Welsh Affairs Committee - Minutes of EvidenceHC 131

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Oral Evidence

Taken before the Welsh Affairs Committee

on Tuesday 13 March 2012

Members present:

David T.C. Davies (Chair)

Stuart Andrew

Guto Bebb

Geraint Davies

Nia Griffith

Mrs Siân C. James

Karen Lumley

Jessica Morden

Mr Robin Walker

Mr Mark Williams


Examination of Witnesses

Witnesses: Ian Hulatt, Mental Health Adviser, and Lisa Turnbull, Policy and Public Affairs Adviser, Royal College of Nursing, Dr Julian Olver MBE, Deputy Chair of the British Medical Association (BMA) Armed Forces Committee and a consultant anaesthetist in London, and Dr Andrew Dearden, Treasurer of the BMA (a GP based in Cardiff), gave evidence.

Q45 Chair: Can I thank the witnesses for coming in this morning? We are running a few minutes late and we have quite a lot of questions. There are four of you, so I am going to launch straight into this, if I may. Please do not be offended if I speed up people’s questions and answers because time makes that necessary. Could you briefly explain-one spokesman from each perhaps-the organisations that you work for and what they do in relation to veterans’ issues?

Ian Hulatt: My colleague and I are from the Royal College of Nursing. I am a mental health adviser and my colleague is a policy adviser in Wales. Our role in this subject is twofold. We are providers of services to individuals-veterans-both in the UK and operationally. Our members will also be consumers of services provided to veterans as they will be serving in the defence forces.

Q46 Chair: Thank you very much. Dr Olver, would you explain a little bit about your organisation-the BMA?

Dr Olver: The British Medical Association is the professional body for all doctors. I am on the Armed Forces Committee. We represent and support mainly serving medical officers and reservists. We obviously have concerns about those that leave the forces and provision for their care afterwards.

Q47 Chair: Do any of you have accurate information about the number of veterans in Wales? Also, do you feel comfortable with the current definition-which I believe is that anyone who has spent one day in the Army, Navy or Air Force is considered a veteran-or is it perhaps too wide a definition?

Dr Dearden: One of the difficulties we are often faced with is that we always have estimates of how many servicemen and servicewomen there are anywhere in the UK. The last estimate that we saw was anywhere between 200,000 and 250,000 service personnel within Wales. Looking at the population of Wales, that is roughly one in 20 people. That might suggest that the definition is quite a broad one if we are talking about something that is almost as common as depression, epilepsy and eczema all joined together. It is quite a large number of people. One of the difficulties is that there is not a good, consistent way of people being recorded as veterans. Therefore, there is not an authoritative number. If you look at almost every report, it is always an "estimate", a "guesstimate" or an "approximate". The guesses or estimates being given are very similar, but the problem is that there is not a good single, consistent way to gather that information.

Q48 Chair: Do you think that this definition-one person serving one day in the armed forces becomes a veteran-creates too many people, perhaps, to help and to target help at?

Dr Olver: That definition is to qualify for a veteran’s badge, which veterans can claim. They are unlikely to have acquired servicespecific health needs from that short period. Of course, these numbers include all the national service people. The demographics of veterans is not clear. Those who have recently left the forces are perhaps more prone to having special requirements.

Lisa Turnbull: I concur with the estimate that Dr Dearden gave and also say that one of the most significant tasks of the Health and Wellbeing Service that was developed by the Welsh Government is going to be the gathering and assessment of data and also being able to draw more conclusions from it as time goes on. That is an important role for that network. It also highlights the significance of placing the services developed for veterans within the wider context of mental health services and other health services more generally. Even though there are very specific needs, there is also a broader context as people move into different facets of their identity and there are different branches and so on and forth, which may have different needs.

Q49 Mr Williams: I want to turn to the co-ordination of services and the question of who is responsible for the provision of veterans’ healthcare. In both the RCN and BMA submissions you inferred that there were unresolved issues of responsibility between the MOD, NHS, the UK Government, the Welsh Government, local government and the charitable sector. It is quite a complex picture, is it not, and, of course, that is not very helpful to the needs of the veterans. Who in Wales provides the focus for the provision of support? You have suggested that there were problems. Can you give examples of how that confused picture in practice manifests itself?

Lisa Turnbull: The picture has recently become clearer with the establishment of this network by the Welsh Government. We hope that that will increasingly become a focus for work. However, it seems that the next stage of improving co-ordination of services will be to make sure that there is co-ordination with services in local government in particular so that we can make contact with people about housing and some of the social services issues. It may be that the next stage is to develop better links between health and social services. There is a variation between services provided to veterans and those currently serving, depending on how they have left the service, and there are also services provided directly by the MOD and sometimes jointly with UK charities. There is an issue about making sure that UK charities particularly are connected in to how the services are offered in Wales. In summary, we are optimistic that the picture is perhaps improving, but there are some areas of links where more work needs to be done.

Q50 Mr Williams: But you would acknowledge that it has been confused to date. The positive step is that you are hoping that the Assembly’s initiatives will draw the different strands together.

Lisa Turnbull: Yes, in the last year with the establishment of this service.

Dr Dearden: That is probably right. One of the difficulties is that people often try and set something up to be helpful without always stepping back and looking at how it might integrate into the whole thing. Very often, in trying to involve other organisations or other bodies, it is the way that they work together as opposed to independently that is the difficulty.

I will give an example. If I have a patient who is with me, I am responsible for their care directly and I act both as a provider and a signpost to other services. I have been a GP now for 18 years, and I have never been asked for information on a person moving into the Army apart from the entry medical. That gives all the information, but I have never had anyone ring me or write to me, once the person has been admitted to the forces, and say, "Could you explain a bit more about this or that?"

Coming back the other way, when someone is discharged or leaves the forces, they are supposed to fill in a form, which they then bring to the GP, that summarises their medical history. Again, I have been a GP for 18 years and have seen three of those forms. I have written to the forces several times and now I have given up trying to get that uptodate medical information because it does not come forth. So there are a couple of areas where we could certainly improve the transfer of information, not only from the Ministry of Defence to the NHS but within the NHS itself. That is probably where a lot of the work that we could do could be done.

Q51 Mr Williams: You pre-empted, very usefully, my next question in terms of the transition protocol. Your experience has been that, certainly on discharge, the process has not been efficient.

Dr Dearden: No.

Q52 Mr Williams: It has not been effective. Why, in your opinion, has the MOD been unable to provide an electronic system of data sharing? Would that be of help to you?

Dr Dearden: To be fair, it is probably because the NHS does not have an electronic system of information sharing for them to share with, if I may be so bold. In a sense, we are now working towards having GP-to-GP transfer, which is in its infancy. Within the NHS IT, there are several providers for GP systems. We are now working not only to have each of those systems talking together but even across boundaries or borders. That is still quite young in its development at the moment. It is probably a little bit too much to ask the Ministry of Defence at this present time to have an IT delivery system that exceeds what the NHS has. For example, if someone transfers to my nextdoor practice, I have to print everything on paper, take it round and give it to them. They then take the paper and input everything back on to their computer because we do not have that kind of transfertransfer yet.

Q53 Mr Williams: Is that unique to you and GPs that you know and are working with, or across Wales can you think of any examples of local health boards that are employing strategies like that?

Dr Dearden: It is still at the IT level at the moment. There are pilots now running to develop the systems to enable that kind of systemtosystem, practicetopractice transfer. In a sense, we probably have to wait for the NHS to be able to do that before they can accept any electronic information from other people. From the Ministry of Defence, for example, it would still be good for me to have paper copies of a discharge summary. The things I expect from secondary care to primary care I should be able to expect from the Ministry of Defence to primary care.

Q54 Mr Williams: What do you put that fact down to-that over your years in practice you have only had three of those forms?

Dr Dearden: It probably would be wrong for me to comment as to why that information is not available. I could surmise. First, I do not think there is a system in the Ministry of Defence to allow that information to come easily to me. The NHS has whole departments of records, record shifting and registration and movement of that information, because predominantly it is still at a paper level in general practice.

The second thing is that some servicemen do not want you to know where they have been or what they have done. It is almost as if they want to start afresh or without any baggage. I have often had people tell me only three, four or five years later what they were part of. It is probably simply that at the moment there is not a-I will use the word-tradition of passing that information to and from the civilian and military medical personnel.

Q55 Mr Williams: Finally, specifically in terms of physically injured veterans and their discharge, the Royal British Legion has told us about new arrangements in place in England, Northern Ireland and Scotland and protocols dealing with that. Do any of you know how those systems work and whether there are plans to apply a similar protocol to Wales?

Dr Olver: I am afraid I do not have knowledge on that.

Ian Hulatt: I am afraid not.

Dr Dearden: If I may say so, probably the difficulty is that we do not have experience of those systems because they do not exist in Wales. If you would like me to, I can certainly ask the other councils and committees of the BMA what their experience is of those particular systems and we could submit that evidence to you afterwards if that would be helpful.

Mr Williams: That would be very helpful, yes.

Dr Dearden: We will make a note of that and do so.

Q56 Chair: Dr Dearden, I am slightly puzzled at the thought of people printing things off computers on bits of paper and then taking them round to other people to type up again. It is probably an obvious question, but even I know that you can cut and paste and then send by email. Is that something that is not allowed for some reason?

Dr Dearden: One of the difficulties is with confidential medical information being sent on a public email. The development that we have, for example, is that I can now go on to my hospital’s pathology, so I can get blood tests, xrays and things like that, but it is a very dedicated thing. At the moment I am just beginning to be able to send referral letters by electronic means, saving my secretary some time and effort. You would think that the NHS’s IT was markedly more advanced than it currently is. It is fair to say that NHSwide IT projects are not littered with successes.

Chair: That is true.

Dr Dearden: I suspect that might be an endemic of the actual problem. As an example, the outofhours information is very well developed in Wales in general practice for outofhours emergency, but that is purely name, history, drugs and allergies. It does not go into some of the other information. It is fairly simple but works extremely well at the moment.

Chair: I detect a culdesac there. Interesting though it is, we had better stick to the general veterans’ issues.

Q57 Jessica Morden: Do you think there are improvements-and this is a question to you all-to be made in raising the awareness among GPs of priority treatment for veterans?

Lisa Turnbull: There are, but one of the things we would specifically like to raise is the development of training resources for GPs, practice nurses, health and support workers and indeed those working in A and E. Those are areas where people will go in, generally, presenting with different issues and where it might be important for the healthcare professional to recognise that they could be a veteran and signpost them. That is one of the areas we want to raise to improve that level of connectivity.

If I may return to the records issue, which I think is related to your question about awareness, one of the things we have suggested as a potential way forward is to have some kind of identifying marker to say that somebody is a veteran, even if we cannot have a transfer of the whole record or history. Again, there are issues that I think it is important to raise about privacy and consent on that, but it might be slightly less ambitious, and indeed perhaps even more helpful, to have that flag rather than necessarily, at this stage, all of the difficulties that have been alluded to with transferring the entire record.

Q58 Jessica Morden: Turning to the BMA, you mentioned in your written submission about having some kind of online resource for GPs to raise awareness of priority treatment. Do you want to explain a little more about what you would like to see?

Dr Dearden: In a sense, there are several things we have been trying to do through that. For example, the GPC (Wales)-the GP Committee in Wales-recently wrote to the local medical committees, which are the representative bodies, to ask them to inform all GPs about the priority treatment and so on. The Royal College of GPs now has an elearning tool, which takes, I think, about two hours; so it is relatively extensive. But in six months only about 320 GPs-I think that is in the UK-have accessed it because it is a selfmotivated thing. Only those people who are registered with the College would access that.

Certainly, in terms of raising awareness, things like the letters and the articles in the GP press are very helpful-the educationaltype things. Also, almost every area now has what we call educational afternoons or training afternoons, where the practices are covered by alternative services and the GPs and staff go for training. It may very well be that one of the ways we can highlight this is for each local health board to integrate some training about the veterans into their annual training cycle. In Cardiff it is called CPET, and basically it is a postgraduate educational afternoon. Half of them are based in practice but half are run by the LHB. Certainly, resources will always be necessary for that, but it is also about opportunity. It is also about competing educational needs because almost every group-carers, ENT, mental health-would like more training and more awareness. It is not always just about the availability of training opportunities but also the competitiveness of them. That sometimes is a difficulty for the educationalists: how do they fit everything in and get everybody to have the same training at the same time?

Jessica Morden: Finally, is there a role for Veterans’ and Armed Forces Champions? Do you get them together and discuss their role? Is this something they could be increasing awareness of?

Chair: Do you want to answer that, Dr Olver?

Dr Olver: Briefly on the last point, can I mention Dr Price, who is with the Wales Deanery, and his online package that we have referred to in our evidence? That looks like a very good project to go for. Did you ask about the Veterans’ Champions?

Q59 Jessica Morden: I asked about their role and whether there is anything that can be done. Have there been meetings of the Veterans’ Champions to discuss their role and promote it?

Dr Olver: The BMA has not had meetings with the Veterans’ Champions.

Ian Hulatt: On that point, as an organisation, the Royal College of Nursing has membership entities, groups and forums within it. One of those that have been increasingly active is our Defence Nursing Forum, which has a very key role to play in raising the awareness of defence nursing among our membership through publications, congress and conferences and so forth. Also, that has another function of raising awareness among the nursing organisation itself of the needs of those nurses who are themselves veterans, who would have specific needs when they return to practice, to their employer, having served. We have quite a role to play as an organisation in promoting that awareness among our membership.

Q60 Geraint Davies: On a very simple front, in terms of the promotion of priority treatment of veterans, is there not a facility simply to have a little poster in GP practices or to encourage Facebook campaigns, perhaps saying, "If you have a neighbour who is a veteran, why don’t you let them know they have priority?" or simple mechanisms rather than these complex training strategies?

Dr Dearden: Educational research on the effect of a poster in a GP’s surgery is that, once it has been there for a little while, it becomes part of the wall and is usually covered over by something else. The difficulty is that posters and things of that nature, such as handouts and messages on repeat prescriptions, are good for those who attend their GP, but a large proportion of these people do not attend their GPs regularly. The idea is right, but it is almost better to go broader and consider chemists, dentists and other groups, because sooner or later most people will go down one of those avenues. When the British Diabetic Association were looking at increasing diabetic awareness, they used the sides of bus stops and buses, and they found a big surge in the number of people going in for simple things like blood tests-sugars and glucose.

It may be that something a bit more public is required. The difficulty in GP practices is that it is good for those who go in but not for those who do not regularly go there. Part of the training, I would suggest, is that we should extend it way beyond the GP. A lot of people know my receptionist and my nurse better than they know me. We need to have the whole practice-and I would suggest the whole community care group-aware of it and trying to publicise it as much as possible. The idea is very good but we just need to broaden it a bit.

Q61 Guto Bebb: I have had a number of constituency cases where I have had exservicemen and women who have mental health issues complaining about the lack of support from the NHS in Wales. Could one of you explain to me whether there are any specific procedures in place in terms of transferring servicemen and women from the services to the NHS? What are the processes to support them or to ensure that the files are transferred from one to the other at that point in time?

Chair: Dr Dearden, you have suggested that there aren’t any processes. Would anyone else care to add to that?

Lisa Turnbull: Part of the issue, going back to the point about the nature of a veteran, might be to do with whether we are talking about somebody leaving the services after a very long period of time and having full transfer and support services, or about somebody leaving after a short time-sometimes a very short time. Also, particularly relevant for us as the Royal College of Nursing is talking about those who are serving in the TA and who therefore will have seen armed conflict and be a veteran in that sense but will not necessarily be in the regular services. There are slightly different procedures in each section, which is complicating the area.

One of the issues that we have become aware of fairly recently is that those in the TA can return from service to find that, because they have been away from the UK for some time, they have automatically been deregistered from their GP service. One of the things we have been exploring with our colleagues in the BMA is how to solve that kind of loop in the information process. So there are different systems and that is maybe part of the problem.

Dr Dearden: In terms of specifically relating to the mental health issue, perhaps we can come back to that one in a moment. It is a very good point that my Royal College of Nursing friend has made. The difficulty is that the priority gives them priority within their clinical need. It does not exceed someone who has a greater clinical need. They are subject to the same waiting times or the same lack of services as other NHS users. It is just that they have priority within their band of clinical need. The difficulty is, for example, that if the greater clinical needs increase in numbers, the lower clinical needs drop down and have to wait longer, even if they are servicemen, because it is the band of need as opposed to the proportionality.

Q62 Chair: In real life, how useful is it to be getting priority? Will people notice any real difference in their waiting times if they are veterans?

Dr Dearden: Without being political, the longer the waiting list-

Chair: We would not expect that from the BMA.

Dr Dearden: No, indeed; certainly not. I am grateful to you for putting that on the record. The longer a waiting list is, the less effective this priority becomes because the greater clinical priority takes priority. If the waiting list is relatively short and people will only wait a few weeks, then that priority will take them to the top of that clinical band. There is an issue as to the priority versus the provision of NHS services. Where there is a gap, it affects servicemen equally, although perhaps to a lesser degree.

Ian Hulatt: I want to make the point as well that, when an individual presents with mental health problems, it may be after quite a considerable length of time. The complexity of the problem will be challenging to them in their life and the people who live with and care for them but also for the services to meet that need. There is a good argument to be made for earlier intervention, but caught up in that is the individual’s ability to step forward perhaps and seek that help. It falls in the broader issue, probably, of antistigma and people’s concerns about stepping forward and declaring that they have a mental health issue. It also falls into the provision of talking therapies for all citizens in Wales if they are seeking help earlier. That is to reinforce your point.

Q63 Guto Bebb: Specifically on the issue of support for service people with mental health issues, from what I gather there have been two pilot projects in south Wales, I think I am right in saying. What are the key lessons that have been learned from those pilot projects and are there any support services now being implemented as a result of those projects?

Dr Dearden: If I may say so, the witnesses following us are intimately related with that particular service, but I think the Assembly has recognised that the pilots have worked well, have achieved some of the aims that they were meant to and now there is an allWales service, which was established at the end of 2010. As to its actual demand and so on, probably the witnesses after us would be better placed to answer, if I may be so bold.

Lisa Turnbull: I would like to add something on the previous question you asked about the actual service provision. It is an excellent point that we cannot lose focus of the need to increase the provision. We have flagged up in our evidence that one of the issues relates to the lack of psychological therapies available in Wales at all. That is very important. My point about the wider context of mental health services is that that is something that needs to be addressed. If it is not addressed, we will not be able to meet the need. As this service becomes more established, we would expect more people to be referred to it as awareness rises and demand will increase. We have to be in a position to meet that demand.

Q64 Guto Bebb: On that specific point, in terms of the lack of service provision, is that worse in some parts of Wales than others? Being a north Wales MP, it would appear that the services in north Wales are poorer than in other parts of Wales. Have you any evidence to support that?

Lisa Turnbull: The next witnesses might be better placed to answer, but the establishment of this allWales network has been positive in the sense that my understanding is that posts have been created in each of the local health boards to lead and act as a focus for the service. Indeed, there is at least one post-if not 1.5-in Betsi Cadwaladr. That is helpful, but none the less there are undoubtedly still historical differences. I would have thought one of their goals would be to ensure consistency rather than simply leaving it to the historical patterns of provision or the actual local health board itself. Clearly, as the data gets stronger, we may see different patterns of demand in terms of where people are being recruited from and where people are returning to. That is something that we may be able to establish then and map service provision against it.

Q65 Geraint Davies: In the light of what has been said, if there is a delay in the identification of discharged veterans who have mental health problems and a lack of engagement with the whole system and downstream that in fact generates higher costs because things have become more complex, do you think there is a case for compulsory screening of all veterans as they leave the services-a simple screening-to identify risk so that you can get early intervention and lower unit costs?

Chair: Dr Olver, what do you think, as somebody who has served in war zones?

Dr Olver: Certainly, as a reservist, as part of the demobilisation process, there is a mental health talk, there are leaflets that we are given and cards with support numbers to call should we have any problems. I do not know if regulars at the end of their service get anything specific on that.

Q66 Chair: How widespread a problem do you think it is of people coming out of war zones in Iraq or Afghanistan with mental health problems as a result?

Dr Olver: The figure that is mentioned is 8%. When we have been discussing this, we think that is not 8% of the 200,000 or 250,000. It is probably 8% of the more recent discharges from the military, but it is still a significant number.

Q67 Geraint Davies: On the screening, compulsory screening might be a bit more expensive, but there are ways of risk managing your target, are there not? People who are coming off the front line in Afghanistan, for instance, are more likely to have a mental health, traumatic problem than people who have been sitting in Germany just before they leave, perhaps. Would a move from a situation where there is not apparently any screening and automatic engagement to targeting where there is likely to be risk be a good idea or a practical possibility?

Dr Olver: Certainly for people coming off the front line there are mechanisms in place. There are people who undergo what is called TRiM training, which basically is for their mates, or a certain proportion, to have undergone training to identify those sorts of problems. As to screening for leaving the forces, I am afraid I could not comment on that. It is not my area of expertise.

Q68 Karen Lumley: Would veterans with mental health issues get a different kind of treatment in England? Would it be better, different or is it all uniform?

Chair: Do you have any thoughts on whether England or Wales give better treatment?

Dr Olver: There is a helpline number. There is an arrangement with Combat Stress to help with veterans’ mental health problems. I am not sure of the exact details of it.

Ian Hulatt: Taking my point about "Rather than the end stage of a long history of struggle and using various means of resolving the individual’s conflicts, such as alcohol or going through different situations", in England the argument could be made that there is an Improving Access to Psychological Therapies programme, which has had large amounts of investment and training of low intensity and high intensity staff.

Mrs James: I wanted to ask a little bit about this.

Ian Hulatt: If the individual was to seek help earlier, it could be argued-in fact, yes, it would be argued-that there is greater provision for the population as a whole than there is in Wales.

Q69 Mrs James: You have gone on ahead to what I particularly wanted to ask you about. All of your submissions have mentioned that there needs to be an increased investment, awareness and education and training on veterans’ issues, particularly mental health awareness and so on. How do you see that this would be best undertaken? You have already mentioned the Improving Access to Psychological Therapies programme. There are things that are happening, but how do we raise awareness with frontline health professionals?

Ian Hulatt: Sometimes awareness and signposting is good, but sometimes it is about actual services and skills in the hands of the health professional, whoever they are. If you think of a spectrum of competencies, referring to Dr Dearden’s point about his receptionist, it is quite appropriate that a receptionist would be aware of distress and feel confident to intervene when an individual is distressed. That would go across a spectrum of competencies. What you are aiming for is a work force that has a range of psychological competencies. Then they could meet individuals’ needs at various points. I would take the view that nurses are well placed to do that because of their position in people’s lives, but there is a range of healthcare professionals from a range of intensities who could offer that assistance, sometimes signposting and sometimes providing an evidencebased intervention. That requires investment.

Q70 Mrs James: You say in your submission that you were concerned about this and that there is a specific problem in providing posttraumatic stress disorder services. Are you saying that this is all going to be dealt with by training? How are we going to increase that training? What sort of levels of training will they be?

Ian Hulatt: As I say, there is a range, yes.

Mrs James: I am finding it difficult to grasp.

Lisa Turnbull: We have specifically said that Wales should be looking at the IAPT programme that has operated in England. We should be looking at trying to implement something very similar in Wales. That is a very specific suggestion that we would make.

Dr Olver: Dr Dearden has already mentioned the elearning packages that are available. Another area that is important is that exservice personnel tend to be culturally slightly different. They have their own culture and they would feel happy talking to doctors and nurses that had a military background, but that is not practical because there are not enough to go round. It has been suggested that healthcare professionals should at least try to understand the culture of exservice personnel.

Dr Dearden: I have a small comment. One of the things that perhaps we could consider-and should consider a little more-is people’s prequalification education, when they are very open. Most medical students remember the one odd thing they saw in some lecture theatre. Perhaps it is something that we could consider, and I go back to the competition element about training. A lecture in medical school by someone from the forces or someone coming out, or something like that-you would only perhaps need one per year-would implant the thought in their mind very early. I am speaking medically, but we could go right across the medical and nursing ground to say, "This is an issue that is slightly different." It is like saying, "Smoking causes these kinds of problems regularly. Being in the forces regularly causes these kinds of problems." It is a medically important thing to know that smoking causes this and that service can sometimes cause this and this. That might implant something in someone’s mind early on and maybe that is something we could think about. Rather than just thinking about the people who are already in practice, we could also increase the number of people who are treating. Perhaps we could go back and try and implant earlier in people’s minds that there is a causative relationship between service and some illness groups.

Q71 Mrs James: Very quickly-sorry, Chairman-you also mention in your submissions this lack of integration between health and social care and what is happening in the wider community. Do you think that this could be improved in any way, and if so how?

Lisa Turnbull: I will echo the point made earlier. Now that this network has been established, the next step has to be the relationship with the services provided by local authorities-seven local health boards and 22 local authorities. That is where housing and social services are. It is going to be important to make sure that there is co-ordination at the strategic level but also on the ground. Going back to the point about the people who are meeting and providing advice about one issue-say, housing-they might well also be aware of the potential service that they could signpost this person to in health. That is the next stage where we have to improve the co-ordination.

Q72 Mrs James: Do you think that there could be some parallels drawn with the Prison Service? I do not want to say anything about the criminality at all, but this is where we are moving to, are we not? We are getting these things into place for people before they leave prison. We seem to be managing to do that within our Prison Service, and ever-increasingly prove it, yet we do not seem to be able to do it for our armed forces when they come back out into the wider community. You would not release a prisoner without having a knowledge of where they were and what they were going to be doing. Yet, when I talk to veterans, they do not seem to think that the Army, the Navy or the RAF should look after them when they leave. I am quite shocked by that.

Chair: That is an excellent point, but may I say that we are out of time now so I have to appeal to everyone for very short questions and answers? Perhaps you could give a short answer to that.

Lisa Turnbull: Yes, that is the goal. It is a laudable goal.

Q73 Mr Williams: You mentioned the role of local authorities, housing and other aspects of the picture. Does it worry you that, to date, only two local authorities in Wales have adopted community covenants that are addressing the broader picture? That is obviously of some concern.

Lisa Turnbull: As I said, I hope the next witnesses will be able to answer some of these questions. It is fantastic that we have this allWales network now in health. The next stage is to make sure that that is encompassing all of the different services. Absolutely, yes, you would expect all the local authorities to be fully on board both at the strategic level and that there is some communication at the front lines where people are meeting and dealing with people.

Chair: I assume the other members of the panel would agree with that.

Q74 Nia Griffith: I would like to address my questions to the RCN representatives, and could I ask Ms Turnbull to raise her voice a bit because the acoustics are not brilliant in here? You have talked about there being a lack of places for alcohol detoxification in Wales. Is that a Walesspecific problem? Have you identified spare capacity in England, or is it something that is a problem across the UK?

Ian Hulatt: I do not think it is a case of spare capacity, but we would argue that there is a range of ways that alcohol detoxification can occur. It can be a homebased and communitybased service as well as a residential one. It is a skilful approach that can be delivered by healthcare professionals. We are saying that people perhaps are not having the level of access to that service that they require.

Q75 Nia Griffith: I want to take up something that one of our other witnesses has brought forward, which is the issue that, very often, the alcohol problems occur because of the alcohol culture that is there in the armed forces to start with. How do you think the MOD should tackle that?

Dr Olver: The MOD is aware of this. There are alcohol-awareness problems. There are poster campaigns. We have young men in foreign places with cheap alcohol; it is a very difficult circle to crack.

Q76 Nia Griffith: You do not have any particular strategies, ideas or views on what should be done.

Dr Olver: I can only say that the MOD is aware of it and that there are campaigns to reduce alcohol use.

Lisa Turnbull: Going back to an earlier question about screening and advice on leaving the service, this is very relevant for alcohol misuse. If you see the norms of alcohol use in inservice life and then the norms outside, that transition point is quite important, and also the fact that there may be support mechanisms inservice that are masking the abuse or the misuse of alcohol that then are not there. The behaviour carries on; it has not altered, but they are in a different environment. The point about the advice, signposting and transition is very important. Again, it may be relevant to the point about healthcare professionals being aware of people being veterans and of potential alcohol misuse and going back to that training and awareness point about how people, when they present with the issues, are then treated or cared for.

Q77 Nia Griffith: We have also heard differing views about rehabilitation centres, especially specialist rehabilitation centres, as to whether you should have fewer but UKwide centres so that all the people suffering from a particular difficulty can be in one place, or whether there should be more facilities provided in Wales. Perhaps you could elaborate a little bit on what you have said to us in your statement.

Ian Hulatt: There is a parallel case there with other rehabilitative and specialist treatment centres. If you make them large and nonlocal, you are excluding the individual from their community and their supports. Generally, as a principle, it is agreed to be unattractive to remove an individual from their environment. You can see the argument perhaps on a costeffectiveness basis, but, if you think of outofarea treatments, an individual is being removed from their environment and I do not see how that could be considered to be supportive for that person.

Q78 Nia Griffith: You would rather see some upgrading at, say, somewhere like Rookwood.

Ian Hulatt: I think it is appropriate that services are provided locally in the communities that people belong to.

Q79 Mr Walker: I am interested to know whether you feel the devolution settlement and the arrangements, health being a devolved matter in Wales, help or hinder the cause of supporting veterans and whether you have any examples of where there are perhaps either obstacles or opportunities created by the devolution settlement.

Lisa Turnbull: The creation of this network is an excellent example of a good way forward. To go back to the point that was made earlier, it is important that the agencies work together to make sure that there is co-ordination, both at a strategic level and in terms of the actual professionals delivering the service. That would cut across criminal justice. I have mentioned housing particularly. I can think of very significant organisations, like the CAB, which are absolutely crucial. That principle of co-ordination and communication has to apply to all of the agencies, and particularly also to the charity sector. That is significant because they are providers, both commissioning services and also directly providing services. So it is important to bring them on board and particularly look at how they are working in their relationships as well.

Q80 Mr Walker: Does anyone have any comments about how well the Welsh and the UK Governments are coordinating in terms of these efforts?

Dr Dearden: It might be difficult for us to say how well they are coordinating because-and I will say this-we do not see a lot of evidence of it. In a sense, on the ground, they may be talking, correlating and working well together, and we may not see the work that is being done. I am not suggesting that there is not any work done. It is simply that we may not be fully aware of what is being tried or attempted and so on.

In terms of the improvement in Wales, I would say probably over the last maybe three to five years the veterans have become an issue that has become increasingly well known throughout Wales. Many of the things that are now being thought about and talked about-and indeed the sort of work that you are now doing here-are a product of the kind of work that is being done. Certainly if we go back maybe 10 years, I would suggest that veterans and their needs were far less talked about than in the last three to five years. Is that because of devolution or awareness, or is it because of work other people are doing? It would be hard for us to say which one it is, but the good thing is that we are now talking about it far more in the last three to five years.

Q81 Mr Walker: That brings me neatly to my final question. Both the Welsh and the UK Governments now have a Veterans Minister with responsibility for veterans’ issues, and perhaps I could ask each member of the panel this. If you were able to raise one issue with them in order to try and improve the provision of services to veterans, what would it be?

Lisa Turnbull: It would be to say that the issue of psychological therapies needs to be addressed in Wales, and we need to look at our work force and make sure they are skilled up to provide the service that we know is needed.

Ian Hulatt: I would possibly encourage the Minister, or the person involved, to undertake an audit of the psychological therapies that are held and exist within the work force already and may well be lying dormant.

Dr Olver: I would hope that they would fulfil the commitment on prosthetic provision for veterans.

Dr Dearden: I would like them to look at the continuity of care for those who leave the NHS and go into the MOD and then leave the MOD and come back. We miss a lot of the people through the gaps that are presently there.

Chair: Thank you very much indeed for that very useful evidence session. We are very grateful.

Witnesses: Professor Jonathan Bisson, All Wales Veterans Health and Wellbeing Service, Mark Birkill, Community Veterans Therapist, and Simon Pyke, Associate Chief of Staff, Mental Health and Learning Disabilities Clinical Programme Group, Betsi Cadwaladr University Health Board, gave evidence.

Chair: Good morning. Thank you very much for coming along. As before, we are running a little behind time so I am going to launch straight into this and ask Karen Lumley to begin.

Q82 Karen Lumley: Can I start with you, Professor Bisson? Can you explain to us, as lay people, exactly how a veteran accesses the service and how they would benefit?

Professor Bisson: Yes. The veteran can access the service by selfreferring, by, with their permission, a family member referring them or by a member of the health profession referring them. Also, we get a significant number of referrals from other agencies that are involved with veterans, in particular the SPVA, the Royal British Legion and also the Citizens Advice Bureau. We see people coming through them. It is an openaccess openreferral system.

Q83 Karen Lumley: What sort of service would they experience?

Professor Bisson: If referred into the service, they would get a full, comprehensive assessment by one of the veterans’ therapists who is employed by the service. The assessment would look at their psychological and mental health needs, also their social needs and touch on their physical needs as well, although there is not expertise within the service to provide a full physical assessment. They would be screened and then referred as appropriate for fuller assessment if necessary.

Once the assessment has been done, there is a management plan, if you like, put together in conjunction with the veteran that addresses their needs. That may or may not involve aspects of input from the service itself, from other areas within the Health Service and also from other agencies and services that may help them. A typical veteran would receive some ongoing input from the veterans’ therapists. They may come and see somebody like myself to have an assessment to see if psychiatric medication is appropriate for their needs. They would probably be referred into another agency, such as the SPVA, to look at their pensions and perhaps the Citizens Advice Bureau regarding some financial issues that they have raised with us. The Royal British Legion may be able to help them and liaise with social services regarding social aspects of their care. So there is a holistic approach to that individual’s needs.

Many veterans, as you know, also have physical problems in addition to psychological ones. With things like knee and back difficulties, we may also initiate a referral to the local orthopaedic service, for example, to look at those things.

Q84 Karen Lumley: Do you work closely with the local health boards?

Professor Bisson: We do. The service is embedded within the local health boards. All the veterans’ therapists-for example, Mark-are employed by a local health board in Wales. The hub of the service is based within Cardiff & Vale University Health Board, so Neil Kitchiner, the principal clinician, and myself, as director of the service, are both attached to that health board. The other individuals, who are all employed by their local health boards, have management structures within that health board. Then we have an overarching management structure. It is a hubandspoke model in full collaboration with the health boards.

Q85 Karen Lumley: They all work really well together; there is no reluctance from certain health boards.

Professor Bisson: No, I do not think there is any reluctance from health boards at all. With the financial downturn and the stress on finances within the health boards, there have been some issues in rapidly employing people through the redeployment systems that are going on, but we are now at the point where we have employed everybody in their posts and we are up and running.

Q86 Karen Lumley: Mr Pyke, can I ask what priority you give to dealing with the veterans’ issues?

Mr Pyke: From the health board, it is seen as a very important issue and we are very keen to get the service up and running fully in north Wales. We have employed Mark as a therapist. We have a Champion on the health board as well, and he is very keen to ensure, through subcommittees of that health board, that the veterans’ service in particular is reported on alongside other services as well.

Q87 Karen Lumley: I notice you have worked in both England and Wales. Have you noticed any difference between the treatment veterans get in England and what they get in Wales?

Mr Pyke: As some of the previous witnesses have mentioned, there is the issue of the overall access to psychological therapies, which does seem to be more widely available in England than in Wales.

Q88 Karen Lumley: Mark, who are you accountable to?

Mark Birkill: We are embedded in the management structure of BCUHB, but we see ourselves very much as an allWales service. We meet sixweekly as a group of community veteran therapists across Wales, so we get a lot of clinical guidance and discussion. We will discuss a lot of service issues in those allWales venues or forums.

Q89 Karen Lumley: Would there be big differences in areas of Wales as to how quickly a veteran could be referred to somebody like you, or would it be a uniform sort of wait?

Mark Birkill: It is uniform. We are trying to have equity of access to service across Wales. The same referral pathways operate everywhere.

Q90 Karen Lumley: How long will it usually take for a veteran to see you?

Mark Birkill: I can only speak for Betsi Cadwaladr. We have only recently started to assess people, so it is hard to know how waiting lists and so on will pan out, but we will try and assess people very quickly. We want to engage people as quickly as we can.

Q91 Guto Bebb: Obviously I welcome your appointment, but I am aware that, in north Wales, Betsi Cadwaladr health board would be the first to acknowledge that there is a differential service between east and west, let alone between Wales and the northwest of England. Is that the experience that you have found since you have been appointed?

Mark Birkill: I hope that will not transpire. We are trying to see people in every sort of conurbation across north Wales. I will be seeing people in Bangor. We do not want people referred, say, from Wrexham to be seen within a week and people from Bangor or Anglesey within two weeks. We will try and create clinics so that we can counter that.

Q92 Stuart Andrew: Can you tell me how many veterans the service is currently working with?

Professor Bisson: Probably about 150 individuals, I would imagine, would be being seen in an ongoing manner. It is difficult to give exact figures. During the pilot project that occurred within Cardiff & Vale we saw 150 individuals over the twoyear period. The majority of those would receive some ongoing input from the service, if only in a case management role to check that they are engaging with the services that they have been referred into.

Q93 Stuart Andrew: I can guess what the answer to this question will be, but are there sufficient resources being allocated to the service?

Professor Bisson: We would always like to have more; of course we would. Picking up on your colleague’s point, Cardiff & Vale-which, because it has been around for the longest, is the most mature service-has a waiting list of a few weeks to be assessed, but it is between six and nine months from being put on a waiting list to receiving the psychological treatment that is indicated. We are trying to address that by other initiatives. Within our nonveterans’ arm of the service, the waiting list is about 15 months. Veterans are advantaged by the new service quite significantly, clearly. It would be very nice, and I am sure we would all like it, if we go to see somebody and we are told we need psychological treatment, to receive it the next week or within a few weeks of that. There is a waiting list, and whenever there is a waiting list it would be nice to have more resources.

Q94 Stuart Andrew: Looking to the future, how do you see the service developing?

Professor Bisson: We are getting established. As Mark says, everybody is meeting very regularly now. We have agreed on a care pathway across Wales in conjunction with the nonstatutory sector as well as the statutory sector. I would like to see that rolled out across Wales. At the moment we are meeting with various different bodies to see if we can work together in partnership and roll that out. That would increase the capacity of the service because some charities employ individuals to provide a psychological treatment service. If we can combine the two together, the sum of the whole would be greater than the individual parts, and we would be able to deliver evidencebased treatment according to the agreed model more quickly to veterans.

Q95 Stuart Andrew: You mentioned in answer to Karen’s question the range of support that you offer, but can you give us today some specific examples of how you might treat posttraumatic stress disorder?

Professor Bisson: For posttraumatic stress disorder, if it occurs on its own, which is very rare, the treatment of choice is a psychological treatment known as traumafocused psychological therapy. There are two main ones: traumafocused cognitive <?oasys [dc4] ?>behavioural therapy and eyemovement desensitisation and reprocessing. The NICE guidelines<?oasys [dc0] ?> recommend that those are delivered over eight to 12 sessions. We tend to give individuals up to 16 sessions of therapy using one of those techniques if that is their presentation. Usually, individuals have comorbidity with their posttraumatic stress disorder, so we are also, for example, treating a depression or perhaps addressing a substance use issue alongside that or trying to help an individual come off alcohol before they engage in the psychological treatments. That would be a fairly typical way of dealing with that sort of issue.

Q96 Stuart Andrew: There is still a bit of a taboo with mental health issues, is there not?

Professor Bisson: Absolutely.

Q97 Stuart Andrew: There is a real barrier for people coming forward. How do you tackle that? Do you see that as a problem or is it being dealt with?

Professor Bisson: No. I agree with you; it is a big problem. There is a big stigma attached to mental health difficulties. In fact, I think posttraumatic stress disorder, for some individuals, is almost seen as a slightly sanitised mental health disorder and a more attractive thing to suffer from, which in fact can get in the way of some other disorders that need to be treated in individuals actually being treated appropriately. Basically, you have to start at a societal level, raising public awareness and helping to reduce stigma. We have seen some very big steps in that over recent years, but there is a long way to go.

Q98 Stuart Andrew: Finally, do you have any concerns about the integration between health and social care?

Professor Bisson: Yes. We can always work more closely with individuals, and you have to take a joinedup psychosocial approach to the needs of the majority of veterans. The majority of veterans do not present with simple issues. If we do one thing without the other, we are going to fail the veterans. A lot of our work is trying to work together with social services-and also, as I say, with the third sector-to provide an optimum package of care that is joined up for our veterans.

Q99 Karen Lumley: As to the 150 that you have talked about, what sort of age profile do they have?

Professor Bisson: The average age of a veteran that we would see would be around about the 40 mark overall. In fact, probably the modal presentation is somebody in their 40s rather than being younger or older. We are desperately trying to get in contact with a greater number of younger veterans. The fact that we are seeing people for the first time in their 40s signifies that a lot of people wait a long time before they get in contact with us, which is something we have to overcome and goes back to the earlier useful discussion as to seamless access or seamless transitions from the military to the NHS.

Mark Birkill: Interestingly, of the referrals we have had in Betsi Cadwaladr, there are two clusters of ages. One is mid40s to mid50s, but we have had an equally high number of early to mid20s, who are possibly early service leavers.

Q100 Geraint Davies: You talked earlier about the increasing access to psychological therapies that operate in England but not in Wales. Would you like to see that in Wales, and can you see any reason why it should not be rolled out in Wales?

Mr Pyke: The simple answer is yes, we would. We have some psychological therapies available within the service but not at the same level. The issue for rollout in Wales would be one of cost and resources and also then the access to the appropriate training of staff.

Q101 Geraint Davies: Do you think there is a problem here that, if you invest in England in these services, you get a return by having more people going to work and lower unemployment benefits, but that return is not available in Wales because of devolution? If you invest the money, the money goes back to the Exchequer. It does not go back to the Welsh Assembly Government, does it?

Professor Bisson: No. You raise an important issue. Within Wales there is access to psychological treatments but through different avenues. There has been a lot less investment, as we all know, in Wales in terms of improving access to psychological treatments. But, for example, all of the veterans’ therapists that we have employed are qualified in delivering cognitive behavioural therapy, which is one of the main things within the IAPT scheme. In England, you do not have as many veterans’ services like ours that provide that. Then there are primary care counselling services, for example, in Cardiff & Vale, which deliver several of the things that the IAPT system delivers. I would very much welcome having more psychological treatments available in Wales, for sure, but it would not be right to think that there are no psychological treatments available in Wales.

Q102 Geraint Davies: Are you saying there is underutilised capacity and we could roll out a better service sooner rather than later?

Professor Bisson: I do not think there is underutilised capacity at the moment. We perhaps could look at the skills of individuals and think how best to constitute the service to make sure that people get access to psychological treatments at the right time. A lot of individuals receive supportivetype interventions at the moment while they are on waiting lists for psychological treatments, which clearly is a bad use of resources at the end of the day. If you can train up more people within the system, then-

Q103 Geraint Davies: But is there anything in this argument that there is a return in England-because you have lower dole costs by getting people back to work-and there is not a return in Wales because that benefit is taken in England and is not compensated in the Welsh grant?

Professor Bisson: Personally, I have not seen the evidence to be able to state it as starkly as that, but theoretically it could be true.

Mark Birkill: I have heard that argument but I have no evidence.

Q104 Jessica Morden: Do you have any concerns about GPs and a lack of awareness about priority treatment for veterans?

Mr Pyke: There is an element, as part of our role in developing the service, in helping to educate and work with GPs more closely to make sure they are aware of the needs of veterans. Again, one of the previous witnesses highlighted the issue of training both pre-registration and postregistration. That would be very useful for GPs as a whole.

Q105 Jessica Morden: Do you think there is a problem then?

Mr Pyke: I would not say there is a problem. I would say more that there can be variability about knowledge of the issues, and I think we can raise, perhaps, the standards therein.

Q106 Jessica Morden: Apart from training, is there anything else that it would be helpful to do, in your opinion?

Mr Pyke: Again, if we are clear on pathways of working, it would be making sure that GPs are aware of that. I think the provision of information, not just to GPs but also to the general public at large, about veterans’ issues and understanding how people can access services-not just at the GP but at the secondarycare level-would be helpful as well.

Mark Birkill: The community veteran therapists are rolling out a programme of presentations to services and at some point will be including general practice in that. One of the things we highlight is the priority service and making sure that people are aware of that.

Q107 Nia Griffith: We have heard about the lack of data on veterans in Wales. Can you explain a little about how this affects your work and how you would like to see things put right, what sort of data should be gathered, how it should be transmitted and so forth?

Professor Bisson: It would be very useful if everyone, when they registered with a general practitioner, was asked if they were a veteran or not so that we have that data on absolutely everybody. I agree with the earlier comments in terms of the difficulty of determining who and who is not a veteran in Wales. We did a research study where we tried to look at a crosssection of veterans in Wales and found it very difficult to ascertain a proper population of veterans. We went to the SPVA, to Combat Stress-the charity-and also through King’s College’s large cohort of individuals who were recruited in 2003, and interviewed over 200 individuals. The results of that research strongly suggested-and I think clinically encounters suggest this as well-that you have a small minority of individuals with very major complex needs among veterans, but probably the majority of veterans are doing very well and are integrated fully into life as civilians.

Q108 Nia Griffith: Can you tell us a little about the data hub that Cardiff & Vale have been preparing and how that might be rolled out?

Professor Bisson: Yes. We have agreed a standard data set of information we should collect from all veterans that we see who come through the service. The veterans’ therapists and all of the different spokes of the service are now collecting that data and they are making monthly submissions into the hub. We are collating it in the hub, and then we will be able to provide accurate statistics on an allWales basis as to what is going on with the veterans that come into our service, which will hopefully help with service development to identify what the real needs of the veterans are and mould our service to try and meet those needs appropriately. That only deals with the individuals that come into the service and there is work needed for others.

Q109 Nia Griffith: Is that purely statistical or is it about individuals and their needs? Do you see the difference? Is it about data collection or is it about being able to help?

Professor Bisson: The data collection-the transfer-is of hard numerics, so that is quantitative data that has been collected in. We also collect qualitative data from individuals by asking them how they found the service. That would be supplemented, if you like, by individual comments from veterans. In the research, we did a combination of both numbers and qualitative statements from individuals as well. I think it is a very good point that you need to look at both of them.

Mark Birkill: The data collects demographic details and clinical data also from clinical measures, measuring anxiety, depression and so forth.

Q110 Mrs James: I want to ask Professor Bisson particularly about the work of charities. Are you concerned that there are charities in Wales who are apparently treating posttraumatic stress disorder, offering cures and some sort of miraclelike improvements and yet they do not seem to have any medical training?

Professor Bisson: Yes. I am very concerned about that, as I think a lot of us in the service are. I agree with the comments of the earlier panel in that I think there are a lot of people with the best of interests there and all people want to do is to help improve the health and wellbeing of veterans. But there has been a lot of research done to show what treatments are effective and which ones are less effective. As we have treatments that have been shown to be more effective, we should be putting our eggs in that basket and training people up to deliver on those treatments. To be honest, it is very confusing for the veteran at the moment because there is a lot of publicity going on with different bodies saying that they have the miracle cure perhaps and, sadly, often that is not true.

Q111 Mrs James: Do you think we need better regulation of service charities?

Professor Bisson: We definitely need better regulation. Personally, if any individual is putting themselves forward as a therapist, I believe they should be registered with a proper body and regulated by that body so that you can check their credentials and make sure they continue to have the ongoing development they need to do that. Our proposal is that we would be very happy to work in collaboration with charities, to offer them support, supervision and training and also to learn from them in collaboration together. But at the moment there is a slight situation where there is some competition going on. It is not only with charities with individuals without any qualifications or training. There will also be individuals in the private sector who will be offering treatments and who have training to deliver them.

Q112 Mrs James: There is a limited pot, obviously. Do you think that there are too many service charities that might be competing for that pot on a wider basis?

Professor Bisson: Personally, yes. There has been a mushrooming of the number of servicerelated charities. I was speaking to a colleague from the Royal British Legion, who was saying that they have to police different websites to make sure that they are not there with their logo-

Mrs James: Endorsing them.

Professor Bisson: -saying that they do that. I know that, personally, I have been contacted by a couple of people saying, "Do you know that you are advocating such and such a charity?" that I have had nothing to do with at all.

Mrs James: It is worrying.

Professor Bisson: It is difficult and I think regulation could make a big difference.

Q113 Chair: Is that a view shared by the members of the panel?

Mr Pyke: Yes, I would fully endorse those comments.

Q114 Mrs James: Particularly to both of you from Betsi Cadwaladr, if you are working with thirdsector organisations, what process would you go through in choosing or endorsing them?

Mark Birkill: The guidance we have had from the pilot site in Cardiff is to use the big charities, the reputable ones-perhaps I should not use that word-the Royal British Legion and SSAFA. We would like to coordinate our work with Combat Stress also so that we do not duplicate and work in competition. I have been impressed by the RBL, SSAFA and some of these bigger charities. They occupy the same territory but have a very mature working relationship with each other and complement what each other is doing.

Q115 Mrs James: Do you think the public are getting confused about where the money is going and how it is being used? I have talked particularly to friends and they are generous, but they are very hazy about where it goes.

Professor Bisson: Yes.

Mr Pyke: Yes.

Q116 Geraint Davies: On this, I have come across examples where homoeopathic practices are coterminous with GP practices. You go through the GP for the homoeopathic practice, which basically legitimises the homoeopathic practice as something that might have scientific basis as opposed to some sort of form of witchcraft. I am wondering whether you think it should be wrong that homoeopathic practices should be allowed to be coterminous with GPs so that the public is not confused. In particular, we are talking about veterans here.

Chair: That is a very clever use of a Select Committee to get a totally unrelated question in, but let us have it. I am all for exercising fairness.

Geraint Davies: Do you have a view? It does link to this thing about charitable and nontested-

Mr Pyke: There should be an evidence base to how people deliver services from any level. If there is not an evidence base to it, I do not think that the NHS should be endorsing it.

Q117 Mr Williams: Some of the evidence we have had has talked about the need to have a dedicated specific rehabilitation facility-a rehabilitation centre-in Wales and there is the issue about the distances that we are expecting clients to travel to access those services. What rehabilitation centres are located in Wales? Should there be a military rehabilitation centre in Wales, and what is your view on those who say that there is not that critical mass of clients in Wales to have such a service?

Professor Bisson: When you say "rehabilitation", do you mean psychosocial rehabilitation or physical rehabilitation?

Q118 Mr Williams: I mean both physical injuries and those with mental health concerns.

Professor Bisson: As was alluded to earlier, we have a rehabilitation facility in Cardiff-Rookwood hospital-which would deal with the severe end of the spectrum in terms of amputees, basically. There is provision there and it is beyond my expertise to say whether there is a need for more physical rehabilitation centres. In terms of psychosocial rehabilitation programmes, I do not think there is strong evidence to say that you need to have inpatient rehabilitation facilities for veterans. In fact, for me, as was alluded to earlier on, the evidence very much points to you being better off having very effective rehabilitation programmes that are based within communities, which can keep individuals in their communities, and as they are being rehabilitated they are using the new skills they are developing within their communities. To detach people and take them away for two weeks or more, spend time there, and perhaps have time out and have a good time but then come back in, often does not address the real issues that need to be addressed. They are very costly entities.

<?oasys [dc6] ?>I am greatly in favour of having well designed psychosocial rehabilitation programmes. We conducted a study two years ago funded by the Ministry of Defence to develop a rehabilitation pilot<?oasys [dc0] ?> programme for the first Gulf war veterans-the 199091 Gulf veterans-and I felt that we came up with a good model that could be tested further. This is something we are hoping to introduce into the allWales veterans service to test more. That involves individuals having treatment for their mental health difficulties but, alongside that, looking at other issues-for example, reskilling themselves, thinking about gradually taking the steps to move into employment in the future, getting more involved socially in different groups, and exercise programmes, for example, at the local gym. There is an absolute wealth of different opportunities within the local community if they are well coordinated and put together. In terms of an inpatient psychological treatment facility, I do not think there is a need at all.

Mark Birkill: As a psychological therapist, much of our work is based on incorporating the body of the therapy into normal daily life activities, and that cannot be done in inpatient centres. There is a sort of separation of the two.

Q119 Mr Williams: Is there a disparity in the availability of the services in the way in which you are able to deliver them in terms of urban and rural areas? In one of your earlier answers you talked about delivery of service in conurbations. More generally, Wales is a rural country. How accessible are services in other settings?

Mark Birkill: Do you mean how accessible are our services?

Mr Williams: Yes, your services.

Mark Birkill: At the moment, we are planning on seeing people in a community hospital, a GP surgery over in Bangor and an outpatient part of the district general hospital in St Asaph. We are trying to move away from mental health services so that stigma issues do not bar people from coming into service. It does leave large gaps of north Wales where we perhaps will not have a clinic, but, if we find that a lot of people are maybe coming from the Llŷn Peninsula, then we will try and set up a clinic in that area. It is very much a work in progress.

Mr Williams: I suspect that is the case for midWales as well, so thank you.

Q120 Stuart Andrew: You have just answered the question, but, specifically as we are talking about the stigma issue, the point you are making is interesting in terms of whether it is known why people are walking into a building. How much of a barrier do you think that is currently for people accessing the service, particularly if they need mental health help? I am thinking of the wider community who might think, "We know why he is going in there." Is that a problem?

Mark Birkill: Do you mean in terms of a veteran accessing the service?

Stuart Andrew: Or anyone, I suppose.

Mark Birkill: In relation to veterans, they are a group that has this distinct cultural flavour and, therefore, we want to try and make those services as destigmatising as possible. It tends to be a lesser issue for the general public-for Joe Public.

<?oasys [pc10p0] ?>Mr Pyke: We have had cases-not particularly with veterans but maybe a bit wider-of people who are referred to mental health services by their GP not realising that it is mental health services, and, as soon as they come and see it is mental health services, they do not want a service because of that stigma issue. We will try as far as possible. The whole idea of community integration and offering services alongside other generic services is quite important.

Q121 Geraint Davies: I am going to ask a general question as to whether devolution generates any obstacles to the provision of services to veterans and their families. Is there a reasonably joinedup approach, or are there problems and what are they?

Professor Bisson: Within Wales itself we have been very fortunate that the last Health Minister took a big interest in the veterans’ service and she actually funded the allWales service. Veterans have definitely been the beneficiaries of that decision. In terms of joining up, there are differences, clearly, between England and Wales. When we are connecting with people that are largely based in England, in explaining our situation as being different, we need to have that conversation. Once you have had that conversation, people can work with it very easily, but sometimes there are assumptions that we work in exactly the same way as England and we do not.

Q122 Chair: Do we have any further points on that? We would love to hear more from the previous Minister about the good work she has done. The post of Minister for Defence Personnel, Welfare and Veterans at a UK level and in the Welsh Government has been effective, though, overall, you would obviously suggest. Can you judge whether the level of service in Wales, Scotland or England is better at all?

Professor Bisson: Wales was the first country to roll out a service across all the health boards, so we have people embedded within each of the health boards. In England that did not happen, but money went into Combat Stress, which you are probably familiar with, to develop services in combination with two neighbouring trusts in England. Proportionally, head for head, Wales did well out of that. In Scotland they have taken a slightly different approach with something called the Veterans First Point system, which is much more about focusing on the social welfare issues to start off with. A pilot has gone on in Edinburgh, and I understand that there are now moves afoot to think about rolling that out across Scotland in totality. In Scotland there is a Combat Stress facility. In England there are two Combat Stress facilities. In Wales there are no Combat Stress facilities, but veterans in Wales have access to the Shropshire Combat Stress facility. In broad terms, veterans in Wales have at least as good a service as people in the rest of the United Kingdom, if not better.

Q123 Chair: Would other members of the panel agree with that?

Mr Pyke: Yes, I certainly think veterans’ issues were raised within the health board more significantly in the last 12 months or longer.

Chair: Excellent.

Mark Birkill: I am not really in a position to comment on services in England, but when we come together as an allWales service, it feels like we have a good common purpose and there is a lot of enthusiasm and energy in that.

Chair: Excellent. We like to end on a positive, cheery note. Thank you very much indeed for coming along and giving evidence today.

Prepared 8th February 2013