Examination of Witnesses (Questions 80-99)
MS SAMMIE
CRANE, COMMODORE
TOBY ELLIOTT
RN, AIR COMMODORE
EDWARD JARRON,
MS SUE
FREETH AND
MRS ELIZABETH
SHELDON
12 JUNE 2007
Q80 Mr Jenkin: Has the presence of
a minister for veterans made any difference?
Commodore Elliott: Going back
to my experience of sitting on a veterans' forum—which was
chaired by the Minister for Veterans on Friday—he meets
with veterans' representatives, that is, the executive of COBSEO
and one or two others and representatives of other responsible
government departments and those for Wales, Scotland and Northern
Ireland. There are civil servant representatives of the ministers.
There is something called the Minister for Veterans task force
which seems to have fallen into disarray, or it is not meeting
very regularly. I think that the Minister for Veterans is finding
it very difficult to get the other government departments to engage
to the extent he would like in a co-ordinating role to ensure
that veterans get the visibility they need.
Q81 Mr Jenkin: What role should the
Ministry of Defence have in providing healthcare for veterans?
Commodore Elliott: Healthcare?
Q82 Mr Jenkin: We are talking particularly
about healthcare in this inquiry, but if you want to make a broader
point do so.
Commodore Elliott: The answer
is that the Ministry of Defence has made it quite clear for many
years that veterans' healthcare is provided by the National Health
Service. It is absolutely adamant about it and we cannot move
the department on that. There is very little that it can do. It
has made some arrangements for TA casualties with mental health
problems to go to the defence medical services for an assessment
and maybe a little bit of treatment, but that is about it.
Ms Freeth: The minister has pressed
for the delivery of priority treatment for war pensioners by the
NHS, but the ability to leverage that systematically and consistently
across the country does not appear to be possible. The legion
would like to see the minister ensuring that veterans do get the
treatment to which they are entitled and were promised.
Q83 Mr Holloway: Fifteen years ago
for a television programme I spent three months living homeless
in London. There were a lot of ex-servicemen, admittedly some
of the national service generation. How much evidence is there
that there are large numbers, or any, homeless ex-servicemen now?
Commodore Elliott: About 10 years
ago an ex-service action group on homelessness did a study and
found that one in four of those sleeping rough in London were
ex-servicemen. A study which is about to report indicates that
that is down to six per cent, which is a pretty good achievement.
The MoD has played a large part in providing housing for single
ex-servicemen who leave the Services and have nowhere to go. The
ex-service organisations also help in this regard. I believe that
six per cent is the lowest we will ever get.
Q84 Mr Holloway: What about temporary
accommodation? I have a guy in my constituency who was injured
in Iraq. He is staying with his girlfriend's parents because he
cannot get any sort of council housing. What is the situation
there?
Ms Freeth: There have been improvements.
A number of new projects have assisted, but more accommodation
is needed and is in the process of being provided around the country.
There are two new projects, one in Catterick and one in Yorkshire,
that will take place in the next two or three years, but in the
meantime housing is a problem. There is a need for short and medium-term
housing particularly for the most vulnerable, that is, early service
leavers who are not entitled to any of the support that people
get if they stay for four years. In both health and social care
the biggest group of people with difficulties are the early service
leavers who are not entitled to the kind of support that is available
once four or five years have been served.
Commodore Elliott: You raise a
very important issue. There are people camping out with friends
who are invisible to us. That is an area where we must do our
best.
Ms Freeth: Work is being done
by the minister to try to get the local connection system back
in place for individuals so they get priority treatment. Ex-servicemen
and women and those who support them still do not know enough
about how to access housing provision in their areas through local
government.
Q85 Mr Jenkins: When servicemen leave
the Services the employer has a duty of care. What does the employer
put in place to ensure that when someone leaves he does not have
his medical records put in his hand and is simply told to look
after himself, but that when he is settled down his medical records
will be accessed and sent speedily to the GP of his choice and
this is the support he requires, etc? At the practical
sharp end we may just have some influence on the MoD to bring
about an improvement in that area rather than the provision of
housing 15 years down the line. Do they give them that linkage?
They cannot give them their medical records because they might
lose them, but do they make sure the linkage is there and the
records follow ex-service personnel?
Commodore Elliott: The procedures
for medical discharge involve handing the patient across to the
National Health Service, and the medical records go with the patient
into the NHS. All too frequently the problem is that the Services
do not know where that patient will end up. He has nowhere to
go. A lot of servicemen who are being discharged will not contact
their local GPs and all the services that they should connect
up to until they are in trouble, and therein lies a huge problem.
In fairness to the Ministry of Defence, I think it is an extremely
responsible employer in this regard. The resettlement process
is probably second to none. I do not think anyone else does resettlement
in this country for people who leave their employment. The servicemen
themselves have a role to play in all this, inasmuch as they are
responsible for doing all the things that need to be done, except
in the case of very damaged people where special arrangements
are made to make sure local NHS services are provided. I do not
think that we should be too worried about this, apart from being
aware that some servicemen, whatever we try to do, will not do
what they are advised to do.
Ms Freeth: At the moment a lot
of information is given to people at the point of departure and
when they come to medical discharge they have all the other problems
that go along with that. I believe that there is too heavy a reliance
on information on paper that is given to people, which they probably
do not read and certainly do not digest. There is just too much
of it. We need a more personalised approach to service departure.
The new personnel system which the Royal Navy has started and
is about to be adopted by all the Services will be an automated
one where people terminate themselves. They will go online and
their termination papers will be processed electronically. I can
understand why that is a perfectly sensible and efficient way
to complete the paperwork, but there is a real danger that part
of the process of personal preparation will disappear when we
should be increasing it rather than diminishing it.
Air Commodore Jarron: One of the
problems we have is making contact with veterans because of data
protection. Once they have gone there is no way to track them
and the MoD is not allowed to pass to us the names and addresses
of people who have left. Service leavers are inundated with information
on discharge, resulting in a huge pile of paper in which any communication
from Veterans organisations is more often than not simply lost
or ignored. I think I still have mine from when I left a few years
ago. Very often is not immediately after you have left that the
problems set in; it is three, four or five years down the track
when things are not quite working out as you would have liked.
We have no way to go out to these people other than through our
network of local welfare officers who hopefully keep a finger
on the pulse. It would be extremely helpful to have some way to
access veterans.
Ms Freeth: A paper system has
been introduced and SSAFA, ourselves and the regimental associations
are taking part in this. I think it has been in place since April.
There is a piece of paper in the termination pack for people to
complete and send on to us. I do not know how many people have
left, but every single one has been offered this in the past two
months. We have not received one.
Air Commodore Jarron: That is
exactly the point I make. A piece of paper in a pile that
high will still be lying there two years later.
Q86 Mr Jenkin: Ms Freeth, in your
memorandum you describe the lack of a seamless transition from
Ministry of Defence care to the NHS, but should not the ministry
maintain responsibility particularly for the people who have been
on active service, whether or not they have been injured? Should
not responsibility for those people be maintained by the Ministry
of Defence so that they keep the records, keep track of them and
maintain responsibility for making sure that care is delivered?
Is that not what the British people would expect for these people
who have made such big sacrifices for their country?
Ms Freeth: I suspect that was
expected from the creation of a new veterans minister. The ministry
has done a great deal in terms of repositioning and valuing the
veteran and his contribution to society through public commemoration,
but in terms of improving the quality of what is provided for
the individual I do not think there has been a huge improvement,
which is disappointing. I suspect we may well have felt that we
had more leverage when we did not have a minister. We have to
go through him to press other government departments. There seems
to be almost less influence over those departments than there
was when we did not have a veterans minister.
Q87 Mr Jenkin: Do you think that
a lot of ex-servicemen, particularly those who have suffered injury
and perhaps are unable to work, feel dumped by the system?
Commodore Elliott: Yes, they do.
Ms Freeth: Certainly, the people
who come to us do feel that. Clearly, we are the people who have
the most difficulty. We will know about the exceptions, if you
like.
Q88 Mr Jenkin: How widespread is
that problem?
Ms Freeth: It is not a massive
problem but it is growing. There is a concern about unexpected
and increasing injuries, particularly the increased mental health
presentations, and something needs to be done to provide better
and more joined-up support.
Q89 Linda Gilroy: Some of the witnesses
made a remark to the effect that the way in which their organisations
are set up prevent them from doing certain things, unlike the
RFA. In the wider community there is a move to get the third sector
to act as partners to take on services. Is that something that
you would want to look at as organisations? You have a long tradition
of providing services particularly for veterans. I would have
thought that on the whole veterans would prefer to turn to organisations
which they feel are of their own rather than necessarily a government
service as such.
Commodore Elliott: This is exactly
the process of which we are trying to take advantage. All too
often the funds that one is after are disaggregated down to local
level. For a UK-wide operation like Combat Stress that creates
a huge problem. I am absolutely convinced that Combat Stress provides
exactly what veterans' mental health problems need, as long as
they are not too extreme. It is a case of finding a way to get
a nice block of £10 million to provide this service seamlessly
for veterans across the United Kingdom using the principle of
the third sector that is funded to do the Government's work. I
do not mind; I think we should be doing the Government's work.
Q90 Linda Gilroy: A number of remarks
have been made to the effect that it would be good if government
funded this but not necessarily directly.
Commodore Elliott: We cannot raise
the money charitably to do all of the work that we need to do.
We fund about 40 per cent of what we do from charitable income
at the moment and we think we are asking as much as we dare from
the hugely generous public who keep on saying, "Why ask us
to fund you to do the Government's work?" I do not think
there is now an issue about the third sector doing the Government's
work. We are delighted to do it; we have a huge and proud tradition
going back nearly 90 years and we think we can do it in partnership
with the NHS, the Ministry of Defence and everyone else. It is
just a case of sorting out the funding.
Ms Freeth: A number of us have
been looking at the individual payments programme and have been
briefed on that. The ability to be partners locally, however,
is not something for which local government is willing to select
us because we can provide a service only for our community. Our
charitable objects restrict us to working with our community,
unlike other organisations that have a broader remit. I think
that is unfortunate. In some of the pilot areas for individual
payments we would have liked to be part-players, but under the
current criteria we are not permitted to be because we cannot
provide a general service.
Q91 Mr Holloway: There are very large
numbers of ex-servicemen in Iraq working in the private security
industry. Will this compound your problems in the future?
Ms Crane: Yes.
Commodore Elliott: When these
chaps come home they are referred to us for treatment. We are
very concerned about the fact that they go back afterwards. I
think they are being rather stupid, but in those cases treatment
is funded by their insurance companies, so it makes it much easier
to provide what they need.
Q92 Willie Rennie: We have covered
the general structure of health services. What about mental health
services, in particular the Chilwell Centre for the TA, the Priory
Group and its services and the other structures within the services?
How is it operating?
Commodore Elliott: It has been
very interesting because they have gone through major restructuring.
We are talking of in-service mental health provision. They have
gone for a community-based mental health service where the community
health centres are based in garrison towns, naval towns and so
on. I have to say that, based on anecdotal evidence from the soldiers
and sailors who have come onto our books, and the fact that we
have a very good relationship with many community health practitioners
who are serving the Royal Army Medical Corps, naval people and
so on, this seems to be very good. It is a great improvement on
the past. As to the Priory Group, this is designed for short doses
of treatment for very difficult patients. We have no evidence
as yet—I do not know whether the MoD has any—about
how effectively all this money is spent in terms of treatment
outcome. I am not sure how it is being measured, but we will have
to wait and see.
Q93 Willie Rennie: Do you have concerns
about value for money?
Commodore Elliott: I have a question
about it, because I would not mind having the money and contract
myself as part and parcel of a service that I believe would be
more appropriate, which is to provide a service like that to in-service
patients as well as veterans. This is an aspiration.
Q94 Willie Rennie: I have heard contrasting
figures of £500 a day to get Priory Group services compared
with £200 for the service that you provide.
Commodore Elliott: We are looking
for £247 in this year's settlement, but we are not doing
what the Priory Group does; we do not have as many doctors as
they do and so on, so we are not comparing like with like. They
do acute work; we do chronic work. To go back to in service, I
think it is much better. Another matter that is so important is
that education must be in place so that people understand what
it is that is beginning to get to them if they start to suffer
the psychological effects of trauma. That is getting much better.
For about eight years the Royal Marines have had a system called
TRIM—trauma reduction management system—which is a
command-led rather than doctor-led scheme. That has been trialled
in the Royal Navy, successfully I understand, and at a defence
welfare and aftercare conference the other day where I spoke the
chief of general staff said that he wanted TRIM for the British
Army now. My message is that an occupational hazard of being a
serviceman is that you are more likely to end up with psychological
wounding than physical wounding. We need to be just as grown up
about psychological wounding rather than treating it as something
shameful and stigmatising and deal with it on the battlefield
and in recovery, just as we do with our physically wounded people
where battlefield procedures are second to none, as we know from
the people who come home. That message is getting across. We need
to be grown up and treat these people in the same honourable way
as we do the physically wounded.
Ms Freeth: The ongoing research
of the King's Fund demonstrates that the operational tempo is
having an impact on top of what Commodore Elliott describes. We
can already see that, so we should be preparing for how to respond
to it rather than wait until those research reports emerge in
two years' time.
Commodore Elliott: If one turns
to Chilwell, it was the society who reported first that we were
seeing TA soldiers coming to us very soon after returning from
active service being discharged into the NHS and not getting what
they needed there. They came to us. Subsequently, Professor Wesley
produced a study which showed that for psychological casualties
from Iraq the figures were four per cent for the TA and two per
cent for regulars. He has reported very recently that the TA figure
has gone up to six per cent and for the regulars it is four per
cent. The society believes that those figures probably hide another
couple of percentage points; there are casualties there who do
not present because of stigma and the military ethos issue, among
other things; or it may be that as soon as the soldier gets back
from active service he discharges himself into the community and
becomes one of the vulnerable service leavers. They go outside
into the community in the hope that these terrible nightmares
and flashbacks will go away but they do not and they start to
deteriorate. But I want to be quite positive about what I have
seen in service.
Mrs Sheldon: As I understand it,
we are looking at the service person but there is also the family.
Parents and families are very seriously affected by emotional
trauma. Sometimes it is very hard to understand that the person
who has come back is completely different from the person who
went away. Again, they should be brought within the umbrella of
whatever mental health care is offered to make sure their concerns
and worries are also taken into account. Perhaps we have a narrow
definition here and we ignore this at our peril. At the end of
the day, if these issues are not addressed the whole relationship
breaks down in the family and that has an impact on the person
in either returning to service life or being able to rebuild a
new life outside.
Q95 Chairman: Are we ignoring it
currently?
Mrs Sheldon: All of us have evidence
of cases where it is being ignored. Again, I think it is due to
a breakdown in the systematic tracking of families and picking
up the symptoms as soon as possible. It is a matter of making
sure that professional help is easily and quickly available, not
putting barriers in the way that the process is handled both within
the service and externally. It is a matter of making sure that
within service when people are helped to make the transition to
the outside it is understood that the whole family needs to be
embraced in the concept, not just the service person.
Commodore Elliott: I could not
agree more. The society's constitution is such that it is supposed
to look after only veterans, but that has been broadened. We are
now starting to roll out services for veterans' families and adolescent
children. Adolescent children are very badly damaged by the experience
of having a father who comes back a changed man and behaves in
a really frightening and horrible way. Earlier I spoke about evidence
that families in service did not resort to what was available
and came to us instead. This is of great concern to us.
Ms Crane: I was at a camp in Cyprus
where decompression for units coming out of Iraq takes place.
I met a padre there who said that TRIM was being delivered to
TELIC 10 that had just returned. The problem with families is
that a lot of us are trying to raise awareness about the psychological
effect of multiple deployments and operational tempo. Among lots
of spouses and children at schools overseas there is increased
awareness. People know that this happens and it is not something
one should be so ashamed of and there are people who can help.
I think it is the more remote families, partners and parents who
are particularly vulnerable and we do not see. Unless service
people want us to talk to them there is no way we can contact
them. Another factor that has a big impact is public opinion and
sometimes media pressure. If it is an unpopular deployment that
has an additional effect on how people feel.
Chairman: You mentioned padres. It is
often the padres and commanding officers who bear the brunt of
this. They are expected to be the long stops and themselves have
no one with whom they can talk these things through.
Q96 Willie Rennie: Returning to the
veterans' service which we have covered at various points during
the session, the age profile has changed. It is a much younger
group of people who now come to you. First, what impact does that
have on your service? Second, what waiting list do you have? You
have referred to funding difficulties. How difficult is funding?
Third, from where do most of your referrals come? Is it from community
GPs or elsewhere?
Commodore Elliott: As to age profile,
we have made a deliberate change in policy and we "outed"
this issue about eight years ago. At the same time, we have started
a major revision in our clinical uplift for treatment. Whilst
we still have a large number of World War II veterans on our books
who benefit most from the respite and convalescent aspects of
being in a treatment centre, there are a lot of much young veterans.
Over the past four years, partly because a lot of the World War
II chaps have got beyond the age when they are able to come in
for treatment, the age profile has dropped from an average age
of 61 to 51. That is a huge decrease in age for those people who
understand how data works. At the same time, we have had a very
large increase in the number of referrals. In the past three years
we have had a 27 per cent increase, or nearly 1,000 referrals
a year. For a small organisation like ours that is causing us
a great deal of overstretch. I am prepared to use that term. I
also use it when speaking to the secretary of state and the veterans
minister whenever I possibly can. That has been accepted. I am
really pleased that the Minister for Veterans is about to announce
a 46 per cent increase in the funding that he is to provide for
remedial treatment which will help us to a large extent to increase
the number of clinicians and skill mixes that we have in our treatment
centres.
Q97 Willie Rennie: Do you think that
the increase in referrals is due to the fact that people are more
aware of your service or a change in the number of people who
suffer from these conditions?
Commodore Elliott: All I can say
is that there are far more people out there than we know about.
Far more of them and their families are more aware of the issue
and understand it. Quite often it is the wife or carer who brings
Fred to our front door and says, "Take this man; otherwise,
I am going to walk out on him." It may sound amusing but
it is not; it is very sad, and it is good that we have found him.
From where do referrals come? About 10 per cent come from the
National Health Service and social services; about 30 per cent
come from our fellow ex-service organisations, for example The
Royal British Legion, SSAFA and regimental associations working
with us in partnership, which is very important. We are increasing
our capability to work in partnership, not only in terms of finding
partners but also in terms of the services that we can provide
to them. The remaining 50 to 60 per cent come by way of self-referral.
We are not exactly certain whether the guy has called a helpline
and been told to go to Combat Stress or he has found us on the
Internet, or his mates, carer or whatever have told him about
us, but that is a group which is really growing. We convert about
65 per cent of these people to active clients, as we call them,
so each year we have about 600 new cases where we provide treatment
and welfare support. As to funding, we rely heavily on income
from the veterans agency and the war pension treatment and travel
allowance that we get for providing treatment for up to six weeks
a year to war pensioners, but only two per cent of last year's
intake who arrived at our front door because of mental health
issues had a war pension. We do not turn them away; we worry about
them first and how the hell we are to fund what we are doing for
them comes second. In that area we are working very hard with
the minister and the secretary of state who understand our problem,
which is our need to find funding for that 40 per cent of the
work we do. As to the clinical priority, far more of the newer
guys than the older veterans need to come in and get what we can
provide. The challenge we have at the moment is that we cannot
afford to open up the beds for them because we need the money
to keep all the beds open. We need to have a clinical priority
for admission rather than the funny balance that we have at the
moment.
Ms Freeth: One of the difficulties
we have is that not everyone can be referred to the services that
Combat Stress can provide. The charities support other people
who perhaps do not have direct or provable combat-related needs
but still are veterans with health needs. There are two groups,
one of which we want to provide for and direct to local services
that we cannot access; the other are people with other difficulties,
for example problems with addiction. Commodore Elliott's service
is not able to take those people. These are people in very extreme
circumstances. For these people there is a shortage of service
provision. In our case the problem is particularly alcohol abuse.
We have small numbers of people who are drug addicts. This is
a group of people—I am sure SSAFA would say the same thing—for
whom we need new services. At the moment, those services really
exist only in London and are not in adequate supply.
Q98 Willie Rennie: Why is it necessary
for those to be military-based services or services related to
each Service? Why cannot the community not fund them? I know that
mental health and addiction services are pretty poor relations,
but why does it have to be in the military?
Commodore Elliott: If I may answer
that, this is my specialist area. The truth of the matter is that
the National Health Service tries to provide for these people.
Veterans go to the NHS and get a very good service. They are happy
with that and we do not see them, but the veterans we see say
that when they go to the NHS they will be referred to, say, a
PTSD support group. They will sit in the group with people who
have had terrible car accidents, traumatic child births and all
the rest of it. He will be one soldier who has worn his best mate's
brains down the front of his uniform and seen terrible things
in Kosovo and so on. When it comes for him to talk about his experience,
which is part of the process, either he bottles out and leaves
the group straight away or reduces the group, including the therapist,
to tears. He traumatises the group. They just do not fit in. The
worst thing is that they feel they cannot say anything and so
they get no benefit whatsoever from it and leave treatment.
Ms Freeth: There are two groups:
there are people who want to receive therapy as a group of veterans
and individuals who do not want to do that. We need services for
both categories but there simply are not enough in the community
generally for people who need drug and alcohol treatment. We need
more of them. Our community seems to need a greater supply of
that than perhaps other parts of society.
Q99 Willie Rennie: We return to Mr
Jenkin's earlier point about the responsibility of the MoD for
ex-servicemen. If there is such a difference in their needs the
ministry should have a greater responsibility. I am pleased that
you will be getting extra funding, but do you think there is sufficient
funding for addiction as well as all the other services?
Commodore Elliott: The answer
is no. It is very difficult to deal with drug and alcohol addiction.
Seventy-five per cent of the chaps on our books have major alcohol
and drug problems. We do all we can to encourage them to detox
and all the rest of it. We manage to get some of them to sign
a no alcohol contract so that whilst they are with us they can
benefit from the treatment we provide which includes working on
alcohol problems. This is a really difficult group. I am sure
that you have all heard of Dr Alan Jones and T Guinn. There are
some really hard cases. They want to help half of the time; for
the other half they want to do their own thing. They are incredibly
difficult to deal with. At the moment we have a committee on which
sits some ex-service rough-sleeping units. That is looking at
the issue of whether or not it is possible to contain and provide
these men with what they need in the sort of environment that
many of us want to sustain. They can become very difficult to
cope with; they can disrupt the whole unit, destroy the therapeutic
environment that we need to do our work and be very dangerous
both to themselves and the staff. That is not to say we do not
try to identify how we may do this, but the sad thing is that
for a lot of them the only time they get what they need is when
they are in prison, and even then they do not get it all.
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