Examination of Witnesses (Questions 280-299)
MR DEREK FEELEY, MR GEOFF HUGGINS, DR NADINE HARRISON
11 OCTOBER 2007
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% 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 2 to 3, 3 to 4% of the general population
and it is probably closer to 10% 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% 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.
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