Evidence heard in Public

Questions 303 - 347



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Oral Evidence

Taken before the Defence Committee

on Wednesday 6 July 2011

Members present:

Mr James Arbuthnot (Chair)

Mr Julian Brazier

Mr Jeffrey M. Donaldson

Mr Dai Havard

Sandra Osborne

Ms Gisela Stuart

Examination of Witnesses

Witnesses: Air Vice-Marshal David Murray OBE, Assistant Chief of the Defence Staff (Personnel) and Defence Services Secretary, Claire Phillips, Deputy Director, Violence, Social Exclusion, Military Health and Third Sector Programme, Department of Health, Surgeon Vice-Admiral Philip Raffaelli, Surgeon General, and Lieutenant-General Sir William Rollo KCB, CBE, Deputy Chief of the Defence Staff (Personnel and Training), gave evidence.

Q303 Chair: May I say welcome? Welcome back to General Rollo. Surgeon General, very good to see you. Would you like to introduce yourselves, please?

Air Vice-Marshal Murray: My name is Air Vice-Marshal David Murray. I am employed as Assistant Chief of Defence Staff for Personnel, and have a particular interest in charitable activities in connection with this.

Surgeon Vice-Admiral Raffaelli: I am Surgeon Vice-Admiral Philip Raffaelli; I am the Surgeon General.

General Rollo: I am Lieutenant-General Bill Rollo, the Deputy Chief of Defence Staff for Personnel and Training.

Claire Phillips: I am Claire Phillips, the Deputy Director at the Department of Health, with responsibility for military health as well as violent social exclusion and third-sector partnerships.

Chair: Thank you very much. You are all most welcome to this session in our inquiry into military casualties. The questioning will be begun by Gisela Stuart.

Q304 Ms Stuart: Welcome to the Committee. If I may, I will start with Admiral Raffaelli. If you were to look back at the past 10 years, we have made extraordinary advances in terms of soldiers surviving injuries. I wonder whether you can give us a breakdown of just what happened in terms of the rate of those injured and surviving in comparison with other conflicts we have been involved in.

Surgeon Vice-Admiral Raffaelli: Of course. Would you like me to start with why I think there may have been changes that have resulted in more survivors? I think it is the long-term thing, that there is a whole end-to-end treatment package. We are now much more focused on providing serious care, from the point of wounding, through retrieval back to the forward hospital, through the air to Birmingham-so, end to end. In all of that, we have been working in considerable partnership-that is partnership in many areas, between the three Services, between the Regulars and Reserves, with our international military partners and with the NHS and the Department of Health in other areas.

In quite specific terms, one of the direct focuses-working with Americans, in particular-was the recognition that catastrophic blood loss at the point of wounding was the single biggest killer in the short time frame. In fact, 50% of the people were dying from blood loss. So a lot of effort has gone into how to deal with that, by using things like combat application of tourniquets, novel blood products and bandages to hold bleeding back. They are delivered not only by medical personnel forward, but by the soldiers themselves, who are trained, and by team medics. So the first thing is, at the very point of wounding, to save the life and then rapidly follow that up with our combat medical technicians or our medical assistants, who are trained to a higher level, and for them to take forward the blood products and the rest to deal with that.

The next stage of course is to retrieve the wounded as expeditiously as possible, and we do not just do that on our own; we also do it with our international partners, the Americans in particular; their Pedro and DUSTOFF-dedicated unhesitating service to our fighting forces-retrieval helicopters are tremendous. We have a different approach to that-we don’t have the quantity that they have, though as I say we do work in partnership, but we have the Medical Emergency Response Team helicopter, which is just a mission Chinook. What that does is it takes to the casualties a higher level of care, almost taking the emergency room to the casualty. So with a consultant-led team on board, we can provide high-level resuscitation, we can incubate people and we can provide blood products-that is a big change, to deal with that physiological disruption that major trauma causes. We can reheat them and deal with acidosis, and we can even put on aortic clamps if they are severely injured high. We can certainly anaesthetise and bring them back safely.

They get back to the hospital, and again it is a combined, consultant-led team approach. They know what is coming in, as best they can-in terms of the number of casualties, the problems they have-so they can prearrange the reception to deal with them, if necessary even bypassing the emergency department and going straight into operating theatre. The job is very much focused on what we call damage control surgery, which is that life-saving and physiological stabilisation surgery, to get the casualty into the best possible condition.

For UK-based and other multinational coalition partners, the next part in the chain is to get them back home as safely as possible. The RAF is quite exceptional at that-the critical care support team and transport system is quite remarkable. When I speak to colleagues in other health care systems, they sometimes say, "We wouldn’t take that chap up three floors", but we bring them back 3,000 or 4,000 miles. That is again down to a consultant-led team, focusing specifically on the patients.

Q305 Ms Stuart: Some of my colleagues will come back and pursue that a bit further. Could you answer two very specific things? The American system is still different. They take the patient to the doctors whereas we take the doctors to the patients.

Surgeon Vice-Admiral Raffaelli: Yes

Q306 Ms Stuart: And how does the ratio of injuries to fatalities compare in the different systems?

Surgeon Vice-Admiral Raffaelli: That is a very fair question that we keep asking ourselves. They have helicopters for quick retrieval-scoop and run, if you like. We use them slightly differently. We will use the MERT for whichever casualty demands it. So we pick up US soldiers and they also pick up British soldiers. It is a question of the right asset to the right casualty at the right time. It is hard to compare. We know that we have saved people and had unexpected survivors during flight. So we believe there is an advantage, to some extent. Last week, I was at the Institute of Surgical Research in San Antonio and the Americans are taking to their Congress just now a proposal to introduce a MERT equivalent to supplement what they are doing. We must not in any way denigrate the Pedros and DUSTOFFs. It is an essential part of the whole spectrum of retrieval of injured patients and in numbers. It is really resource intensive-both the rotary wing asset requirement and the teams on board to deliver MERT. We simply could not provide it everywhere and nor could the Americans.

Q307 Ms Stuart: So are the medics still breaking harmony guidelines?

Surgeon Vice-Admiral Raffaelli: We very rarely see any breach of harmony guidelines among the medics. There have been one or two numbers and in almost every case I am aware of, it has been voluntary by the individual. When they do things like the continuous attitude survey, it does not arise at all. In fact, going on operations is very much what they are about and want to do.

Q308 Mr Havard: A friend of mine is a Reservist who does this, too. You use Reserve forces in that activity as well as full-time forces?

Surgeon Vice-Admiral Raffaelli: Absolutely. The way we deliver our medical effect goes back to partnership. If you were to go into a field hospital in Bastion, you would not know whether that man or woman behind the mask was Navy, Army, RAF or Reservist, or indeed whether they were American, Estonian or, shortly to be, French people. We also use some people directly from the NHS in small numbers and their system supports operations. They may have a particular skill in paediatric intensive care nursing, for example, that we do not commonly provide and people have come forward who are willing to do that, not necessarily wanting to pick up the Reserve part. You are absolutely right: we use the whole gamut, including Reserves who are a critical part of our armoury.

Q309 Ms Stuart: That is very helpful. Could I turn to Claire Phillips? Ten years ago the NHS said that it needed to support what the MoD did in terms of medical services because of the critical mass needing support. Now in some areas what happens within the Army context is quite superior to what is happening in the NHS. Are you content that we have sufficient cross learning from each other?

Claire Phillips: Yes. Thank you. There are huge opportunities for us to learn from each other and we recognise that the huge advances that have been made are things that we can learn from in the NHS. So as the Surgeon General said, the Reserves are obviously very important because they are going back into the NHS and taking a huge amount of operational experience with them. It is often said that one Reserve spending some time in Bastion will have more trauma experience than he will see for months and months, if not years, in the NHS. So that is clearly important.

As well as that we have defence medical staff who are embedded in the six Ministry of Defence hospital units that we have in this country. So they are constantly working alongside each other, sharing the learning and so on. Then we share research. We have a joint National Institute for Health Research in Birmingham now in which we have invested £34 million in the past few years. We have recently announced that we are going to invest £20 million. That is a partnership between the Ministry of Defence, the Department of Health, the hospital in Birmingham and Birmingham University. That will look at surgical reconstruction and microbiology to see what we might share and learn there. Obviously we are doing a lot of learning internationally as well.

Q310 Chair: Can you say what proportion of troops are surviving who might have died in earlier conflicts? Do you have any figures for that?

Surgeon Vice-Admiral Raffaelli: We cannot say proportion wise. The mechanism for calculating unexpected survivors is dreadfully complex. It is based on injury severity score comparators. Above a certain level, you begin to grade them as major casualties. With each case, we give them what is called a new injury severity scoring and then we sit in a peer group and compare with each other. In pure numerical terms we believe that about 208 or 210 in the last five years would have fallen into the "not expected to survive" group. It is a multivariate analysis process and it is a predictive number. What I think we could say very confidently, and the NAO picked this up when it audited us last year, is that against all standard comparisons that we do-I am trying to avoid giving an exact number because it does not really exist-one in 10, or one in 15 end up surviving longer than we would have expected. But it is a case-by-case analysis; that is really what I am saying.

Q311 Chair: Yes, it must be very complicated. What challenges do you have in the physical care of troops when they come back to the United Kingdom?

Surgeon Vice-Admiral Raffaelli: Once they get back?

Chair: Yes.

Surgeon Vice-Admiral Raffaelli: They do come back in a remarkably short period of time. It can be anything from 24 hours to 48 hours, or three days. So they are still extremely injured and seriously ill people. The first challenge is to actually provide for that high level of intensive care to continue. Queen Elizabeth hospital at Birmingham is, quite simply, a fantastically well set-up unit.

Q312 Chair: We visited that last week and we were most impressed.

Surgeon Vice-Admiral Raffaelli: The other thing, of course, is that it’s a completely combined approach within that unit now, and consultant led. It is very much an NHS lead by the time you get there, but our people are well embedded. So I think that that is the first challenge, to actually secure that survival, and they do very well. I’m delighted to say that very few people have actually ended up dying in Birmingham.

The longer-term thing, though, is with the level of severity of injuries that they’ve received, and is much more challenging in many ways. You’re well aware that, with the high level of IEDs, the lower halves of the body are particularly damaged. That can be really quite high these days, and people are still surviving. So it’s about how to secure a good functional outcome for these young men, how to help them to heal as best they can, and then, in the longer term, how to provide them with whatever support, be it at one end prosthetics, at the other perhaps, in some cases, longer-term nursing, particularly if there are head injuries involved as well. The thing is to ensure that that support is delivered to them, and then carried on in the longer term.

From our perspective, we will not look to discharge people until we’ve got them to the best level of functional ability that we’d hope we would do. The work we have been doing at Headley Court, where I know you have also visited, is an example. Some of the high-level casualties we would absolutely expect to be with us for, say, three years, to ensure that we’ve got them to that best possible level.

Q313 Chair: Yes, we did visit Headley Court, and, as ever, it’s breathtaking in its ability and scope. Is the level of activity at Headley Court sustainable? What do you think will happen to Headley Court when Afghanistan finishes, from the point of view of British troops?

Surgeon Vice-Admiral Raffaelli: Okay. Yes is the answer on sustainability. The core business for Headley Court, even today, remains dealing with the large number of soldiers, sailors and airmen who incur muscular-skeletal and other injuries. That is still about 70% to 75% of their daily activity, and that does and will continue. We have been modelling with DASA over the last-well, we do it all the time. We regularly model on what the capacity and capability requirements of Headley Court are. Last year, we put in a temporary ward to uplift the high-level beds to 96, and recently we submitted a new statement of requirement to the new Defence Infrastructure Organisation, with the intent of increasing capacity in two increments, between October and early next year, to 144 high-level beds.

We are not pressurising that point just now, but we were looking at the casualty rates and the in-patient rates to Headley Court. As the casualty spectrum has changed, the critical new factor is the dwell time that we are keeping them in Headley Court before they’re discharged. This is partly because we’ve not had enough time yet-we’re not discharging at the rate that we will in due course-but also because some of the other arrangements are developing. As I said, we will not let people go until we are comfortable that we’ve got them to a level that is appropriate. On that basis we are incrementing its size over the next year to sustain it, and we will continue to take that view.

Q314 Mr Havard: This is a question about those who are injured on operations-including casualties in the field, as you’ve been describing-and those who are in service and injured otherwise, or have developed general health problems. Could you say something about the differences between those two, or whether one learns from the other and helps to support improvements across the piece? What is happening?

Surgeon Vice-Admiral Raffaelli: In terms of how we deal with them or treat them, we treat them all exactly the same. They get whatever they require medically. It’s a clinical driver; that’s the requirement. When it comes to the discharge at the end point, again, they are treated the same. General Rollo will be the one to talk about the Army recovery capability and the rest, but through the medical boarding systems, which I ran when I was in the Navy and have overview of, they are treated in entirely the same fashion. Part of the process is for the medics to predict the outcome and how long it will take to get there. But then it is the command side that takes the decisions on the longer-term employability of the individual.

Q315 Mr Havard: Yes. One thing that strikes you at Headley Court is that the people there are at work. They are still in the forces; there is the esprit de corps and that sort of thing. That is great for those casualties who were injured on the battlefield. What about the same sort of process for the rest of the people, who are injured and physically unwell?

Surgeon Vice-Admiral Raffaelli: That is a very good point in terms of rehabilitation. There is something we do differently from the NHS, which for very good reasons focuses on the individual. Given our occupational and regimental approach to life, we have found an approach that works for our people, though it is not necessarily transferable. We maintain that command and control and use group dynamics to bring a lot on. That camaraderie and a little bit of competition help them to use that class approach to all of the rehabilitation, whether in our primary care facility, our regional units or at the top of the pyramid at Headley Court. That is the same for all of them. Even the seriously injured ones, though they often need individual care at specific points during their care pathway, as soon as they are able to get into group classes, that is what we move to do.

Q316 Chair: General Rollo, would you like to add anything?

General Rollo: Not on the policy point, which has just been covered. Our view is that we should treat all our people the same, certainly as far as medical care is concerned, but also employment. It is too difficult otherwise. Your best man may be injured on operations or he may come back and be injured shortly afterwards-or before-in training. It would be neither fair nor efficient to do anything else.

Q317 Mr Havard: One reason for the question is that we are looking at the Covenant and a particular part of it, trying to break it up. We have started with casualties. We recognise that they are unwell and that they are casualties not just because of the things that are obvious. Everyone concentrates on aspects. We want to try to deal with all the people who serve, if it is in relation to a general commitment to them, as opposed to when they are in a particular place.

General Rollo: But I would emphasise the Surgeon Admiral’s point. The vast majority of people at Headley Court, now and when not on operations even more so, have non-operational injuries. They are the everyday wear and tear you get from pursuing a pretty challenging lifestyle.

Q318 Sandra Osborne: Admiral Raffaelli, will you give us your opinion on what types of mental health problem are emerging in those who have served on operations?

Surgeon Vice-Admiral Raffaelli: There are three groups, if you like. The public perception, understandably, is of conditions such as post-traumatic stress disorder, which is a particular issue with us. We monitor this very closely. I know you have spoken with Simon Wessely. There is also Defence Analytical Services and Advice, and our own departments of community mental health. The PTSD rates we are seeing just now are-in broad terms, as far as we can tell-very similar to those that exist in the general population, so somewhere between about 3% and 7%.

My hesitation is partly because there is not great data for the general public. It has not been looked at for a good number of years. Based on what we know from previous studies-there is nothing to suggest that has changed-that is a true statement. We know that within those numbers there are some groups that are slightly higher than others. Those who have been directly involved in combat-not in every particular cloth that they come from-are none the less higher. There have been some slightly higher levels in those in the Reserve grouping, and sometimes younger people and younger women. All are within that broad spectrum of general comparability with the general population. That is measured by the Simon Wessely team, who do it through a questionnaire process, so we are pretty comfortable in saying that it is an independent, scientifically rigorous approach.

We also measure very regularly, putting it into DASA’s hands, which does it independently. We look at referrals to and diagnoses within our departments of community mental health. We have our consultant-led psychiatric teams. The numbers there are actually lower. In our last group numbers, we had 66 cases confirmed as PTSD, which is about a 0.3 per thousand rate over that three-month period. The reasons we think it is lower are slightly speculative. We think there are two reasons. Simon Wessely’s work involves self-declaration, which brings a bit of fuzziness, but may also be a more frank admission.

One area where we are working hard across the military spectrum is to make it absolutely clear to people that a mental health problem is no less worthy, if you like, than a broken ankle. We are working hard at ensuring that stigma is not an issue, so as to encourage people to come forward. There may be some people who don’t come forward to departments of community mental health. Using Simon’s measures as a benchmark has given us a feel for that. As I say, we are doing what we can to de-stigmatise that. We have approaches to try to minimise it and use non-medical approaches, allowing people to come forward.

As a result of the work that Andrew Murrison did on "Fighting Fit", we are working with the Department of Health and are in the process of introducing something called Big White Wall, which will be a self-referral into a carefully run, properly governed internet facility that will be open to serving people, veterans and families. Within it, they will be able to get advice and be signposted to what is appropriate for them. That will be the first issue.

PTSD is certainly something that our people will see. However, despite what we are asking these men and women to do, it is at a low level. We take it seriously and monitor it both in-service and thereafter. As long as we continue these high levels of operations, there is a population that is continually at risk, so we have to keep doing that and keep an eye on whether some people may present later, for whatever reason. At this stage, there is no evidence that there is either a tidal wave or an iceberg, but we need to keep monitoring it and not relax until we are in a position to know whether that is appropriate.

Much more common are general mental health problems, such as depression, anxiety and the rest. They are absolutely comparable to control groups of ex-service people, non-deployed people and the general population. The one area where we do seem to present more often in our age group-that is, below the age of 35, after which they return to normal-is alcohol usage. I use the term "usage" quite carefully, because there is a wide spectrum: alcohol usage, excess alcohol, alcohol abuse, alcohol dependency, alcoholism. The measures don’t really differentiate between them. There is a relatively low threshold in one sense at which you become a positive, but using that same marker, we are at about 13%. That is a couple of times above a comparable group in the general population might find.

When they deploy for six months, they don’t drink for six months. When they come back, they have a go at it. There is a degree of binge drinking. What we are not seeing is frank alcohol-related diseases of a level that would be indicative that it was a major problem, but we have to be cautious again, because the time lapse for this younger group in developing those problems is longer. We do know-again, mainly from Simon’s work, but also from work that General Bill and I do between us-that their drinking pattern returns to that of the general population by the time they are about 35. It is a complex thing and we do not have all the answers. We have a reasonable feel of where it is, and we put a lot of effort into education. From the minute these young men join us from the training park, we make it absolutely clear that they understand the danger of alcohol.

The forces have had a history of not being averse to alcohol in a lot of settings. We have moved on a fair bit from that, I think. A recent article in Soldier magazine went back to the stigma thing, where people with problems have come forward and spoken. We of course retain the command ability. If someone is causing problems, we can command them on to an education course. We can’t enforce treatment and would never do that, but we are doing as much as we can at present to ensure that they understand the consequences for them, the regiment and their buddies on deployment, although they do not drink on deployment. It is a complex issue, but that is one part we still need to do some work on.

Q319 Sandra Osborne: Can I ask General Rollo about the King’s research? It points to the fact that, where harmony guidelines had been breached, there was a possibility of an increase in PTSD, alcohol problems and so on. What account have you taken of that?

General Rollo: The first thing to do is to try to avoid breaching harmony guidelines. They are guidelines, and they can be broken if there is a good reason to do so. The current rate is, by historical standards, quite low. I think it is 0.8% for the Navy, 5% for the Army and 2.6% for the Royal Air Force. If you compare that to the past, in 1998 and 1999, when we went into Kosovo, it was about 50%. Why would we do it where there are scare skills? We would use volunteers wherever we could, but it does sometimes happen. However, in overall terms the rates are quite low.

The other point that Simon Wessely brought out was that in some cases it wasn’t the breach of harmony guidelines; it was the unexpected breach of them. I can think back to some American examples where people who had just done their 12 months were suddenly told, when their kit was on the ships, that they had to turn around and go back for another three months. That was clearly a tricky call, but luckily for us we are not normally in that boat.

Q320 Chair: May I interject here? You mentioned the question of people volunteering to breach harmony guidelines. Are there any data on whether there is less consequence for a voluntary harmony guideline breacher than for someone who is forced to breach harmony guidelines?

General Rollo: Chairman, I am not aware of any, but I can come back to you on that one.

Q321 Sandra Osborne: Are people who have been physically injured more likely to suffer from mental health problems as well?

Surgeon Vice-Admiral Raffaelli: There is good evidence from other sources that physical trauma, or indeed just general illness, leads to an increased potential for mental health problems. That would cover all of them. We do not have any direct evidence. Simon’s team have been doing some specific work for us to look at that, and I understand they’re on the edge of publishing some more data. The peer journals that publish these things get very nervous of early discussion of it.

We have also been monitoring our seriously injured people very closely from the time they get back, from Role 4 at Birmingham through into Headley Court. Initially it was pure audit work to ensure that these chaps were okay, and that was all very positive. It has now reached the stage where, about six months ago, I commissioned a formal prospective study to look at those high level casualties and chart their mental health outcomes and how it goes through. It is time that we did that. The hesitation previously was always that the psychological assessment tools are frankly pretty broad brush. The sensitivity and specificity is sometimes not as crisp as we would like, and not all of them have been validated either in our cohort, or in these kinds of high level patients.

Of course, what we do see-you’ll have seen it at Headley Court-is that life is labour for these chaps. But the overwhelming impression you get from our clinical staff who are with them day in, day out, is that their cup is actually more than half full more often than the other way around. They are very positive. Following through in the longer term is where I think our particular duty and interest must lie.

Q322 Sandra Osborne: We were very impressed by the morale-if I can put it that way-at Headley Court. It was really quite humbling to see.

May I ask about people who have been in multiple deployments? Some of the research from King’s shows that, for example, family problems at home and the effects of family on people who’ve been deployed are big factors. What about people who have been deployed on multiple occasions?

Surgeon Vice-Admiral Raffaelli: One thing that Simon Wessely and Nicola Fear’s research has shown is that these things are incredibly complicated, but adverse circumstances, or difficulty at home, is probably one of the single biggest contributors to the challenges that people then find when they are deployed. It is very inter-relational. Indeed, one of the areas that we have had endless discussions about is that today, in this communication age, the contact with back home is really, really regular. I spent my younger days in nuclear submarines; when you left the wall no one spoke to you for three months, and there were no other problems. It was remarkably easy to do. But it’s not that way today. It is a very complex cycle, and when you have that back-and-forth stress you can see that if someone goes away multiple times, especially if there isn’t time to step down in between, that can compound itself. But there are no really hard data; that is a serious problem. We are certainly concerned that you can see that being added to. I don’t know if General Bill wants to add anything?

General Rollo: Common sense leads you to think that there would be a rise in PTSD, particularly for people in exposed places over multiple deployments. As far as I am aware, the evidence does not show that at present. In terms of families and the interaction that Admiral Raffaelli mentioned, I agree. The mental health surveys we have done show clearly that a significant factor in mental distress in theatre can be problems at home, as you would expect, because you feel very helpless stuck out in the desert somewhere when you know there is a problem at home that you cannot do anything about. Knowing that families are properly looked after is a really important element of operational effectiveness.

Q323 Mr Havard: People say that Reservists are worse off when they come back because perhaps they are more isolated or have less support. I do not know whether there is any evidence of them being any worse off. Have you done any work on that? If there are particular difficulties for them, what preventive measures are being put in place to deal with it?

General Rollo: Do you want to start with the evidence, and then I’ll come in with what we are doing?

Surgeon Vice-Admiral Raffaelli: Within the spectrum of mental health problems that I described at the beginning, Reservists are one of the groups that show a higher level of problems. There is a measurable effect, but it is relatively small.

Q324 Mr Havard: But there is a measurable effect?

Surgeon Vice-Admiral Raffaelli: There is, but there are Reservists and Reservists. Those who are deployed in groups and in different command structures have a different spectrum from those who would be completely on their own.

Q325 Mr Havard: One-off augmentees, or something?

Surgeon Vice-Admiral Raffaelli: Absolutely.

General Rollo: When the figures first showed that there was a slight increase in the instance of mental health problems in Reservists, it was back during Telic 1 in 2003. Our supposition then was that it had something to do with the fact that we called people up at very short notice, landed them among groups of people whom they did not know and with whom they had not trained. Perhaps not surprisingly in those circumstances, they had a greater instance of mental problems. Then you come back to the aftermath and the fact that support mechanisms for individuals coming back into civilian society were not developed.

Since then, we call people up on a much more structured basis and do so well ahead, so they can train with the people with whom they will deploy and integrate into teams. When they finish, they go through the Reserves Training and Mobilisation Centre. There is a mental health briefing session there, where people who feel they have problems can put their hands up and that is followed up.

We are also better in terms of the focus by Reservists’ commanding officers on looking after the Reservists when they come back. They have to have the same mandatory stress debriefing as Regulars, and there is an allowance within the number of training days for that to happen. It is quite clear that it is for commanding officers to ensure that it happens. They are much more focused than they used to be on the fact that individuals coming back really have to be looked after and have an arm put round them.

None of that detracts from the fact that when they go back to work, they are among a group of people who have not gone through the same experience. That applies to a certain extent to the Regulars-if you are an individual augmentee, you go back into an organisation that has not been deployed, which is more difficult than when you come back with your regiment.

Surgeon Vice-Admiral Raffaelli: All I would add is that even with recognition of that, we have put in place some additional support mechanisms should people develop a problem later. There is a mental health programme at Chilwell, to which the Reservists can be referred at any time, and, if required, they can be referred to the medical assessment programme at the Baird health centre.

We recently collaborated with the Department of Health, the Royal College of General Practitioners and the Royal British Legion to give an information booklet to GPs, which does not focus solely on Reservists, but includes them, so that GPs have a wider perspective. Hopefully, if they turned up anywhere with problems, they could be linked back in and access the programmes. If they access any programmes, they are entitled to come back to our departments of community mental health, because we can provide a level of expertise and empathy. That is open to Reservists, should they be among the unfortunate ones who have a problem.

Q326 Mr Havard: I want to come back to that on a later question about the continuing arrangements, particularly with the NHS.

Q327 Sandra Osborne: Can I ask you about the identification of people who are experiencing mental health problems as a result of being in operations? Is the MoD good at identifying that and how is the use of TRiM working out? What has been the impact since it was introduced?

Surgeon Vice-Admiral Raffaelli: There is a whole end-to-end approach here. Really from the minute people enter the Services there is a large educational process to make people aware of what they may be expected to face up to and the normal responses that they must recognise and not be frightened about. That is repeated in all parts of leadership training so that people can first of all contextualise what is happening to them. The trauma risk management programme was introduced initially with the Royal Marines and was specifically aimed at not medicalising what can just be really quite large emotional responses, but ones that are normal. If you lose someone in your family in a bad car crash, you have the same kind of grief, loss, anger type responses. So the TRiM system is essentially a peer support mechanism that takes people through the incident they have been in and analyses that to a degree. It does not get into the medical parts, but reminds people of what issues there may be and, equally, what issues may persist that would be beyond the typical range and may require further help.

All the evidence that we have is that it does not cause any harm. That is an important statement. People used to do something called critical instant debriefing, when you would throw a counsellor at someone who is in a crash. We know that that caused problems. There is an eminent study in the States of survivors of air crashes; a year afterwards people had greater psychological problems. We are categorically not getting that. What is very difficult, however, is that we are not putting on a control group with this. When they tried to do that some years ago, when I was researching in the Navy, we had a large number of naval ships that did not then do anything operationally. So it did not work. It would not be ethical to do it today. So we are confident that it does not cause any harm. We are happy, as we have described, that the outcomes that we are seeing in terms of mental health are pretty good, given the circumstances we are in, so it is something we are keen to continue with. The feedback we get from people is that they feel it is a very useful process.

General Rollo: May I build on that for a second? As SG has said, the key issue is that it is a reduction in stigma-a reaction to an unpleasant incident is normal. Within the Army very frequently now it is the Company Sergeant Major who is trained as the TRiM counsellor. That in itself sends a very clear message that this is not something that is soft in any way: the hardest man in the company is responsible for it. When you talk to a group of warrant officers, they are very focused on this, as indeed is the chain of command. They want to know more. They understand what it is for and they understand very clearly its benefits. You are talking to people who have now had repeated operational exposure. They know what they do. They know what they are going to have to face and they know what they need to do to help people.

When people come back-I won’t go through the mechanics of the process-there is a system for monitoring those who have been exposed to particularly unpleasant incidents and for checking up on them at regular intervals to see whether they improve or not. It is normal to have the reaction. It is normal to improve. If you don’t improve then you need help. The chain of command is very focused on providing that. We are lucky. We have no queues for access to mental health care. The system works well, I think.

Q328 Mr Havard: In the process there is a sort of three-day thing? Somebody has been exposed to something and you say that that person needs an intervention. Then there is a review in three days’ time. The process is that the management-the chain of command-makes an evaluation after three days. That seems to be a period in the process. Is that just an organisational thing or is there a particular reason relating to the manifestation of a problem?

Surgeon Vice-Admiral Raffaelli: It is not tied into the manifestation.

Q329 Mr Havard: There is not a medical reason for it?

Surgeon Vice-Admiral Raffaelli: It is not a medical reason. It is just a sensible process time frame.

Mr Havard: Okay.

Surgeon Vice-Admiral Raffaelli: But then we have a follow-up system thereafter. Everybody who is deployed is then interviewed by the commanding officer 30 days after the deploy; not to go through TRiM as such, though it would include those, but to ask if there are any issues and problems at that kind of level.

Q330 Sandra Osborne: May I ask Claire Phillips, how effective is the National Health Service in comparison, in providing support to people who have been deployed?

Claire Phillips: It is an area where we have made huge improvements. The Government recently published their mental health strategy, which is called "No Health Without Mental Health." It gives equal weight to mental health as to physical health and there is a separate section on treatment of veterans-as there was in the previous Government’s mental health strategy. We have invested £7.2 million in this spending review period to implement the recommendations that Dr Murrison made in his report "Fighting Fit." There are several components of that. One is that there is a real uplift in mental health capacity for veterans, so we are establishing specific posts all around the country with people who have specific expertise in dealing with veterans’ mental health. That is a partnership between the NHS and the third sector. It is actually Combat Stress that we are working with, so that is an important development.

We recently established a 24-hour helpline through Combat Stress. The contract was given to Rethink, who have a lot of experience in this field. We have received nearly 3,000 phone calls, which is quite a lot, within the first three or four months. The Surgeon General mentioned Big White Wall. That is an online therapeutic community, if you like, that is open to veterans, to serving personnel and indeed to families. We are trialling that; that is at a fairly early stage at the moment. Help for Heroes have put some funding into that, so it is at an early stage, but we will be launching a full service for veterans on Big White Wall within the next couple of months. That will be important.

We have commissioned the Royal College of General Practitioners-who are absolutely crucial in this-to develop an online learning facility to tell GPs far more about veterans and to be more aware of the sort of issues facing them, and indeed those in the Armed Forces and their families in particular. We are setting up a Veterans Information Service, whereby veterans will be asked 12 months after they have left how they are feeling, telling them about what sort of services are available locally and asking them whether they need any help. We will be trying to do that in an open and engaging way and trying to overcome the problems of stigma that have been identified already and the delay in help-seeking that we know men in particular are prone to. That is a problem for men in the whole community, not just veterans, but veterans may be even more prone to it.

We are also doing specific work with veterans to make sure that they are able to access NHS services. So all of Dr Murrison’s recommendations were accepted in full and we aim to implement them very rapidly with our partners in the third sector, and of course in MoD.

Q331 Sandra Osborne: Finally, I believe there are ongoing pilots with regard to supporting Reservists once they have been demobilised. Is that correct and can you give us any feedback?

Surgeon Vice-Admiral Raffaelli: In what particular sense?

Q332 Sandra Osborne: The pilots for the support of Reservists post-demobilisation, as I understand it.

Claire Phillips: I think the Surgeon General has already mentioned that there is a mental health service for Reservists and that has been going for some time.

Surgeon Vice-Admiral Raffaelli: In the last year or so we have run a number of veteran support pilots around the country. There is one in Scotland, which was Veterans First, for example, which was reported on by Sheffield University. That was done in collaboration between the Ministry of Defence and the Department of Health and the Devolved Administrations in each area. They were all slightly different models and they ranged from a veterans’ drop-in service to a more specifically focused one in Edinburgh and the direct link into Midlothian’s mental health services. They had military experience front of house and people could get access to services. That is what you may have heard about.

The report from that was really quite positive and we are now working with the Department of Health on how to take the lessons learned from these quite different pilots and decide what is the best model to go ahead. They are still running at present-I think virtually all, if not all of them-

General Rollo: They had a two-year life originally.

Surgeon Vice-Admiral Raffaelli: Yes, so we are analysing the lessons learned to carry that on.

Q333 Mr Havard: That chimes in partly with what I want to ask about: return to civilian life. One of the questions that everyone struggles with is how you sustain these things over periods of time. The life-changing injuries that some people have mean that they will need particular support. You would get it the same as I would. The people at Headley Court will say that they have all these fantastic new limbs and state-of-the-art equipment, but they are concerned that in 15 or 20 years’ time they will have state-of-the-art stuff that is not state-of-the-art any more. How does a £15,000 limb get replaced? There are particular questions of sustainability for such individuals, but it raises the broader question about the Transition Protocol and the sustainability of all these mechanisms.

Surgeon Vice-Admiral Raffaelli: This is something that all three share.

Q334 Mr Havard: Absolutely, and one of the questions that I would like to get to at some point is consistency or coherence of application across the UK, given that there is a devolved structure.

Surgeon Vice-Admiral Raffaelli: The point is absolutely critical. We recognised some time ago that the cliff-edge, immediate handover was simply not acceptable. We have been working in real partnership to have an earlier reach in from the Department of Health so that there is a sloped handover. The focus is individual case management. We have been running some pilots to test that with individuals, and some of those have been completed. We have been trialling things: for example, there were a couple of guys who no longer needed to dwell so much in Headley Court but were not yet ready to leave service. We worked with the relevant PCTs, which took up the community care, the ongoing physiotherapy and so on. There will not be one answer for all cases, because they are all so different, and the family circumstances are different as well. When we talk further about transition I will hand that over to General Rollo.

If we talk about prosthetics, for example, after his previous work Andrew Murrison’s next target was quite rightly prosthetics. Very helpfully, Mr Mike O’Brien had made the commitment that veterans would get not only the same level of prosthetics, but whatever was used in the future. That was a very positive statement from our perspective, and clearly it was a challenge for all.

Dr Murrison’s report is due to be issued very shortly, and it is absolutely core. The answer, I am sure, will be partly similar: to work together so that everybody understands what we are using, what the functional benefits are and what the outcomes are, and to work with the Department of Health and the Devolved Administrations to ensure that that same level of support can be provided. It is not just about the replacement C-Leg at £15,000; there is the socket, and a skilled prosthetist is required.

Although the gross numbers of trauma in the NHS are much greater, the number of multiple amputees is thankfully much, much lower. There will be a similar issue to the one that we have seen with major trauma centres. If you are really seriously injured, you ought to go to a leading consultant who has seen a lot of patients like you in the past week. There will have to be some kind of approach to it, and I know that Andrew Murrison is looking very hard at recommending a way ahead on that.

General Rollo: Can I pick up on the Transition Protocol? Over the past two to three years, as we have-in many ways fortunately-had a number of unexpected survivors who are really very seriously injured, it has become clear that we really have to get this right. The answer could not be to stay in the service for ever, but equally we absolutely could not have an unsatisfactory transition, hence the pilots. Claire will, I am sure, expand on this in a second, but the key lessons learned from them are actually fairly straightforward. You need to start early, you need continuous engagement and you need to have single points of contact who are there consistently right through the process. I am absolutely sure that there is also a piece about looking after the family as well as the individual. That is really tricky stuff, and every case is different. It is very hard to meet everybody’s expectations, but that is clearly what we have to try to do. I will pause there, but I would be very happy to come back to the wider subject of transition in a minute.

Claire Phillips: We have set up a training system, and we have had three or four joint sessions between people in the military, NHS people and local authorities who are responsible for adult social care. We have applied the principle of continuing health care to people at an early stage, so, as soon as somebody is admitted to Headley Court, we should be planning for their discharge. They need to decide where they are going to live and so on, once they are discharged from the Armed Forces, if that is what happens to them. As I said earlier, we have established the Armed Forces networks all over the country. We have 10 such networks that bring together the military and the NHS. They are led by an Armed Forces champion in every strategic health authority and that situation will carry on, even when the SHAs are clustered together. That has been a very important part of the way we have worked.

We have learned a lot from the pilots that we have run over the last year or so. Key things include having that single point of contact in the military, as well as far earlier engagement, and there has been quite a lot about language. We speak very different languages in the military and in the NHS, so we have had to learn something about one another and to try to avoid using abbreviations and so on. It is obviously a multidisciplinary approach. Clearly, the person in the military will have to engage with everybody-not only within the NHS, but within local government-who will need to provide social care support. That is all very important, and communication is key.

One of the challenges, as General Bill alluded to, is care of families and managing their expectations. There is no doubt that their loved one, when they are still in Headley Court, gets the most fantastic care, and all the transport is paid for and so on. There is something about managing families’ expectations, so that when that person leaves, the family is prepared for the level of support that they will receive. That is what we are doing. We will have further training as required, but there is a lot that we are learning from the first few people-six or eight, I think-that we have put through the protocol so far.

Q335 Mr Havard: Earlier, you alluded to GPs, and a booklet for them. We have other issues that we are trying to discuss, such as how you track people over time, or that some people do not want to be identified, while others do. There is a whole series of monitoring issues and so on that are bigger than just this immediate area, but questions are raised about enduring social care, particularly in a devolved environment.

The description you have just given is of the English health service. I wonder whether you can help me; I am from Wales-I do not even understand Wales, never mind England. The question is that the commissioning arrangements will be very different, as will the enduring arrangements. If there is a central commitment in a covenant to-at least-a consistent application, if not a uniform application, how will we see that the transition model works for everyone who leaves? It is not just those who are immediately severely injured who have been through Headley Court; there are also all those who have served, however injured, or however ill. Can you perhaps help? I know you know will not have an exact answer to any of that.

Surgeon Vice-Admiral Raffaelli: I think that I can partly answer that. We have a Ministry of Defence and Department of Health partnership board that is co-chaired by myself and Sir Andrew Cash, on which the Devolved Administrations sit. So, a lot of these discussions are also played out in that forum. We rotate our meetings and go, as I said, to the four countries. They are all different, as you say, but they are all seeking to deliver the same effect. All of them are really quite different-in some ways, Scotland is a single, unified health care delivery system, and it is relatively easy for them do it. Wales has had some challenges, but the commitment level is the same. I know, because I have seen the draft, of the work of Andrew Murrison, and he recognised those difficulties when it came to prosthetics provision. I would not like to pre-empt his final proposal, but one of his options is to look for a central, Treasury-sourced allocation to each of the four countries to address that very problem, because he was equally concerned that if there was an inadvertent diversion of committed funds for prosthetic support to veterans, that would be equally unfair. I think he has recognised that pretty clearly and come up with a proposal to address that concern.

Claire Phillips: Could I also add that the Devolved Administrations, which, as the Surgeon General said, were represented on the partnership board, have also signed up to the transition protocols? We do work very closely with them; we have several sub-groups and there is a lot of ongoing contact, as health is a devolved issue.

Mr Havard: Our concern, as you rightly said, is that it is an individual solution, an individual’s journey. Across all of that, they move around as well. They are not all just from Wales or England or wherever. Some of them are in Germany at the moment. The interrelationships between the components are something we are particularly concerned to understand is put in place.

Q336 Chair: May I pass on a concern that has been expressed to us in this Committee, but also when we visited Queen Elizabeth Hospital? It is an issue not just for the NHS, but for the Armed Forces and society. There is a concern, quite strongly felt by some of the very badly injured veterans coming back. They feel that it may be fine at the moment, while attention is on Afghanistan, while the deployment is in place, and it is in the headlines day after day. However, in 20 or 30 years, when they are older and Afghanistan is an item in the history books-I should touch wood as I say that-and when the younger people doing most of the funding were not alive at the time of the conflict in Afghanistan, how will they be sure that they continue to have the medical support, for both mental and physical injuries, that they look to get in the immediate future?

Claire Phillips: At the moment we are developing a mandate between the Government and the NHS Commissioning Board, which will be responsible for commissioning services for the population in England. We hope that there will be something in the mandate about the Military Covenant. The Military Covenant is obviously intended to be a long-term arrangement in place for some time. There are also long-term provisions, such as priority treatment, that we are trying to publicise and raise awareness of among GPs. There is often a long delay between somebody leaving the Armed Forces and developing any of the problems we are talking about. That entitlement to priority treatment remains, although it is subject to clinical need being appropriate.

I hope that, by having something in the mandate and in contracts with providers through clinical commissioning groups and so on, those needs will be met in the long term.

Chair: We will all have to keep our eye on that. General Rollo.

General Rollo: There is one way in which that might occur, though it is hard to predict exactly how things will work in 20 years. The annual report on the Covenant seems to be something that could easily be used to focus on that area, among others. It would require the Secretary of State to report annually on how that is working. If that is something that endures, it could be a useful mechanism for keeping this in the public eye.

Q337 Ms Stuart: Thank you. With General Rollo particularly, I want to explore a bit further the support we give to the families of the bereaved and injured. We visited one of the Norton Houses last week, and we know that up at "the Q" they are going to build a Fisher House. Provision has improved continuously. My two questions are: where do you think we could still make more progress? The second is more specific. There was talk at one stage of a specially dedicated coroner, which is now no longer on the statute book as I understand it. Do you have any views on that?

General Rollo: In reverse order, we have a clear interest in supporting families through the inquest system, and we do that in conjunction with the British Legion and the lawyers it employs. We also have a system for providing coroners with background into military structures and the nature of operations. We also have-we have put in place, first in the Army and then on a defence basis-the Defence Inquests Unit, which you may have come across and which is designed to make sure that, without rushing in any way, we provide the evidence that the coroners require in a timely fashion so that things do not drag out.

Q338 Ms Stuart: But my understanding is that when that was set up in 2008, it was meant to link up with a specifically dedicated coroner.

General Rollo: I do not pretend to expertise on that subject. I have a general personal interest in a coroners system that works as well as possible. How to do that is not my speciality.

Q339 Ms Stuart: On the more general question of whether we could do more to support the bereaved and the families of the injured, one thing that was mentioned in Queen Elizabeth Hospital was from someone in the Reserves, who said, "My company never acknowledged the fact that I’m here as an injured soldier."

General Rollo: By "company", do you mean his commercial employer?

Ms Stuart: Yes, his civilian employer.

General Rollo: That is an interesting one. In general, how do we support bereaved families? You will be familiar, I suspect, with the visiting officer system.

Ms Stuart: Yes.

General Rollo: That is a very personal relationship. It continues for as long as it is required. Normally, contact diminishes over a period of about two years, but it remains at whatever level the family wants it to remain, and I believe it tends to find its own level. In addition to that, there is a defence bereaved families support group, which is run through SSAFA and which we support. They have focused on the things you would expect them to, I think, including inquests.

How could we do more, and what is the aim? The aim must be, I guess, for people eventually to move on. I think that that is a very individual process, and there are limits to what we as an institution can do to help. What we can certainly do is make sure that we do not get in the way. Over the years, we have moved a long way from the 1945-style treatment of casualties that, frankly, was still around even 10 years ago.

Q340 Ms Stuart: That is very helpful. A quick question to Claire Phillips. Do you notice an increase of incidents of domestic violence in families where one member has returned from operations?

Claire Phillips: It is a subject that I am very interested in, as I am responsible for policy on domestic violence. It is something that I have discussed as I have gone around military bases, and it is something that is taken incredibly seriously within the chain of command, by welfare people on site and indeed by the military police found on those sites, but the evidence is lacking, I am afraid. It is very difficult to see whether that is the case or not. One expects some increase in the general level of domestic violence in the current economic climate anyway, but as I said, the evidence is lacking.

The Ministry has just published a domestic violence policy for all three Services. That is in response to the cross-Government action plan on violence against women and girls, and there is a cross-Government inter-ministerial group on violence against women to which the MoD belongs, but as I said, what is lacking is the evidence, I am afraid, so it is quite difficult to answer that question.

Q341 Mr Donaldson: Air Vice-Marshal Murray, the MoD memorandum said that there had been a step change in the amount of charitable funding on offer to the Armed Forces. How much additional funding have you received, and are you able to make use of that money from the charitable sector in a sensible way?

Air Vice-Marshal Murray: I think so. There has been a significant change in both the amount of money available and how we have addressed the use of it. Traditionally, our relationship with the charitable sector has really been one of dealing with charities that deal with veterans. We now deal far more with charities that are very interested in serving personnel. The money has not come to the MoD; traditionally, it has been spent by the charities on their own people and their own constituents. Now that we have more interest in the serving servicemen, we have set up mechanisms internally so that we can focus on what we actually need. For example, we run a small organisation within MoD with representatives at a high level from the Army, Air Force, Navy, the medical side and the charities-particularly Help for Heroes, the Royal British Legion, SSAFA and so on. When we recognise that there is need for a particular thing to be built or to happen, we see whether it can be funded internally within the MoD. If it cannot, we have a conversation with those charitable organisations-in some cases they are very well endowed-to see where that money should be best spent to make sure there is no duplication, that we are not spending charitable money when it should be public money, and vice versa, and that we are not, as we almost did at one stage, about to build something for the Air Force 10 miles away from a very similar facility for the Army. We have those conversations in terms of priority and of focusing the money where it is best needed for social and medical reasons.

Q342 Mr Donaldson: How much additional funding has been received from the charitable sector?

Air Vice-Marshal Murray: In the context of this particular issue, we have received, or been promised, about £50 million from the British Legion, up to £100 million from Help for Heroes-that is £70 million actually promised, with another £30 million out there-and approximately £10 million from other smaller charities.

Q343 Mr Donaldson: So is that roughly £160 million all together?

Air Vice-Marshal Murray: I suggest that it will be rising towards £200 million.

Q344 Mr Donaldson: For capital projects, how will you cope with operating and maintenance costs? Will the MoD be able to replace the capital assets at the end of their lives?

Air Vice-Marshal Murray: Part of the conversation that we have when we set up a facility is who is going to be paying for it-who is going to pay to maintain it, who is going to pay to man it, what is its longevity, and what happens at the end of 10 or 20 years when that charity might no longer be around or might no longer wish to fund or support that activity. That is where we bring in our infrastructure experts. We have conversations with the Treasury to make sure that it is comfortable with what we are doing.

Q345 Mr Donaldson: Is the charitable sector now funding programmes that the MoD would previously have funded?

Air Vice-Marshal Murray: I would not say that. I would say that there are some activities that we would have liked to have funded ourselves but for which we haven’t got the money, and that is where they step in.

Q346 Mr Donaldson: So they are funding some programmes that you are not able to fund from your own resources.

Air Vice-Marshal Murray: That is what charities do. We look to see where we should be funding it and where we would expect to fund it. It is not the "nice to have", but the going the extra mile stuff where they get involved.

Mr Donaldson: Vice-Admiral and General, what has happened to your budget for health care and support in the past few years? What are your expectations for future budgets?

General Rollo: Just to make clear the split of responsibilities, ultimately the chain of command is responsible for everything, but in particular it is responsible for health policies-things that prevent people getting ill. In many ways, that is normal chain-of-command activity. It is keeping people fit and healthy, and the normal support systems will do that. There is no separate health budget in the way that your question might imply. The cross-over point is some aspects of mental health and mental health care. Ministers have repeatedly made quite clear to us that, despite the overall financial situation in the Department, mental health care is a priority and we are to say what we need.

Surgeon Vice-Admiral Raffaelli: I am responsible for health care delivery and medical operational capability, some of it directly through my joint units, and some of them with process ownership across the three single Services. I have visibility of the end-to-end piece. We are one of the few areas during the SDSR that actually had additional funds committed, for exactly the reasons that General Rollo referred to.

Q347 Mr Donaldson: Do you have a fund for research? If so, where do you spend that money, and are you still able to continue funding the King’s research?

Surgeon Vice-Admiral Raffaelli: There is a mixture. There is not a single approach to research funding. If I start with the last question first, we are going to continue-it is a shared responsibility. The King’s research is essential and will continue. We talked earlier about what we have done recently. In partnership with the Department of Health and the National Institute of Health Research, we have opened the UK’s first trauma unit up at Birmingham in partnership with the UHBFT in the University of Birmingham to look at surgical reconstruction and microbiology. That is a new initiative. It was formally opened at the beginning of the year, but the actual doors will open this month coming. I have a small research budget within my medical director area.

We also fund a large number of our people as part of their own development to be clinicians or senior nurses or whatever, and we have a programme to target masters degrees and even PhDs in areas of particular relevance to us. We also bid through the science and technology total research budget, which is something in the region of £385 million a year. A lot of that goes on equipment, but a component of it, which is not set aside as such, goes on human factors in their widest sense. That includes medical combat casualty care, personnel matters and men fitting into aeroplanes. We bid quite comfortably through that.

We also collaborate very much with our international partners, particularly the Americans. For example, their Department of Defence has recently invested in the Simon Wesley team to look at some screening for mental health purposes, families and post-deployment. We are a non-screen population. There is a multiplicity of sources. We always want to do more. There are a number of avenues that we cannot pursue, but the core things are being addressed just now.

General Rollo: If we look ahead, I think that COBSEO’s success in the lottery funding for a very substantial programme-Forces in Mind-which it intends to use for research in future, will clearly reach across, particularly into the veterans area, and that will allow us to be much more evidence-based in the future.

Chair: It sounds as though it helps to have a Secretary of State for Defence who is a doctor.

We had better bring this to an end. Thank you very much indeed to you all. I am sorry that we have not allowed more time, particularly for you, Air Vice-Marshal Murray. You did not have quite as much time as you may deserve, but we have particular goals for this evidence session and we are very grateful to you for helping us to fulfil them.

Prepared 8th July 2011