Examination of Witnesses (Questions 400-419)
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
Q400 Mr Jenkins: Any one of the devolved
authorities who gets money allocated from the Treasury.
Derek Twigg: We do not have a
contract with the health administrations for veterans per se
because, as we say, there is a general administration that says
how veterans should be given priority, but again that comes back
to my earlier point. We have a dialogue and continue to press
for improvements. I read out what the Scottish Executive said
at the Veterans' Forum. I was not at the meeting, but I have clearly
read and heard about it and I am sure, I am quite convinced, that
within Scotland there is a real willingness to see improvement
and to see a commitment to veterans.
Q401 Mr Jenkins: A bit more push
really.
Derek Twigg: I can assure you
that will be done.
Mr Bradshaw: I hope you do not
mind me saying, Chairman, I do think it is a little bit unreasonable
to expect us to defend the behaviour of our Scottish colleagues.
I regret deeply the decision by Scottish ministers not to bother
to turn up to your hearing. I think that was inexcusable.
Q402 Chairman: If you are under the
impression that we were expecting you to defend the Scottish Executive,
please correct that, we are not. We are expressing our frustration
with the way that that meeting went.
Mr Bradshaw: Which we share.
Q403 Chairman: Which we fully accept
that you share, but the fact that all of this has to be delivered
through that Scottish Executive means that we have to ask you
questions of how you expect this to be delivered. It seems to
me most likely that in our report we will comment on this difficulty,
particularly about identifying veterans. Quite how we will comment
on it will be a matter for us to discuss and consider, but when
we do we hope you will be responsive and flexible in the way that
the Government responds to our report because we think we have
hit on a quite important difficulty here with what you are announcing.
Mr Bradshaw: I think that would
be very helpful, because one of the three work streams that the
joint partnership board is currently working on is this whole
issue of transition from military to veteran status, and anything
you say I think will be very useful.
Lieutenant-General Lillywhite:
You have mentioned Scotland. I would just like to correct what
I think may be a misapprehension from the minutes of that meeting.
We actually have quite close relationships with Scotland at a
variety of levels for serving personnel. For example, I meet with
the Chief Medical Officer for Scotland, as I have done, along
with the other chief medical officers. Our primary healthcare
headquarters, for example, in Edinburgh has regular meetings with
officials from the Scottish Executive. I do not think that actually
came across in your evidence session, but there are, for serving
personnel certainly and for their families, regular meetings between
the Ministry of Defence and their officials and the people on
the ground in the Armed Forces and the Scottish Executive. I would
just like to correct the impression that I got from the transcript
that there was no meeting of minds at all.
Q404 Chairman: I am relieved to hear
it, as we will all be. I would like to get this evidence session
back on track. Let us begin! Last week we had a briefing from
the Army presentation team and we heard there that the Chief of
General Staff had a briefing team report 2007 which referred to
feedback that the CGS was getting from the Army. It would be most
helpful to us if you, Minister, could see if you can find out
from that report if there are any defence medical issues that
it would be helpful to bring to the attention of this Committee
before we finalise our report, please?
Derek Twigg: Can I apologise that
the Committee did not actually see that report and can I give
you an absolute assurance that you will have a copy. In fact,
I have a copy here today with me which I will make sure that you
will have and any other copies of the services that may be relevant
in terms of this Committee.
Q405 Chairman: That would he very
helpful, but if you have already identified any medical issues
that arise out of that, if you could flag those up to us, that
would save us a lot of time.
Derek Twigg: We will do that.
Q406 Chairman: We would like to get
this report done quickly. We visited Selly Oak in June. I have
to say that we were highly impressed by the quality of the people
there, by the work that they were doing and the standards of care
that they were producing, and we said that at the time and I want
to repeat that today, and there are a lot of good stories coming
out of defence medical care. What we will be doing during the
course of the morning is asking questions which might imply from
the general tone of the way that we ask questions that we think
the whole lot is rubbish. We do not think that. We ask questions
because that is our duty. We, nevertheless, think that medical
care in general is being produced well for the Armed Forces. I
do not want to pre-empt our report, but can you explain briefly
the plans that you have for developing the defence medical services
facilities at Birmingham, how it ties in with Whittington Barracks
in Lichfield and how definite those plans are?
Derek Twigg: Shall I take our
development in terms of Selly Oak and I will hand over Lichfield
to General Baxter. First of all, can I welcome your comments about
Selly Oak. I visited Selly Oak on a regular basis and I think
it was most unfortunate this time last year when there seemed
to be a maelstrom in terms of the press comment on Selly Oak,
and I think that was hugely damaging to morale, not least to the
people who work at Selly Oak. Like any other large trust, there
are always issues and things that do not always go right, but
we are absolutely committed to making sure that happens. The overwhelming
tone that I have had is the absolute amazing care and treatment
that goes on in Selly Oak, not just for the military people but
the NHS staff there. The true story about Selly Oak is the long
operations to save limbs where surgeons carry out, in some cases,
world leading operations and come in on their days off to make
sure people are okay. The civilian NHS nurse who, a soldier told
me, sat up all night with him to comfort him. They are the real
stories about Selly Oak and, as I say, I am glad to see you confirm
that your opinion is that of ours, but, of course, we always watch
to see how we can do better. One of the issues in terms of Selly
Oak has been this issue of a military ward and how that is approached.
We currently have a Military Managed Ward, as you are aware, where
we have around 39 military nurses, we have got two liaison officers
who link in with units of the injured Service personnel, we have
got a military ward manager, welfare officers and psychiatric
nurses and there is obviously a much greater feel in terms of
a military environment than a workplace. It is a very important
partnership with the NHS. In terms of the new hospital building
which is taking place at Selly Oak, we very much welcome the partnership
and we intend to have a ward of up to 32 beds for our needs which
are both for those who are injured in service and some elective
cases as well. The idea behind this ward will be that it can be
broken down into individual units of four beds or, of course,
side rooms as well, and that, of course, will have a majority
of military staff in but it will also have NHS staff. Again, it
is very important that that partnership continues on the ward.
Then, of course, it will have all the facilities of what would
be, I believe, the leading trauma unit in this country, if not
in Europe—an acute hospital with all the facilities that
that provides for our people—but, of course, also enabling
both our people and the NHS clinicians to develop a range of skills
and training expertise. This is some of our early thinking. There
has been an issue around civilians being in the same ward as military
personnel. The intention in terms of this ward would be that we
would be able to manage the ward in a much more defined military
way because of the design the ward will have in place at beginning.
That is not, of course, to rule out at any point, if there is
a real need for it, God forbid, a major incident somewhere, using
beds for civilians or other specific circumstances, but the general
view that we have is that we will be able to make that a much
more defined military ward than is currently the case now, but
that does not in any way undermine---. I am sorry, you are underpinning
the fact here that we want the best possible treatment for our
Armed Force personnel who have been wounded in operations and
elsewhere, and it has been Selly Oak that provides that for us.
Lieutenant-General Baxter: There
are a number of ingredients when it comes to, if you like, the
Birmingham/Lichfield, the dumb-bell, a lot of words have been
used there. There is the military ward that the Minister has talked
about; there is also the training and centre of excellence that
has been built at Birmingham. Where there is the feedback from
operational theatres, just producing that fissionable mass of
expertise to look after battle casualties that is growing, and
that is very important and feeds into the training which goes
on there. So there is a training ingredient, a centre of intellectual
excellence. And you may have come across the Ministry of Defence
Technology Centre for Human Factors that is also based at the
University of Birmingham. So there are a number of ingredients
coming together in the centre of Birmingham; so that is part of
it. The other piece that we are looking to do is to continue to
build on that, if you like, fissionable mass, bringing the various
components together, making sure the thinking piece goes into
the training and the education and to look at concentrating other
bits of training. Our eyes are on taking Whittington Barracks
and converting that into a satellite to the main Birmingham piece.
We are looking at plans now, we are looking at budgets and we
are looking to what we call a Main Gate submission, the investment
decision, early in the New Year.
Lieutenant-General Lillywhite:
Could I thank you very much for your comments on Birmingham and
just reiterate that it has actually had a major adverse impact
upon morale, the comments that we had at the beginning of the
year. I literally had staff, military and civilian, in tears,
as they felt that they were being got at and their quality of
care was being undermined, but I would like to say, though, that
the quality of care that Birmingham has provided has gone beyond
that which is actually seen. They are making a significant contribution
to the quality of care on operations. For example, the weekly
conferences that we have between Afghanistan, Iraq and Birmingham,
where casualties' care is actually reviewed in theatre and back
in Birmingham, allows us to actually improve by learning from
the lessons of casualties we have already treated. They are also
actually assisting us in identifying research that we might want
to undertake to improve the quality of care that we are being
provided and, for example, to further that, the Professor of Traumatology
at Birmingham came with me to visit Afghanistan to look at how
it physically provided care within the Armed Forces. I regularly
meet with the Medical Director at Birmingham to discuss, again,
quality issues. So, Birmingham is contributing to the quality
of care, both directly in the way that you saw it, but indirectly
they are actually contributing in many other ways as well.
Mr Bradshaw: Briefly, Chairman,
the NHS is also benefiting enormously from this collaboration
in terms of expertise and skills and culture, and to confirm what
Derek said, the new hospital will be the biggest critical care
unit in the whole of Europe and it is the second biggest hospital
building programme in Britain.
Chairman: However, we have had
evidence to suggest that a lot of people are unhappy with the
concentration of defence medical facilities in Birmingham, that
it is not necessarily the best solution. On Friday I briefly visited
Haslar, where, obviously, the support for the retention of an
excellent facility is very high indeed. Plymouth—Linda Gilroy,
you have your own views about that.
Q407 Linda Gilroy: I think the issues
at Haslar and Plymouth are very different. I do not think that
Plymouth would say that they were unhappy with what is happening
at Selly Oak, and I would concur with everything my colleagues
have said about the quality of care that we observed at Selly
Oak. I think the points that have been given to us in evidence
are more about the long-term development of the quality of care
in traumatic services and whether, with the concept that there
now is in the National Health Service of contestability, there
may be scope over time, depending, of course, on how matters go
in relation to deployments and battlefield casualties which were
not expected on the scale that we get from Afghanistan and Iraq.
Thankfully these are relatively low compared with the Second World
War and the First World War but, nevertheless, they are war. I
think what I would be interested in, in the Minister's observations
on perhaps the military personnel as well, is whether there may
be scope, not for going back to the old military hospitals—I
do not think anybody has got an appetite for that—but for
looking at whether there is a case for developing other traumatic
services. Plymouth already has what Birmingham/Selly Oak will
have in 2012 under one roof. It is one of only two or three hospitals
in the country providing traumatic services to the scale that
they do at the moment, and I think there is a case for possibly
looking at that in the longer term, but I would not want that,
under any circumstances, to be confused with a desire to go backwards.
Derek Twigg: Perhaps Generals
Lillywhite or Baxter will come in if they feel they need to. As
a top civilian, neither medically qualified nor militarily qualified,
I listen to the advice strongly in terms of what I am given and
the strong advice that I have had since being in this job just
over 14 months now in terms of military hospitals—we are
not going back there for reasons you have espoused—in terms
of the need to work the NHS to give our people the best possible
training and expertise, not just use them say at Selly Oak or
Plymouth or somewhere else but also very importantly in the field.
What I am advised is that it is very important that we build up
this sense of expertise and excellence in terms of providing the
best possible treatment and care for our wounded personnel. Of
course, we are seeing life-saving operations and we are seeing
limbs saved and other miraculous things done at Selly Oak because
of the concentration of our medical expertise and the range of
cases that our people are seeing and, of course, the NHS people
are seeing as well, so we think there is a very strong argument
for having this centre where our wounded people are actually put.
I think another interesting point about this, and one of the criticisms
that I have had regularly in the press and no doubt the Committee
have heard and read about is that one of the reasons why military
hospitals were so good is that they were, of course, full of military
people and all military patients were actually grouped together,
but, of course, we all know that military hospitals had a lot
of civilians in their hospitals as well. So there is an argument
as well—and this has come over quite strongly from the individual
service personnel—that they like to be grouped together,
which of course we can do. Although clearly there has been an
increase in the number of casualties over the last 12 months or
so, it is still, as you say, relatively low compared to other
conflicts and the numbers we have got, shall we say for want of
a better word, we spread people around to different hospitals.
We have reduced our ability to group enough numbers to give them
that sort of feeling of being with their own comrades, and in
a way it helps their recovery. That is the advice I have been
receiving. I can say that I have not spoken to a single Service
person who has said to me that they do not feel that is the best
place for them to be and that they think the system that we are
currently employing is the one that is working for them. There
will always be issues, but I do not know whether General Lillywhite
or General Baxter want to add to that?
Lieutenant-General Baxter: To
take the popularity or otherwise of Birmingham, the last bunch
of student nurses I talked to about ten days ago seemed pretty
happy with the experience they had had—either ones that
are there or ones that have recently come out six months ago.
We are not putting everybody at Birmingham, is another point.
We have always had to balance the business of having too many
people in one place; you then deploy them and create a bit of
a problem for the local trust. So we have always had to balance
where we put surgeons and other specialists around the country
so that we do not create an issue for the NHS getting them to
the right place so that they can get their expertise. Our Minister
has talked about bringing military casualties together—and
I think CGS has been pretty strong on this one—so they support
each other in the healing process, typically 15 at any one time,
I think, in the ward, there or thereabouts. The general statistics
are there but around about 15. If we were then to scatter them
in too many places, we would destroy that mutual support. So there
is always a complex balancing, of not creating an issue for the
NHS and allowing ourselves to bring those patients together. General
Louis talked about that feedback loop into operational theatre.
If we started scattering patients around the place, that again
would create an issue. I do not know if you want to talk about
your initiatives in military medicine.
Lieutenant-General Lillywhite:
I think, first of all, it is worth remembering two of the important
criteria as to why we chose Birmingham. Those two criteria were
that there was a strong relationship between a hospital and a
university, and at the time, of course, the Peninsular University
did not exist. The second criterion was that it ought to be in
a conurbation because that would give us the opportunity to spread
out in a local way should the number of casualties exceed the
capability of whatever it was that we chose. It was also a competitive
process, and the three that actually arrived on the short-list
were Newcastle, Birmingham and Guy's and St Thomas'—all
from conurbations—and Birmingham won and won actually by
a significant margin. That is the first point I would make. Those
are the reasons why we have chosen Birmingham. The second thing
is, in terms of concentrating casualties, although the number
of casualties is significant, we actually need that number in
one place to actually improve the quality. We are learning all
the time from the casualties, just as in the Royal Victoria in
the early seventies we were learning as the result of the new
type of injuries we were seeing at that time. The type of injuries
we are seeing in Birmingham are not seen anywhere else Europe
at all or, standfast Landstuhl in Germany that the Americans have.
These are different from every other casualty. They are casualties
that do not survive in civilian life. We need to actually build
up our expertise in continuing that survival and the quality of
the subsequent outcome, and we need to concentrate that in one
area to actually help develop that. So, that is why Birmingham.
Mr Bradshaw: May I add two other
things, Chairman, the proximity of Brize Norton, the relative
ease with Birmingham being central so that it is easier for relatives
to visit. It is no disrespect at all to the excellent services
provided at Derriford and its hospital, I know very well, but
all chief executives want to increase the number of patients they
treat because they are now paid to do so by Payment by Results.
Q408 Linda Gilroy: Can I make a further
observation on that? That is that that decision was taken some
time ago. There has been a report on trauma services in the National
Health Service in recent days and a recommendation there that
there is a need to significantly improve that under, I think it
was, NCEPOD, who were looking at that for the Health Service.
I just think it would be a pity to not consider the way in which
the National Health Service is evolving. The point would be not
to do something for the sake of it but for the quality of traumatic
services to benefit in the Armed Services as well as in the National
Health Service.
Derek Twigg: We are not just saying
that. You can rest assured we will always keep this thing under
review. You know yourself in medicine and health things are always
evolving and developing and I think, based on the current advice
and situation that we have got, we believe that the current approach
in terms of centring it at Birmingham is the one that is in the
best interests of our injured Service personnel and their families.
Lieutenant-General Lillywhite:
Could I add a different point. It is absolutely right that those
lessons that we are learning on operations should be taken account
of in the civilian area. Myself and certainly my US colleagues
both believe that the lessons we are learning are directly applicable
to civilian trauma management. In fact, I had a meeting with the
new Chief Executive of the Medical Research Council only two weeks
ago, and I am due to meet with him in a small group in the near
future to actually identify how we can exploit the lessons we
are learning on operations for the civilian environment.
Chairman: That is helpful, because
that answers one of the other questions that we were going to
come on to.
Q409 Mr Jones: Can I retrace the
Chairman's comments in terms of being impressed. Certainly when
I went to Northallerton last week I was very impressed by the
people there. One of the more lurid sides of the media campaign
against Selly Oak has been about military managed wards. There
is an urban myth to some of this, which to an extent concerns
me, that even the British Legion in their submission to us are
raising issues around lack of military environment and security
of personnel. I hope in our report we do actually debunk some
of these myths good and proper. Could you just say what approach
has been made on the Military Managed Ward and how is it working
in practice?
Derek Twigg: Our intention was
to develop a much greater involvement from an ability point of
view in terms of numbers and in terms of nurses and in terms of
the welfare support. I am sure I explained before, we have got
about 39 military nurses now, we have got an RSM ward manager
in terms of managing the discipline and the Service side of things
and we have got two liaison facilities who link in with the units.
This is very important in terms of the units in Afghanistan wondering
how their mate is getting on in hospital. It is a very important
linkage they have there and they do a very important job, and,
of course, they have got a number of welfare officers, which are
not just for the injured service personnel but also very much
so for the families. Can I say a word on the families? I think
there has been significant improvement since this time last year
in terms of the reception of families and management in terms
of welfare, and accommodation is provided at Selly Oak for the
families as well. You just walk around Selly Oak now, and it is
like new. There are a lot more military people and uniforms. It
is about managing---. The overall responsibility, as Ben will
confirm, is with the NHS. The hope going to the new ward is that
we can put in an actual ward manager who would have the responsibility
on that ward for all the things that happen in that ward. That
is our intention as far as I can tell you today.
Lieutenant-General Baxter: Just
to add to that, one of issues is the nurse is there to give part
of that military flavour, but there is also patient administration:
the sort of command and control makes the patients, the battle
casualties, feel part of the military organisation, and administer
what has been called "the patient group"—the patient,
families, relatives, friends—through a very difficult time.
The appointment of a Standing Joint Commander Medical. Colonel
Chris Parker, an experienced soldier is going in there, he knows
the issue in the operational theatres, he knows what it is like
looking after soldiers. He will make sure of the command and control,
once they come into the hospital, and then go on in the care pathways,
and ensure that is done in a joined-up way. So, yes, nursing,
but there is also that piece which I call patient administration,
patient command and control, which is probably equally important.
Chairman: We have 15 questions,
many of them with subparts. We have just finished question one.
This is a comment to the Committee and to the witness. It would
be helpful if we could move in a very clipped way through our
further questions, please.
Q410 Mr Crausby: Can you tell us
how the injury profile of operational battlefield casualties has
changed over the last five years? Have you seen more serious injuries,
for example? I am sure that we all hope that this will not continue
indefinitely, but what implications does this have for the provision
generally of healthcare for Service personnel?
Lieutenant-General Lillywhite:
To summarise, body armour, in particular, has actually changed
the profile by making those casualties that would have previously
died from wounds to the centre part of the body survive. So we
are actually seeing very much more serious casualties with significant
limb and abdominal injuries that would previously have died; more
severe, more challenging, not only in terms of the anatomical
injury but the physiology and the support that is required and
the reconstruction that will be required subsequently; that is
the main change. In terms of healthcare, we have spent considerable
investment in the last two years in actually looking at what the
Israelis and the US do, looking at our own research in places
like Porton Down. We have taken the enhancements that other nations
have done, we have applied what I call due diligence to them and,
where appropriate, we have adopted them, hopefully improved upon
them and, as a result of that, as I said, we can demonstrate that
we are actually having significant additional survival. For example,
we have introduced new what are called haemostatic bandages at
the point of wounding, the Israeli bandage we have adopted at
the point of wounding, the new tourniquet we have adopted at the
point of wounding—we have changed the way that we teach
them to apply it—and that has led to significant increased
survival at the point of wounding. As far as treating subsequently,
we have introduced completely new protocols for the way that we
actually resuscitate them. We have moved away from clear fluids
to new blood products. We are actually introducing into theatre
platelets. Platelets have to be carried at a certain temperature
and have to be shaken, not stirred, the whole way during the transport
process. We are, in spite of those logistical challenges, successfully
getting them into theatre and applying them. As of this month,
we are looking at actually producing our own platelets in theatre.
So, over the last period of time, we have responded to the increased
severity of the casualty and we are seeing, as a result, significantly
increased survival.
Q411 Mr Holloway: In terms of helicopter
evacuation, are you trying to manage commanders in terms of the
level of risk they take in terms of operations they conduct on
a given day to assure that they have got sufficient cover to pick
people up in a timely fashion?
Lieutenant-General Lillywhite:
If you actually go to Afghanistan you will see marks on everybody's
maps, circles, that actually indicate when they are going beyond
available medical care, and commanders, if they are going beyond
available medical care, do take a very careful risk assessment;
but, generally speaking, all military operations are occurring
within the two hours there and back of helicopters in Afghanistan,
and we have additionally reinforced those helicopters by putting
on those helicopters consultant-led teams, so the additional distance
that previously would have taken them outside the range of medical
support we have actually mitigated by sending the team in to them.
We have taken the mountain to the casualty.
Q412 Mr Holloway: That is a very
positive change.
Lieutenant-General Lillywhite:
And we are awaiting firm evidence, but the initial evidence is
that that helicopter bourne teams are additionally significantly
contributing to survival. So survival in Afghanistan, where distances
are significantly longer, where evacuation times are longer, is
actually the same as in Iraq where distances are shorter.
Q413 Mr Crausby: I know that you
briefed the Opposition front benches and the Chairman yesterday,
but could you for the Committee briefly tell us what work is being
done in researching the possible incidence and effect of mild
traumatic brain injury? Do you have any initial impression of
how widespread the problem will be?
Lieutenant-General Lillywhite:
I think it is important that the Committee first realise what
we are talking about in terms of the public concern in the United
States which is now transported to here. The public concern is
that very minor head injuries, perhaps so minor that they do not
report to medical services in the first place, are leading to
unrecognised and undiagnosed long-term consequences. There is
actually very little concrete evidence that this is the case,
and it is the main effort of both the US and ourselves at the
present time to seek to confirm that there is, indeed, an issue.
In fact, even before the issue arose in the United Kingdom, we
had already initiated some research. So DSTL (that is our in-house
research organisation) with some of our clinicians in South Tees,
as an example, are looking for blood markers that indicate that
somebody who has been in a road traffic accident has indeed had
trauma, because we might be able to use that to actually identify
people with even more minor trauma. We have actually got work
going on in Porton Down looking at whether or not blasts alone
will cause an injury to the head. We know that blasts will cause
an injury to the head if the head bounces around, but does blast
per se cause an injury to the head other than by bouncing
it around? So we are carrying out some experiments in Porton Down
to identify whether or not that is the case. Working with King's
College that we are contracted with, we are seeking to join the
US research programme to actually do a prospective study on soldiers
that have actually been in Afghanistan and Iraq using imaging
to see whether or not we can identify whether or not there is
damage. I could go on, but I hope that gives a taste of what we
are doing.
Q414 Chairman: Thank you very much.
You will produce something more definitive towards the end of
January.
Lieutenant-General Lillywhite:
Yes. Again, as I briefed you yesterday, after discussions within
the Ministry of Defence and with the Minister we set up a small
project team in June of this year. It has given an internal interim
report to us literally a couple of weeks ago. They are due to
give a formal report on the way forward in March when they can
also exploit some of the reports that we know are due just before
then within the United States.
Derek Twigg: As I said last night,
we hope to have a solution and will keep you informed of any developments
and sensitivities.
Q415 John Smith: I want to go back
to the last question and the very impressive evidence we received
about improved survival rates. Does that, as a consequence, mean
that there is greater reliance on aftercare and through-life support,
both in the Service and after the Service? Is that generating
a large requirement for resources and are those resources being
met?
Derek Twigg: You are absolutely
right to point out that clearly a number of people are surviving
with very, very serious injuries that might not have survived
a year or two ago, maybe longer. You are absolutely right. I think
if you briefly go through the pathway, we have heard about what
happens in the field, both in the reception of the casualty back
to Selly Oak, we have heard about the standard of care there and,
of course, Headley Court—which I am sure we will get into
at some point today, but I am happy, if you want me to, to give
you a brief on that—I think is recognised as world-class
in terms of support for our injured Service personnel and the
rehabilitation they get to there and the prosthetic limbs, which
I think you have probably seen examples of, which are provided.
I am pretty confident that the care pathway there is very good
and excellent, but we always keep it under review and we always
attempt to try and improve it. What is very important is that
we have a care pathway, and we have now put in place a system
which is set back in operations all the way back down to Headley
Court and actually in some cases where people leave the service
a whole care pathway has been put in place there now. The Services
have the responsibility for managing this but I want an overview
of that system, because we hear of cases where people have fallen
through the net or not quite had the support they should have
done—whether it is through the Welfare Service or the Regimental
Association, the Government, we hear all sorts of arguments—so
that is very critical. In October I think we sort of put that
in place, if I remember rightly now. In addition to that, those
most seriously injured will from now on be appointed with a case
officer. Do not forget, a lot of people actually stay in service.
That is the other thing I should mention. Quite a lot of people
now stay in service and it is our intention, where that can be
done, that people stay in service, but those who actually have
to leave the Service because of their injury, there will be a
case officer appointed for each individual and they will follow
their progress and deal with all the issues that might come around,
whether it is housing, welfare, support, healthcare, et cetera,
for a two-year period after they leave and longer if that is deemed
necessary. That has only just been put in place. I think that
will give us extra support and comfort to try and stop some people
falling through the net. In terms of the compensation scheme,
I am not sure how much you are going to go into that, Chairman,
but clearly we have a compensation scheme in place. It is different
from the previous compensation scheme because it now pays compensation
in service, it did not before, and, of course, you get a guaranteed
income payment which for the more seriously injured people is
several hundreds of thousands of pounds during a lifetime. There
are always ways we can improve it. I think we have looked for
where the weaknesses have been. That is why these care pathways
are very important and why the case officer situation is very
important, and also making sure that records actually follow people
and people have the information to make the decisions at that
time and at the right time.
Lieutenant-General Lillywhite:
Again, briefly, we also have a responsibility to ensure that the
quality of survival is improved. Now that we are quite clear that
we are saving those people who can be saved, our main effort is
starting to switch to see whether or not we can improve the quality
of the outcome. That was one of the reasons for my visit that
I mentioned before and my discussions with the Chief Executive
of the Medical Research Council as to what other resources in
the United Kingdom can be brought to bear on improving the quality
of survival which will reduce the requirement for aftercare or
reduced dependency.
Derek Twigg: In connection with
that, Chairman, I did forget something. I think it is quite important.
There might be an issue where you get these standard prosthetic
limbs that are provided by Headley Court. What happens when they
leave in terms of what might be provided by the NHS? We are currently
working with a number of trusts around the country to see whether
we can find a specialism to actually provide the same standard
of limbs for the people who have been through Headley Court, and
I think that would be a very important step forward.
Q416 Mr Hamilton: Chairman, first
of all, can I apologise for being late. I was speaking in Westminster
Hall. If we are taking consultants to the front, so to speak,
most of the consultants are Territorial Army. Does that mean there
is an increased amount of training required to take them to the
front and does that balance have to be balanced out about the
potential danger of coming forward?
Lieutenant-General Baxter: First
of all, the decision on how you go forward is a tactical decision.
Clearly, the situation on the ground will dictate how you go about
it. In terms of training, the medical staff are given the essential
military skills during their call-up, if they are reservists,
but equally if they have been working in an NHS trust they are
given the top-up training before they deploy. Part of the way
we deploy and the way we use aircraft, particularly using the
larger Chinook aircraft, when they go, depending on the commander's
decision, they will have a close protection team with them, they
will have explosives ordnance disposal with them on the aircraft.
They, the medical staff, will be busy looking at the patient.
We want to take away any distraction for the medical staff, but
they do get those essential survival skills.
Lieutenant-General Lillywhite:
If I could add, talking about the risk, I was at a meeting last
week where a lot of uniformed personnel were present that actually
did this job and there was a discussion about the risk that they
were actually subjected to. They all accepted that it was an appropriate
and reasonable risk given the actual effect that they were having
on the patient.
Q417 Mr Hancock: Minister, you raised
the issue of Headley Court, and I think that anyone who has witnessed
what they do and has spoken to people who have been there are
mightily impressed with the facility and the outcomes and the
terrific work they have done. What forward planning have you done
in terms of the anticipated workload falling on Headley Court,
with the possibility that we will maintain the high tempo of activity
that we have at the present time?
Derek Twigg: We have roughly about
40 in-patients at Headley Court at any one time in the current
circumstances. We could actually go to around 60. We do have a
surge capacity in terms of the Regional Rehabilitation Units and
a possibility with one or two hospital trusts around the country
as well, so we are looking at that planning. We are currently
undergoing a review, both in terms of the future needs that we
see at Headley Court, which will be very important in terms of
the development of it for the future, and we have been in discussions
with Mole Valley Council about that process, because obviously
it is an old building, and we have also had discussions about
the facilities we provide. As you know, we spent about £1.7
million recently on a new extension, which is not the prettiest
extension in terms of building but it is very fit for purpose
in terms of the facilities and the capacity it gives us now. So
there is lot of planning work, on which we will report earlier
next year, in terms of the future on that. At this stage we anticipate
being able to deal with any demands, but we do want to look at
the longer, short to medium term future in terms of any developments
that need to take place at Headley Court.
Q418 Mr Hancock: Are you looking
at a re-arrangement of the finances of Headley Court from the
MoD and charitable funding to support it?
Derek Twigg: No, we are not looking
at any re-arrangement. I suspect you are getting at this issue
around the swimming pools and other issues. I am glad you have
raised that. The issue around Headley Court, because, do not forget,
we do not actually own it, it is owned by a trust, which I think
is lost on the press quite a lot, and it is a very important partnership
that we have with the trust there. In terms of medical facilities—the
people, the clinicians—that is paid for by the MoD. There
has always been a history within the Ministry of Defence, and
it goes across health generally and education in terms of charitable
involvement. It has always been the case in terms of health generally,
and I do not think there is anything wrong where someone says
to you, "Can we do something that would be good to help improve
or provide additional facilities?", and that is exactly what
has happened in terms of this issue around the swimming pool.
As you know, we already have a rehab pool and that is used well
and is very important; so we welcome the partnership with the
charitable sector. All the Service charities are very important
to us and we have a very good partnership, and, no, there is no
move to change our priority and commitment to providing the best
possible clinical and medical services for our injured services
personnel.
Q419 Mr Hancock: Are we going to
put more resources in to improve the hydro-facilities there? We
have been told that some of the personnel there have to go outside
of the centre for that facility because there is not the capacity
there.
Derek Twigg: First of all, there
is not an issue of a waiting list to go into that pool. There
is not. It is obviously a very heated pool, as you know, and it
is not necessarily the right one for those with cardiovascular
type issues, and that is why sometimes we take people out to the
pool in Leatherhead. As part of the review that is taking place
all these issues will be looked at in terms of what our future
needs are at Headley Court, and clearly I cannot predict what
the actual costs will be at this point in time, we need to wait
and see what the report is, but we are absolutely committed to
providing the best possible service.
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