UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 427-iHouse of COMMONSMINUTES OF EVIDENCETAKEN BEFORETHE COMMITTEE OF PUBLIC ACCOUNTS
|
|
1. |
This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
|
|
2. |
Any public use of, or reference to, the contents should make clear that neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.
|
|
3. |
Members who receive this for the purpose of correcting questions addressed by them to witnesses are asked to send corrections to the Committee Assistant.
|
|
4. |
Prospective witnesses may receive this in preparation for any written or oral evidence they may in due course give to the Committee.
|
|
5. |
Transcribed by the Official Shorthand Writers to the Houses of Parliament: W B Gurney & Sons LLP, Hope House, Telephone Number: 020 7233 1935
|
Oral evidence
Taken before the Committee of Public Accounts
on
Members present:
Mr Edward Leigh, in the Chair
Mr David Curry
Nigel Griffiths
Mr Austin Mitchell
Geraldine Smith
Dr John Pugh
Mr Alan Williams
________________
Mr Amyas Morse, Comptroller & Auditor General, Mr Robert Prideaux, Director, Parliamentary Relations, and Mr Mark Andrews, Director, National Audit Office, gave evidence.
Mr Marius Gallaher, Alternate Treasury Officer of Accounts, HM Treasury, gave evidence.
REPORT BY THE COMPTROLLER AND AUDITOR GENERAL
MINISTRY OF DEFENCE: TREATING INJURY AND ILLNESS ARISING ON MILITARY OPERATIONS (HC294)
Examination of Witnesses
Witnesses: Sir Bill Jeffrey KCB,
Permanent Under-Secretary of State, Lieutenant General Robert
Baxter
Q1 Chairman: Thank you very much for coming to a very important hearing of the Committee of Public Accounts because today we are considering the Comptroller & Auditor General's Report on Treating Injury and Illness Arising on Military Operations. We welcome back to our Committee Sir Bill Jeffrey, who is the Permanent Under-Secretary to the Ministry of Defence. Sir Bill, perhaps you would like to introduce your two distinguished colleagues.
Sir Bill Jeffrey: On my right, Chairman, is Lieutenant General Robert Baxter, who is the Deputy Chief of Defence Staff (Health) and covers the whole of this area from the policy point of view. On my left is the Surgeon General, Vice Admiral Philip Raffaelli.
Q2 Chairman: Obviously, Sir Bill, on behalf of the Committee I would begin by paying tribute to our troops in Afghanistan, who are obviously doing a wonderful job and, sadly, on occasion sustaining appalling injuries. I would like to note, also, right at the beginning that the Report makes quite clear that your performance compares favourably with the best NHS hospitals, so all your staff should be congratulated on that. Obviously, we want to try and press you a bit further on how you are going to maintain your standards in the future, particularly if there is a rise in the number of casualties. Perhaps I could start by addressing my questions to the Surgeon General because obviously he is the expert in this area but you may wish to pass the questions around. Vice Admiral, what are the main factors that have led you to achieve this good performance, do you think?
Surgeon Vice Admiral
Raffaelli: It has been a good ten years, I
think, since we moved into Kosovo, that we have really realigned our deliveries
to focus on trauma management. What we
have evolved over that period is an end-to-end approach on how we care for
casualties. It starts at the very point
of wounding, where we train our soldiers, sailors and airmen to buddy-care to a
remarkably high standard. We have next
to them Combat Medical Technicians or Leading Medical Assistants who provide
immediate life-saving first aid, and we use a slightly different paradigm than
is used in civilian life, where our focus, given the understanding of the
likely injuries, is very much on controlling the potentially catastrophic circulation
and blood loss. We focus on that with
some novel techniques, using things like combat tourniquets and special clot
mechanisms that stop the bleeding and allow us to save life at that point. I would add, of course, that the actual
protection that the body armour, etc, would provide to people these days is
itself contributing very much to the fact that we have people whose lives we
can save. The next part in the system
that delivers very positive effect is our forward helicopter emergency response
team, the Medical Emergency Response Team, which not only extricates these
people but takes to them a clinical capability.
We have a consultant deployed which equates to the front end of an
emergency department, so they receive high-level treatment on the route back to
the receiving hospital facility at
Q3 Chairman: Obviously, people are surviving now who would never have survived in previous wars and they are going to have to receive treatment for the rest of their lives. They come to Selly Oak and then they go on to Headley Court. How are you going to cope with the increasing numbers in Headley Court so that people are not pushed out into civilian facilities? As I understand it, and perhaps you could confirm this, the military, the ordinary soldiers, are very much of the opinion that they want to be with their own kind in their own place; they do not want to be pushed out of places like Headley Court. How you going to cope with a long-term war and people having to remain perhaps under some sort of care for the rest of their life with very severe injuries?
Surgeon Vice Admiral Raffaelli: It is a big question, is it not? There is a number of points there, if I may. If I can just start with Selly Oak, of course, the whole of what we call the road forward(?), which is the access between Birmingham and Headley Court, it is across the NHS at UHBFT, University Hospital of Birmingham Foundation Trust, that is responsible for the care but we have provided a large number of our own medical people there to supplant and support their capability. We have with them a ward that is very much a military managed ward, so we allow that military envelope round the casualties and patients. It is worth pointing out however that if someone comes with an injury that requires perhaps an ophthalmic surgeon's intervention, then we have another relationship in that area where these people are dealt with. It is also worth noting that a number of our people spend considerable amounts of time in theatre in that environment. It is not a quick burst in Selly Oak; it really is a combined NHS and DMS support.
Sir Bill Jeffrey: Might I add a word to that, Chairman. One of the key issues which we are very
conscious of is future capacity: if there is an increase in casualty rates in
particular, are we ready to deal with it?
I would distinguish between Selly Oak and
Q4 Chairman: Sir Bill, you say that you are a small part but as I understand it, a third of Selly Oak's A&E trauma is taken by the armed forces. That is quite a lot. So say you get ten more men coming in as a result of the present operation, can you give us an assurance that they are not going to be pushed out to another hospital, a civilian hospital?
Sir Bill Jeffrey: The point really is that there is the flexibility there in our relationship with the trust first of all to put our people into other hospitals in the area if the need arises but, secondly, if one is talking about a very large increase, to activate the arrangements that are mentioned in the Report called Reception Arrangements for Military Patients, which brings in the entire resources of the National Health Service.
Q5 Chairman: But you have this voluntary agreement with the NHS, have you not, and that takes the pressure off Selly Oak for five days, is that right?
Sir Bill Jeffrey: It does, and if at that point the increase in demand exceeds what
can be dealt with within the
Q6 Chairman: General, could I ask about Camp Bastion? That is nearly full to capacity, is it not?
Lieutenant-General
Baxter: You have to understand that the system
is a managed system, with people flowing through it. You would look at Bastion and at any time
only about 40% of the casualties through there are UK military; that is fact
one. The other piece to realise is that
we keep people in
Q7 Chairman: What has happened, for instance, in the recent offensive? Have they coped all right there? Have they had enough resources? Have you put in more resources?
Lieutenant-General Baxter: My understanding is that certainly they have coped so far and they are coping.
Q8 Chairman: Has there been a significant increase in casualties going through as a result of the recent offensive?
Lieutenant-General Baxter: I am not superstitious but it is good that the casualty estimates are higher than the actuality.
Q9 Chairman: Can I ask you, either Admiral or General, about so-called minor injuries? They may be minor injuries or illnesses in our terms but in the extreme conditions of Afghanistan, the extreme heat, they can become very serious very quickly. Do you have significant resources to deal with this as well?
Surgeon Vice Admiral Raffaelli: Yes. The Report rightly identifies that early on in the Afghan campaign the actual level of what we call DNBI, disease and non-battle injuries, was far below what our estimates were, that is both in peacetime and in long term, which is up to 10%. It was running at 3 or 4%. We were aware however at that point in the campaign, when we were very much expeditionary, if you like, that we were not capturing all the data that we perhaps would wish to have had. Frankly, when you are on the ground doing that kind of business, it is not the top priority. They have since come up to still well within the estimate level, between 6 and 7% when the NAO were there, and it has remained at that level, which is well within planning assumptions. The spectrum of diseases are very much dermatological, musculoskeletal, some gastrointestinal, so our focus is on where we can prevent some of these things by good practice in accommodation, hand washing, etc. Whilst we would never be complacent at all, we are very comfortable that the resources we are putting in and the levels we are achieving are well within the planning assumptions, which are very historical and very reproducible.
Q10 Chairman: General, the last question is about combat stress, what in my father's or grandfather's time would have been called shellshock. Would members of the TA get as good a service as the regular army, do you think? Obviously, they go back to civilian life and some of these symptoms may take more time to develop.
Lieutenant-General Baxter: That is why the mental health pilots are in place - you may have heard of the mental health pilots, they are mentioned in the Report - and also as a safety net there is the Chilwell facility for people to be referred by general practitioners. There are a number of levels: the mental health pilots, the safety net, the mental health assessment programme and the stress management that is mandated for all servicemen, which is perhaps the most important thing. In the long term we have these mental health pilots, so if someone is out there, perhaps have left the Territorial Army, there are these to catch them, and the mental health assessment programme, and then, to try and minimise that happening, there is a set of policies and operational stress management which exist to identify people who might be susceptible and then refer them early.
Q11 Chairman: The answer to my question whether the TA gets as good a treatment is yes?
Lieutenant-General Baxter: I think the answer is yes.
Q12 Geraldine Smith: Can I add my congratulations to the work of the staff in those battlefield hospitals? It is not just the Report that recognises this but also people have told me that have had direct knowledge of it. It really is a credit to those people who work in very difficult conditions that they provide such a high standard. My concern is also what happens long term. Young men and women who have had their life transformed in the most appalling way through serving their country - what can we do that we are not doing presently to improve the situation when they return?
Lieutenant-General Baxter: I suppose the answer is you can always do better. I think it would be complacent if you did not try and learn lessons and do better. There is a lot of activity in place, and there was an announcement some weeks ago about the Army Recovery Capability, and before that about Hasler Company, the Royal Marine equivalent, which is there really with two roles. One is to help returning people to service as swiftly as possible to make sure - young men are sometimes not the most reliable - that they go to hospital appointments on time and that kind of thing, but also for those who may be discharged at some stage to make sure, for the very badly damaged, that they are handed over properly in terms of both health care and social care, in the case of NHS England to the appropriate primary care trust, in the case of the devolved administrations to the appropriate pieces there. So we do do a proper job of handing people over.
Sir Bill Jeffrey: Could I add a word to that, if I may, which is that I think personally that this longer term issue is one that society at large has not quite grasped the scale of yet. The most we can do is what we are trying to do, which the General referred to, which is most importantly, I think, to work exceptionally closely with the Department of Health and the National Health Service. The key thing for these people as they leave our Service and beyond is that they should find it easy to access the best that the NHS has to offer. What we have been trying to do, through the protocol that the General referred to, is to bring local NHS providers into the process early so that there can be a plan made for individuals three months before they even leave the Services. Joining all that up I think is the means by which we can best address this issue longer term.
Q13 Geraldine Smith: It must be very important for them to be with other soldiers in similar positions who have suffered similar injuries, because only they can really understand what they have been through. What do you do to make sure there is that contact when people need it, and also support for the families?
Surgeon Vice Admiral
Raffaelli: It is a very important point but I
think there is a two-phase part to that.
First, within Service we absolutely focus on providing that environment,
be it at
Q14 Geraldine Smith: Yes, and obviously charities like Help For Heroes must be very important.
Sir Bill Jeffrey: Just on that point, we are sometimes represented as being in some sense at odds with Help For Heroes. The truth is that on this we have been working extraordinarily closely with them and the Personnel Recovery Centres that were the subject of an announcement a week or so ago have been built from the subscriptions of those who have contributed to Help For Heroes, and they will be managed by the Royal British Legion and the Army jointly. So there is a very close interface.
Lieutenant-General Baxter: Sir Bill mentioned the Royal British Legion, and if you look back in history to the role it played to provide that social place where you could come and gather, I think you are going to see something of a renaissance. It had become just like another pub, but I think you will see something of a renaissance in things like the Royal British Legion, regimental associations, various Service associations, to produce that long-term context.
Q15 Geraldine Smith: Can I just ask as well about the mental trauma that people face. I spoke to the mother of a young soldier. He came back really quite traumatised. What help and assistance is available to Service personnel?
Surgeon Vice Admiral
Raffaelli: In Service we have what we call the
Department of Community Mental Health run currently by the three Services but it
has been taken under an Army lead service so we can really focus delivery. We have an arrangement also with three
Staffordshire trusts where we can take in patients if required. For those who are traumatised and end up
being retained within the road forward(?) I talked about between
Q16 Geraldine Smith: Can I ask as well, on a more positive note, the staff in your hospitals deal with such horrific injuries and they get very specialised at dealing with terrible injuries like that. What can the rest of the National Health Service learn from them? What experience can they give?
Lieutenant-General Baxter: From a mental health point of view?
Q17 Geraldine Smith: No, the doctors and nurses who actually treat patients. I remember in Northern Ireland there were cases where some of the people dealing with the terrible injuries and things from bomb explosions were able to use their expertise in other fields, for example, for victims of car crashes.
Sir Bill Jeffrey: This is very much two-way traffic. We learn from the best that the National Health Service has to offer and their trauma specialists. The nature of our experience in recent years is such that they are learning from us as well. I know the Committee has a hearing with the Chief Executive of the NHS in the next few weeks which covers similar territory. I think he would tell you that the NHS benefits greatly from the experience of the quite extreme conditions that our people are accumulating at the moment.
Q18 Geraldine Smith: Can I just ask a final point, again going back to minor injuries and illnesses? Can I ask why they have actually gone up in Afghanistan from 4% to 7% from 2006 and 2009? Is there any explanation for that and is there any connection with the living conditions?
Sir Bill Jeffrey: Our view is that it has something to do with reporting rates because in the earlier part of that period, as the forward operating bases, which are sometimes in quite remote and difficult parts of Afghanistan were being set up, some of the more minor complaints were just not being reported, but there is something real there as well and we are keeping an eye on it. The key point to bear in mind is, as one of my colleagues said earlier, that we are still operating within the 10% that we assume for that sort of minor illness or injury and, as a matter of fact, since the NAO did their study work, the level has remained pretty constant at between 6 and 7% so it does not appear to be getting worse although we are very conscious of the risk that it might.
Q19 Dr Pugh: Can I follow through on the mental health issues. I noted and I think you just referred to the fact that, in terms of diagnosing mental health issues we seem to pick up fewer in the British Army than the Americans or the Canadians do. That is the case, is it not?
Sir Bill Jeffrey: It is. I think we would all be cautious about the figures on this partly because, as the Report brings out, it is not easy to make international comparisons and also because a lot of the studies on Post Traumatic Stress Disorder suggest that it takes a lengthy period in some cases to become obvious. Subject to that, the analyses that have been done, by King's in particular, suggest that the rates are first of all not that different as between deployed and those who are not deployed. If anything, the area of concern is actually around deployed reservists.
Q20 Dr Pugh: The concern I have really is that clearly there is a rate of referral but there may be numbers of cases that may not actually be referred. I think we would all accept that war is extremely stressful and people see some horrid, fearsome things that would disrupt the psychology of almost anybody. What surprises me is that the referral of the Forces appears to be lower than the referral rate of the population as a whole. Is that not intrinsically implausible? You would have thought there would be more mental health issues amongst a population of people who see quite traumatic scenes than amongst those who do not.
Sir Bill Jeffrey: My colleagues may want to comment on that, Dr Pugh. What the studies do suggest is that the incidence of mental health problems among the military is not significantly different from among the population at large.
Q21 Dr Pugh: It is actually lower than the population at large. In other words, it would appear to be the case that in the confines of Committee Room 15 we are far more vulnerable to mental health stress than people in the operational theatre of war. That is what I find implausible.
Sir Bill Jeffrey: I do not know. Maybe it is something to do with the population that one starts with.
Q22 Dr Pugh: They are more robust?
Sir Bill Jeffrey: What is undoubtedly an issue for us is to ensure that mental health problems are identified and, given the stigma that still attaches to it, that people do come forward and when they come forward we have the services to support them.
Q23 Dr Pugh: If we were doing it faultlessly, we would expect similar patterns of referral in Afghanistan and Iraq when in fact we get quite different patterns of referral. You are far more likely to be referred in Iraq than you are in Afghanistan. I cannot think of a good reason for that. Can you think of one?
Lieutenant-General
Baxter: I think you have to look at the nature
of the combat at various times. One
thinks back to
Q24 Dr Pugh: One of the factors, crucially, if you look at the diagram on page 40 at the bottom, is that the Americans do a lot more screening than we do. If you look across at paragraph 4.7, it says, "Research funded by the Department has shown that typical self-completed questionnaires used for screening are imprecise and open to manipulation. Other coalition partners with smaller deployed forces undertake one-to-one interviews with personnel following deployment." This is leading to an impression on my part - and you can correct me if you wish - that we are just not as good at monitoring mental health as other forces are.
Sir Bill Jeffrey: The judgment that is reported in the NAO Report is based on research undertaken at the King's Centre for Military Health Research, which suggested that sort of process was not effective and could well be counter-productive. My colleagues may be able to enlarge on why we decided against it but it was a conscious decision.
Surgeon Vice Admiral
Raffaelli: Very much so. It is not a trivial point whatsoever but all
screening is harmful, and particularly in the mental health area there is very
good evidence that it can actually almost lead to the problems. The other point is that for what you do
screen for, the tests that are used are terribly non-sensitive and non-specific. The trick, if you like, is to monitor your
people and ensure that those who are having difficulties are identified without
using a tool that may cause them harm.
The focus that we have used in the
Q25 Dr Pugh: Certainly you are doing some serious research into the topic at the moment but I do point out, and I think you are not going to dispute, the fact that the Americans have already done the research ahead of us in some respects, because you are actually using some of their results of some of their pilots on battlemind and things like that. Just going on to the level of support, mental health support in Afghanistan is provided by three community mental health nurses, according to the Report. Is that enough?
Surgeon Vice Admiral Raffaelli: Yes.
Q26 Dr Pugh: Is it?
Surgeon Vice Admiral Raffaelli: That is not the total capacity that we have in theatre. We deploy regularly also consultant psychiatrists, both to do audit and the rest. I was out there two weeks ago at the same time as the Professor of Military Psychiatry was out there with one of his consulting assistants, who are looking right across the whole area. We flex out additional resources as they are required but the people who have problems, of course, at that level or who have sustained trauma are brought back.
Q27 Dr Pugh: You are happy with the level of provision where you have three community health nurses and a consultant psychiatrist visiting every three months?
Surgeon Vice Admiral Raffaelli: Yes.
Q28 Dr Pugh: Is it the same consultant psychiatrist or is it different ones?
Surgeon Vice Admiral Raffaelli: It is a number of them.
Q29 Dr Pugh: Would it not help to have the same guy go out all the time? He might develop a level of expertise dealing with the particular kind of problems you are getting out there.
Surgeon Vice Admiral Raffaelli: All of our military psychiatrists, the reason they are in uniform and we do not simply buy it in or use NHS consultants is that very point you are making, that it is important that these people are fully experienced in the military way of life, military support, and that includes what happens on operations. I would suggest it is equally important that we maintain a pool of people who have the skills and experiences you are referring to.
Q30 Dr Pugh: Would you like to comment on page 42, paragraph 4.8, where it says, "There is inconsistent access to non-medical stress management processes on return to the UK for Reserves." Are you comfortable with that?
Surgeon Vice Admiral Raffaelli: I think it was absolutely a correct statement at the time. What General Baxter was referring to are the measures that have been put in place to try and address that area, which had been a concern, which I think are beginning to close that small gap that was rightly recognised. This month, for example, we are running a number of studies, with King's again, to look at piloting - not research but piloting additional support to reserves and individual augmentees - to see how much they would benefit from the decompression systems that we go through, which are also referred to in the Report, to see whether that would provide an additional level of support and monitoring for these people.
Q31 Dr Pugh: When will the King's study be completed?
Surgeon Vice Admiral Raffaelli: These pilots, this month, March, and we will have the work back early April. The thing about decompression that is interesting: we are all convinced---
Q32 Dr Pugh: On that last point, is it possible we could get this research before completing our report here?
Surgeon Vice Admiral Raffaelli: It will be pilots. I do not know what the exact timetable is but it should be available in early April, I would think.
Q33 Mr Williams: The number of unexpected survivors, people who have survived injuries which no-one would normally have expected them to survive is in fact a tribute, as the NAO has said, to the service you are providing for our troops. Equally, the family must be very important in terms of morale, perpetuating the will to live. What do you do to maximise the benefits the family can offer?
Sir Bill Jeffrey: This mostly comes into play, Mr Williams, when those who have
survived, in some cases unexpectedly, come back to this country, are dealt with
initially at Selly Oak, but then in many cases - and I have seen them for
myself - end up at Headley Court receiving rehabilitation, intensive
physiotherapy, the kinds of things that Headley Court does, and at that point
there is a very intensive effort to involve families. There is a facility in which families can
live in order to spend quite a lot of time with their son, in most cases. I would recommend to the Committee
individually to visit
Q34 Mr Williams: Is there any structured support and help or advice service for families to enable them to be of maximum benefit to their sons or husbands?
Sir Bill Jeffrey: I believe there is. One of my colleagues might want to say more because certainly I have seen guidance.
Lieutenant-General Baxter: The very reason we refer to the thing we call "the patient group" is to make explicit the point that it is not just the patient; it is the family, loved ones, that group that has to be looked at as part of the clinical activity almost. That might sound not very good. It is to make sure that people recognise that the family are an integral part, that they are looked after. There are flats at Selly Oak where people can stay very close to the hospital just to enable that whole piece where the family can be together during what is a very difficult time for them.
Q35 Mr Williams: That is very encouraging and to be commended. Are the families given any practical support, such as financial assistance in getting there? They may have to travel from remote parts of the country. What are the guidelines here on financial support to go and see a son or a husband?
Lieutenant-General Baxter: Travel will be either facilitated, i.e. they will be given transport or they will be paid to get there.
Q36 Mr Williams: How widely is "family" interpreted in that sense?
Lieutenant-General Baxter: I would have to give a written reply to that. It would be the nominated dependants, next of kin, who are nominated by the individual soldier, sailor or airman.
Sir Bill Jeffrey: My recollection is that there is some guidance that takes account of the fact that these days families are what would in the past have been seen as unconventionally composed. I think the General is wise to suggest that we offer the Committee a note on that, if you would like to have one.
Q37 Mr Williams: For far too many families they are seeing injuries they never, ever thought of seeing. What is done to help them deal with the shock of what has happened to a loved one?
Lieutenant-General Baxter: A very important part of looking after the patient group is to make sure when they first come there that they are briefed as best you can on what to expect. Equally, they are briefed on what to try not to do to make things worse. It is easy to tell somebody what they are about to see and to suggest to them how they might behave. The reality of what then happens is perhaps different but the whole point of having clinical staff and nurses there, certainly when the family, the loved ones, the extended family, are there, making sure they know what to expect is a very important part of this.
Q38 Mr Williams: For those who do not have family, is there any way you can replace the emotional support that the family gives other injured troops?
Lieutenant-General Baxter: That is where the regimental squadron commando family comes in. If you visit Selly Oak, the ward can be somewhat busy, shall we say, because usually round the bed you will find five, six, seven, eight or nine people. There will be a point that their friends, commanding officers, Colonel Commandants of various sorts will be there visiting.
Q39 Mr Mitchell: Why has there been such a steep increase in minor injuries and illness between Iraq and Afghanistan: 41,900 in Iraq but 83,299 in Afghanistan? Why is that? What is the ratio to troops deployed?
Sir Bill Jeffrey: We need to do the analysis.
I am not sure there is in practice over the period we are talking about,
given the numbers that were deployed at the time, that much difference. I think the Iraqi rates probably relate to
the latter part of the campaign, when we had between 4,000 and 5,000 troops
deployed, whereas in
Q40 Mr Mitchell: Is it not worthwhile doing the analysis? I see from paragraph 3.2 that there are a range of possible factors for the increasing trend, including the intensity and basic living conditions of operations. If you do not know what is causing it, and you do not seem to, how can you deal with it?
Surgeon Vice Admiral
Raffaelli: If I could suggest, if you look at
page 29 of the Report, figure 13, where it has the two graphs, one of
Afghanistan and one of Iraq, they are perhaps slightly misleading in that the
axis on the left-hand side are on different scales, so it makes it look like
there is a considerable difference between Iraq and Afghanistan but, in fact,
if you look, you will see that in both cases per thousand personnel per week,
it is around between 50 and 100 per week.
It is actually, within the terms of the scale of things, very
similar. There is of course that earlier
difference we talked about when you had at the beginning of the
Q41 Mr Mitchell: Thank you for that. It is not that the conditions are so much worse in Afghanistan; the trends are the same?
Surgeon Vice Admiral Raffaelli: I think that is true, yes.
Q42 Mr Mitchell: Why do we not do comparisons with particularly the Americans but other troops in the coalition, first of all about this increase in minor injuries and, secondly, about the effectiveness and the speed of treatment, ours compared to theirs?
Lieutenant-General Baxter: I do not want to drive a wedge between ourselves and the Americans but some of the motivations for reporting things are perhaps higher in the case of US forces. When you try to make comparisons you are on quite dangerous ground because having a medical condition ascribed to an operation is very helpful in getting you Veterans' Administration Benefits, so people are perhaps more punctilious about ensuring that those things go in and are recorded for the future, whereas when people come back here, either the NHS or what-have-you will pick up that loading, and of course, America does not have our health care system.
Q43 Mr Mitchell: That might indicate that Americans are softer than our troops and ours are braver and more inclined to bear injuries without complaint.
Lieutenant-General Baxter: I would not say that. I think there is an incentive mechanism perhaps operating that is not operating for us.
Q44 Mr Mitchell: You do not say it with any assumption of British superiority?
Lieutenant-General Baxter: Absolutely not.
Q45 Mr Mitchell: Do you have routine comparison of injury levels and treatment levels? I would have thought they would be invaluable in aligning us with whatever is the best.
Sir Bill Jeffrey: We do talk to the Americans but what I am not sure about, unless either of my colleagues can answer immediately, and we perhaps ought to check, is just how systematically we compare figures. There are lots of reasons, and the General has just offered one, for treating such comparisons with caution. That is not to say we should not do it.
Surgeon Vice Admiral
Raffaelli: I think at one level, the high-level
trauma, we have two, not the same but comparable systems called trauma registry
comparisons and they use similar but again not exactly the same models. We have good information on comparability of
the high-level trauma, the unexpected survivor arguments, and we spend a lot of
focus on it because that is in some ways the high end of the business. When it comes to the disease and non-battle
injury parts, it is important in overall terms, and certainly the regional
medical commanders as part of the coalition forces maintain an overview, so if
there is a peak of something occurs in whatever country's area, they will
direct resource to look at that. Part of
the problem is that it is a very nondescript bit of business. I know and we keep good records of what the
major things are, and I have already said musculoskeletal, dermatological and
gastrointestinal things but, for example, one of the peaks was during a quiet
time when individuals came forward in the
Q46 Mr Mitchell: Thank you very much. That is very interesting. Is there any indication of any correlation between minor injuries and morale? Both Iraq and Afghanistan are very difficult areas to fight in and in a very difficult situation climatically, in terms of relations with the people and in terms of the kind of tactics used against our troops. Do we have any indications of an increase in minor injuries and a fall in morale?
Sir Bill Jeffrey: Morale is certainly one of the reasons why taking minor injuries seriously is important. I am not sure that we could draw any direct correlation of the kind that you describe but it is one of the reasons why, although the trend is somewhat upwards, the fact that we are well within what previous experience would lead us to assume would be the minor injury and illness rate is quite reassuring in itself.
Q47 Mr Mitchell: The Admiral mentioned unexpected survivors, which is a curious term, but I see that there is a lower percentage of unexpected survivors in NHS hospitals than in military treatment. Is that because of different measurements? I gather in NHS hospitals it is arrival at the hospital door that counts but, in terms of your calculations of unexpected survivors, it is sustaining the injury on the battlefield and everything that follows.
Surgeon Vice Admiral Raffaelli: You are right that there are differences in how we finally calculate and assess them that does make it hard to draw very hard comparisons. They are all based on different forms of what is called International Severity Scores, which are a standard benchmarking system which focuses however on anatomical trauma. So there is a - flaw is the wrong word because it is important that we use a standardised benchmarking mechanism but it does not necessarily capture the wide range of things that our chaps sustain when they are injured and some of the massive physiological challenges that come along with it. In order to then make sense out of what is a relatively unique dimensional scoring system, all of us, be it our forces deployed, the NHS or the Americans, then use a peer review mechanism which takes into account the overall experiences and capabilities. There is a bit of calibration within that but I think we are all comfortable that in each of the areas we are doing the best. At the NHS review, which the NAO reported on and is before the PAC in a few weeks, time, they will identify that there are some areas where the scores are different.
Q48 Mr Mitchell: Have there been any problems with helicopters and evacuations in this survival issue? We had two soldiers from Grimsby killed in that "rogue policeman" incident and they were in a fairly remote checkpoint where it took time for medical help and support to arrive. Have we had any problems because of the remoteness and the lack of helicopters?
Sir Bill Jeffrey: My recollection is that on evacuation, the Report's conclusion is
that we are performing well in terms of timeliness. What the Report picks up in one or two areas is
where helicopter availability has affected other things, like the movements of
medical practitioners around theatre, and our general efforts, which are well
known, to increase the number of helicopters in theatre and their availability are,
I hope, easing that. We have since 2006
almost doubled the number of helicopters and more than doubled the number of
helicopter hours available to operational commanders in theatre in
Q49 Nigel Griffiths: This Report is very praiseworthy of what you have done for our Armed Forces. There seems to have been a very good improvement over the previous Report and many satisfactory outcomes for what is a tragedy and trauma for people. Can I ask you, have you read reports that our Service personnel who lose limbs are getting the best in the world, state-of-the-art limbs as replacements, with all the training and back-up that is needed for their use?
Sir Bill Jeffrey: I believe so. I think the
prosthetics, the quality of what is done, particularly at
Lieutenant-General
Baxter: We are continuously looking at what is
going on, particularly in
Q50 Nigel Griffiths: Have you seen the reports that I have seen that amputees who leave the Forces and then require replacements, perhaps after 36 or 48 months, are not getting and are not offered the same high level of limb or the maintenance of that limb?
Surgeon Vice Admiral Raffaelli: There was a communication issued by the Department of Health, Minister O'Brien, about two weeks ago, I think. He gave an absolute commitment that not only did the NHS seek to provide the same level of modern prosthetic that these chaps are being issued with today but they would keep up with whatever advancements are delivered through Headley Court.
Q51 Nigel Griffiths: Was that in response to criticisms that has not been the case to date?
Surgeon Vice Admiral Raffaelli: I am not aware of anybody who has been in that particular position. I think this was just part of the very positive working together of the Department of Health and the Ministry of Defence that has been developed over the last two years in particular.
Q52 Mr Mitchell: I just wondered, given the fact that there is a prevailing mood of economy in the NHS, and certainly considerable efficiency savings are being expected, how far is this going to impinge on you? I do not know what the financial arrangements are but certainly the physical arrangements if you are going to have a series of designated trauma centres which may not coincide with your treatment centres, is that going to cause you problems? What is going to be the effect of the reorganisation?
Sir Bill Jeffrey: There are two distinct issues. One is NHS resources, where we will need to carry on working very closely with the NHS as we go through the coming period, when we will all be under financial pressure of one sort or another, but I would say that our relationship with the NHS and the Department is stronger than it has ever been. The other is the one that is picked up in the Report, which is whether the plan to have regional trauma centres will make it harder for our people to get the experience they currently get in a number of NHS centres around the country. There are discussions going on now between ourselves and the NHS about how, given that they have yet to select these centres, we can best meet that concern.
Q53 Chairman: Two or three more questions just to tidy up the hearing. General, you gave various reassurances to me about Camp Bastion but I am right in saying, am I not, that it was the MoD's own review, not the NAO, that concluded that Bastion is close to capacity?
Lieutenant-General Baxter: We would expect it to operate efficiently and to capacity and the Commanders Medical in theatre, if there are unexpected peaks, can load-balance between the hospitals in the theatre of operations.
Q54 Chairman: So the fact that it is close to capacity is an aspect of good management, you think?
Lieutenant-General Baxter: I would say it is an aspect of good management.
Q55 Chairman: You recall I asked you about the service that the TA people were getting. Am I right in thinking that the mental health pilots and medical assessment programme require reservists to seek help themselves? What are you doing to identify reservists who may have a problem?
Lieutenant-General Baxter: When you say seek help themselves, yes, if someone says, "I am unwell," if their family identifies something that is adrift, if the general practitioner identifies that something is not quite right, then they can refer to these various capabilities.
Q56 Chairman: But of course the MoD is not set out to identify these reservists. You would presumably say how can you?
Lieutenant-General Baxter: In the operational stress management, when a reservist comes back to the unit, there is a policy of debriefing, making sure that someone is taken through, that the unit is actively aware that a person has been there and is on the look-out for anything. If someone then leaves the reservists, leaves the Territorial Army, and there is not that unit around them, then you are relying on family, friends and GPs.
Sir Bill Jeffrey: Then, as we said earlier, it comes back to the question of ensuring easy access to the general services of the NHS.
Q57 Dr Pugh: A final question on the mental health issue: do you keep statistics of suicide rates amongst both military personnel and ex-military personnel?
Sir Bill Jeffrey: We keep suicide rates among serving military personnel and they are lower, generally speaking, than for the general population.
Q58 Dr Pugh: In some ways one might expect that.
Sir Bill Jeffrey: It is harder, because we are talking about a large population of people, many of whom left many years ago, to track through into the general population. I am not aware of studies that have done so, although my colleagues may be.
Q59 Dr Pugh: Would you be able to say, for example, two to three years after people leave the Services the suicide rate was such and such? You do not know?
Surgeon Vice Admiral Raffaelli: We cannot. It is not unique to mental health. There is a real challenge that the NHS does not flag veterans separately, so we cannot capture that information. Clearly, through some other routes, we may identify the odd one but that is as far as we can go. We are working currently with NHS England to look at a mechanism trying to put that into place but there is the Data Protection Act and other problems. The nearest we can do at present is the work we are doing with King's, which is this longitudinal study, which is not designed to look solely at people who commit suicide but clearly, should that tragedy happen, it will pick that up.
Q60 Chairman: Admiral, a last question for you: do you know how many people have left Headley Court and what their experience has been?
Surgeon Vice Admiral Raffaelli: Of the serious trauma group?
Q61 Chairman: Yes. They have left for civilian life. Do you track what their experience has been?
Surgeon Vice Admiral Raffaelli: Yes. None as of yet. You will have heard a couple of weeks ago, when the Army restated its approach to medical discharges at the same time as the Army Recovery Capability had been put in place, from the current conflicts, and certainly Afghanistan, they are all still in service with us of the higher trauma level part.
Q62 Chairman: A last question for you, Sir Bill. Obviously, Selly Oak is providing an excellent facility. Can you assure the Committee that if it becomes full, our injured military personnel will get just as good treatment elsewhere in the NHS?
Sir Bill Jeffrey: I believe I can. I think, as
I have said earlier, that one of the great virtues of doing this in close
partnership with the NHS is, first of all, that we have access to the best that
they can provide clinically but, secondly, that we have access ultimately to a
much larger system than we could possibly sustain ourselves. The arrangements for flexing into wider
capacity in the
Q63 Chairman: Thank you very much. Gentlemen, that concludes our hearing. Perhaps lastly, Admiral, you would convey our thanks to your staff for the wonderful work they do.
Surgeon Vice Admiral Raffaelli: I would be delighted. Thank you.