Examination of Witnesses (Questions 440-459)
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
Q440 Willie Rennie: Turning to the
issue of active Service personnel and the service that is provided
for them, the Royal College of Psychiatrists have said that the
service is "okay ... but not great" and it is "stretched".
Can you respond to that and is it adequately staffed? If not,
what are you going to do to address the problem?
Derek Twigg: I have seen no evidence
to say that it is not and that we are not working there in the
best possible way, and I will ask the medics to come in and say
something in a minute. If you look at what is provided in terms
of the pre- and post-deployment briefings for personnel who go
into operations, the fact that we have a psychiatric nursing team
and a consultant out there, often embedded with people so that
they are visible, because this is a stigma issue we are dealing
with, it is, I believe, working very well. I have seen no evidence
to suggest that it is not and I think it is a tremendous service
that is provided. In terms of decompression, although there is
apparently nothing anywhere, and the two generals will correct
me if I am wrong, that says that decompression actually works,
everyone thinks it is a very good idea. In the old days where
you might spend a few months coming home, whether you were in
the Second World War or elsewhere, on a ship for a long time,
has of course gone in the main now, and the classic is Falklands
veterans telling me about their time coming back on the Canberra
from the Falklands, whereas now it is a matter of days and you
are back. Talking to a number of Service personnel, some people
think it is a very good idea and some are not so sure; they just
want to get back home quickly, but all your instincts tell you
it is a good thing to do. Of course, the TRIM system, which stands
for trauma risk management, which the Marines introduced during
their tour this year and is a sort of a buddy system led by warrant
officers in terms of talking through their issues or concerns
with each other, seems to be (and again we have no evidence for
this) working well and the I think the Army are adopting that
too. Back here in this country, of course, we have the Departments
of Community Mental Health to which Service personnel who need
to go there can be referred and treated. There are, of course,
also briefings provided for the families on issues that they may
need to look for, and, of course, we have a contract with Priory
in terms of those who need to be in-patients. We are always going
to look at how to improve these things but I think there is a
significant amount of resource in place and an approach which
I think is a good approach.
Q441 Linda Gilroy: On the Priory
Group, can you tell the Committee why it was decided to put that
responsibility for in-service patients out to private contract
and how the contract is performing?
Derek Twigg: It is supposed to
get our people quicker treatment for those who need that type
of treatment. We have a liaison officer who goes there regularly
and sits in on meetings and discussions, and we believe that is
working well. We have no evidence that that is not the case.
Lieutenant-General Baxter: We
wanted somebody who had a joined-up regional, across-the-UK footprint
that could then tie in with the Departments of Community Mental
Health that also have a regional footprint, and the key to making
the Priory contract work is a very close relationship between
the mental health nurse or whoever in the Department of Community
Mental Health interacting with the local bit of the Priory to
make sure that people do not just end up lurking in the Priory.
What we do in the Priory is stabilise the patient and then get
them back into the community where it can be sorted out in a rather
better way.
Q442 Linda Gilroy: Those are fairly
sound reasons but how do you respond to the criticisms that have
been made that they are not experts or specialists in the field,
or they have not been, and that it would be better to be able
to refer it to people who have got military experience?
Lieutenant-General Baxter: The
whole point is that the Department of Community Mental Health
person has expertise and we have military psychiatrists there
and the Priory produces an environment which is stabilising.
Q443 Linda Gilroy: So it is taking
on the contract, they have developed the expertise or had people
embedded with them who—
Lieutenant-General Lillywhite:
Staying with the Priory contract, it was not put out to a private
organisation. There was an invitation for people to bid for it
and it was the Priory that won the contract. The treatment of
our mentally ill in a hospital, any hospital, is the exception.
The intention is only to put into hospitals the minority for as
short a time as possible, and we keep (for want of a better term)
control of that with the military in-reach team that comes from
the community.
Q444 Linda Gilroy: So does that also
deal with the other criticism that has been levied, that there
is a danger that the private sector has a financial incentive
to keep someone in as an in-patient for as long as possible?
Lieutenant-General Baxter: I have
a financial incentive to get them out and I have a redoubtable
Air Commodore sitting behind me who is my sheepdog in doing this.
Derek Twigg: Again, the fact that
we do have people liaising with them and looking at the case is
very important.
Lieutenant-General Lillywhite:
Chairman, could I just make an observation on mental health generally?
I have a personal interest in mental health as a couple of years
ago I spent a whole day being cross-examined in the Royal Courts
of Justice on how we had managed it over the last decade and since
then I have kept a very close eye on how we deal with it. I think
I can say that the quality of the mental health services that
we provide has always been good. There has, however, been an issue
in people coming forward. Soldiers like to be seen to be robust
as well as being robust and yes, that is also an issue with physical
illness as well as mental illness in coming forward. We are overcoming
that, I think, significantly now and individuals now present when
they have concerns, and, quite rightly, they present even when
those concerns are relatively minor. We need to differentiate
between those who are coming forward and saying, "I think
I might have a problem", and those that are eventually diagnosed
as having a problem, and I think that that is what we are seeing
both in our community mental health units where we are getting
a greater number of people coming forward, which is a good thing
from my perspective, but also it may explain why Combat Stress
are getting more calls themselves, because I think individuals
are contacting them with concerns. Unfortunately, Combat Stress
has not been able to tell me—I do not think they have the
data—how many of those calls are from people who have what
would finally be diagnosed as mental illness as opposed to the
concern of the healthy.
Q445 Willie Rennie: The principle
that underpins the Priory Group contract seems to be completely
different from the principle that underpins Selly Oak and the
MDHUs where you are trying to centralise for the specialism, whereas
with the Priory Group you are trying to localise, to keep in touch
with the local placements. Could you explain why there is a difference?
Derek Twigg: In terms of the topic,
it is the same approach as the NHS in terms of the community-type
medicines, that they are more localised in having the institutions
that we had a number of years ago, so actually it is fitting with
what we consider to be, in terms of mental health, the best medical
practice.
Q446 Willie Rennie: Is the Priory
Group not the specialist in this regard?
Derek Twigg: They have places
around the country so we can try and get people as locally knitted
as possible in terms of mental health.
Q447 Willie Rennie: But even so you
are not creating a military environment which you were trying
to do at Selly Oak.
Lieutenant-General Baxter: We
do not want them to be in the Priory for a nanosecond longer than
they have to be. The best place is to be alongside the regiment,
the battalion, with the Department of Community Mental Health
producing the expert support. That is the ideal, to treat them
there. We make them feel as normal as possible as early as possible
rather than keeping them together and they are all feeling bonkers
together. I am sorry; I am not sure how that will translate down
the line.
Q448 Chairman: It is a medical term.
Lieutenant-General Baxter: It
is getting people into that military flavour and obviously it
is a different dynamic from physically injured patients where
for clinical reasons they have to be in a hospital environment.
Q449 Chairman: You have caused the
Health Minister to wince.
Mr Bradshaw: It is so refreshing
to know that political correctness is alive and well in the military.
Lieutenant-General Lillywhite:
Could I incite the clinical difference? Both on operations and
in peace for people with mental health you do not evacuate unless
it is absolutely essential. You try and treat them in the environment
which is supportive, which is normal. You want to normalise them,
so sending them somewhere miles away is wrong. That is why we
closed Catterick, because that is what we were doing. That is
why the people on the ground in Germany have closed Wegberg because
even the people on the ground think it is wrong to try and send
people a long way. For your combat casualties you evacuate, and
in the case of the combat casualties we are having at the moment
they are different from any other casualty in the United Kingdom,
so we need to centralise those to learn from it.
Q450 Linda Gilroy: Except, I really
do think Mr Rennie is right, that there is a balance to be struck
and it is really not quite as black and white as that because
the battlefield casualties, where traumatic stress is being dealt
with very well at Selly Oak, also have stress dimensions to them,
and there is also the question of the families, and while I would
not quarrel at all with the fact that people are not going to
complain when you visit because they are receiving marvellous
care, whether that is the very best that can be done in future
I think is something worth keeping under review. Families do have
issues travelling to Selly Oak from the extremities, from the
far south west and from Scotland, where it may be possible to
blend those two things together once Selly Oak is established
on its course of excellence.
Mr Bradshaw: I think this mental
health issue is the most complex issue that we face in this and
you probably face in your investigation. Just to support what
Derek has said, what they are doing in the military does reflect
what is happening in the civilian treatment of mental health as
well in that we are moving away from centralised institutional
care. Yes, there needs to be centralised care for the kind of
trauma that Linda has just spoken about but the ongoing mental
health care is much better provided in the community.
Q451 Chairman: Professor Appleby,
I saw you nodding there and you should be allowed to say something.
Is there anything you would like to add to what has been said
on this?
Professor Appleby: From an NHS
perspective the model that is being described is very much in
line with current service provision. The modern idea of providing
mental health care is that it is primarily community-based, that
small in-patient units provide back-up of a very specialist kind
linked to what is then provided in the community. It seems to
me from what I know of the MoD version of mental health care that
it is very much in line with those NHS principles.
Q452 Chairman: But does not an issue
arise here with the fact that the community as a whole has no
experience of military service and therefore these people being
treated in the community do not understand the community that
is surrounding them in which they are being treated?
Professor Appleby: Do you mean
once people are discharged back into NHS services?
Q453 Chairman: Or when they are getting
out-patient Priory care.
Professor Appleby: I will have
to talk about NHS services which are my remit. I think that is
an issue, that absolutely is an issue. It is one that I think
in the last few years the NHS has been much more aware of. I do
not think we were having the kind of discussion a few years ago
that we are having now about the military experience of mental
health staff. It was not taking place in the way it is now, and
the new pilots reflect that because the new pilots are an attempt
to combine the best of what NHS mental health care provides with
military experience and expertise.
Derek Twigg: I think it is very
important to make the point because in terms of our Departments
of Community Mental Health that was militarily divided and it
is the Priory contract which obviously does not have --- actually,
there will be a few people who work in Priory who have had some
military experience. I could not give you the numbers on that,
but it is our liaison with them to talk about that and that is
again the key thing which Professor Appleby mentioned in terms
of the new pilots giving a better understanding of the military
ethos and the issues that arise from military service.
Q454 Mr Holloway: Thinking about
the future, we have got Armed Forces that are now working way
beyond the planning assumptions. We have got many thousands of
people working in the private security industry for British citizens,
normally ex-soldiers who are in these environments for a very
long time and often at more risk than serving Servicemen. Is the
NHS ready to be hit by a bow wave in ten, 15, 20 years' time?
Mr Bradshaw: I think, as we have
already acknowledged, that there is still work to be done on the
culture and the receptiveness of mental health services in the
NHS to the particular needs of the client groups that you have
just described and that is why we are supporting these pilots
and we will be very interested to see how they develop. In terms
of capacity, there has been an enormous expansion of NHS mental
health services since 2003, 31% in real terms, and the Secretary
of State recently announced another £170 million for psychological
therapies, so this is a rapidly expanding service which I think
most fair-minded observers would accept has transformed the quality
of mental health services in recent years, and that capacity will
continue to increase.
Q455 Mr Holloway: What does Professor
Appleby think on that specific point of a bow wave coming from
these two different groups?
Professor Appleby: The answer
is in the two things we were talking about, first of all improving
the understanding of some of the experiences that ex-Servicemen
will have faced so that the NHS as a whole has a greater capacity,
a greater knowledge, which will help it provide better care, and
the second thing is the psychological therapies work which Ben
Bradshaw has just referred to. This is a major initiative for
us in mental health care, probably the biggest and most ambitious
change in mental health services of the last seven or eight years,
maybe one or two of the biggest since the NHS was set up to run
mental health services, and it is there to acknowledge that if
you are going to improve the mental health needs of the community
you have to provide better psychological therapies, you have to
provide better primary care. Most of the conditions which are
likely to affect people who have been servicemen and who report
some years later are going to be depression, anxiety, sometimes
PTSD, although that is not at all the most common diagnosis, and
all of those things are primarily treated through psychological
therapies. That capacity to treat people with psychological therapies
has not previously been enough and this new initiative is an acknowledgement
of that and a massive expansion of what we can achieve.
Q456 Mr Hancock: If I can just go
back to the primary contract, is that cash limited, ie, are there
people waiting for a place in the Priory because there is insufficient
money to fund their places?
Lieutenant-General Baxter: Not
to the best of my knowledge.
Derek Twigg: Not that I am aware
of, no.
Q457 Mr Hancock: What is the success
rate of the Priory for when Service personnel go there? Have you
got information relating to the numbers who have returned to active
service having completed their treatment?
Lieutenant-General Baxter: There
is a crude figure, and I will get prodded in the back if I am
saying the wrong thing early on, of a grand total of about 7,500
who present with some sort of symptom. We heard of about 150 being
discharged, which implies that there is a large number of people
being returned to productive, active military life.
Q458 Mr Hancock: It would be helpful
if the Committee could have some information about the throughput
in the Priory and the discharge numbers of Service personnel who
have completed a course there but have not returned to Service
duties and have left the Armed Forces. 3
Lieutenant-General Lillywhite:
It is important to recognise that only the most seriously ill
go to the Priory.
3 See Ev 153.
Q459 Mr Hancock: Yes, I can understand
that.
Lieutenant-General Lillywhite:
What we do at the moment is certainly measure the outcome of the
whole system, with the mainstay, of course, being the military
DCMHs. They are the teams that are responsible for the care. The
overall majority, a significant majority, all return to work but
we can find out the proportion that have gone into the Priory
that return to work. I do not have that immediately to hand.
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