Examination of Witnesses (Questions 460-479)
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
Q460 Mr Hancock: Can I raise one
issue about veterans, many of whom, sadly, end up homeless, and
the statistics say that at any one time a thousand ex-Servicemen
are on the streets of London homeless and a number in prison,
many of them suffering from mental illness problems, and whether
or not they are getting the right sort of treatment and assistance.
Can you address those issues?
Derek Twigg: Yes, sure. In terms
of the last study that was done a few years ago, there was a drop
in the number of homeless on the streets of London. I have asked
for some further work to be done on this in terms of the current
numbers but there is no indication that that has increased but
we do not know is the latest because the previous survey was a
few years ago now. There are a number of projects around which
are particularly important in terms of in North Yorkshire, at
Colchester and at Catterick in terms of accommodation for single
Service persons coming out of the Forces. There is also the Compass
Project where the British Legion do a great job with us in terms
of getting people who have been homeless back into the mainstream,
giving them good accommodation and the potential to get back into
work. There is a lot of work going on in a number of projects
around the piece. In terms of the Prison Service, I think it is
a very important point you make. There is a study taking place
in Dartmoor at the moment, which clearly we will share with you
when that is completed, in terms of the numbers of ex-Service
personnel who are now prisoners. I have written to the Department
of Justice to offer the help of Dr Ian Palmer, our person across
there in St Thomas's Hospital, because we have to be asked in
because it is provision within the NHS and they might want to
say something about this. If he can help either via the GPs or
missions and also visiting prisoners if that is required, he would
be available to do that. We are taking a number of initiatives
around the Prison Service.
Q461 Mr Hancock: Are you given any
information when a prisoner arrives into a prison that they have
a veteran status and your department is informed?
Derek Twigg: Prison is within
the NHS. I am not passing the buck but it is the NHS. They could
have left the Service many years ago or recently or whatever.
Q462 Mr Hancock: Yes, I know, but
as you are the Minister for Veterans I am interested to know whether
there is a mechanism for the Department of Justice triggering
the fact that there is another ex-Serviceman about to enter prison
and is there a tracking mechanism to assist them in any way?
Derek Twigg: Not that I am aware
of.
Q463 Mr Hamilton: In answer to Adam's
question about a bow wave coming, one of the problems may be,
of course, that this will be dealt with in different ways depending
which country you are living in because of the different health
authorities. How would you deal with that, and could I suggest
that one of the issues might be a greater use of the ex-Services
clubs which are not just social clubs; they are far bigger organisations?
I take the point that you made earlier on about many of the troops
being macho in the sense that they do not want to admit they have
a problem. My concern is that as they come out of the Armed Forces
and move back into society in general they do not have the comradeship
that they normally have. One of the places they do have that comradeship
is in the Legions throughout the UK. It is a suggestion, Chairman,
that we could utilise the Legions in a far greater way to assist
us in that long-term mission.
Derek Twigg: We work very closely
with the British Legion, as I say. I will just give you an example.
In my own constituency the British Legion club has done some sterling
work with veterans who have come out in recent conflicts.
Q464 Mr Holloway: There is a tiny
comment here. The Data Protection Act is causing a real problem
for these veterans' organisations because whenever they want to
get details of people, if they have not signed the thing to join
these organisations as they leave the military, these organisations
have no way of finding them.
Derek Twigg: That is resolved
now. They get information in the leavers' pack for the five main
charities.
Q465 Mr Holloway: Yes, that is what
I was alluding to, but if they do not do that it is very hard.
Derek Twigg: That is what we have
asked, but they seem to be content with that.
Q466 Robert Key: Could we focus specifically
on Combat Stress? I know the Minister, Derek Twigg, has been to
Combat Stress in Leatherhead and some of us have as well, and
a very fine job they are doing, but Combat Stress tell us that
the demands placed on their services are far outstripping their
ability to meet them. It is the usual balance—voluntary
sector, state funding. Could you tell us how much money Combat
Stress is getting from the taxpayer and whether it is all coming
from the Ministry of Defence or whether the Department of Health
is also funding it?
Derek Twigg: No. We were funding
Combat Stress to the tune last year of £2.5 million, I think,
and we are just gong to increase the overall amount in stages
to 1 January next year by 45% on top of that. That will help them
develop their clinical governance and the ability to deploy more
clinicians and practitioners in terms of their general support
to the veterans. It is very important that you understand that
of course we have a very close relationship with Combat Stress,
and you are right, I have been to see Tyrwhitt House but also
up to Hollybush House in Scotland as well and hope to visit Shropshire
some time in the near future. Actually, the Shropshire one is
very important if I may pause there for a minute. The whole purpose
of the new pilots is to look at the whole holistic approach here
and they are key partners. It is not just between ourselves and
the NHS; it is also Combat Stress, and they are working with us
to set up a system whereby we can refer people there and they
can refer people to the NHS, and I think that will set a very
good grounding for the future provision of services for veterans
in this area.
Lieutenant-General Lillywhite:
I think it is important to recognise that Combat Stress, under
some pressure from us, is actually reviewing how they are treating
those of their clients. They have previously been a kind of respite
home rather than a treatment centre. They have just appointed
their medical director which they did not have before. They are
working, as the Minister said, with us in terms of the pilots.
I think there will be an issue in the longer term as to the balance
between the community and how many go into the Combat Stress homes
that may relieve the pressure on the homes that Combat Stress
are saying they have.
Chairman: We will now move on
to MoD funding and healthcare services overseas.
Q467 Robert Key: The funding the
MoD provides for healthcare for Service families overseas simply
has not kept pace with the increase in funding in the NHS. NHS
spending has increased dramatically. Why has Defence Medical Services
spending not matched that? Why is it lagging behind?
Derek Twigg: We recognise that
is the case, that we have not matched it. As you know, our funding
comes directly as part of our overall settlement. We provide health
services and that is something we are working on at the moment
and having discussions with the Department of Health on and how
we can continue to improve that with initiatives that are being
taken, but it is the case that we have not at this stage been
able to keep pace with the National Health spending and that is
something we are working on at the moment and having discussions
about.
Q468 Robert Key: With the Treasury?
Derek Twigg: It is part of our
bid. We will put the bid in for that.
Q469 Robert Key: Can you go on affording
the Princess Mary Hospital in Cyprus and the Royal Naval Hospital
in Gibraltar?
Derek Twigg: As you are aware,
because I think the Committee visited Cyprus, we are looking at
the whole issue in terms of the provision of health services in
the likes of Gibraltar and Cyprus, and obstetrics and gynaecology
of course have been looked at. We have had the Royal College look
at that and they have endorsed our approach to looking at how
we can provide through a local provider the services for our people
out there, and that could be through the sort of contract we have
currently with Guy's and St Thomas's. They have endorsed that
approach and work is ongoing on that to bring about those improvements
we want to see.
Q470 Robert Key: Can I ask very specifically
about IVF services? The memorandum we have received from the Department
of Health points out that now, if a soldier and his spouse are
moved from one end of the country to the other, there is an arrangement
between the primary care trust to pay for it, but if a Service
family is moved from Britain to Cyprus or Germany there is still
a break and it still depends on the PCT, on bargaining between
the Ministry of Defence and PCTs, as to whether a course of IVF
treatment can be continued or whether in fact it will just fizzle
out, and that is causing great distress to some people.
Derek Twigg: You are right: there
should be in terms of the UK no change in terms of the waiting
list position and they should continue with the treatment. In
terms of people moving elsewhere, I would very much hope and what
should happen is that the regiment or the unit should be very
sympathetic to not moving people while that treatment is ongoing.
I cannot give you an absolute guarantee that that is happening
but that is certainly my view about what should happen and that
generally is the picture as I understand it.
Q471 Robert Key: It is a reassuring
view, Chairman, but the fact is that you cannot necessarily hold
up the posting of Service personnel because their wife is receiving
treatment.
Derek Twigg: We can. I would expect
the Services to be very sympathetic to doing that. Clearly, there
may be on some occasions a real practical reason why that would
not happen and we would have to look at that in an individual
case but certainly that is how I would expect the system to work.
Lieutenant-General Baxter: As
a brigade commander, one of the things is a couple coming forward
and saying, "This is our situation and we would like to do
it". The chain of command can be a bit scary sometimes, but
certainly in my time as a brigade commander about two or three
came up and we said, "Okay, stay put". That is anecdotal.
Derek Twigg: We need to make sure
that people actually do have the confidence to do that.
Chairman: We come to the final
set of questions on Reserve personnel.
Q472 Willie Rennie: Do you not think
that the MoD should be worried that the Defence Medical Services
are so reliant on Reserve personnel? Is there any way of reducing
this reliance?
Derek Twigg: As you know, we published
a few months ago the new manning structure and we are round about
90% now in terms of our requirements, but of course we have used
and we will continue to use Reservists. They play an absolutely
essential part in that. While we continue to bring about and make
improvements in terms of recruitment with all sorts of initiatives
and retention mechanisms we will continue to rely on Reservists
for some time into the future. Having said that, I think it is
also very important from the Reservists' point of view that they
get the chance to go and practise what they joined up for in the
first place. I know from having been out to the field hospitals
in Iraq and Afghanistan that the expertise and challenge they
have had there are something that they have widely welcomed, and,
of course, as one Reservist said recently, "I have had more
opportunity to practise my skills on trauma here than I have had
in my whole career in the NHS", and that will benefit the
NHS as well. We recognise that we have got pressure points, we
recognise that we are increasingly using Reservists, but I think
there are many benefits to doing that as well.
Lieutenant-General Lillywhite:
In terms of reducing reliance on the Reservists, it is important
to stress that our manning position is significantly improving.
Just to use one example, anaesthetists, in 2002 we only had 20
of them. We have got 45 today. Because they are in training now
we know we are going to have 71 by 2012, against a requirement,
admittedly, of 95, but manning is increasing. In some areas like
orthopaedics by 2012 we will be slightly over our requirement.
That, of course, will automatically reduce the reliance on the
Reserves, if we are working within DPAs. Clearly we want the Reserves
on operations with us for two reasons: one, when we are working
in advance of DPAs. For anything other than—
Q473 Chairman: Do you mean planning
assumptions?
Lieutenant-General Lillywhite:
My apologies—defence planning assumptions, when we are working
at the higher scale, when you need more forces, but it is important
that we use the Reserves anyway because that is actually why they
joined the Reserves. We are seeing an increasing number come into
the Reserves in order that they may deploy and if we do not use
them in a sense we will lose them.
Q474 Mr Hancock: One of the interesting
things, visiting the MDHU in Portsmouth, was the non-show of any
Reserve Forces for us now in the MDHUs, and that is the largest
one in the country. I would have thought there was an advantage
from time to time in that Reserve personnel would have been brought
in to the MDHUs to help their problems of when a third of their
staff might at any one time be on deployment or awaiting deployment
to a theatre. Is that a conscious decision you make, not to call
Reservists in to backfill?
Lieutenant-General Baxter: There
is an interesting point in another set of disciplines. When Reservists
were called up to man the Base end, I think it was in Marchwood,
and the regulars went out. Reservists were called up and went
to do the Base. That really was not quite as satisfying as going
on operations. People, Reservists wanted to go to theatre, that
is why they joined up, so it is a careful managing human expectation
piece here, and I think if we said, "Join the Reserves and
you will have a thrilling trip from Northallerton to Portsmouth"—
Mr Hancock: Oh, come on, General.
They would love the opportunity.
Q475 Willie Rennie: How do you manage
your workforce demands and needs for the various hospitals and
local health services when there are perhaps large numbers of
Reserve personnel going out to theatre? How do NHS managers manage
that and is there central guidance?
Mr Bradshaw: There is guidance
that the NHS should facilitate on the duties that Reservists have
to undertake. Workforce planning is left to individual trusts
under the Strategic Health Authorities, but one of the things
that ought to help and may already have helped, in the case of
anaesthetists, the military meet some of these capacity challenges
is the fact that we are training more medical staff and doctors
than ever before. We have expanded the number of medical training
places, we have opened two new medical schools, so whereas in
the past the NHS itself was short of quite a number of specialities
that is now no longer the case and that should have a positive
knock-on impact on the Defence Medical Services as well. There
is just one thing that Mr Key said. I would not want the Committee
to go away with the impression that because the Health Service
has had a good settlement in spending terms in recent years, perhaps
an even better one than the MoD, that means that Armed Services
personnel are receiving a worse service. He pointed to one particular
example of IVF, which I think we all accept is a challenge for
the Services, but for the vast majority of procedures waits are
significantly less for Armed Service personnel than they are for
ordinary civilians.
Lieutenant-General Lillywhite:
Could I just assist in terms of the impact on the NHS? About four
or five years ago we did actually do a proper study into looking
at what would happen if we mobilised two Reserve field hospitals,
and the impact upon the NHS is quite small. The proportion that
we draw from the NHS is a very low percentage, one or two per
cent. I cannot remember the exact figure. Only with a couple of
particular individuals where they were quite key to the trust
did there appear to be a significant impact upon the NHS and it
was felt by the NHS that they could manage that given a little
bit of time and some leeway.
Mr Cash: In the six MDHUs there
is a question of co-ordination to make sure that the Reserve medical
hospital does not go out at the same time as MDHU staff and get
deployed; that is an obvious point, but in the Partnership Board,
which is the work between the MoD and DH, one of our three priority
areas now is workforce and this whole issue and how we incentivise
people, how we reaffirm the message about Reservists, that employers,
NHS trusts and so on should give priority to these people, and
we are pulling all the chief executives together across different
regions to reiterate this issue of supporting people who want
to be Reservists. That is one of our work stream areas.
Q476 Willie Rennie: That is my next
point because I have suffered from discrimination against somebody
who was in the Royal Naval Reserves in my constituency from the
education authority which was refusing to let them go on training.
We have heard from the BMA that there is discrimination against
those who are Reservists within the NHS. You mentioned that there
was only 1 to 2% reliance on Reservists and therefore the impact
is small, but have you discovered discrimination against Reservists
in the NHS?
Mr Cash: Not specifically. The
issue, according to the needs of the Service, is to go away on
the 15-day camp that is required, and normally what will happen,
and we need to re-emphasise this, is that that will be absolutely
supported, normally a week's pay, the normal leave, and normally
either annual leave or unpaid leave for the second week. We have
not come across these cases. What we do need to do to make sure
the flow of workforce through to the Reserve units is maintained
is to reiterate this with chief executives and medical directors
all round the country and.
Mr Bradshaw: I would urge Reservists,
Chairman, to use the complaints procedure if they feel that their
rights are being infringed.
Q477 Chairman: You would be wholly
supportive then of Reservists continuing to work in the NHS?
Mr Bradshaw: Absolutely.
Q478 Chairman: Surgeon-General, is
there anything you want to add?
Lieutenant-General Lillywhite:
No, I do not think so.
Q479 Willie Rennie: When the Reservists
come back from deployment in theatre what kind of support is in
place within the local hospital in the NHS to make sure they are
able to acclimatise back into the normal NHS service, and what
advice is given to other health professionals when dealing with
those individuals themselves?
Mr Cash: They normally get a de-briefing
with the occupational health department within the trust or the
hospital to go through any issues they may have, and normal line
management responsibilities with their immediate line manager
to talk through any issues they may have, and there is a kind
of open line through, of course, the human resource or the personnel
director in the organisation.
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