Examination of Witnesses (Questions 60-79)
MS SAMMIE
CRANE, COMMODORE
TOBY ELLIOTT
RN, AIR COMMODORE
EDWARD JARRON,
MS SUE
FREETH AND
MRS ELIZABETH
SHELDON
12 JUNE 2007
Q60 Chairman: You are a fascinating
and very difficult combination of great vulnerability and self-sufficiency.
Ms Crane: And where we are located
has a big impact on it. We reflect in urban areas the number of
families that can drive. We have a lot of families living in isolated
locations that cannot drive. They are supposedly married but are
single parents and therefore have problems accessing medical care
in some cases. Unit welfare officers, who are my heroes, often—
Mr Holloway: I was not criticising all
of them but just making the point that a guy who does not tell
someone that he is entitled to a travel allowance is dead wood.
Q61 Chairman: I think we have gone
into that enough.
Ms Crane: But they do help and
during operational deployments they organise assistance for families.
At the end of last year I was at a coffee morning and I asked
a spouse what she had been doing during the deployment. She said
that it had been a difficult pregnancy and she had to get the
bus to Salisbury three times a week but it took seven hours. She
was only in Larkhill and so was fairly close. I told her that
the unit would have helped her and she said that she thought she
had to do it. Some of it is our own fault, but how doctors perceive
us is a problem. Medical notes also do not follow us very quickly;
we do not have access to them. We do not seem to have much of
a problem in transferring from one waiting list to another for
operations, but it is more of an issue for therapies and specialists.
Again, there is a national shortage and that means that by the
time we have reached the top of the list people see that we shall
move quite quickly and therefore are reluctant to start expensive
care or do not take it seriously. IVF is a major problem for families.
As far as concern waiting lists, we have the most cases. We would
like families to have retention of quarter, which means they can
stay in the house where they are presently situated until they
get to the end of their IVF treatment. It is a postcode lottery
and expectations can be raised. If one is Shropshire one can get
two cycles; if one is in Wiltshire one can get only one. Some
may argue that to move from Wiltshire to Shropshire is an advantage,
but it is a difficult stage. We are a young community. We have
a high proportion of young families and it is additionally difficult
if you are a couple that wants to have children and is trying
to get IVF treatment.
Q62 Robert Key: I have experience
of a number of cases in Salisbury. The Ministry of Defence has
always argued that if you are starting a cycle in Salisbury and
are then posted, overseas, for example to Germany or Cyprus, it
will fly the wife back to complete the cycle. Is that not the
case?
Ms Crane: I think that is the
case. The MoD is helpful in those circumstances. The majority
of moves are within the United Kingdom. Remember that we are way
off the scale compared with the national average for moving outside
a local health authority area.
Chairman: You are talking about many
of the same issues that came up during our inquiry into the education
of service children.
Q63 Linda Gilroy: I believe that
my colleague Mr Key will return to the issue of dentistry which
is probably highest among the issues that you have mentioned.
Do you have any good examples of primary care trusts that have
taken particular interest in any of the transitional issues you
have mentioned?
Ms Crane: I am ashamed to say
that I would probably hear the least where it is most successful.
I do not hear an enormous amount about this issue. We are here
to discuss it and therefore I will tell you what I know, but generally
I think it is working relatively well other than in the dental
area and in specialisms such as IVF.
Ms Freeth: One concern is that
the families of former commonwealth soldiers, who are now some
six per cent of the force, are entitled to medical care when they
are here, but not to other statutory support in the same way.
We find an increasing number of complex cases where everyone around
them has been unable to assist. That is certainly a group of people
we need to look out for to provide better support for them.
Mrs Sheldon: I should like to
broaden the discussion to the emotional side and the impact that
all of these issues can have on relationships. It is a matter
of making sure that families have access to professional and independent
counselling support which has continuity to help them through
some emotional aspects associated with service life which has
its own distinct pressures. These things are very complex and
cannot always be solved within a two-year posting.
Q64 John Smith: I want to return
to IVF. How big a problem is access to IVF for service families?
What about access when one is posted overseas, not when one has
started treatment and comes back to continue it? Is it a problem?
Ms Crane: I would have enormous
difficulty giving you the scale of it because I can go on only
those who report it to me. I presume that IVF rates in army families
are comparable with the rest of the population. I would have to
look back at those statistics. Obviously, where it does not work
it is emotive and is a problem. It is a matter on which families
approach us. I know that hospitals overseas have provided it as
and when they can and generally quite successfully.
Q65 John Smith: Is there any evidence
that access to IVF treatment is causing particular difficulties
for service families and results in either the break-up of families
or the premature termination of service in order to access these
medical services?
Ms Crane: I think that it is ongoing
treatment that is important. Let us assume one has decided that
one wants IVF treatment. Quite a long process is involved. It
may be that an area does not want to take on the case because
it knows one is moving; it may be that one starts and there is
a posting and one cannot finish the treatment. I do not think
that the problem lies so much in initial access; the issue is
one of ongoing access.
Q66 John Smith: Is there any evidence
that there is a difference in access to services, not just IVF
but other therapies, as between commissioned officers and other
ranks? Are commissioned officers turning more to private treatments
because they may be in a financial position to do that because
of inadequate access to therapies such as IVF, including dentistry?
Is there any such evidence coming through to service family associations
and other organisations?
Ms Crane: I have no evidence that
that is so other than in the case of dentistry. I know that a
high proportion of officers have sought private dental treatment.
Q67 Robert Key: It is perfectly clear
that a lot depends on where the service family ends up living.
Sometimes one may find oneself in a very large military garrison
like Tidworth or Catterick where defence medical services, for
example GP services, may be available, but that is quite rare,
is it not? Do you think there should be special arrangements—fast-track
facilities—for service men and women and their families
to access NHS physicians and dentists?
Ms Crane: I would like to see
some way in which families can access—never mind a fast
track—dentists and specialist therapists on moving, especially
those with special needs who have an additional difficulty in
this area.
Q68 Robert Key: Given there is no
question that there is a huge shortage of NHS dentists, particularly
in areas around Salisbury Plain garrison which I know best, do
you think it would be a good idea to explore the Ministry of Defence
helping to fund private dental treatment, which after all is what
most of the population has been forced to do under this Government?
Ms Crane: I think it would be
wonderful.
Ms Freeth: We would support that.
Obviously, we see veterans. One of the difficulties is the huge
mismatch between what people are entitled to when serving, and
certainly when they are injured, and what they are entitled to
when they leave and become veterans. That difference creates some
of the dissonance. We would like to see those services being extended
at least for some period whilst individuals are veterans.
Q69 Robert Key: I want to ask about
wider health provision for families. Health is not just about
sore toes or tonsillitis; it extends into areas of family health
including education where there are services children in local
primary schools with, for example, ADHT and also to social service
support where you have a large number of broken families and marriages
and the care of children, the burden of which falls on local authorities
across the country. Is that a particular problem on which you
have views?
Ms Freeth: Those are not areas
in which we have had problems brought to us and on which we can
report.
Commodore Elliott: I have noticed
that in our work we receive more and more calls from carers of
soldiers who are extremely worried about their husbands and need
quite a lot of advice from us because they are frightened to go
to the in-service provision that has been made for them, normally
because it is the soldier who does not want to indicate to the
authority that there is a problem caused by his psychological
injury. We are just rolling out a new service, which we will fund
ourselves, to help families of our veterans and that will open
up the service to in-service people even though it is not strictly
speaking our bailiwick.
Mrs Sheldon: This is one of the
areas in which we are very heavily engaged in providing professional
social work support to families in Germany, the UK and across
the world. We are receiving a lot more calls for help from families
that have a lot of pressure because of relationship and emotional
problems. It is not just a problem affecting the spouse or partner;
it affects the children. There are very serious issues in terms
of child care and also mental health problems.
Ms Freeth: In other countries
health monitoring of families is available and used. Certainly,
I think this is an area that should be considered. Obviously,
it is a difficult area but it is important to be able to catch
these sorts of issues as early as possible and to respond to them.
We know that according to the King's Fund study of individuals
that is being done there is an alarming dependency on alcohol,
not necessarily understandably. That also has an effect on family
life. Health monitoring is critical. At the moment all we have
is a commitment to a short-term piece of work that has been extended,
but I believe that it should be a permanent part of the bailiwick.
Mrs Sheldon: This is where a close
relationship between the specialist agencies and the unit welfare
officer and units on the ground is essential. A unit welfare officer
is not trained to spot the symptoms of big problems that arise.
Although secondary care within Great Britain is provided by the
Army Welfare Service there is still a need to turn to specialist
agencies that can help. It is absolutely critical to have people
who are trained and are agile enough to spot where problems arise
sooner rather than later. There is patchy provision across the
MoD in the sense that each service has its own way of providing
welfare support. The RAF uses professional social workers, for
example, and the Army employs people within the chain of command.
There must be a holistic approach. One must be very careful that
one moves initially from the command as the point of contact to
the specialist agencies so there is consistency.
Q70 Robert Key: Perhaps we may turn
to the provision of health services for families abroad. SSAFA
has given us evidence that growth in the defence medical services
has been less than half that in the National Health Service as
a whole. There has been an increase but it is not as great. Another
way of putting it is that it is falling behind. Has that impacted
on service families abroad? What is your perception of the provision
of healthcare to families posted abroad?
Ms Crane: I touched on this earlier.
There is at the moment a real problem about the provision of doctors
and dentists overseas. It all comes back to parity funding. Because
the MoD is not signed up with the NHS and the funding comes through
the ministry there is no obligation or capability of providing
the same facilities overseas as in this country. Much of the facilities
overseas are really good, and I have had experience of them in
several countries. I have been very grateful for that very familiar
and close-knit arrangement, but the lack of doctors means that
there is not that continuity of care or empathy from one person.
The employment of locums has an effect on the local budget which
makes it even more difficult to provide services. That is one
of the big issues I raise.
Mrs Sheldon: I support Ms Crane.
Obviously, what one does is try to provide a service that matches
the standards of the NHS. There is an obligation to meet those
standards, namely that an adequate number of people are there
to provide that service but within ever-dwindling funding.
Ms Crane: When I accompany my
husband I sign off from my local doctor and then sign on when
I go overseas. Why does not my NHS funding go with me? Why does
it stop?
Q71 Robert Key: The answer is that
in this country local primary care trusts are funded per capita
to include military personnel and their dependents, but that does
not happen overseas.
Ms Crane: But not military personnel
because they are not part of NHS funding.
Robert Key: It does include military
personnel because it has been a bone of contention for many years
between the Ministry of Defence and the Department of Health who
now seem to agree that primary care trusts and other trusts receive
funding to include military personnel, but that is a technical
point.
Q72 Mr Jenkins: Before we go too
far, that is exactly the point I want to raise. My local community,
which has expanded over recent years, has always missed the boat.
We were being paid for 50,000 although we had a population of
55,000. By the time we got the next settlement we got money for
55,000 but had a population of 60,000. Two or three years ago
we managed to move ahead because we got paid for 75,000 although
there were only 33,000 there. The PCT now has the money. I expect
that in a garrison town with 15,000 to 20,000 young and fairly
fit and active individuals there will not be the same strains
on the services as there will be with a mixed population that
includes a good number of old people and pensioners who cost the
NHS and PCT a lot more money. If one has all this money in a PCT
where does it go? Why are you not asking them to bring in dentists
and sign contracts for GPs and specialist facilities? You do not
have a big demand but what is there is not being met by the PCT.
Ms Crane: One would then pay the
medical professionals the equivalent of what they are paid within
the PCT and one would attract more people to those jobs. That
is the main issue.
Q73 Mr Jenkins: I am referring to
the actual provision within the community in mainland Britain?
Ms Crane: I thought we were comparing
it with overseas.
Mr Jenkins: The overseas argument is
a different one. But in locations in Britain the PCT has a duty
and responsibility to provide GPs, dentists and so on. They have
been very successful in managing to fund extra dentists in my
area, so we do not have a problem with NHS dentistry. Why can
they not do the same here? It is a matter for the PCTs; they are
the ones who put the contracts in place. Therefore, if your PCT
is not doing it someone should start asking why not.
Q74 Mr Jenkin: Ms Crane, you have
raised a very interesting question. Should not the Ministry of
Defence have its own PCT and ring-fenced NHS funding to spend
on servicemen and women and their families wherever they may be,
whether they be at home or abroad? Then we would not have the
problem of competition. By placing so much emphasis on the National
Health Service as it is we have put servicemen and women and their
families in competition with all the other resources in the NHS.
I think that most of the public regard that as unacceptable. Do
you agree?
Ms Crane: It sounds very interesting
and I would love to look at it.
Ms Freeth: Certainly, with the
devolution of spending in particular areas it is very difficult
to lobby PCT or authorities to address the needs of their service
communities. They are not willing to do that. We need a national
arrangement to make sure everybody gets the same quality of support,
because at the moment it is very difficult. Each of us would have
to lobby individual parts of all of the PCTs and all local authorities
and that is simply not something of which we are capable to make
sure things are delivered.
Q75 Robert Key: When a family hears
that it will be posted overseas, are there some places in respect
of which it says, "Great! They have wonderful medical services"?
If so, which are those places? Do they sometimes groan and say
that they do not want to take their families there? If so, name
them, please.
Ms Crane: That is a bit unfair
out of the blue because some of my information is rather old.
A lot of families that go to Germany will say, "This is great."
That is why the reduction in the number of medics there has been
so difficult for people. The level of delivery of the Army Medical
Service in Germany and Cyprus has been very good. I had experience
in Brunei. I had babies in Brunei, Hong Kong and places like that
and it was great.
Q76 Robert Key: Which are the places
that give rise to a groan? The defence medical services overseas
are all wonderful, are they?
Ms Crane: I think it depends on
what you want. I do not have a lot of evidence about the Falkands,
Belize, Batus, Brunei, Nepal and Naples. I do not know the detail
of each one.
Q77 Willie Rennie: What is the view
of health services for military personnel in Scotland? Do you
have any evidence of differences between England and Scotland
or even Wales?
Commodore Elliott: I have an opinion
about Scotland with regard to veterans and mental health. Of all
the administrations the Scottish Executive is the most forward
thinking in dealing with mental health in the community, including
veterans with mental heath problems. I get most excited about
the discussions that we are having at the moment with the Scottish
Executive. In Wales the head of the mental health policy unit
believes that veterans should be treated the same as everyone
else; in other words, there is no difference. The same is true
of Northern Ireland where because of security issues there are
problems to which home service veterans are very sensitive. We
are going through a process of work in partnership with the MoD
during which the funding arrangements for the work we do with
veterans will be transferred from the MoD, where under the service
pension order we get some of our war pensioners treatment funded—that
system avoids a postcode lottery; it is exactly the same for a
veteran regardless of where he comes from in the United Kingdom—to
one where we will be funded by the NHS. I am extremely concerned
by the fact that we will have to deal with PCTs and individual
veterans, which means we will have a contracts department that
is larger than the whole of my staff put together. Undoubtedly,
there will be a postcode lottery and differences in opinion between
the administrations as to what they want us to provide. I am extremely
nervous about going down that route. I quite like Mr Jenkin's
idea that it should be applied to the work of my charity. I would
like to have a top slice and my own budget which avoids all of
these difficulties and can get on with our work, which is to look
after veterans who are very ill and in desperate need of help
without having to worry about that.
Q78 Mr Jenkin: We are coming on to
ex-servicemen and women. At the moment, what responsibility does
the Ministry of Defence demonstrate for the health and welfare
of ex-servicemen and women?
Commodore Elliott: I have sat
on the Confederation of British Service and Ex-Service Organisations
(COBSEO) ever since the Prime Minister announced that there would
be a minister for veterans within the MoD. I have watched the
whole process grow. We have been talking about having a minister
for veterans for the past 60 years and now we have one. It is
still early days, because unfortunately ministers change every
five minutes. When the first minister, now Lord Moonie, met with
us he said that government believed there were certain things
that the ex-service organisations did better than government and
it wanted them to go on doing that. I think it is absolutely terrific
that we should be working in partnership for the benefit of our
veterans. We have a huge role to play in this because of our history.
The ex-service organisations were founded because there was nothing
for veterans after the First World War or, even earlier, after
the Crimean War. There is a huge amount we can do together. I
think that the Government is embarrassed by some of the things
that are emerging at the moment. As we all know, at the moment
mental health is a particular issue. Some of what has been reported
is very accurate. The articles in the Sunday Times were
fairly accurate, but there were one or two minor points of details.
I think they are beginning to grasp that this is an issue where
we have to do better, but I want us to do better together in partnership.
Ms Freeth: The charities play
an increasing role in supporting the welfare of veterans from
the oldest to the youngest. We wonder whether or not that is sustainable
largely because of the present prioritisation of social support
in the community. If you are not at serious risk you cannot access
many of the social services that are available to you and welfare
organisations are being drawn more into service provision. We
do not and cannot provide health support to veterans which is
a critical area for us. Under our charitable objects none of us
is able to provide health support other than in Commodore Elliott's
case. Therefore, we are frustrated by the difficulty that veterans
experience in terms of accessing health support for areas that
are the result of, or are exacerbated by, service-related injuries.
Q79 Chairman: Perhaps I can bring
you back to the precise question asked by Mr Jenkin. What role
does the Ministry of Defence demonstrate in looking after ex-servicemen?
Ms Freeth: Its role is to provide
a pension and information service. It does not provide services
to veterans in terms of health and social support.
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