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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 134-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE DEFENCE COMMITTEE
MEDICAL CARE FOR THE ARMED FORCES
Tuesday 27 November 2007 DEREK TWIGG MP, LIEUTENANT-GENERAL ROBERT BAXTER CBE, LIEUTENANT-GENERAL LOUIS LILLYWHITE MBE, MR BEN BRADSHAW MP, PROFESSOR LOUIS APPLEBY AND MR ANDREW CASH Evidence heard in Public Questions 372 - 493
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Defence Committee on Tuesday 27 November 2007 Members present Mr James Arbuthnot, in the Chair Mr David Crausby Linda Gilroy Mr David Hamilton Mr Mike Hancock Mr Adam Holloway Mr Brian Jenkins Mr Kevan Jones Robert Key Willie Rennie John Smith ________________ Memoranda submitted by Ministry of Defence and Department for Health
Examination of Witnesses Witnesses: Derek Twigg MP, Parliamentary Under Secretary of State for Defence, Lieutenant-General Robert Baxter CBE, Deputy Chief of the Defence Staff (Health), and Lieutenant-General Louis Lillywhite MBE QHS, Surgeon-General, Ministry of Defence, and Mr Ben Bradshaw MP, Minister of State for Health Services, Professor Louis Appleby, Mental Health Clinical Director, and Mr Andrew Cash, Co-Chair, DH/MoD Partnership Board, Department of Health, gave evidence. Q372 Chairman: Welcome. This is our fourth evidence session on the medical care for the Armed Forces and it is our final evidence session. We are taking evidence today and we are most grateful to both of the Ministers in front of us from the Ministry of Defence and the Department of Health. I think this is a first. No, it is not a first in this parliament - we had the Secretary of State for Defence and the Foreign Secretary as well - but we are most grateful to you for coming with your teams. We have done a second stage of the web forum we have been running and we have decided to extend that by one further week, and I will take this opportunity for advertising the address, which is www.parliament.uk/defcom, so I hope people will get on to it and start telling us their experiences, bad and good, of the medical care available to the Armed Forces. Ministers, normally we do not have an opening statement but, in view of the announcements that you made on Friday, we think it would be extremely helpful if you could just summarise what it was that was set out then because I am sure that those questions and those issues will run through the whole of this morning's evidence session. Which of you would like to begin? Derek Twigg: If I could say briefly, I announced on Friday the pilot schemes for mental health for veterans and these will be at six places in the country. We announced both Camden and Stafford, which are just about to get off the ground, but there will also be pilots at St Austell, Newcastle, Cardiff and at a place in Scotland as well. We are spending around £500,000 on this project in the initial stages. The pilot will last for two years. Basically, the Ministry of Defence, with our expertise through defence mental health, will be working via the veterans units as well as with the NHS providers of mental health in these locations and that will be really to enable clinicians in the Health Service to gain a better understanding of the issues around those who have served in the Armed Forces and the issues that might arise, which often impact upon their mental health. Of course, in a number of cases there will be a number of people working in the pilot areas who have served in the Forces themselves, but really to build an expertise in centres of excellence around the country in managing those with mental health who have served in the Armed Forces. As I say, this will run for about two years. I went to Camden on Friday and Stafford yesterday. There is great enthusiasm at those pilots for that and I think a very exciting project is in place there. In terms of Scotland, I am not able to say at this time exactly where that will be, but what I can say to the Committee is that discussions are on-going with the Scottish Executive. We will, of course, ensure the same funding that applies to the English and Welsh schemes as well and we look forward to getting that pilot up and running as quickly as possible. Q373 Chairman: Minister, do you want to add anything to that? Mr Bradshaw: It may be helpful if I outlined the other part of the announcement that we made on Friday, which was around extending the priority treatment to veterans. Priority treatment has existed since 1948 to those veterans who are pensioned out of the Service because of an injury or a condition that is service-related, to all veterans for any service-related condition. This was based on a system that has been up and running in the constituency of the Secretary of State for Health in Hull for some time and it will extend the priority from currently 170,000 to potentially five million veterans in the country. Would it also be helpful if I introduced my supporters? Q374 Chairman: I was going to say, now that you have set those out, would you mind very much introducing your teams? Mr Bradshaw: Not at all. On my left is Professor Louis Appleby, who is the Mental Health Clinical Director for the Department of Health, and on his left is Andrew Cash, who is the joint Chairman of the DH/MoD Partnership Board. Derek Twigg: On my right we have got General Louis Lillywhite, who is a Surgeon General, and General Robert Baxter, who heads our health services. Chairman: Thank you very much. There will be plenty of questions arising out of that, and we will go during the course of the morning into the detail of what have you said. Willie Rennie. Q375 Willie Rennie: If five million veterans suddenly came forward and demanded priority treatment, that would obviously create chaos in the system. How many people do you actually envisage coming forward and taking advantage of this service? Mr Bradshaw: The experience in Hull has not been that it has created chaos in the system. I think it will depend to start with on how well informed both the individual patients themselves are of their right but also the response of the local health communities, and we do not expect that five million people are suddenly going to come forward and that will create chaos. In fact, I believe that part of the problem that we have at the moment is not enough veterans are aware of their right to priority treatment and not enough Health Service professionals are aware that veterans have those rights. It is something that we remind the Service of on a regular basis. We do so annually, both through our operating framework and through the guidance we put out, but we would encourage veterans who think they have a condition and a right to priority service to demand that right and, if they do not get it, to complain and we believe there will be fewer problems than there might have been in the past, Mr Rennie, because, of course, waiting times for the general public have been dropping dramatically and will be 18 weeks maximum by the end of next year. Chairman: Hold on. We run the risk of getting seriously derailed onto this issue. I have Kevin Jones, Mike Hancock and Robert Key all wanting to catch my eye, but I just wonder whether it might be better for us to delay these questions on priority treatment. I am in the hands of the Committee. Mr Hancock: We need to follow it up. Chairman: We will follow it up. Robert Key: It does come later. Chairman: I have a sense from the Committee that actually you would prefer to get on with it now. Willie Rennie: I think we had better deal with it now. Chairman: Okay. Willie Rennie. Q376 Willie Rennie: From the Hull experience, how many more people came forward and, therefore, if the same as happened in Hull happened all over the country, how many people would come forward? Mr Bradshaw: I am not aware that there are any concrete figures in Hull, but I am aware that it has not caused any significant problems and it has been a very popular initiative. Q377 Mr Jones: I am concerned with what you say about Scotland, because we had a very unsatisfactory evidence session in the Scottish Parliament with the Scottish NHS who, I have to say, I think Willie Rennie, as a Scottish Member, described as embarrassing. There was no real comprehension at the head of the NHS in Scotland that veterans came anywhere special. So, one of the concerns is that that has not been pinned down, which perhaps explains how the needs of veterans and also the needs of service families is going to be more reinforced with the Scottish NHS because, I have to say, we were not impressed by what we heard. Mr Bradshaw: I am not responsible for the Health Service in Scotland. Q378 Chairman: Neither of you is. Mr Bradshaw: I am sorry; I thought that question was directed towards me. Q379 Chairman: That is the problem. Mr Bradshaw: Can I clarify? The NHS is responsible for the health services that are provided to veterans; I am responsible for the NHS in England. I understand that my Scottish counterpart has also announced that they will be giving priority treatment to all veterans. They have a different system - they do not have the 18 week target, for example - but she has announced, I believe, that they will offer priority treatment, but that is a matter for her, Chairman. 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 of 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, may be 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 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 that there will be something there that might worry the GP; he then has to request 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? 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 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, if you like, centre of excellence that has been built at Birmingham itself where there is the feedback from theatre, just generally 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, 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 that we do in that areas, and our eyes are on taking Whittington Barracks and converting that into, if you like, that 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 have 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 - so I think that is an issue. 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 you are trying to keep the numbers in the right place and, I think, General Louis can add to his objectives and improving, if you like, the knowledge-base in military medicine. 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. So there is always a complex balancing, of not creating an issue for the NHS, allowing ourselves to bring those patients together. General Louis talked about that feedback loop into theatre. If we started scattering that 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, there was not a university on the peninsular. 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 St Thomas' - all from conurbations - and Birmingham won and won actually by a significant margin. That is the first point I would make. There are 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 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 Brice 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 Dereford 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, NCEEPOD, 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 centering 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 North Allen (?) 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 RSN 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 it is also patient administration: the sort of command and control makes the patients, the battle casualties, feel part of the military organisation, administer what has been called "the patient group" - the patient, families, relatives, friends all that lot - through a very difficult time, the appointment of a standing joint commander medical. Chris Parker, an experienced soldier going in there. He knows the issue in the operational theatre, he knows what it is like looking after soldiers, to make sure of the command and control, once they come into the hospital, and then go on in the care pathways, and 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 actually. 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 haemastix 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 actually also is significantly contributing to survival. So survival in Afghanistan, where distances are significantly longer, in fact 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 area) 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 Kings 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 opt-out training before they deploy, and part of the way we deploy and the way we use aircraft, using the larger Chinook aircraft, when they go, depending on the decision, they will have a close protection team with them, they will have explosives or disposal with them on the technical thing. They will be busy looking at the patient, looking in. We want to take away any distraction, but they do get those essential survival skills and they do not worry about them. 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 Unit 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. Q420 Mr Hancock: Are the Ministry of Defence prepared to spend what is needed to bring Headley Court up to a facility where it would have on site the right facilities for these people? Derek Twigg: We are absolutely committed to providing the best possible treatment and service and care for our people. As I said, the report is going on at the moment. I do not want to pre-empt what that will say, but we are absolutely committed to doing that. Mr Bradshaw: I think there has been a slight misunderstanding about the role of the hydrotherapy pool at Headley Court. It is different from the role of a swimming pool. The temperature is different. The hydrotherapy pool is used for different sorts of complaints at different stages of complaints. It is not a question of it not being big enough or of there being too much demand, as Derek has already said. Ideally you need the use of both a hydrotherapy pool and a swimming pool. Whether you could justify having a full-time swimming pool is a matter for Headley Court. Lieutenant-General Lillywhite: When Headley Court let it out that they had difficulties with capacity we immediately provided the additional ward. They have never said to me that the arrangement they currently have with the local authority for the use of the swimming pool is inappropriate or is causing them any difficulties. Were they to do so I would, of course, consider whether or not we ought to provide one on site, but to date they have not come forward and said that the arrangements they have are sub-optimal. Q421 Chairman: With regard to the recent news of behaviour at the Leatherhead swimming pool by the local community, which I am sure we all consider to be simply disgraceful, has it ever happened before? Derek Twigg: I am personally not aware it has happened before. Clearly, we were extremely disappointed that that happened. Mole Valley Council's reaction has been absolutely superb and I think they are now up to offering free use for visiting families as well of the wounded, which I think is excellent. Q422 Chairman: Can I ask one final question on funding? Are the increased use of Headley Court, the increased demands on Headley Court and on Selly Oak and on general healthcare covered by the contingency reserve? Derek Twigg: Yes. Q423 Chairman: They are? Derek Twigg: Yes. Q424 Chairman: Thank you. We have been very impressed by the MDHUs we have visited. Would you accept that they are primarily places in which medical and nursing staff from the Defence Medical Services can be trained alongside NHS staff rather than providing secondary care for military personnel? Derek Twigg: I think the answer is both. Q425 Chairman: Are they single Service? They seem to have a strong single-Service ethos. That is what I found when I went to Frimley Park anyway, that some of the MDHUs -- Derek Twigg: I will ask the Army to answer that. Lieutenant-General Baxter: Of course, the MDHUs have a historic connection. At Derriford, with the large naval presence, you would be a bit surprised if there were lots of people in khaki round there. At Peterborough again there are the cold-war air bases, Ely Hospital, those kinds of thing. At Frimley Park, around Aldershot and up around the far reaches of South Tees there will be a natural centripetal effect to pull those in. However, all of them have a joint flavour to them. I am trying to think: is there one that does not have someone of other cloths in it? I do not think so. Q426 Chairman: I am sure. It was just that they were positively labelled, "This one is an RAF one, these three are Army ones, this one is a Naval one". Lieutenant-General Baxter: Chairman, you know how proud we are of our tribes and our tribal markets. Chairman: Indeed so. Q427 Willie Rennie: Why are there no MDHUs in Scotland, Northern Ireland or Wales, and does it not have a detrimental effect on the operational forces in those areas? Derek Twigg: I asked this question and it is basically for historic reasons. I think a lot of the MDHUs have grown up near to the military hospitals. It does not stop our Service people from getting fast-track treatment at other trusts or getting the same standard of care as someone in England, for instance; it does not affect that, but historically it has been the case. It does not mean, for instance, that Scotland will not have one. The honest answer is that we are keeping that under review, but that is the reason for it. Q428 Willie Rennie: When we visited Edinburgh some of the people were being shipped out, I think to Northallerton, to get the treatment they needed, which seemed an awful distance to travel when Edinburgh has got some excellent medical facilities. Lieutenant-General Lillywhite: Quite a lot of our military people in Scotland get treated in Scotland and all the practices have relationships with their local NHS and they use them. Clearly, if there is an advantage in going down to Northallerton they will take advantage of that advantage, so that, if I may say so, deals with Scotland. Just to clarify Northern Ireland, we still have our Musgrave Park military wing in Northern Ireland. That works in conjunction with a local hospital - it is not a trust there - and clearly, as the reorganisation in Ireland goes forward, we will keep under review how we deploy our secondary care personnel there. Q429 Mr Hamilton: Just to follow up that point, if a person goes down south for a long time are arrangements for their family to be able to come down? The second thing I want to say is that in the literature you indicate that they do receive medical attention in Scotland, it is true, but that is fragmented at present because of the working relationship they have with each of the health boards, so how do you deal with the fragmented relationship they have in Scotland? Derek Twigg: They should not in any way be unfairly treated compared to people in England. If there are any cases I would be happy to look into them, Mr Hamilton. Mr Hamilton: I read in the paper, Chairman, that the minister responsible for health in Scotland indicates quite clearly that there is a good relationship with the (?) health board but there is a need to improve the relationships in other places, so I will bring it to the attention of the minister. Q430 Mr Jenkins: How many of our Service personnel who are admitted for medical treatment go into a military hospital and how many go into the NHS when it is elective treatment? What is the breakdown exactly? Mr Bradshaw: We are not satisfied that these are completely accurate, but it is about 65 per cent military to 35 per cent not. Q431 Chairman: Given that you had no notice of that we are impressed. Mr Bradshaw: I have done my homework, Chairman. Q432 Mr Holloway: It strikes me from the stuff this morning that if we are going to continue with this level of operational template perhaps the Committee should do an inquiry into the wider issue of veterans and perhaps look to the United States which might have some lessons for us. Whilst Selly Oaks is much more focused now it took time to react to the criticism and it strikes me that the MoD, whenever there are problems, tends to justify and defend. I know of at least one general who thinks that you guys could be a little bit more proactive and should we not look at ourselves a bit more in order to pre-empt the criticisms that you are bound to get in the future in terms of treatment of veterans? It is a cultural thing almost. Derek Twigg: First of all, I spend a great deal of my time defending the Government's position in various parts of the press because I think there is a very good story to tell, quite frankly, and Selly Oak was one example of that, or whether it is Headley Court or our regional rehabilitation centres or the type of treatment that we have out in operations. I think we have been proactive but I think the fact that the Secretary of State has announced his command paper, which will look at the whole issue about what we now currently provide in terms of our Service personnel and veterans, the whole range of healthcare, welfare, accommodation, will be a really good way of setting out the arguments for what is happening on the ground, what more needs to be done and what we can do to improve that further. I think that is going to be a very good way of doing that, but I can give you an assurance, Mr Holloway, that we do everything we possibly can to get out the positive messages. Q433 Mr Holloway: It is not about messages; it is about delivery. Derek Twigg: When I was talking about positive messages it is about the delivery that we provide. As I say, if you go round and talk to the individual wounded Service personnel at Selly Oak, like I do, the overwhelming view there is of a very positive message about how they and their families are being treated. Q434 Mr Holloway: Forgive me, but I am saying that I think you should be far more proactive in seeking out things that are wrong and will be picked up. It is terrible that we do it if it comes down to negative publicity in the press. Derek Twigg: I am sorry; I misunderstood the question. No; we do. That is why, for instance, I visit Headley Court and Selly Oak and other parts of the healthcare system, and obviously Iraq and Afghanistan, to talk to those delivering it and look at where the issues might be and where we can improve things, and that applies to other parts of my role in terms of veterans and healthcare. Q435 Mr Holloway: I wonder how Lieutenant-General Lillywhite feels about this idea of being more pre-emptive. Lieutenant-General Lillywhite: We are. Q436 Mr Holloway: You were not. Lieutenant-General Lillywhite: We are. In terms of all the improvements that I described, that is the result of us being extremely proactive. The work that I am doing with the Medical Research Council I referred to before is us being proactive and seeking where we can improve quality of care. Derek Twigg: Can I just give you an example? This does not seem to get much publicity, but, of course, we have a major contract with King's College in which we are monitoring and assessing those people who served in Iraq and Afghanistan on a variety of issues. Mental health is one that comes straight to mind but there are lots of different issues we are having them working with us on and looking at issues and how they are affecting them in their service during their time in Iraq and Afghanistan. It is very proactive. We are not sitting waiting for problems to happen. We are going out there and trying to find out what is happening on the ground and how we can improve it. Lieutenant-General Baxter: And my job is to play the dark laddie as, if you like, a customer and go and ask all the stupid questions about why do we do things. On the very question about MDHUs I asked, "Why have we got one here?". That is part of my role as a non-professional medical person. Q437 Mr Holloway: In the interests of maintaining morale then perhaps you should put a tabloid newspaper head on sometimes when you do it. Mr Bradshaw: The Concordat has existed since 2002, long before the negative publicity around Selly Oak, and the work programme has been dealing with a lot of stuff, like the role of Reservists in the NHS, what we can do to encourage more Reservists in the NHS, what happens to Service personnel's families when it comes to moving and dropping off waiting lists. These are issues that have been work in progress; they have not just been done because of negative tabloid headlines around Selly Oak. Lieutenant-General Lillywhite: Just talking about being proactive, a significant number of my staff spend a lot of time visiting places like the United States. Our pain consultant is about to go over to look at how they manage pain and see whether we can learn any lessons from the way they do it. I have mentioned mild traumatic brain injury. I have had staff going over there to consult and see again whether there are any lessons for us. We go and visit the Institute of Surgical Research down in San Antonio to discuss where we are doing better than they are and where they might be doing better than we are to try and ascertain what are the factors that lead to better outcomes. There is an awful lot of intense proactive work occurring. It is not just at my level; it is at levels right down to the working level. Q438 Robert Key: Can I just touch on one very brief point? A number of consultants and clinicians in my hospital in Salisbury are in the Reserves and serve regularly in, for example, Afghanistan and Iraq. They come back and are reviewed by their chief executive and told they are not doing enough trauma surgery in the hospital, when in fact they are the experts. I just wonder if the National Health realises how lucky it is to have Reservists who are clinicians getting real experience of trauma surgery and so on coming back. Mr Bradshaw: I certainly do, Chairman, and I think good practice in the National Health Service does, but I fully acknowledge that that good practice is not as widespread as it should be. One of the things we are considering doing is putting more explicit advice in the annual operating framework about the need to encourage Reservists, not just for the reasons that Mr Key has outlined in terms of the expertise that it delivers to the National Health Service but also for the cross-fertilisation of cultures which I think is very important. Chairman: I want to move on to mental health now, which is a major area that has come up a lot this morning already. Q439 Willie Rennie: The MoD has said that the incidence of medical discharge from the Armed Forces due to psychological illness was extremely low, running at about 0.1 per cent in January 2007, but Combat Stress in their evidence to us said that they have seen a massive increase in the number of people presenting to them with a 30 per cent increase over the last year to round about 885 new referrals. There seems to be a bit of a contradication between the two. Can the Minister explain that? Derek Twigg: The figures - and we can probably provide them to you - are that roughly in terms of the number of Service leavers a year, round about 150 are discharged with mental health problems and I think around 25-30 with PTSD. That is not in any way belittling the fact that for those people that is a tremendous difficulty and is affecting their lives, so I just want to put that on record. One of the problems, of course, is that many people will not present with the symptoms for some years after they have left, often ten or 15 years, and I think that is maybe where the disparity is in terms of the figures. We are doing regular assessments, as I mentioned previously, with King's College in terms of mental health and lots of other issues for those currently serving in Iraq and Afghanistan and that will obviously inform our future policies. If I could explain the approach that I have put in place in the last 12 months or so, we have done a number of things which are to do with the fact that when people leave it might be some years after before they present with symptoms. For instance, we have increased Combat Stress's funding by up to 45 per cent from January next year. As I announced on Friday and spoke briefly about at the start of this meeting, pilot schemes have been put in place so that we can improve how we treat and care for our veterans who may have left the Service some time ago. I have also extended the medical assessment programme across the way at St Thomas's Hospital, so those veterans who since 1982 feel the need to have an assessment for mental health can go there free of charge and have an assessment by a former military psychiatrist, Dr Ian Palmer, and, of course, the Reservist mental health scheme came out of the study that King's were doing, so that where there was an albeit small but statistically significant difference between those we deployed and did not deploy in terms of their mental health we put them in the Reservist mental health scheme. I think we have recognised that there is more we have to do and we have to deal with that, but in terms of the figures, because many people are saying it is later on, the question comes back to, "Therefore, what do you do for those people?", and I think the initiatives I have just described are part of that road to doing more. Q440 Willie Rennie: Turning to the issue of active Service personnel and the service that is provided for them, the Royal College of Physicians 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 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 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, there is 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 per cent 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. Lieutenant-General Lillywhite: It is important to recognise that only the most seriously ill go to the Priory. 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. 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 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 per cent 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 per cent 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, if you like, man the back end, as regulars say, I think it was in Marchwood, the regulars went out, Reservists were called up and went to do the basing and that really was not quite as satisfying and there were consent operators as well who 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 one to two per cent 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. Q480 Willie Rennie: And other health professionals, is there advice given to them? Are their work colleagues given advice about how to deal with them? Mr Cash: Yes. People do a round of promoting this, so in most organisations, and again we need to re-emphasise this, you get heads of departments together to (a) say as an employer they encourage it, and (b) what do you do with people when they come back? Make sure you de-brief them, make sure that you do not perceive them to have any issues that have arisen from their service. Q481 Willie Rennie: It sounds quite loose. Is there a need for more? Mr Cash: I think there is room for more and I think that is why we have picked this up as an issue in our next phase of work, to really restate that we support this, so we are planning, as I say, to pull people together, probably the human resource directors of various organisations on a regional type basis, to re-emphasise what they need to do. Q482 Chairman: I would agree with what Willie Rennie has just said about it sounding quite loose because when I visited Frimley Park people being de-briefed by people who had no experience of military service at all, who just did not understand the sorts of things that people had been through, was an issue and I hope it is something that you will seriously address. Derek Twigg: Okay. Can I just say it is obviously our responsibility as well and I think it is in an area where we would look to do more. Q483 Mr Holloway: I have found the answers to our questions highly relevant and it is very nice to see such grown-up people in key jobs in all this. Derek Twigg: Do you mean all of us? Q484 Mr Holloway: Of course, all of you. However, I cannot help feeling that yet again we have got the "everything is absolutely marvellous, wonderful, we have thought of everything" line. We spoke earlier about pre-emption. Obviously, with members of the press sitting around you are not going to give us the precise things that you are working on but there must be areas that you are quite worried about and you are probably quite relieved we have not touched upon. What are they? Derek Twigg: To take your general point, I will give you an example - Selly Oak. There is no problem with clinical care or anything like that, but we looked at it and said, "What more can we do in terms of welfare support both for the Service personnel coming in and also for their families?", so we have improved that tremendously. We have talked again about Headley Court and the review about what further we need to do. Everyone says it is excellent and, of course, it is excellent but we are not resting on our laurels but are looking at what further we can do. In terms of mental health, we clearly saw there were issues there. That is why we have introduced the medical assessment programme and why we have gone down the pilots. On the specific issue about Reservists we have just been talking about now coming back individually, and the effect on their mental health compared to the regular Army, there is another example. Q485 Mr Holloway: So we are not going to see headlines in six months' time of the kind that we have had in the past that we have been letting these young men and women down? Is that what you are saying? Is it now broadly sorted? Is the chapter over? Derek Twigg: If I could give you a sort of guarantee that there will never be anything go wrong or the press will not ----- Q486 Mr Holloway: I was not asking for that. Derek Twigg: I know, but that is what the point is. I think if you look at the way some of these things are reported you would expect there is a systematic breakdown. I think from your own investigations, and certainly our personal experience of some of those people who have to deliver services, that is not the case. Clearly, in terms of veterans, and not least in terms of mental health, there have been gaps and issues there in terms of how we can improve that, and there always will be areas where we can improve, but I do not want to give you a sense or complacency here. There is not, absolutely not. Q487 Chairman: Before you move on, something prompted your statement on Friday. Did that statement on Friday imply that there is ongoing work, that it is not settled, that there are still things you will need to be addressing because you are not entirely satisfied that we are in the right place here? Derek Twigg: You will know from statements I have made in the House in terms of the pilots and initiatives we are talking about that it is about - well, we announced it, we did it then. Yes, we are not completely satisfied because we want to ensure we get the best possible system. It is not a case of resting on our laurels or resting on the last initiative or the last announcement. It is about moving forward and looking all the time. As the Generals will tell you, there is an absolute commitment ministerially, the same in the Department of Health, to provide the best possible healthcare and support, and we are looking to make that change. I will just give you an example which we have not touched on today but we had it ready to give you, and I think we should do it at this point. One of the things I said to the Surgeon-General when he came to the job was, "How do we know that the health services we are providing are as good as we all think they are and that generally people tell us they are, given the gaps and problems, so how do we measure that?". One of the things we are looking at is having an independent look at the services, to have the Healthcare Commission look at them. That is my answer back to you, that we are prepared to do that. I do not know what that will come out with. I hope it will come up with a very good report but the fact is that I want to make sure we have absolutely the best systems in place. Q488 Chairman: David Hamilton has just asked if that is for the whole of the UK. Derek Twigg: Yes, and abroad. Q489 Mr Hamilton: The reason for asking is that you have the responsibility because Ben Bradshaw does not represent the UK; he represents England. He represents English health authorities; that therefore represents 87 per cent. Derek on the other hand does represent the UK. I raise that question quite genuinely because we have seen the discrepancy in education. Derek Twigg: Our services are UK-wide as well. Mr Bradshaw: DMS is UK and abroad and I think the Healthcare Commission has already indicated that they would be very happy to undertake a review. Lieutenant-General Baxter: The Partnership Board are very keen to get the Chief Medical Officer of Scotland and appropriate people from Ireland and Wales so that when something does come up, and I like to think of myself as a fairly persuasive person, we can say, "Look: what are you going to do about it?", and then if I get no satisfaction ----- Lieutenant-General Lillywhite: I would just like to answer the question do we have any worries and perhaps correct a slight mis-impression that I might have given earlier. Manning still concerns us. We are significantly improving our manning in many areas but we have a workforce that is very junior, that in many cases, particularly in the nursing area, is inexperienced. We still have some way to go to produce the number of specialist nurses, for example, that we want and, although consultants as a whole are improving significantly and have improved significantly over time, there are a couple of areas like general surgeons and general medical practitioners where we do not seem to be having the same improvement as we are having in other areas, so there are still one or two areas that we have not quite got right which we are looking at. Q490 Chairman: So if there were any worry that you would put at the top of your list of worries manning would be the one, would it? Lieutenant-General Lillywhite: No. Q491 Chairman: Then what would? Lieutenant-General Lillywhite: What would be top of my list would be to ensure that the quality of care we are producing is as good as we think it is and that is why the Healthcare Commission external audit is an important part of the work. Lieutenant-General Baxter: Everything would flow from that. Mr Bradshaw: In response to Mr Holloway's question about this terrible phrase "horizon scanning", I think the work programme at the board gives a good indication of where we think the main concerns are, but because of the rapid development of both medical treatment and technology and the rapid changes in military techniques and technology these things are constantly changing and our challenge is to try to stay abreast of the latest developments and deliver, as we have all said, the best healthcare possible. Q492 Willie Rennie: Following on from Mr Hamilton's point, will this Commission to check on the quality of the care follow the patient, and if it follows the patient will it make sure that it goes all the way through the system so that it goes from the GP and covers the secondary care, in which case full partnership with the Scottish Government and the Welsh Assembly will be absolutely essential to make sure that works, so that it is not just about your services within the military; it is also about the services across the board. Is that the case? Lieutenant-General Lillywhite: I can give you an assurance that we are looking at the care of our casualties wherever they are treated. I expect the Healthcare Commission to assist me in being able to identify whether there is any sub-optimal treatment anywhere that our servicemen are treated. Q493 Mr Hancock: Is it possible as a veteran to get Mr Holloway some priority to have his blackberry surgically removed as quickly as possible? It should be of some priority. Derek Twigg: I shall make sure he gets a veteran's badge. Chairman: We are reaching the law of diminishing returns. I think we had better close this evidence session and say thank you very much indeed to both of you, Ministers, and to your teams for some very useful evidence on an exceedingly important subject. |