Examination of Witnesses (Questions 40-59)
MS SAMMIE
CRANE, COMMODORE
TOBY ELLIOTT
RN, AIR COMMODORE
EDWARD JARRON,
MS SUE
FREETH AND
MRS ELIZABETH
SHELDON
12 JUNE 2007
Q40 Mr Holloway: Has the media attention
led to improvements?
Ms Freeth: I believe it has focused
attention where necessary and as a result of some of it there
have been improvements.
Q41 Mr Holloway: So, that has been
largely helpful?
Ms Crane: I deny that. I believe
there was an internal battle in the MoD which was already tackling
this and I am not as convinced.
Q42 Chairman: Mrs Sheldon, you said
that you felt the media were concentrating on the wrong things.
Mrs Sheldon: I think that it ought
to concentrate on the aftercare and onward management and support
of patients and their families. There has been an awful lot of
attention on Selly Oak and improvements have been made, but the
focus should be on gaps in public funding to support families
of patients for onward rehabilitation, not necessarily by the
media but it is hoped by decision-makers.
Ms Freeth: I think that dislocation
and disaffection start once they have left. The support they are
able to receive at Selly Oak and access to services back in their
own NHS areas is extremely variable. The individuals who are in
contact with them and the ability to enjoy the support from colleagues—those
with whom they are familiar and who understand them—is a
major factor. How that is addressed is a real challenge. There
is an expectation that the NHS can just pick it all up. To work
that out will be a major challenge for the MoD and the NHS.
Mrs Sheldon: It is a risk because
families will, if they are feeling unhappy and disaffected, go
to the media. Recently, a family which had a high expectation
that their son would go on to Headley Court but who landed up
in a specialist unit were very disappointed and felt let down.
One cannot talk about the rights and wrongs of that, but certainly
expectations have been mismanaged, or they have failed to understand
what would happen. As a result, they went to the press.
Q43 Linda Gilroy: Commodore Elliott
mentioned his work on the discharge medical policy committee and
some new arrangements.
Commodore Elliott: This is the
Army's sickness and absence management system.
Q44 Linda Gilroy: That is very new.
Will it address the sorts of issues we have just heard, or do
other things need to be taken on board to improve that?
Commodore Elliott: There is a
stage where the wounded casualty will be discharged back to his
home whilst he waits to become fit to go back into service or
awaits the medical discharge procedure. That is a very dangerous
period. Under the old Y list system soldiers were lost to the
system; they were forgotten and felt neglected. We have on our
books veterans who have been through the Y list and have developed
severe and enduring mental health problems which have been caused
by being lost in the system. The sickness and absence management
system is designed to prevent that happening and I applaud it.
I am quite convinced that if it is made to work and the right
resources are allocated to it the system will stop a lot of this
happening. Having listened to what Mrs Sheldon has said, I believe
there is a stage beyond service that we need to consider more
than we have so far. Quite recently, we heard from the director
of the Army Welfare Service about additional people who had been
allocated to look after very seriously damaged people who have
been discharged from hospital. They have run their cases until
they are back in their own homes, wherever they happen to be,
and when they come up to medical discharge. He also talks about
looking after them as veterans, but when you challenge him he
says that normally the service looks after veterans until two
months after discharge and the absolute maximum is about two years.
I think there is a lot of work that ex-service charities need
to do together with in-service people to look at life beyond those
two months. Frankly, he will not have the resources to manage
these cases for the rest of their lives. There is a wonderful
challenge there for all of us to work together. I believe this
is something that the service community, including the ex-service
community, should do. We can look after our own; we have a lot
of resources that can help do that.
Q45 Chairman: Commodore Elliott,
am I right in thinking that people present to Combat Stress on
average about 15 years after they have been discharged from hospital?
Commodore Elliott: Last year we
had nearly 1,000 cases. The average length of service was 11 years.
We have a lot of very experienced and battle-hardened veterans
coming to us, but, sadly, they are not being attracted to us until
on average 13 years after discharge. Therein lies a real challenge
in service as well as after it to try to pick up these men and
women much earlier, because the earlier they are picked up the
more effective the help we can give.
Air Commodore Jarron: One area
that we are looking at now is how we can give better support to
those who are about to be medically discharged. They have had
treatment and then go home; they are split from their unit and
have no local support. The medical discharge process can take
anything up to six months. There is a long void when there is
no support whatsoever and it is an area that we are picking up
increasingly.
Chairman: Perhaps we may come to that
in a few minutes. That is a crucial area on which we want to concentrate.
Mr Jenkins: The difficulty is that we
started to shut down the defence hospital units and put them into
the NHS. We have now had some experience of this, albeit an unwanted
one in view of the number of people coming back wounded. Given
that choice and your experience, was it the right decision to
put the provision into the NHS? The turnover of clientele and
the level of experience can never be matched by defence hospitals.
If it was the right decision, can you now see a future for others
as well, which is important? What mistakes were made? Is there
a catalogue of mistakes? We are trying to find out the truth rather
than urban myths. Some people run around with gloom and doom.
There are good things and bad things. Let us make sure we get
rid of the things that are not good before we extend this programme
anywhere else. I want to find out whether it is getting better.
Can we have military-managed wards? We may have only one severe
burn victim but four beds. It may be impossible to deal with it
unless we have four. A smaller number means that given the specialist
set of clinical skills we will never get them in, but as soon
as we can get them together we will have a ward for military personnel
and we can manage that ward. What lessons if any can you offer
us? We will go to Selly Oak and ask about their experience. If
you have any facts with which you can supply us we would be very
grateful. What lessons have we learnt?
Q46 Chairman: Could that be split
into two questions? The first question is: was it the right decision
to go to Selly Oak with the gloss of military-managed units? The
second question is: what lessons should we have learnt from it?
First, was it the right decision?
Mrs Sheldon: I do not think it
was the right decision at the time because nobody could foresee
or build into the planning assumption the number of operations
that would be carried out. Let us not forget that Selly Oak started
off as a teaching hospital for military medics. They have worked
very hard to improve it. That were big mistakes made, but the
good thing is that the clinical resources are now centred on the
need. That is the right decision but it has come about in an unfortunate
way.
Q47 Chairman: It was a wrong decision
but it should not now be overturned?
Mrs Sheldon: Yes, absolutely.
Ms Freeth: I believe that it is
the right way to go. We do not have access to all the figures.
Will one centre there be enough?
Air Commodore Jarron: Clinically
and financially, it is very hard to criticise the decision to
go there. There is a big emotional issue here. Servicemen like
their own things; they love their own regiments and comradeship
is very much part of what service is about. Interestingly, at
this year's annual conference there was a resolution moved by
a veteran that we should approach government to re-establish our
military hospitals in support of our men. It failed because practical
arguments were put forward. Nevertheless, there is a very big
issue about the emotional wellbeing of these people. It is exactly
the right business decision, but what we have to do is make sure
that we do not throw out the baby with the bathwater and lose
the emotional support that is so important.
Commodore Elliott: We are rather
too far down track to go back. I think we have shut the last military
hospital. It is interesting that we are about the only country
in the western world that has a system where we rely on the NHS
to look after our servicemen and women and veterans. The alternative
model seems very attractive to me because you end up with a quasi-military
environment which is so good for both in-service people and veterans
who in the old days went into the military hospitals when there
was enough room for them. They gained a huge amount from that.
That is not available to us. I suspect that if we look back at
what happened over the past couple of years at Selly Oak we were
caught out, but I believe that this is a question for the surgeon
general and defence medical services rather than us. We have gone
forward quite a bit since being caught out, and from what I have
been told I am quite convinced that Selly Oak will be good news
in future.
Ms Crane: I agree with what Ms
Sheldon said earlier, but this goes wider than just the treatment
of those who suffer wounds from operations. A big complaint that
comes in all the time is access to medical care for those now
serving in the Army who need minor operations to get fit to go
back on exercise. That is where the draw-down of the military
hospitals is having greatest impact. That applies also to those
who are discharged from Selly Oak having had a high level of clinical
care and need somewhere to convalesce before they can go on to
Headley Court.
Q48 Chairman: Let us turn to the
second question about the lessons learnt.
Mrs Sheldon: One thing I have
picked up—this is purely anecdotal—is the strain and
stress of military and NHS staff at Selly Oak in becoming used
to each other's working practices. For some NHS staff the sight
of some of the casualties who have been dealt with has been pretty
horrific and traumatising. Taking things forward, one needs to
think about the way they are supported. Turning to patients and
their families and taking it forward, the question is how best
they can be supported emotionally through the journey back to
full recovery, or perhaps into a new life in the civilian community,
making sure it is properly supported throughout. One can say that
the SAM system is a great improvement, but it is also a matter
of making sure there are people who are able to help these families
in a personal way. The numbers are not particularly big, but,
by golly, the problems they have in coming to terms with it are
tremendous. Therefore, I think it is absolutely critical to make
sure they have someone who almost helps them along that journey.
Ms Freeth: I do not believe one
can separate health and social care particularly at Selly Oak.
People need all of the information to travel with them right the
way through their journey from Selly Oak and on to where they
are being referred. That is not happening. We need to learn a
lot from that. We need to design in the fact that this is a special
place and there is a need for training and support for staff.
We also need unusual things one would not expect to have elsewhere
that must be planned in for the future rather than thought about
afterwards, because they create unnecessary unpleasantness and
difficulties for everybody involved. We need to continue independently
to evaluate the quality of the service there.
Air Commodore Jarron: It has largely
all been said. Fighting the war and winning is relatively easy;
what matters is what comes behind it. We have found that elsewhere.
It is the long-term recovery process that needs our attention.
Commodore Elliott: I agree with
that, but I also pick up Ms Crane's point about the other injured
and ill servicemen who await treatment in the NHS. I have attended
a naval medical board of survey. Two of the five case I heard
whilst there indicated that these people had waited a huge amount
of time to get treatment in the NHS. I suggest that the Committee
could take evidence from the MoD about how much down time there
is among servicemen awaiting treatment in the NHS which they would
not have had in the service hospitals.
Q49 Mr Holloway: You said that people
presented 13 years afterwards. I believe that following the Falklands
there were 300 suicides and numerous suicides among special forces
from Gulf War 1. My understanding was that if you had a bad day
it was best to get people back with military people as soon as
possible. Do you think that the separation of people from the
system and their unit is storing up further problems for us in
future?
Commodore Elliott: Most certainly,
in the context of mental health we are very interested in whether
or not we should be bringing serving soldiers, who are in the
sickness and absence system, into the society's work to prevent
the bad day you are talking about. As to the suicides which have
been quoted in the press in the past few days, it needs to bottom
out. We do not really know how many of the Falklands war veterans
have committed suicide since.
Q50 Mr Holloway: Is that not part
of the point?
Commodore Elliott: I am keen to
do this if no one else is. We need to create a roll of names to
be provided by the veterans themselves so we can say whether or
not this is true. Veterans are quite upset that the system does
not seem to believe them.
Ms Freeth: Suicide research is
going on at the moment and we need to learn quite a bit from it.
At the moment evidence about the causes is inconclusive.
Q51 Mr Holloway: This is not about
verification but about our responsibility to these people who
have experienced these things. There have been numerous wars in
the past few years. It sounds to me as if we will have a big problem
13 or more years down the line if we carry on in this particular
vein. We are not thinking ahead, are we?
Ms Freeth: We can certainly see
a growth in people presenting for a whole series of different
reasons. All of the charities provide an opportunity which we
see benefiting people when they come back into contact with others;
they have some direct experience. That familiarity is absolutely
critical, but it is not always possible to provide the best care
close to the unit.
Q52 Mr Jenkin: We have spoken at
length about Selly Oak. The Committee will visit Headley Court
and Selly Oak in due course. What is your experience of other
Ministry of Defence hospital units? Do you have anything important
to say about them?
Commodore Elliott: There are not
any.
Mrs Crane: Are you talking about
overseas?
Q53 Mr Jenkin: Cyprus, for example.
Mrs Crane: My report would be
based purely on the family perspective of care for families overseas
and what is happening there. Do you want that to come into this
discussion?
Q54 Chairman: Yes.
Mrs Crane: Suitable pay for civilian
medical and dental practitioners is an issue for families, particularly
in Germany where recruitment has been difficult. That leads to
lack of continuity for family medical care which is the MoD responsibility
overseas. The same goes for dental care overseas. Those are the
kinds of issues of which we have experience at the moment.
Q55 Chairman: We are also talking
about units at places like Frimley Park. Are there any comments
on other military units in hospitals?
Mrs Crane: I should like to pick
up the question of healthcare provision for families overseas.
Chairman: Let us leave the question of
families overseas. What about other military units?
Q56 Mr Jenkin: What about Northallerton
and Peterborough?
Ms Freeth: In terms of the NHS
services for which there are contracts for service healthcare,
one bit of feedback is that some people have to travel a long
way to access that care. I believe that there are six contracts
in place at the moment in NHS services specifically for serving
people. There do not appear to be enough of those to enable people
to have easy access. It does not appear that the ability to receive
sensible treatment that will get people better as quickly as possible
is delivered under the current six contracts.
Q57 Mr Jenkin: I think we have already
covered this question, but, in case there is anything that you
want to add, do you have any concerns about the care that service
casualties receive in theatre and during evacuation?
Ms Crane: I think that it is far
more successful now than in the past, and well done on delivering
it.
Q58 Mr Holloway: Obviously, all the
witnesses agree that rehabilitation care has improved over recent
years. Where do you think we are with that now, and what further
improvements can be made?
Mrs Sheldon: I think that Headley
Court is doing a fantastic job, but again the wider, holistic
issue is to make sure that patients can support each other and
keep family units together at a very important time in their lives.
That is something which up until now has not really been properly
looked at. At Headley Court there is limited temporary accommodation
in the grounds. There are refurbished family quarters which will
happily house one family but perhaps not two or three. Sometimes
they have to squeeze in people. There is also a small house in
the grounds which has a dozen rooms suitable for single person
accommodation where service people have generally gone to practise
their skills on new equipment and so on. At Headley Court it is
really important to have the families with the patients to help
them rebuild their lives. That sort of infrastructure is not in
place. Again, where necessary we provide charitable funding to
help them set up accommodation nearby, but ideally that is something
which public funding should provide.
Ms Freeth: There is a short supply
of medium-term rehabilitation for people with complex injuries
who will need assistance for 18 months or possibly two years and
who will not stay at Selly Oak but, it is hoped, go back to their
locality. As a service provider of homes we have been approached
and over the past five years have taken in some four or five individuals
who have stayed with us two or three years. One of our homes specialises
in being able to provide support, because we have physio and occupational
therapy on site. Were larger numbers of individuals to come through—that
looks like a possibility—it would be difficult to find the
resources to cater for those people certainly together. It is
likely that they will go off to a unit that may have no military
input or connection with, or little experience of, long-term military
rehabilitation. Looking at the numbers, we do not have enough
information as to whether this perhaps should be a new service,
but medium and long-term rehabilitation is in short supply. In
the NHS it is difficult to get access to day rehabilitation services.
Q59 Linda Gilroy: In terms of the
provision of medical care, how well do you think service families
are looked after when they return to the UK from overseas postings?
Ms Crane: For most families returning
from overseas and moving round the UK the biggest issue is dental
care. It is an issue for the whole country. Government tells us
that it should improve within the two-year timescale of the new
contracts, but for us it is a much bigger issue. We move every
two years, so by the time we have found an NHS dentist and are
on that waiting list and perhaps are getting close to some sort
of care we are moved again and have to start from scratch. It
is not a list that is transferred from one practice to another.
An additional issue—I do not have a lot of evidence to support
it—appears to be that if there are two serving parents,
of which there are an increasing number, their dental care is
with the MoD and dentists will not sign on children without a
parent in a dental practice. That group has a specific issue.
Families do not have a problem accessing NHS doctors; we have
not picked up an issue in that regard. Sometimes it takes a while
to work out where you are when you have just moved, but we believe
that a lot of NHS doctors are rather bemused by us. I have had
conversations on it. They see us as a rather vulnerable group
living in isolated locations. We are not necessarily the same
as the rest of the population during this period of high operational
tempo. We believe there is a high rate of antidepressant prescribing
which arguably takes place quite quickly rather than after careful
consideration. We have considered doing more research on it, but
it is a very difficult area to delve into. I certainly do not
suggest that all army spouses are manic depressives; we are a
very strong bunch.
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