Examination of Witnesses (Questions 380-399)
DEREK TWIGG
MP, LIEUTENANT-GENERAL
ROBERT BAXTER
CBE, LIEUTENANT-GENERAL
LOUIS LILLYWHITE
MBE QHS, MR BEN
BRADSHAW MP, PROFESSOR
LOUIS APPLEBY
AND MR
ANDREW CASH
27 NOVEMBER 2007
Q380 Mr Jones: I was not asking you
that. I was asking him.
Derek Twigg: I think the evidence
given already, in terms of partnership boards, exists and at different
levels amongst our medical community meetings take place and this
is discussed. In fact, if I can just say to you, even as recently
as June this year---. I chair a veterans forum, and this issue
was discussed and the Scottish Executive representative was very
clear that this was an active issue on health, it was a devolved
issue, and essential to ensure a consistent approach in delivery,
and the advice was issued every year and disseminated by IT systems.
So, we have had discussions with our colleagues in Scotland, as
I say, both in terms of our medical people in the partnership
boards and at other levels, but, of course, at ministerial level
the Veterans' Forum will discuss all these issues around veterans'
health, and veterans' priority treatment was raised during the
last Veterans' Forum meeting.
Q381 Chairman: Could I ask you before
you pursue your further discussion with Scotland to read our evidence
session on what happened in Edinburgh, because Kevan Jones is
right, it was unsatisfactory.
Derek Twigg: Yes. We are not being
in any way complacent. As I say, we will continue to have further
discussions to take up the issues, and I have read the evidence
session and I have also talked to a number of the members of the
Committee, who expressed their concerns to me.
Q382 Mr Jones: I am not saying the
problem was with you, it was actually with the Scottish NHS?
Derek Twigg: I think what I am
trying to say is that from the defence point of view we are actively
engaged and we will certainly continue to do as much as we can
to ensure the subject is given a profile, but, as I say, it is
a devolved matter in terms of the Scottish Health Service, but
you can rest assured as a Committee that we will continue to do
all that we can.
Chairman: Thank you. Mike Hancock.
Mr Hancock: Whilst everybody would
accept that veterans should have this degree of priority, I cannot
understand why Hull was chosen as a place for the trial to take
place. In an area like South Hampshire, where there is a high
disposition of service personnel returning, tens of thousands,
that sort of priority will place real issues for the trusts running
the hospitals in that area, particularly the big one in QA Portsmouth.
What are you going to do about making sure there are resources
available if there is a huge take-up of this priority for veterans
in areas where there is a high predominance of retired service
personnel? In Portsmouth, Colchester, Aldershot, Tidworth, round
the Salisbury area, many of them have high concentrations and
they would have been, surely, the places to trial something like
this.
Q383 Chairman: I would normally say
Minister, but I am going to find it very difficult to keep calling
both of you minister, so I will say, Ben Bradshaw.
Mr Bradshaw: I think the reason
that it was trialled in Hull, Chairman, is because, I think I
am right in saying, the Chief Executive is an ex-military man,
so he had a particular understanding and sympathy for this issue,
but the question is absolutely right. The presence not only of
veterans but also of service families is already reflected in
the spending allocations given to PCTs. That already happens.
The board is doing a special bit of work. One of its current pieces
of work is working with ten of the PCTs with the greatest populations
of service families and veterans to see if there are any particular
issues there in terms of waits, but I would repeat the point that
I was making earlier. Of course, by the end of next year in England
no-one will have to wait more than 18 weeks between GP referral
and treatment, whether that be an operation or otherwise, so the
issue of non-military NHS patients feeling that they are somehow
being shunted to the back of the queue should not arise because
they will be waiting less time next year than they are now, even
with priority treatment for veterans.
Q384 Robert Key: The memoranda from
both the Department of Health and the Ministry of Defence go into
the legislative background to the arrangements you have described
and also customer practice dating back decades. If we are to have
priority treatment for ex-Servicemen how does the receptionist
in the GP practice know that there is a serviceman walking through
the door? How does the A&E receptionist in a hospital know
that it is a Serviceman or woman or ex-Serviceman or woman who
has walked through the door? Are their NHS cards marked? Do they
have a red star on their record? What is the process? It is terribly
simple, but what is the process which allows for priority treatment
and allows those who are going to have to pay for it from their
budgets and to be accountable for it to know that they are actually
spending the money in the right way?
Mr Bradshaw: With A&E, Chairman,
there would not be any question because A&E patients are treated
within four hours because they gave got an urgent need. With general
veterans presenting themselves at GPs surgeries, when they leave
the Services, if they leave for medical reasons, there is a package
that is arranged between the military medical system and the NHS
and the local PCT or GP. They are entitled within a year, if they
do not leave on medical grounds, to a GP referral, but we do rely
on veterans themselves to identify themselves and to seek this
priority treatment as their right and, as I said earlier, one
of the difficulties is that not enough do. We remind the Health
Service of its responsibilities and the Chief Medical Officer
is writing out again to GPs to remind them of the priority treatment
scheme and the fact that that has now been extended to all veterans.
Robert Key: I am not satisfied
with that, Chairman. There must surely be a system in place where
immediately a doctor's receptionist can identify: this is a veteran,
and there is not such a system. It depends at the moment upon
the veteran saying, "I am a veteran", and then the receptionist
will not even know what questions to ask, and it does matter surely?
Q385 Chairman: Mr Cash, do you want
to add anything to that? I just gleaned from your body language
that you might.
Mr Cash: Obviously, if they are
veterans, in two ways really: first of all, they will be informed
of this when they are in the Services and then become a veteran,
so the individual will know; secondly, it will be in the operating
framework, it will go out to each PCT and then out to each GP,
so it is that way, but essentially, at the moment, the more complicated
packages of treatment that the Minister has talked about are arranged
between the military and the PCTs, the GP direct or a mental health
trust or an acute trust.
Q386 Chairman: Surgeon General, do
you want to say anything?
Lieutenant-General Lillywhite:
No, because, of course, you are dealing with veterans, which I
am not responsible for, but I would just confirm that when somebody
with a health condition is actually discharged from the Forces,
we do actually ensure that the care is actually passed over in
as seamless a way as possible.
Robert Key: But there is still
no process that identifies the individual person. We have heard
from Combat Stress, for example, that it is typically 12 to 14
years before a mental condition manifests itself to a Serviceman.
Twelve to 14 years later, if there is no method of identifying
an individual person as a veteran, no-one is going to believe
them if they walk in off the street and say, "I am a veteran
and I left 14 years ago." "Pull the other one",
will be the reaction. Surely a system can be set up.
Chairman: It seems to me that
we have alighted on a rather important point here. Kevan Jones
is next.
Q387 Mr Jones: What you told us is
complete nonsense, is it not, because you actually do not track
veterans? The big problem is—Mr Key is exactly right—that
once people leave the Services they go into the NHS system where
there is no way possible of actually tracking where they go to
and, 14 years later, as has just been said, you can take their
word for it. Should there not be a system whereby we could really
keep the promises? It is all right promising these things for
veterans but we should actually have some marker or record that
they have actually been a veteran. As for talks with the PCT,
it is complete nonsense: because I actually spoke to my Chief
Executive of the PCT the other week and asked her how many times
or what correspondence or contact she has with the MoD. Nothing.
So this idea that PCTs are actually on top of all this is just
not the case.
Mr Bradshaw: Can I respond to
that particular point. She is under an obligation to read the
annual operating framework and the guidance that we issue to PCTs
which draw attention to the Concordat, the special arrangements
that apply to veterans; but on the point about records, my understanding
is that when a Service personnel leaves the Armed Services, they
are given a summary record of their medical records which they
then take to their GP and when the two computer systems are integrated,
which they will be as part of the National Computing for Health
national IT network, this will, as I understand it, be automatically
transferred. So there is a record that they are a veteran, they
have it, and we do rely on them to then take it to their GP when
they register with the GP. If they are pensioned out for a medical
reason, this is all managed for them by the military support medical
teams.
Chairman: Thank you. Mike Hancock.
Q388 Mr Hancock: I was just going
to say, when I visited the medical facilities at QA along with
our clerk a week or so ago, I raised the point that GPs had questioned
the ability of themselves to get medical records which were comprehensive
and clear about what had actually happened to service veterans
when they came to them, and I was assured that that was not the
case because they did not get a summary, they actually got a fairly
detailed paper. It is a summary?
Mr Bradshaw: Yes.
Q389 Mr Hancock: That summary does
not include, in some instances, the sorts of injections that personnel
would have had. Certainly veterans who in the last ten years,
maybe in the last five years it might have changed, but certainly
anybody who left the Armed Forces before that period of time,
their GPs will tell you time and time again the very real difficulty
in achieving accurate medical records from the MoD. I think the
point is valid. How easy is it for you now to make those medical
records readily available to a GP on request when a service person
signs up at that new GP's surgery? It ought to be an automatic
process, did it not? The GP immediately alerts the MoD: "I
have got a new veteran on my list. I want his comprehensive medical
records in my hands."
Derek Twigg: Can I just say (and
General Baxter will come in and correct me if I am incorrect here),
people leaving the Services get a summary record, as you quite
rightly say. If the doctor so wishes, they can then request the
actual detailed medical record. Obviously, when the new IT system
is up and running, it will provide a lot more information in terms
of accessibility. In terms of war pensioners, they also get given
a letter from the Service Personnel and Veterans Agency. I am
not sure if it has some historical context in that it has never
been a sort of systematic system going back to the Second World
War. This is a system which clearly, as I accept, we have got
to see what more we can do, but I think the fact that they do
get a summary record and they do get a letter from War Pensions
is a very important point to make in the context of this debate.
Q390 Chairman: I will call on Surgeon
General, then Adam Holloway, then John Smith, then I want to get
back on track and I will make a comment after John Smith.
Lieutenant-General Lillywhite:
Can I make a couple of points. First of all, as far as medical
records are concerned, we keep for 100 years the medical records
of all people who are actually in the Armed Forces. They are kept
somewhere on the east coast, they are comprehensive and they can
be obtained easily on request. I only visited there about a month
ago. There did not appear to be a waiting list in terms of responding
to anybody's request for records. They can be provided, but it
is incumbent upon the GP to request them. I think there is another
issue that we do need to bear in mind, and that is not all veterans
want it to be known that they are veterans, so we just need to
be careful about being too proactive in some cases. An individual
who has left the Armed Forces, wants to sever connection with
the Armed Forces, in some cases, not many but in some cases, may
wish that severance to be complete, and we need to be very careful
about being too proactive and overriding an individual's wish.
Q391 Mr Holloway: Notwithstanding
General Lillywhite's point, I wonder what General Baxter thinks.
How much can you rely on ex-Servicemen to flag themselves up?
I have been to a GP a few times in the last 16 years, leaving
the military with an injury from parachuting. I do not think I
have ever mentioned that I was in the military; it did not really
occur to me to do so. So if I, who am fairly pushy, have never
done that, how do we expect some guy who is less so to do so?
Lieutenant-General Baxter: I think
you go back to General Louis' point. People have a right to their
privacy and if we were to put a little ink mark on their foreheads,
it would be getting in the way of what they wanted to do. The
point about the medical records: the summary is there so the GP
knows if there is something there that might worry the GP; he
then has to request the record with the patient's permission.
You have to balance, if you like, identifying people versus people's
right to privacy and information about them; so a little more
thought there before doing this on the hoof.
Derek Twigg: I think it is a very
important point that you make, and it is true to say there are
differences of opinion. Unless I have been somewhere else in the
last 12 months I have been doing this job, I think health has
had a pretty high profile in the media and the issue around priority
treatment has probably never had such a high profile in terms
of the media generally. Taking into account whether it is through
the partnership boards, the various notes that go through PCTs
and information that is coming around the system in terms of priority,
and obviously your investigation, I think there is much better
understanding. Even in terms of mental health, in terms of the
stigma attached, it is very difficult for a lot of service people
to deal with. It is, I believe, improving. Yes, there is a lot
more that we can do and it is important that we look at that,
but I think to suggest that a lot is not happening and the fact
that the publicity around this has not been much greater in recent
months, certainly the last 12 months, I think is something we
should not overlook.
Mr Bradshaw: An illustration of
the cultural problem to which Mr Holloway refers is that we are
only aware of one complaint ever from a veteran about not getting
the priority treatment.
Mr Holloway: They just do not
complain.
Q392 John Smith: You will have to
forgive me, but I do not quite understand how this priority treatment
will work in practice when a constituent of mine presents himself
to the GP. The highest proportion of veterans in the population
is actually in Wales and we do not enjoy, unfortunately, the shorter
waiting times for treatment and referral; so I suspect in Wales
this is going to be an issue, with much longer waiting times.
What will actually happen when my constituents present themselves
to the GP which means they will get priority when we have got
long waiting times? How will it work in practice?
Mr Bradshaw: As long as the GP
is satisfied that the complaint or the condition that the veteran
is presenting is related to their service and as long as there
is no clinical reason in terms of another more pressing case or
an emergency why this person should not get priority treatment,
that person will be prioritised in terms of their wait. That is
how it happens in Hull and that is how we would expect it to happen
everywhere else.
Q393 John Smith: I think this is
very, very important for veterans to understand clearly. What
the ministry is saying is that if two of my constituents present
themselves to the GP with the same clinical problems, they are
clinically equal, or 200 people present themselves to the medical
services and they are clinically equal, then a veteran will get
priority over the other 199. Is that what you are saying?
Mr Bradshaw: As long as the clinician
could satisfy him or herself that the problem was related to the
service, yes.
Chairman: I do apologise to Brian
Jenkins because he did catch my eye a lot earlier and then I got
distracted.
Q394 Mr Jenkins: Minister for Veterans,
in relation to the response you gave to Mr Jones with regard to
the unfortunate evidence session we did in Scotland, would you
take this opportunity to state now that if any agency, be it in
Wales, Scotland or in England, fails to meet the standard we require
for servicing veterans you will do what? What exactly will you
do rather than, "We will try and talk to them. We will work
to them"? If they are failing to meet the obligations, what
are you prepared to do?
Derek Twigg: Clearly, the National
Health Service knows, but it is the health departments in each
study in Scotland and Wales. I cannot tell them what they should
and should not do, but as the veterans' minister I am the advocate
for the veterans and I am certainly, if you ask people, not shy
in coming forward in terms of advocating veterans' issues and
these are discussed at various forums. I mentioned one example,
the Veterans' Forum. Also I have got a meeting coming up shortly
with members of the Scottish Executive. I will meet my fellow
ministers; I have met health ministers on occasions during the
last year to raise these issues, so I continue to press for improvement.
The thing about veterans, very clearly, is it is not just the
Ministry of Defence, it is a cross-government approach which is
very important to all this. So, I will continue to advocate and
to speak and discuss these things with my colleagues and other
government departments on devolved administration and about how
we can continue to improve that. I sensed a great deal of willingness,
and I was not at the evidence session, and clearly understood
how it went, to actually improve these things and take these things
forward and I can guarantee that will be top of my agenda.
Q395 Mr Jenkins: Sure. If an agency
is contracted to the MoD to look after veterans and have they
failed in what you believe should be provided across any area,
you are saying—
Derek Twigg: I am sorry, I thought
you were talking about government. If anyone has got a contract
with us, then we expect them to deliver the contract, full stop,
and we will deal with it as necessary. That has not happened.
Q396 Mr Jenkins: So you have got
the power to do that?
Derek Twigg: If we have got a
contractual position with an organisation, that is absolutely
true.
Q397 Mr Jenkins: You have got the
willingness to do it as well?
Derek Twigg: Absolutely, because
at the end of the day what matters most is how our veterans and
Service personnel get treated. That is our absolute priority.
Q398 Mr Jenkins: You have got the
willingness to sort out an agency in England. Why have you not
got the willingness to sort out an agency outside England which
you have responsibility for? It is not devolved to you.
Derek Twigg: Can you be more specific?
In terms of the Scottish situation?
Q399 Mr Jenkins: Scotland, Wales,
yes.
Derek Twigg: Which agency in particular
in Scotland?
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