be counterproductive to intervene too quickly with people who suffer from traumatic experiences, that natural resilience would work in many cases. Can you let us know what your view is of that? Dr Freeman: There is very strong evidence now that the vogue for psychological debriefing, ie doing something early, 48 hours to ten days after a traumatic event, be that to civilians or to soldiers, can be harmful. The reason for that is by nature most of us are very good at avoiding that, the best way of coping in the short-term --- Q228 Mr Jones: Politicians better than most people! Dr Freeman: --- may well be to try not to think about it. Some people can do that really well and if you sit them down in a psychological debriefing group and say, "You've got to tell me your story, and not only will you hear your story again but you are going to hear five other stories from other people", that can be damaging. Q229 Chairman: We have heard stories about there being difficulties about the transfer of records from the MoD to the NHS. Have you heard anything like that? Dr Freeman: Yes. Historically I have had great difficulty but now I have to say it works extremely smoothly with a phone call and you can often get through to the Service GP or psychiatrist and get details. That really has not been a problem recently and I think that has been a big change. Q230 Mr Hamilton: Combat Stress told us ten per cent of the referrals they receive are from the National Health Service and the vast majority from ex-Service organisations are the ones who direct people to the appropriate organisations. Does that mean that the National Health Service is failing veterans in getting that information forward? Dr Freeman: Yes. Q231 Mr Hamilton: It does? Dr Freeman: The National Health Service in general does not do well in getting young men into treatment, and this is a problem across the board, not just for Service personnel. We know that the highest rate of complete suicide is in young men, even though women have many more attempted suicides. We need to be much more innovative in how we get these men into treatments. The idea that you have a clinic somewhere, that your GP refers you up, you sit in a waiting room with ten other people and you have a largely verbally based psychological treatment is just a complete turn-off for many men. There have been quite a lot of experiments in Scotland about running clinics in ASDA, having quite a different approach to getting men with stress problems into treatment. Q232 Mr Hamilton: Could I follow up something you said earlier on, and what you have just said. In my constituency, which is Midlothian, just south of here, there are six ex-Servicemen's clubs. Could the MoD not utilise the facilities they already have that exist recognising the fact that many of the ex-Service personnel will frequent these places because that is where their comrades are and people who have been through the Services would understand? Is there not an argument that the MoD should utilise these facilities far more than they are doing at the present time? Dr Freeman: Or do that in partnership with the NHS. There is now a retired psychiatrist called Dafydd Alan Jones who ran an infamous unit in Wales called Ty Gwyn and he came up to Scotland to run clinics, he did them in Boswell and Perth, and he managed to get 60-80 men in an evening to come to a church hall to discuss these issues. Clearly the men valued that peer group relationship, valued seeing a psychiatrist who knew about military matters, and that is the sort of approach you need, I think, rather than, "Here's a specialist clinic. Go to your GP and your GP will send you a referral, you will be on a waiting list for a few weeks, you will go and sit there next to someone with depression, anorexia, etc." Q233 Mr Hamilton: You deal with Lothian NHS, it would be quite good if Lothian NHS, the MoD and the various legions all worked together to see if they could come up with a pilot. Dr Freeman: The same with TA centres as well, we should have links there. Q234 Mr Jenkins: Drug and alcohol addiction is high among ex-Servicemen. Should we treat this as a separate special group to try and tackle that for these veterans? Dr Freeman: A cultural change needs to happen in the Services about the use of alcohol to relieve stress. It should be less tolerated than it is, but that is a social rather than a medical issue I think. In terms of special treatment services, I think there are probably enough ex-Servicemen with alcohol problems to set up some limited programme for Scotland, for example, one in Glasgow, one in Lothian, perhaps one in Tayside. There would be enough people where they could be treated on a group basis. As you know, the problem is the AA approach, which is very widely used in the non-statutory sector, does not go down well with most soldiers. They are not going to buy complete abstinence and they are not going to buy God. Q235 Mr Jenkins: The other one is about our prison population, that there is a disproportionate number of ex-Army. Not ex-RAF or ex-Navy, ex-Army again. Because of the mental problems they have and because of the prison system, should they be treated separately as a priority within our prison system? Dr Freeman: Yes, and it is one of the things we are just trying to plan in Scotland. We have had a very extensive programme of early intervention, guided self-help, all sorts of things for people in primary care with depression and anxiety, and I think we now need to transfer that to the Prison Service. Not the men who are banging their heads against the wall and are psychotic in prison, the severely mentally ill, but there is a significant morbidity of depression and anxiety, and these men are there, you could treat them, you have got a captive population. Q236 Willie Rennie: Do you not think it is a disgrace that veterans have to rely on charity, organisations like Combat Stress? Dr Freeman: I do not think it is a disgrace, no, because about half of Combat Stress's money comes from central sources, so it is not all charity. I do think that it should not rely on charity alone. Conversely, there is something about the independence from the establishment which may be an advantage for some men. Some of these men feel very disenfranchised from the Army and from the NHS but can ally themselves to something that they see as independent. If you could maintain that independent streak but have secure funding that would be a good idea. Q237 Chairman: Dr Freeman, I think we have got to draw this to an end now. May I thank you for what has been one of the best episodes of evidence I think this Committee has ever had. You have been extremely straightforward, clear, clipped, you have kept to time and we are most grateful. Dr Freeman: Thank you. Memorandum submitted by the Board of St John and Red Cross Defence Medical Welfare Service
Witness: Dr J Gordon Paterson OBE, Chairman, St John and Red Cross Defence Medical Welfare Service, gave evidence. Q238 Chairman: Can we have Dr Paterson, please, from the Board of the St John and Red Cross Defence Medical Welfare Service. Dr Paterson, may I begin by thanking you very much for coming to give evidence today and also for the memorandum from the Board of St John and Red Cross DMWS. First, can I ask you to tell us precisely what you do and who you are? Dr Paterson: I think if I can introduce myself and then the organisation which I have the honour to chair. I am a medical doctor, trained in Edinburgh. I was Director of Public Health in Aberdeen until I retired in 1999. Completely apart from that, I have had 40 years' involvement with the British Red Cross, initially as a Branch President, which is an honorary appointment. Immediately after retirement I served for three years as Chief Medical Officer to British Red Cross. The Organisation which I chair is an interesting one. It is a separate, independent charitable company. I think the members of the Committee may be interested in its origins. During the Second World War, volunteers, and I stress volunteers, in both St John and Red Cross were alerted to the fact that there was a need to supplement clinical services with welfare input and that voluntary initiative by the two voluntary aid societies led to the creation of a Service Hospital Welfare Service. For the avoidance of any doubt, this is not a group of well-intentioned ladies - mainly ladies - who did not get their hands dirty, these individuals deployed with British military hospitals throughout the world. I think then, as now, the staff were recognised by clinical staff as providing a very valuable service working alongside, and as effectively as, members of the clinical team. Very briefly, just to bring you up-to-date, in the late 1990s I should stress that the former Service Hospital Welfare Department was funded by a combination of grant-in-aid and the funds which had been accumulated during World War II held jointly by Red Cross and St John. The government indicated that they were not happy with grant-in-aid and would prefer the organisation to be a formal contractor to the MoD, so in 2001 we incorporated as what is now the Defence Medical Welfare Service. Although its parents, Red Cross and St John, are recognised in our title, we are not part of either organisation. The Prior of the Order of St John and the Chairman of British Red Cross are the two members of our company, but other than that we are an independent organisation. We were awarded one short-term contract. The contract we have at present was won in competition with two other organisations and runs until March 2009. I think rather than my going on at length, Chairman, I would be more than happy in the limited time available to clarify anything in the written submission or to answer questions. Q239 Mr Jones: I have read this and it is very useful background to how you came to be here but I am not actually clear what you do. It would be very helpful to me, and I am sure other members, if you could explain two things: one, what do you do in terms of this contract and, two, more importantly, what is it that you are asked to deliver that you are saying you are not delivering, because it is not quite clear? Dr Paterson: It is a question I am often asked, usually in social gatherings, and I use two graphic examples. A Serviceman is wounded in Iraq today, he may well be hospitalised, have no equipment other than the clothing that he comes in with because it is all back with his unit. Obviously doctors and nurses are preoccupied with saving the man's life and dealing with his injuries but there is a whole raft of things to be done in terms of literally providing some clean clothing, providing a DVD that he can watch in his hospital bed, supplementing the military communication channels back to home. In the most extreme situation, when a Service person is killed, our staff will accompany relatives from the airport to the mortuary to view their loved one. It is a combination of really quite soft welfare roles and some fairly hard and demanding emotional tasks. Q240 Mr Jones: That is very helpful, but where does it fit in? For example, when we went to Selly Oak earlier this year and we saw accommodation being provided by SSAFA and other organisations, where do you fit in? Are there demarcation lines that one organisation does not do what you do, or what? Dr Paterson: The building on the Selly Oak site is actually an NHS building. Our contract does not allow us to do anything to that building other than visit the people in it. The main focus of work at Selly Oak is actually daily or more frequent visits to the patients on the ward. Since that written submission was produced, we have increased our staff from three to six. As I am sure you will realise, the numbers of casualties coming into RCDM are now at an all time high and we feel it is essential to maintain a 24-hour service. Q241 Chairman: The impression that comes through your memorandum is that you feel essentially that you could be doing more, in a sense that you are under-used and under communicated with, is that correct? Dr Paterson: Yes, it is. As you probably realise, the statement of requirement for our service is essentially written by the Surgeon-General and the contract is managed by the contracts branch of the MoD, and those are two completely separate individuals and organisations. Sadly, there is an assumption that when you ask to do more you are asking for more money, and we are not. I believe there is the potential to provide better welfare service, more intensive welfare service with the resources we have, and I have given some examples in the paper. Our contract requires us to provide an inpatient hospital welfare service. If a Serviceman comes back to the same hospital for an outpatient visit six weeks later our contract does not allow us, in fact, to see them and yet that Serviceman or Servicewoman may well have established quite a strong relationship with a welfare officer, as may the members of his or her family, yet it does seem a lost opportunity not to continue that contact. The resource implications, I suspect, would be minimal. Q242 Chairman: What do you think then should happen when the contract comes up for potential renewal in 2009 to resolve some of these issues? Dr Paterson: I think two things. There should be a root and branch review of what it is that is meant by a hospital welfare service and is it really just an inpatient service. Many of the criticisms, some of them probably exaggerated, are that people get lost in the system. There is one specific issue. I am assured that the Joint Casualty Compassionate Cell, which is a Tri-Service organisation, does know the whereabouts of all personnel who are hospitalised, not just in the Ministry of Defence Hospital Units. Our submission would be that these are very often people with whom we have established a relationship when they have been in Selly Oak and I do not believe it would be breaching confidentiality rules if that organisation was to say to us, "This serving member of the forces, who you already know, has actually been hospitalised six miles down the road and maybe you would like to make contact with them". We would not impose our service but the feedback we have had from Service personnel is that they would appreciate it. Q243 Chairman: What would you say that you do as an organisation that is different from what, for example, SSAFA does? Dr Paterson: We are very much part of the clinical team. Some of our staff have healthcare backgrounds but we are not clinicians; we are definitely not clinicians. If you ask the military commanders, and certainly if you ask Defence Medical Services staff, they would say that our personnel are integral members of the clinical team, they are there on day one when the casualty is hospitalised, and that is quite different from the other organisations. Q244 Mr Jones: That last point is very useful. Do you really think what is needed here is that the MoD/NHS needs to clearly define - it is possibly because there have been some bad news stories, some true and some not about the way in which people are dealt with - the contract when it comes up for renewal and it needs to be a bit wider than what you do or a series of organisations coming together to put together a welfare package around the individual which would be not just your side in terms of the clinical element but also, for example, how you deal with families, next of kin and things like that, so we do not possibly get duplication or a mismatch as you are describing where demarcation lines are drawn between you and another organisation? Dr Paterson: There was a very unfortunate set of circumstances at the end of last year when, in fact, there were numerous individuals and organisations giving very mixed messages and I think a lot of Service personnel and families were very confused as to what was the right story. Can I stress that we are not in competition with these organisations. Q245 Mr Jones: No, I am not suggesting you are. Dr Paterson: We work very well. I do take your point that clarity of what it is that is required and who can contribute what to that requirement would be very valued. Q246 Willie Rennie: Is it confidentiality reasons that are stopping you contacting people in other circumstances? Dr Paterson: It is very interesting because most of our staff in normal circumstances are deployed in Germany and it is not a problem. My experience, having worked with data protection for 40 years, is the Germans are much keener on data protection than we are, yet if any serving member of the British Armed Forces is hospitalised in Germany there is a free passage of information, so I do not understand it. Q247 Willie Rennie: Is that the reason given in this country as to why you cannot go to the outpatients? Dr Paterson: Yes. Q248 Mr Jones: But you are under contract, are you not, from the MoD? Dr Paterson: Yes. Q249 Mr Jones: It is not as though it is like me, Joe Bloggs, or my organisations coming off the street and saying I want to have access to these people. Surely they are referring people to you, are they not? I cannot get my head round that one. Dr Paterson: This is in stark contrast to the behaviours of the clinical staff because our staff sit in on multidisciplinary case meetings with the chaplain, the psychiatrist, the surgeon and the nurses. Q250 Mr Jones: But the taxpayers are paying for your services, are they not? Dr Paterson: Indeed. Q251 Mr Jones: So why should that be any different from a taxpayer paying for the services anywhere else? Dr Paterson: Lest I sound paranoid, you probably realise that this argument of confidentiality has been raised on a number of occasions when a number of Service families have said, "My son got lost in the system". I was very encouraged by Dr Freeman's comments about the fact that clinical information now passes quite quickly from the MoD to the NHS, but I do believe, and I think our staff feel slighted that we cannot be trusted with clinical information, we are bound by a code of confidence. Q252 Willie Rennie: The fact that you have had to come before us to tell us this, does that indicate a breakdown of the relationship between you and your contractor? Dr Paterson: Not at all. Can I say that we enjoy very good relationships with the MoD. They are aware we are here and were offered sight of our submission. They are very relaxed that we are here. Mr Jenkins: If I can just say, Chairman, I sympathise with you on the Data Protection Act. In the past I have had to go to the Information Commissioner several times to get things clarified and to get him to send signals out, but jobsworths abide in this world and for some reason they just do not read legislation or understand. If it is for its primary purpose, and the primary purpose in this case is to trace, track and look after the welfare of an individual patient, they can release that information but, unfortunately, they do not read the small print, they just act as a jobsworth and stop people doing their job. Q253 Chairman: In your submission you gave an example of someone who did not appear on bed state lists issued to DWMS and you heard about his visits to hospital only because his mother 160 miles away told you he was going to be in hospital. Dr Paterson: Yes. Q254 Chairman: When something like this happens presumably you make representations to the Ministry of Defence to say that there ought to be better communication with you under your contract. Dr Paterson: Yes. We had a very productive meeting with the current Surgeon-General a few months ago and we made a strong plea that the regional model of working that we have in Cyprus and in Germany, which is basically anywhere there is a Serviceman or Servicewoman in hospital we visit, was extended to the UK. The Surgeon-General was very receptive but, sadly, nothing has happened. Q255 Chairman: Looking at it for a moment from the Ministry of Defence's point of view, what do you think their difficulty in relation to doing this has been? Dr Paterson: I think there may be two explanations. One is the MoD themselves may not have known about Patient A, that he had moved from a military Ministry of Defence Hospital Unit, had gone home and had then been readmitted to an NHS hospital. They may not have known. I think my second point is had they known, at the moment the system would not have prompted them to tell us that the patient had been admitted to a nearby hospital, either because they did not want to tell us or they felt they should not tell us. Q256 Mr Jones: The example you have just given, is that someone who has left the Armed Forces that you are talking about or somebody who is in it? Dr Paterson: No, he was still serving. Q257 Mr Jones: Surely the MoD would know about that individual. Dr Paterson: They may not have done. If he had gone back to a private home as opposed to living in barracks it may have been a civilian GP who referred him into the local hospital. Q258 Chairman: Surely his unit would be well aware that he was not turning up for work. Dr Paterson: He was on sick leave. Q259 Chairman: Ah, yes. Good point. You do not get involved in Headley Court, do you? Dr Paterson: No, and that surprised the Surgeon-General because Headley Court has had a lot of publicity in the recent past around its hostel accommodation. The Surgeon-General was very surprised. In fact, I think he had assumed that we were because clearly the welfare needs of patients who are being rehabilitated and their families are quite substantial. Again, the Surgeon-General suggested that we ought to be involved; we are still waiting for an invitation. Q260 Chairman: Is the Surgeon-General's invitation not sufficient? Dr Paterson: No. Unfortunately, we can only do what our contract says. That sounds like a jobsworth's response, I do apologise. Certainly we cannot exceed our operational locations as described in the contract. Q261 Chairman: How would you think that looking at the use of St John and the Red Cross things could be improved for Service personnel? What would be your overall approach to making things better? Dr Paterson: I think the organisation is invisible. I suspect all the members of the Committee had never heard of us. Sadly, even in the higher ranks of the military many people have never heard of us. The people who really hear about us and sing our praises are the people in the hospital units and the Commanding Officers and the people who use the service. Our profile and awareness needs to be raised. Q262 Chairman: That is a matter for you, is it not? Dr Paterson: Well, it is, but I think there is a communication process within the military. I also think the artificial barriers to the passage of information should be broken down. We are willing to go anywhere that our services are required, whether it is in Germany, Cyprus or the UK. We have got two welfare officers in Iraq at the moment and two in Afghanistan who are fully respected members of the team. I just feel that the people who have been operating in that environment and come back to the UK do feel very frustrated that the skills they have exercised in the theatre of war are not used in a more civilian setting in the UK. Chairman: Thank you. Willie Rennie, and then I think we ought to move on. Q263 Willie Rennie: Who provides welfare support for those at Headley Court? I know you do not but do other organisations? Dr Paterson: I have no idea. Chairman: Dr Paterson, thank you very much indeed. We are most grateful to you for coming pretty much at the last moment actually. Thank you very much. Witnesses: Mr Derek Feeley, Director of Healthcare Policy & Strategy Director, Mr Geoff Huggins, Head of Mental Health Division, Healthcare Policy & Strategy, and Dr Nadine Harrison, Medical Adviser, Primary & Community Care Directorate, Scottish Health and Wellbeing Department, gave evidence. Q264 Chairman: Lady and gentlemen, thank you very much indeed for coming to help us with our inquiry. I wonder if I could ask you, please, to introduce yourselves and say what you do and why you do it? Derek Feeley, would you like to begin? Mr Feeley: Derek Feeley. I am Director of Healthcare Policy & Strategy in the Scottish Government's Health Department. That means essentially I am responsible for advising ministers on a range of healthcare policies that stretch from mental health all the way through to issues around hospital configuration, etc. One of my areas is around relations with Whitehall and, therefore, my interests are in defence matters. Mr Huggins: I am the Deputy Director for Healthcare Policy & Strategy, Head of the Mental Health Division, and I have got responsibility for all matters in respect of mental health within Scotland. I am a member of the senior Civil Service and do liaison with Combat Stress. Dr Harrison: I have a GP background. I work as a medical officer in the Primary Care Division in the Scottish Government Health Department giving advice to ministers on all sorts of aspects of policy and strategy. Chairman: Thank you very much. Q265 Mr Hamilton: Can you explain, briefly, the ways in which the National Health Service in Scotland work with the MoD to look after the healthcare needs of Service personnel and veterans? Mr Feeley: I can kick off with that. I guess the first thing to mention is that there is a concordat, which the Committee may be aware of, between the Department of Health and the Ministry of Defence but signed up to by health ministers from the devolved administrations too. That helps set a framework, if you like, for the relationships between the departments. On the back of that concordat we, in the Health Department, issue guidance to our NHS Boards and I can make the latest form of that guidance available to the Committee if that is of interest. The ongoing management of the relationship between the Health Departments and the MoD is done through what is called a Partnership Board. The Partnership Board meets about quarterly, certainly three times per year, to identify areas of common interest and opportunities for co-operation. Q266 Mr Hamilton: What special provisions do you have to make for the needs of the Service communities within Scotland? Mr Feeley: It works at a number of levels, I guess. We are responsible for healthcare for Service families and their veterans directly and working in partnership with Defence Medical Services to provide health services for the Armed Forces. The guidance to which I referred sets some of that out. Nadine can talk in some detail about primary care services. On secondary care, members of the Armed Forces based in the UK are entitled to the full use of NHS facilities on the same basis as civilians. Q267 Mr Hamilton: So there are no special provisions? Mr Feeley: There are provisions for access to high quality services through the NHS. Q268 Robert Key: But no fast-track facilities, as in England? Mr Feeley: No fast-track facilities. There will be a range of factors that a clinician will take into account in determining how quickly to see a patient, and one of those will be their occupation. We would not automatically see every Service person before every civilian, if that is what you are asking. Q269 Mr Hamilton: That answer means there is no provision made other than a normal provision for ex-Service personnel if they go to see a doctor. If you listened to the first part of the evidence session, and I am sorry you were not here at the time, the doctor indicated the possibility of information passing when a person walks in off the street who is ex-Service personnel or, indeed, Service personnel on the sick, because many of the local doctors do not know the issues that affect them. In England that has been addressed by the fast-track system. What is the special provision agreed in Scotland? Mr Feeley: Are you talking about ex-Service personnel? Q270 Mr Hamilton: And Service personnel. Mr Feeley: Geoff will be able to answer that. Most people are discharged without particular medical needs. Some have very specific medical needs and every effort is made to have those needs ready to be addressed in advance of their discharge. There is a good deal of collaboration and communication before the Service person is even discharged to enable them to get access to the NHS services that they need as quickly as they need them. Chairman: We will come back to that in just a second. Q271 Willie Rennie: Are you aware of the fast-track system? Mr Feeley: In England? Q272 Willie Rennie: Yes. Mr Huggins: I think he means priority treatment. Mr Feeley: Is that what you mean? Q273 Willie Rennie: We understand it is called fast-track. Are you aware of that? Mr Huggins: In Scotland we would call that priority treatment for war pensioners. It applies in Scotland and we --- Q274 Willie Rennie: This is for serving personnel, there is a fast track system. You can go down to the five MDHUs in England and get fast-tracked treatment. Dr Harrison: There is not a specific place in Scotland where that happens but they would go to the English hospitals. Q275 Willie Rennie: But you are aware of that system? Dr Harrison: Yes. Mr Feeley: Yes. Dr Harrison: They would go to Northallerton probably. Q276 Mr Jones: The MoD tell us that certainly in England in terms of war pensioners there is an entitlement to priority NHS treatment and obviously free prescriptions in certain circumstances. Is that the same in Scotland? Mr Huggins: Yes. Mr Feeley: Chairman, sorry if I misunderstood Mr Hamilton's question, I thought he was talking about services in the NHS in Scotland. Chairman: He was. Q277 Mr Hamilton: I am specifically asking about Scotland. Naturally, being a Scottish MP, it is important from our point of view, and representing Glencorse Barracks we have an interest in what happens. How often do you meet with MoD officials and at what level do you meet them? Mr Feeley: Our representative on the Partnership Board is one of the Deputy Chief Medical Officers, Professor Peter Donnelly, so at a very senior level. That Board meets three to four times per year. Q278 Mr Hamilton: How many times? Mr Feeley: Three to four times. Mr Huggins: Because of the discussions that we have had in respect of Combat Stress we have been meeting with the MoD officials more regularly on particular issues around veterans and mental health. Most recently we met with them on Monday of this week in the context of the announcement made on, I think, Tuesday by the MoD in respect of fees for Hollybush House and the other Combat Stress centres. We have a regular and ongoing dialogue at the moment around improving care for veterans. Q279 Chairman: What triggered that increase in contact with the Ministry of Defence? Mr Huggins: It was the HASCAS report. The Health and Social Care Advisory Service produced a report in 2005 into mental healthcare for veterans, largely at that time focusing on the services that were being provided by Combat Stress but also looking more widely at the range of service needs that veterans had in respect of mental health. That has generated both the consideration of the current fee base for Hollybush House but also the consideration of a wider set of policy and delivery measures around mental health for veterans. Q280 Mr Borrow: There was a reference earlier to the Ministry of Defence Hospital Units in England, the five of them that exist in England and the fast-tracking system for serving personnel. We understand that at the time they were being designed there was no interest from the NHS in Scotland and, therefore, in the NHS in Scotland there was no unit up for consideration as far as Scotland is concerned. Is that something that you would like to see addressed? Do you think there would be a benefit in having such a unit in Scotland? Mr Feeley: I think the existing system works well. There are very few complaints from Service personnel about the way in which they receive healthcare in Scotland. If there was a view that further MDHUs were required then it may well be that the Scottish boards would be interested in applying but we would need to look at all the circumstances at that time. As it stands just now there is no opportunity. Q281 Mr Borrow: Following on from that, MDHUs do give an opportunity for military medical personnel to work alongside civilian NHS medical personnel. Are there any opportunities in Scotland for that to happen? Do you think it would be a good idea if there were more opportunities? Mr Feeley: It would always be a good thing for there to be more opportunities but there are a number of opportunities that do exist, particularly in and around Edinburgh. We have some military staff working in general practice, we have a number working in a number of specialties, including psychiatry and orthopaedics at the Royal Infirmary of Edinburgh, and we have got one working in urology at the Western General Hospital in Edinburgh. There is the opportunity for that kind of exchange and I do agree that it is extremely valuable. Q282 Mr Jones: You say it works satisfactorily but it would because you are exporting the patients to England, and I would not complain if I was in that system, but we were also told this morning that the MoD also then pay a premium for fast-tracking people through the Scottish system. How does that work? Mr Feeley: I think it works through contractual arrangements between the MoD facility and the NHS Board. Q283 Chairman: Mr Feeley, you said just now that there was an announcement about Combat Stress on Tuesday. I am very sorry, I am ignorant of it. Can you tell me what it was, please? Mr Feeley: Mr Huggins can fill you in. Mr Huggins: The MoD, the Scottish Government and Combat Stress have been discussing the basis on which to take forward aspects of the HASCAS report, which I referred to. One of the key elements of the HASCAS report was improving the clinical capability of Combat Stress as an organisation, in particular the proposition that they should have a medical director who is a consultant psychiatrist, but also to increase the range of professional nursing and psychology staff. To do that, Combat Stress were clear that the fee basis they worked on would need to change, and in practice what we have seen over a period of time has been a negotiation between the Ministry of Defence and Combat Stress about exactly the degree to which their fee base would need to change, which has effectively been resolved and was announced on Tuesday. Q284 Chairman: Was this part of the Comprehensive Spending Review? Mr Huggins: No. When I said Tuesday, I am clearly confused because what I meant was last Thursday, of course. As with you, I have been travelling somewhat and I am equally confused. The announcement was made last Thursday and effectively what it provides for is a phased uplift of fees with the uplift running across 2007-08 culminating in a final raise in January to a 45 per cent increase, at which point Combat Stress should have significantly greater clinical capability. That was an announcement which was followed by the Scottish Government which funds the service which is provided within Scotland as, of course, veterans is a devolved matter in respect of healthcare services. Q285 Mr Jenkins: Since you say veterans is a devolved matter, what exactly do you do with regard to the higher level of drink and drug dependency amongst veterans and the fact that we have got more veterans in prison as a percentage than the general population who suffer from mental problems as well? Are they just left within the prison system or do they get priority in the Scottish NHS? Mr Huggins: At the moment we have a discussion with the Scottish Prison Service about how we can improve the general quality of access to healthcare services within prison because we found it quite challenging to offer mental health services within prison environments. At this stage we do not have a policy which provides differential treatment on the basis of military service or otherwise within the prison context or access to services. Certainly part of the discussion that we are having, and will be having, with Combat Stress and other organisations is around greater access to substance abuse and alcohol services. This is a challenge we face not just with this population but across a range of populations. Q286 Mr Jenkins: On drink and drugs and prison, the answer is you have done nothing yet but you are having meetings and talks on it? Mr Huggins: There are programmes in place which offer assistance in respect of substance abuse and there are programmes in place in respect of alcohol within the prison context. Q287 Mr Jenkins: For veterans? Mr Huggins: For people within this context. There are not specific, separate programmes running in prison for veterans, no. Q288 Chairman: Are you aware of the proportion of prisoners in Scottish prisons who have mental health problems? Mr Huggins: It probably depends how you describe mental health problems. In terms of mental health we think of a spectrum of care needs from those who might have diagnosed mental illness, people with schizophrenia or bipolar disorder. That is around to two to three, three to four per cent of the general population and it is probably closer to ten per cent of the prison population. We then look at those who might have mild to moderate mental health problems, depression, stress, anxiety, which at any point in time is probably running at between 20 and 30 per cent of the general population but is considerably higher within the prison population, it is going to be 50, 60, 70 per cent. For many it is a natural response to being incarcerated, probably locked up for extended periods of time, to be stressed and anxious being separated from loved ones. There are programmes that are run in terms of befriending programmes, listening programmes, activities which are intended to address those issues. When we talk about mental health problems we have to be quite careful in drawing those distinctions because those are mental health problems that were they in the community would be managed within the community by normal GP-style services. Q289 Chairman: Dr Harrison, do please feel free to chip in whenever you feel that you would like. Dr Harrison: Yes, thank you. Q290 Mr Jones: You said that NHS services for veterans was a devolved responsibility and we have heard what you are doing in terms of looking at veterans in prison, for example. How is that actually dealt with by NHS Scotland? Is it looked at as a separate thing altogether? How is it managed? Mr Huggins: The prison currently operates its own separate medical service which operates a medical service for prisoners. It is a challenging area and I think our collective view is we could offer a better medical service and we are in discussion with the prison medical service about how we would do that. Q291 Mr Jones: What about veterans not in prison, the general veterans' health, how do you manage that as the NHS in Scotland? Mr Huggins: In terms of the veterans' mental health we are in discussion with Combat Stress both about the service which is provided in Hollybush House, but we are also in discussion with the MoD in respect of the proposed pilots for community and primary services to veterans. We recognise that veterans are a distinct and different population who have a different background and who in many cases are looking for a different way in to access services. We recognise that there are organisations like Combat Stress which are clearly very acceptable and seen as good gatekeepers and good access points. At this stage, with the co-operation of the MoD and others, we are looking to develop approaches which are particular to veterans which enable us to improve those services. That is part of the outcome of the HASCAS report. I think we will shortly be seeing similar pilots announced in England and Wales. We have a developing programme of work to actually improve the quality of service at the moment. Other than that, at the moment veterans will receive services as other members of the public do. We are recognising that there is a distinction and a difference. Q292 Mr Jones: So you have not actually got a separate policy for veterans in Scotland in the NHS? Mr Feeley: They get priority treatment for the condition or disability for which their war pension is payable, if that is what you are referring to. Q293 Mr Jones: No, I am asking, as the NHS, do you have a policy area to look at veterans? If you have been devolved the responsibility for it, it is an area where clearly you are looking at the mental health side of it but in terms of the care of veterans in general has any policy work or anything been done on looking at veterans as different types of customers from the rest of us? Mr Feeley: We issued guidance to boards in 2006, the precise date eludes me at the minute, that reminded NHS Boards in Scotland of the entitlements of veterans. Chairman: We will come on to further mental health issues in just a moment. Q294 Willie Rennie: Often guidance that is issued by any organisation gathers dust on a shelf. Have you done any follow-up checks to see how well that guidance has been implemented? It was suggested earlier on by Dr Freeman, if I understood him correctly, that perhaps we should have a shop front for veterans so that they can go in, they do not know what is wrong with them perhaps but they could have access to a wide range of services. What would you think about that? Mr Huggins: I can certainly pick up the latter point. That is a discussion that we have been having with Chris on the basis that what we are looking for here perhaps is a better door for people to go through, and a door which people find acceptable. We have certainly indicated a willingness to pilot that sort of idea. Q295 Willie Rennie: What about the implementation of the guidance? Mr Feeley: We have put guidance out roughly every two years and it is always followed up with a reminder to chief executives of NHS Boards that we expect the guidance to be applied and it is then for the management in the local boards to take whatever action is necessary to get this firmly on the --- Q296 Willie Rennie: Out of ten, how well is it implemented? Have you got a measure? Mr Feeley: We have not got a measure that would enable us to do that. I guess our major measure of these kinds of issues would be are we getting a lot of complaints about them, and we are not. Q297 Chairman: When you say you do not have a measure, do you monitor how well your guidance is followed? Mr Feeley: Not specifically. Q298 Chairman: Should you? Mr Feeley: It is impossible to monitor how every bit of guidance that goes out is implemented. We have regular performance reviews with NHS Boards about every aspect of their performance but some of this is about the actual clinical interaction between a GP or a practice nurse or a frontline clinician and a veteran, and unless you are sitting on top of that interaction it is an extremely difficult thing to measure. Q299 Mr Jones: Is this something that is different from the rest of the country where this has been a massive issue about how veterans are treated? Certainly my postbag and local newspaper in England have been inundated with various stories and criticisms of the Government and the NHS about how veterans are treated. Has it been completely different in Scotland? Mr Feeley: It is difficult for me to compare since I do not know what it has been like in England. Q300 Mr Jones: Wait a minute. You have got the campaign now being run by the British Legion and you have got newspaper headlines about the treatment of veterans, has that not even touched the Scottish newspapers or Scottish political scene at all? Mr Feeley: I suspect your Scottish colleagues are better placed to answer that question than I am. They will get a different kind of postbag from mine. Mr Jones: They might be, but --- Q301 Chairman: There is a bit of a sense here of your issuing guidelines and seeing this ship sailing off into the mist and you saying, "Job well done" without contacting the home port to find out if it has come in or not. Mr Feeley: The Partnership Board would pick up a lot of these kinds of things. There will also be interaction between the facilities and the local health boards. I am certainly aware of a good deal of regular and very positive discussion between Redford Barracks and NHS Lothian, for example, about the day-to-day issues around service delivery. That is the kind of level at which that would be done. Q302 Robert Key: Could I ask if you have heard about the Help for Heroes campaign. Mr Feeley: Yes, I am aware of it. Q303 Robert Key: Good. I wonder if you could help me and tell me whether the new arrangement reached last Thursday with Combat Stress has covered a particular problem we were told about when we visited Leatherhead, and that is a lot of veterans do not present with mental health needs until an average of 14 years after they have left the Services and, therefore, they are not in receipt of a war pension and that presents an enormous funding problem for Combat Stress. Was that one of the issues that was addressed? Mr Huggins: As I understand it, the figures that I have had from Combat Stress indicate that the majority of people come forward at about 12-13 years and they are eligible to receive war pensions. The difficulty is in establishing a case and establishing the linkage between the problem and the health problem, whether it is mental health or other problems. From what I have seen, the majority of the people who Combat Stress are offering help to have appeared significant periods of time after their time in Service. There is no barrier there. Q304 Robert Key: There is a barrier because it is the difficulty in awarding the war pension, which is the funding mechanism. So nothing has changed in that respect as a result of last Thursday's announcement? Mr Huggins: They have not changed the regulations. Robert Key: I am sorry to hear that. Chairman: We may well come back to this again. We will move on now to the issue of healthcare of Service families. Mr Hamilton: Before I get on to that, would it be possible for you to inform the Committee by a note about the number of people who are in prisons, in answer to Brian's question, who have a history of being in the Armed Forces because you indicated that information is gathered. Could you get that information and send it on to us and any other information that you think might be relevant because if certain matters are devolved to Scotland, as we are taking an evidence session in the UK, it is important the Scottish dimension is put into that. I know you have already given us some information but some of the factual information about the Prison Service and the point that Brian raised, which I think is very relevant, I would like to see that coming forward. Q305 Chairman: Are you clear of what you have been asked and will you be able to provide such a note? Mr Huggins: I am clear of what has been asked. I did give information on our assessment of the mental health needs of those in prison. I do not know that we have a figure for those people who have had military service within the prison system but I can certainly make inquiries. Q306 Mr Hamilton: You do not have a breakdown? Mr Huggins: Pardon? Q307 Mr Hamilton: You do not have a breakdown? Mr Huggins: I personally do not but I can certainly answer the question. Corporate Scottish Government will provide that information if we have it. Q308 Mr Hamilton: One problem raised during the course of the inquiry relates to Service personnel returning home from overseas postings and finding it extremely difficult to register with National Health Service GPs and dentists. What procedures do you have in place to help Service families coming back to Scotland from overseas? Dr Harrison: Any family coming into a community has an entitlement to register with a general practice in their area, so there is no difference there. I suppose it is the local intelligence of knowing where to go, if you like, when they arrive back. There should be no barrier to families registering with a local GP's practice. We do not have problems like full lists in Scotland but I think there are some problems in some parts of England with that. Q309 Mr Hamilton: And dentists? Dr Harrison: Some areas have more difficulties in providing NHS dental treatment and dentists for people to register with. There is an obligation on the health boards to provide a general medical practitioner for every citizen whereas there is not for an NHS dentist. I have no knowledge of whether Service families have particular difficulties over and above the rest of the population. Q310 Mr Hamilton: So, effectively, as a family or an individual they have to fend for themselves in whichever area they go to, they have to find out for themselves? Dr Harrison: In dental terms that is more of a fending process. For general medical practitioners they can approach the health board and they will tell them who their local GP is and to go along to register. Q311 Mr Hamilton: Could the MoD do more to make the transition easier? Dr Harrison: I suppose they could give them an information pack, and I suspect they might well already do so. Q312 Mr Hamilton: I am thinking more along the lines that it is not just about the health services coming out, the MoD could help insofar as contacting local authorities about housing needs, for example. There is already a welfare officer who deals with personnel who are leaving the Armed Forces and they try to assist them. What I am trying to get to is if they are going to Lothian, Glasgow, Aberdeen, is there something rather than just a pack? Is there something where they can sit down and somebody will talk to them and say, "These are all the things you need to do", which includes dental treatment, who you sign up to, what village or town you are going to, where the local GP is going to be in that area, and, indeed, if they can get on to the housing list? Mr Feeley: I think these are really matters for the MoD, but if the MoD wanted to develop those kinds of arrangements we would certainly be very happy to --- Q313 Mr Hamilton: They are not matters for the MoD if they are Scots coming back into Scotland and they are all issues which are being dealt with by a devolved government. At the end of the day these are matters that must affect individuals coming in. To put it across just to the MoD is absolutely outrageous. Mr Feeley: I am trying to explain. I assume that you would want --- Q314 Mr Hamilton: It sounds like there is a price tag at the end of it. Mr Feeley: No. There is lots of information that is available and it would not be a huge, onerous task. I assume you would want that material available to Service personnel before they are discharged. Q315 Mr Hamilton: Yes, of course. Mr Feeley: Which is why I was trying to get over the message that I think principally, in terms of leading this work, the MoD would have to take a role. Mr Hamilton: Chairman, could I suggest at the next meeting of the three or four meetings they have a year that is one of the issues they raise for them to deal with it through a welfare officer and it is something they should tell the families coming out. Q316 Chairman: I am concerned about this meeting that happens three or four times a year. Again, it is a bit like the ship sailing off into the mist. I have this impression that these three or four meetings a year that happen are considered to be the contact that you need to have with the Ministry of Defence and the notion of these veterans being heroes who fought for their country does not really stray outside the Ministry of Defence and it is the Ministry of Defence that is there to deal with these problems. If they have got education problems, health problems, that is the Ministry of Defence's problem. This is the impression that I think this Committee is getting from the evidence you are giving us today. Mr Feeley: I am not sure how you are getting that impression. Q317 Mr Jones: You are doing a good job at it. Mr Feeley: As I have said, we believe that the healthcare services that personnel, their families and ex-Servicemen get in Scotland are extremely good. Q318 Chairman: But no better than anybody else is getting? No recognition of some of the special needs that they may have from all we can hear. Mr Feeley: Priority treatment for veterans for their condition. Priority treatment through the MDHUs if it is required. Chairman: Those are English. Mr Jones: We are paying for that. To be honest, I am very glad we have come here today to come to this session because I think it reinforces something which came out of our inquiry into education for children in Armed Forces' families, which is this complete disconnect between devolved administrations and the MoD. Mr Feeley, you sit there and say you have got policies but you have got no policies for dealing with veterans, you have told us. As I understand it, to be fair to Mr Huggins, you are going to look at mental health services because it has been upped on the agenda in terms of Combat Stress and you have amazingly said to one of your local Members of Parliament that basically Service families in his constituency have got no special treatment, you have got no priority on this, and all you are doing, as the Chairman says, is sending up paper to say, "This is what the policy is". Go to Mr Keys' constituency and I am sure his local health authority has got a completely different attitude from that, and they have in mine as well and mine has not got huge Service families. If I was a Service family or a member of the Armed Forces from Scotland listening to you three I would be pretty appalled and depressed, frankly. Chairman: I would feel that I was not high up the agenda. Q319 Robert Key: Could I just ask Dr Harrison to clarify something about dentists. I think you told us that a Service family, perhaps coming back from Germany, would have to find out where their local NHS dentist was and there is no particular help available to anybody, is that right? Dr Harrison: The local health board will have information on where NHS dentists and where general medical practitioners would be. Q320 Robert Key: We have something in England called NHS Direct, which you can phone up and they will tell you where your nearest NHS dentist is to where you live. I think the equivalent is called NHS24 in Scotland. Dr Harrison: Right. Q321 Robert Key: Do they not provide that service? Dr Harrison: They could do. Q322 Robert Key: But do they? Dr Harrison: Yes, indeed. Q323 Robert Key: They do? Dr Harrison: Yes, but the health board is a more direct approach. Q324 Robert Key: That astonishes me because surely the health board is not something that I would ring up and say, "I've got a tummy ache, what should I do?", that is something I ring up NHS24 for. Dr Harrison: That is not the same question. You are asking about where they would find where they should register, and you would go to the health board for that because that is an administrative place. NHS24 will tell you --- Q325 Robert Key: I am sorry, in England it is not. Anyone can phone up NHS Direct and discover, "This is where I live, this is the number of my street, where is my nearest NHS dentist?" That is not available in Scotland? Dr Harrison: They can phone NHS24 and ask those same questions and they will get an answer. Q326 Robert Key: I thought you just told me they could not. Dr Harrison: No, I did not. Q327 Robert Key: That is for the NHS Board. Dr Harrison: They could also phone NHS24 and get medical advice. They would probably be told where to go for family medical care. Q328 Robert Key: Probably. Dr Harrison: They would be, sorry. It depends. If it is out of hours they might be dealt with by NHS24. Q329 Chairman: Records of Service personnel. We have heard that there has been a significant improvement in records being transferred from the MoD to the NHS. Is that your experience? Have you heard of any problems in transferring records? Dr Harrison: There are two separate services. There is the military MoD Medical Services and the NHS Medical Services and the two do not, as far as I know, exchange records directly, they do not have a shared record. There would be a discharge note or some information given to somebody who was coming out of the Services. Is that what you are referring to, when someone comes out? Q330 Chairman: Let us suppose an ex-Serviceman is discharged, perhaps he has been severely wounded in Afghanistan and he needs his treatment to continue under the NHS, somebody needs to know what has happened to him, what drugs he has had, what operations he has had. How does that get dealt with? Mr Feeley: It would be contact between the MoD and the local NHS Board which will be responsible for that individual's care. Q331 Chairman: Have you heard of any difficulties in transferring the records? Mr Feeley: None whatsoever. Indeed, we asked all NHS Boards in preparation for this meeting whether they had experienced difficulties of that kind and all of them told us that they had not. Dr Harrison: Could I just clarify, I was answering a question about transferring records which is, for instance, my GP records would be transferred somewhere else, but what you are talking about is transfer of information and I agree with the answer that has been given. When I answered and said that there was not a transfer of records, I was talking about the entire record not being transferred. Q332 Chairman: We are not medical practitioners. Dr Harrison: No, but it is different. Q333 Chairman: There may be a serious difference in your mind but we would need that to be explained to us. Dr Harrison: There is a distinction as well between what happens in a situation such as the one that you described and what happens in the ordinary situation of a Serviceman coming out of the Services and he has not really got anything particular wrong with him, he is quite fit, so he is being discharged, and that is just through the primary care service. Q334 Chairman: If someone moves from Portsmouth to Edinburgh, would his records be transferred to Edinburgh? Dr Harrison: Is this MoD or NHS? Q335 Chairman: No, if a postman moves from --- Dr Harrison: NHS, yes, their records would be transferred. Q336 Chairman: But if a soldier moves from Portsmouth to Edinburgh --- Dr Harrison: This is primary care records you are talking about? Q337 Chairman: Yes. Would they be transferred? Dr Harrison: From the MoD to the MoD in Edinburgh? Q338 Chairman: Yes. Dr Harrison: Yes. Q339 Mr Jones: No. Dr Harrison: As far as I know, this is an MoD matter obviously from Portsmouth MoD to Edinburgh. Chairman: Anyway, Mr Feeley told us that none of the NHS Boards had suggested there was any problem over this. Mr Jones: That is not the question you are asking, Chairman. The question you are asking is if you were a serving member of the Armed Forces in Portsmouth and you were discharged but you actually came to live in Edinburgh, would your MoD records be transferred to the local NHS. That is the question you were trying to get at. Q340 Chairman: It was. Dr Harrison: The two sets of records are separate. There would have to be some communication if there was an ongoing medical condition. Q341 Mr Jones: But what is the procedure for doing it? Dr Harrison: There is not a procedure, they are separate records. Q342 Mr Jones: No. Dr Harrison: It is the same as the Scottish Prison Service has their own medical services. Q343 Mr Jones: No. If I move from Durham to Edinburgh you have just told me when I register with a GP in Edinburgh my records will come with me because I am a civilian. Dr Harrison: NHS records. Q344 Mr Jones: Exactly. If I am Army, Air Force or Navy personnel and I retire or finish up in Edinburgh, you are saying you are not aware of a system that allows my medical records then to transfer to my local GP. Dr Harrison: From the MoD to the NHS? Q345 Mr Jones: Yes. Dr Harrison: That is correct. Q346 Chairman: Do you think there should be? Dr Harrison: I think it is very helpful to have a lifelong medical record. Q347 Robert Key: This is very serious indeed. I wonder if we could clarify this by asking for a note of exactly what the situation is. Dr Harrison: This is not a Scottish thing, this is NHS. This is not exclusive to Scotland. If you move from Portsmouth to York the same thing would happen. Q348 Willie Rennie: We were told this morning about the process that is involved in transferring records from the MoD to the NHS and it is not automatic that the records do get transferred. Do you think it would be beneficial if it was automatic that they do get transferred between the two organisations so the NHS fully understands the medical problems that an individual has faced? Would that be of benefit? Dr Harrison: Yes. Having a continuous medical record, particularly at a primary care level, is very, very beneficial, yes. Chairman: That is something that we can ask for a note on. Maybe not from you, maybe from the NHS in general, but health being a devolved responsibility in Scotland it affects you. If you were able to tell us what your views are of it, it would be helpful. Mr Borrow: Just following on that point, Chairman. My understanding of the situation is that if someone leaves the Services and goes into civilian life and signs up with a GP, a good GP would contact the MoD and seek the medical records held by the MoD, but there is no requirement on the GP to actually secure those records. The question is, does the absence of a requirement on a GP to do what seems sensible and proper cause a problem? Is there any evidence that causes a problem or should we, as a Committee, be recommending that there is a procedure put in place to make sure that those records are transferred? I think that is where the Committee is. Q349 Chairman: I think that is very well put, thank you. We are content now to move on. Did you hear the evidence of Dr Freeman at the beginning? I do not think you were in for that. Is there anything else you would like to ask about mental health, Robert? One thing that he said was that psychiatrists generally on receiving patients who have had a history of being in, say, two or three combat zones may have no experience of, or understanding of, the sorts of stresses that those people have been under. Do you recognise that as a problem or as a fact? Mr Huggins: I think that is entirely likely to be true. Q350 Chairman: Given that these people are doing this for us, do you think it is a problem which requires to be dealt with? Mr Huggins: Generally, where we are now in 2007 is that we have a model of care which is not about the single clinician. It is not about the single doctor relating to the single patient. We work with social workers, nurses, psychologists and psychiatrists, so generally, if there is a particular need in respect of the care of a particular patient, what we will look for is to ensure that need is met somewhere within the team. In the discussions that we are having in respect of provision of services for veterans in respect of mental health, that is where we see the particular value that an organisation such as Combat Stress, which involves volunteers and others with experience, can actually bring to the process. The difficulty would be if we expected everybody in every clinical team to have every experience, we simply would not be able to deliver that. Increasingly, care is team based rather than individual based and we think that gives access to a wider range of skills, talents and experience. Q351 Chairman: Okay. The suggestion that Dr Freeman made was that since many of these veterans will never consider going anywhere near psychiatric nurses or psychiatrists of any sort, but they are quite likely to approach GPs for physical ills, it would be helpful if GPs had some training in recognising the need for mental health treatment. Is that something that you would feel able to respond to? Mr Huggins: It is, again, a more general issue in that I would say there are many people who are reluctant to present themselves to psychiatrists or mental health services. What we have seen both in work environments and in public health environments is that people manifest with lower back pain, "I feel a bit low", they respond through taking more excess alcohol and substance abuse, they do other things. GPs are increasingly aware of the range of reasons why people might be showing particular symptoms which might be linked back to traumatic stress of different kinds. Certainly we are doing work in Scotland about the range of factors that might cause people to present in GPs' surgeries with different forms of problems: issues around child sex abuse; issues around trauma in early life. These are similar issues that require GPs to have that understanding of the wider reasons why people might turn up in their surgeries. I think my answer is therefore yes and it is certainly something that we are working on. Q352 Mr Jones: Can I try and understand the system in Scotland. You have clearly got this now on your radar screen and the reaction you had to some of our questions was you devolved this to the local boards. What powers have you got to ensure that these things you are going to try and do are carried out? In terms of at a political level in Scotland, how high do you think health for veterans and Armed Forces' families is? Has it ever been discussed in terms of a report in this place or anything else? Mr Huggins: It certainly has been discussed in the Chamber on occasions. Q353 Mr Jones: By who though? Mr Huggins: I recall the First Minister discussing it. Q354 Mr Jones: This one or the last one? Mr Huggins: It would be the last one, this one has not had much time yet, and he certainly identified it as an area of funding. The Scottish Executive, as was, committed a certain amount of funding towards the redesign and redevelopment of Hollybush House because of the priority veterans had for the organisation. It is an issue which has political and service delivery profile. Q355 Mr Jenkins: What was the money spent on? Mr Huggins: What was the money that was allocated to Hollybush House spent on? Q356 Mr Jones: Yes. Mr Huggins: The Hollybush House unit has been significantly redeveloped in the last two to three years and is about to be reopened on Monday. Q357 Chairman: On Monday. Mr Huggins: Yes. Q358 Mr Jones: The other side of the question is what powers have you got to ensure that the health boards do get this on their radar screen or carry out what they are doing? Mr Feeley: Health boards are subject to regular performance review. There is a monthly meeting between the minister and the chairs of all the health boards. There are regular meetings between the chief executive of the NHS in Scotland and the chief executives of the health boards. We are in regular contact with our counterparts on boards to make sure that policies are turned into action on the ground. There was a recent report carried out about scrutiny of public services which reported that the Health Service was over-scrutinised, but we believe it is appropriately scrutinised to make sure that policies are turned into good services for patients, including veterans. Q359 Willie Rennie: My understanding is that the difference between Scotland and England in the NHS is that it is more advisory and health boards have got slightly more independence and can take clinical guidance and other guidance and can implement it in their own ways with their own priorities. Is that your understanding of it? Mr Feeley: One of the key differences between the NHS in Scotland and the NHS in England is that we do not have the kind of purchaser/provider split that you have in England. The boards have responsibility for both planning and commissioning the services and providing, and the boards have responsibility for secondary care, primary care, mental health services, public health services, so they can provide the whole range of services to Servicemen, their families and veterans, ordinary members of the public. It is perhaps easier to get a handle on who is doing what when you are only holding 14 organisations to account. Chairman: We will move on to personnel issues. Q360 Willie Rennie: This question is about Reservists. Do you know how many Reservists work within the NHS? Have you got a figure for that at all? Mr Feeley: I do not have that. We could provide you with a note. Q361 Willie Rennie: We have heard from the British Medical Association that it is a disincentive to work in the Reservists in terms of your career, that it has a detrimental effect on your career. They said specifically: "given the choice of two equal candidates for a consultant post [an employer is likely] to appoint the candidate with no reserve liability". They went on to say: "reserve liability... will often be considered a handicap and a disincentive to recruit". Is that your understanding within the NHS? Do you think there is a problem with recruiting Reservists from the NHS? Mr Feeley: I have not had that issue put to me as a problem previously. Q362 Chairman: But if you were in charge of appointing a consultant, would it not be your natural inclination to choose someone who is able to give you more time for their appointment and who was not likely to be whisked away to Afghanistan or Iraq? Mr Feeley: We would expect that appointment to be made purely on the merits of the candidate. Willie Rennie: I find this absolutely astonishing. I feel embarrassed, in fact, that we have come here, I have dragged my colleagues from down South - I did not have to drag them up, they wanted to come up really - and there are so many questions we have asked you that you do not know the answers to. If you are not the right guys perhaps we could get the right guys in London in front of us. There are so many questions that are obviously important questions that you have been unable to answer. Some of them you have been able to answer but this last one on Reservists, the bit about dentists and Service families, so much you have been unable to answer and, honestly, I feel embarrassed that you do not seem to have a handle on it. If you do not have a handle on it, does someone else have a handle on it, and if they do not, what is being done about it? Chairman: Do you want to answer that? Kevan Jones? Q363 Mr Jones: Can I ask you in this way: have you given any guidance or strategy to health boards about their policy on employing Reservists? Mr Feeley: No. Mr Huggins: To be clear, were we to say to health boards that they should offer an advantage --- Mr Jones: I am not saying that. I am just saying, have you given any guidance about how they should treat people who are in the Reservists, for example, whether they be nurses or anyone else? For example, I know if you go to my local strategic health authority, you have the Reservist unit in Newcastle which is completely staffed by local NHS people and they have a very positive attitude towards it and have a policy on it about time off, training and career development. Q364 Chairman: Would you like to answer that question? Have you given any guidance? Mr Huggins: I am not aware that we operate a separate policy which is different from any other policy which applies to Reservists in public life. Q365 Chairman: Do you actually have a view as to whether it is a good thing to employ Reservists? Mr Huggins: Certainly we have a strong view that it is good to employ people from a diversity of experience and background and Reservists is one of those. It is valuable to us and it is valuable to the wider public good. That certainly would be our view. Q366 Chairman: But that view would be based on diversity rather than on the need to support our Armed Forces. Mr Huggins: No. I certainly said also that there was a wider public good in supporting the Armed Forces as well as the value that we take. There is a value that we take as an organisation and the wider state takes in terms of the commitment that our organisations can give. Q367 Chairman: But this is a view that you have not promulgated to the NHS Boards? Mr Feeley: I referred earlier to guidance that we issued to boards about relations with the Armed Forces. The guidance was issued in March 2006 and it says in that guidance: "In support of the twin health goals required by defence, ie a trained and deployable healthcare capability and the maintenance of a fit and health Service population" etc., that the "DMS will benefit from a range of things which include assistance with loan or secondment to the DMS of NHS personnel to fill civilian medical appointments, NHS expertise to assist in the development overall of defence-wide health needs, encouraging and supporting NHS staff to become members of the volunteer Reserve Forces enabling them to develop new skills, both professional and personal", so in our guidance to boards there is that kind of encouragement and support. Q368 Chairman: That is very good to hear but you were not aware of it. Mr Feeley: I perhaps misunderstood your question which seemed to me to be about do we give boards guidance about how they should use Reservists. Q369 Chairman: Mr Feeley, if you were not aware of it when you gave your answer a few minutes ago to Kevan Jones, how can you expect the NHS Boards to be aware of it and how can you expect the employers of people who are actually deciding whether to choose a consultant or somebody else to be aware of this encouragement for Reservists? It seems to me that there has been no concentration on this issue at all. Mr Feeley: Other than, as I said, we have given boards guidance. Mr Jones: One line. Chairman: But you do not monitor how it is followed through. Q370 Robert Key: Chairman, we have already asked for a note on how many of your clinicians serve in the Reserve Forces. I wonder if you could also include the statistic for the number of consultants and other clinicians in hospitals in Scotland whose salary is paid for by the Ministry of Defence. This is quite a common arrangement. My own foundation hospital in Salisbury has at any one time between five and eight clinicians, including consultants, who are Reservists, and indeed I met three of them yesterday at Strensall in Yorkshire who are about to deploy to Afghanistan and one from Ninewells in Dundee. It is seen as a huge benefit to the hospitals concerned that they have men and women with this expertise. If nothing else, they have an extra dimension to trauma service that they can provide. They are the only people who are likely to have had to cope on a daily basis with blast wounds, shooting and so on. Perhaps if we could ask for the statistics it would act as a stimulant in Scotland to encouraging a higher profile for the work of Reservist clinicians. Mr Feeley: We will provide such a note. Chairman: That would be very helpful. Thank you. Q371 Mr Jenkins: The MoD says, and this might appear to be a sick joke after this hearing but it is not, in future it wants to work more closely with the NHS in providing healthcare for Service personnel. What advantage or disadvantage would you consider would arise if the MoD came to you and said, "We would like to work more closely with you in providing healthcare for our Service personnel"? Mr Feeley: There are a range of areas that we could build on. We could do more around information sharing. There is a deal of work that could be done around prevention and anticipation of health need, which I think touches on some of the points that were made earlier about alcohol and substance misuse. I take the Committee's point that we could do more around the promotion of the joint benefits of particular skill sets of clinicians. I would welcome such an overture. Chairman: I think it would be good also if you did not rely on these four meetings a year to form your sole relationship with the Ministry of Defence because what the Ministry of Defence does and what you do ought to be completely integrated for the good of our Armed Forces. If there are no further questions then I would like to thank our witnesses and declare the meeting closed. |