The Armed Forces Covenant in Action? Part 1: Military ...€¦ · London: The Stationery Office...

HC 762 Published on 15 December 2011

by authority of the House of Commons London: The Stationery Office Limited

£23.00

House of Commons

Defence Committee

The Armed Forces Covenant in Action? Part 1: Military Casualties

Seventh Report of Session 2010–12

Volume I: Report, together with formal minutes, oral and written evidence

Additional written evidence is contained in Volume II, available on the Committee website at www.parliament.uk/defcom

Ordered by the House of Commons to be printed 6 December 2011

Defence Committee

The Defence Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Ministry of Defence and its associated public bodies.

Current membership

Rt Hon James Arbuthnot MP (Conservative, North East Hampshire) (Chair) Mr Julian Brazier MP (Conservative, Canterbury) Thomas Docherty MP (Labour, Dunfermline and West Fife) Rt Hon Jeffrey M. Donaldson MP (Democratic Unionist, Lagan Valley) John Glen MP (Conservative, Salisbury) Mr Dai Havard MP (Labour, Merthyr Tydfil and Rhymney) Mrs Madeleine Moon MP (Labour, Bridgend) Penny Mordaunt MP (Conservative, Portsmouth North) Sandra Osborne MP (Labour, Ayr, Carrick and Cumnock) Bob Russell (Liberal Democrat, Colchester) Bob Stewart MP (Conservative, Beckenham) Ms Gisela Stuart MP (Labour, Birmingham, Edgbaston) The following were also Members of the Committee during the Parliament: Mr Mike Hancock MP (Liberal Democrat, Portsmouth South) Mr Adam Holloway MP (Conservative, Gravesham) Alison Seabeck MP (Labour, Moor View) John Woodcock MP (Lab/Co-op, Barrow and Furness) Mr David Hamilton MP (Labour, Midlothian)

Powers

The Committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the Internet via www.parliament.uk.

Publications

The Reports and evidence of the Committee are published by The Stationery Office by Order of the House. All publications of the Committee (including press notices) are on the internet at www.parliament.uk/parliament.uk/defcom. A list of Reports of the Committee in the present Parliament is at the back of this volume. The Reports of the Committee, the formal minutes relating to that report, oral evidence taken and some or all written evidence are available in a printed volume. Additional written evidence may be published on the internet only.

Committee staff

The current staff of the Committee are Alda Barry (Clerk), Judith Boyce (Second Clerk), Karen Jackson (Audit Adviser), Ian Thomson (Inquiry Manager), Christine Randall (Senior Committee Assistant), Miguel Boo Fraga (Committee Assistant) and Sumati Sowamber (Committee Support Assistant).

Contacts

All correspondence should be addressed to the Clerk of the Defence Committee, House of Commons, London SW1A 0AA. The telephone number for general enquiries is 020 7219 5745; the Committee’s email address is [email protected]. Media inquiries should be addressed to Alex Paterson on 020 7219 1589.

The Armed Forces Covenant in Action? Part 1: Military Casualties 1

Contents

Report Page

Conclusions and Recommendations 3

1 Introduction 9 Scope of the inquiry 9 Other reports 11

2 Medical treatment and rehabilitation 12 Background 12 The stages of medical treatment and rehabilitation 13 The provision of medical treatment 14

Resources 14 Advances in medical care resulting in more personnel surviving injuries 15 Queen Elizabeth Hospital 18 Defence Medical Rehabilitation Centre at Headley Court 19 Transfer of lessons between the MoD and the health services 20

The provision of treatment for mental health problems 20 Incidence of mental health problems 20 Research into the level of mental health problems in the Armed Forces 22 Reservists 23 Research 24 Mental health problems in theatre 25 Alcohol misuse 26 Decompression for those returning from operations 28 Trauma Risk Management 28 Mental health issues for medical staff 28

Support for families 29

3 Return to military service or civilian life 32 Recovery Pathways 32 Redundancies 33 Transition protocol 33

4 Support for former Service personnel 35 Compensation 35 Priority health treatment for those leaving the Armed Forces 36 Long term support for injured Armed Forces personnel 37

Prosthetics 37 Brain injuries 38 Mental health problems 39

5 Relationship with the charitable sector 42 How the MoD works with the charitable sector 42 Increase in charitable funding 42 Organisation of the charitable sector 44

2 The Armed Forces Covenant in Action? Part 1: Military Casualties

Conclusion 46

Formal Minutes 47

Witnesses 48

List of printed written evidence 49

List of additional written evidence 49

List of Reports from the Committee during the current Parliament 50


Conclusions and recommendations

Introduction

1. We wish to pay tribute to all the British personnel, both military and civilian, who are currently serving or have served on operations in Iraq, Afghanistan, Libya and elsewhere but, in particular, to those who have lost their lives, and the many more who have sustained life-changing injuries as a result of these conflicts. We have witnessed the courage of those severely injured working determinedly to return to active Service. We would also like to express our deep gratitude for the vital contribution made by the families of Armed Forces personnel. We also wish to recognise the dedication and skills of regular and reservist medical personnel, both in theatre and in the UK, in treating and rehabilitating those injured in action, often at some risk to their own lives and mental well-being. (Paragraph 1)

Medical treatment and rehabilitation

2. The evidence of Admiral Raffaelli, supported by that of the Families Federations, sets out the extraordinary quality of care given to our Armed Forces almost from the point of wounding. We commend the Armed Forces medical services for the improvement in all aspects of the medical treatment of injured personnel in theatre from emergency treatment by comrades and then the Medical Emergency Response Team followed by staff in the hospital and then evacuation back to the UK. We note, however, that this greater survival rate of very seriously injured personnel has serious implications for the quality of life of these personnel and for the resources required to maximise this quality. (Paragraph 23)

3. We note the significant advances in treatment resulting in a higher proportion of injured personnel surviving than in previous conflicts. We were impressed with what we saw and heard about the medical treatment in the Queen Elizabeth Hospital and rehabilitation services at the Defence Medical Rehabilitation Centre at Headley Court. We commend the MoD for improvements in the medical treatment and rehabilitation given to injured Service personnel and seek assurance that the new arrangements will be adequately resourced so they may be maintained over the longer term. (Paragraph 28)

4. We would encourage the MoD and the Department of Health to continue collaboration between the UK and USA defence medical services. (Paragraph 29)

5. There are significant opportunities for the NHS to learn from the experiences of the MoD in dealing with traumatic injury. In response to this Report, the Department of Health should tell us what mechanisms, other than medical personnel returning to the NHS after operational service and the recently created Centre for Surgical Reconstruction and Microbiology, it uses or intends to use to ensure the transfer of such valuable experience and advances in medical treatment, both in England and in the Devolved Administrations. (Paragraph 32)

6. The number of calls to the recently established helpline demonstrates the high level of need for mental health support for veterans. We welcome the MoD’s increased


attention to mental health issues. In response to this Report, the MoD should update us on progress on the implementation of the Murrison Report, Fighting Fit. (Paragraph 38)

7. We look forward to hearing the results of the King’s Centre current research on the impact of physical injury on mental wellbeing and the effectiveness of post-operational screening. The MoD should review its practices in response to the results of this research. We also recommend that the MoD continue to fund research into the mental health of those deployed on operations, in particular, the impact of multiple deployments and the stress of being in a combat role. (Paragraph 45)

8. We recommend that the MoD should commission research into the homecoming experiences of reservists and the support and understanding of families and employers. (Paragraph 46)

9. We recommend that the MoD should monitor Armed Forces personnel who have been deployed on operations to determine if PTSD or other mental health problems emerge while personnel are still serving. The MoD should respond to any indication of future problems rapidly and effectively. (Paragraph 47)

10. We recognise the importance of support for the families of deployed personnel, not only because it is right to look after the families but also because Armed Forces personnel are less likely to develop traumatic stress symptoms if their families are supported. We recommend that the MoD review its support for families when personnel are deployed on operations in the light of the results of the King’s Centre Research. (Paragraph 50)

11. It is unclear to us whether the MoD regards the misuse of alcohol and other dangerous risk-taking behaviour as part of a pattern of reprehensible behaviour which requires punishment or discouragement, or a manifestation of stress which requires treatment, or indeed a combination of both. We recognise that the MoD has been trying to tackle the over-consumption of alcohol but there is more that should be done. We recommend that the MoD carry out a study into what is driving the misuse and abuse of alcohol in the Armed Forces and what more could be done to modify behaviour which is significantly at variance with that of the general population. The MoD has yet to recognise the seriousness of the alcohol problem and must review its policy in this area. (Paragraph 55)

12. Whilst we recognise that it is not possible to do a formal piece of research on the Trauma Risk Management system, we recommend that the MoD evaluate the use and benefits of TRiM and compare it with other similar systems. In response to this Report, the MoD should tell us what it is doing to minimise the number of personnel who are not picked up by the use of TRiM, particularly reservists and those deployed as single augmentees. (Paragraph 58)

13. We commend the MoD for its recognition of the impact on medical staff in working with very severely injured Armed Forces personnel and for the introduction of greater support for such personnel. Such support for medical staff should continue and similar support should be introduced for those staff deployed in theatre and


continued when they return home, particularly for reservists who are demobilised on return. (Paragraph 60)

14. In the rest of this Report we have set out the many areas where the MoD is providing outstanding care in relation to military casualties. The MoD rightly recognises, however, that this cannot always be said for the support it gives to families, and in particular children, in the event of the loss or severe injury of a member of their family or someone else the family knows well. The impact of such an event can be widely and deeply felt. While the MoD does in other circumstances acknowledge that it is often the families left behind at home that bear the brunt of the difficulties caused by deployment, it is time the Department turned that acknowledgement into action, and we urge it to look again at the support services it provides for the families and children of Armed Forces personnel. (Paragraph 67)

Return to military service or civilian life

15. The concept that it is a duty of employment to return to health is one which shows clear benefits. This approach combines peer support and a structured military competitive environment which is best designed to aid recovery. (Paragraph 70)

16. We commend the development of the recovery pathways for promoting the recovery of injured and ill personnel. In particular, we are pleased to see that the Army is now managing its injured and sick personnel better although we recognise that the ARC was only recently established and the Army has yet to see its impact. We are concerned that the ARC might not have sufficient capacity to deal appropriately with the number of sick and injured personnel in the Army. In response to this Report, the MoD should tell us the latest position on the numbers covered by the ARC and whether the ARC will reach its target capacity of 1,000 by April 2012. The MoD should also inform us whether this capacity will allow all seriously sick and injured personnel to be supported. (Paragraph 71)

17. We recognise the difficulty faced by the Armed Forces in determining which injured personnel should remain in the Armed Forces and those who should be medically discharged, especially as many personnel wish to remain in the Armed Forces because it is their chosen career and of worries about future access to treatment. We recommend that the needs of the individual should be taken into account when deciding on medical discharge and that those for whom a civilian career would be more rewarding should be encouraged to consider the benefits to themselves of leaving. (Paragraph 73)

18. We agree with the MoD’s policy that those in medical treatment or rehabilitation should be protected from redundancy. (Paragraph 74)

19. We are concerned that the arrangements put in place by the MoD for the transition of personnel may be disrupted by the future re-organisation of the health service in England. We wish to be kept informed by the MoD of the results of its work with the providers of health and social care. In particular, the MoD should tell us whether medically discharged personnel are receiving consistent services, no matter where in the UK they live. (Paragraph 77)


Support for former Service personnel

20. The Government should exclude Armed Forces compensation from consideration when determining means-tested benefits without the need for each person to establish a personal injury trust. We agree with the Veterans Minister that the lump sum payment from the Armed Forces Compensation Scheme is intended to be compensation rather than earmarked to be spent on social care. We therefore conclude that this is not a matter for debate but one which should be dealt with urgently. If it is left to be dealt with following a consultation and debate in the country, there is a risk that in the short term some members of the Armed Forces might be disadvantaged. (Paragraph 81)

21. We recognise that payments under the Armed Forces Compensation Scheme are borne by the MoD and there is, therefore, a risk that they are competing for funds against other defence needs such as weapons systems. We shall consider this subject further when we undertake an inquiry into the needs of veterans. (Paragraph 82)

22. The policy on the provision of priority treatment to veterans is not clear. We would like to see tangible evidence that the education of GPs is working in regard to the provision for priority treatment for veterans with conditions as a result of service in the Armed Forces especially when it comes to treatment for mental health problems. The MoD should institute an education programme to inform Armed Forces personnel leaving the Services about what they are entitled to with regard to health services. We look forward to seeing coverage of the Armed Forces Covenant in the mandate between the Government and the NHS Commissioning Board and the establishment of similar arrangements being agreed with the Devolved Administrations. (Paragraph 85)

23. In respect of those who have lost limbs, there are likely to be significant medical resource costs, not just costs of prosthetics but also in provision of qualified and experienced staff. We regard it as essential for former Service personnel to receive the same level of support after leaving the Services as they did whilst serving. We are pleased to see that the Government has accepted the recommendations of the Murrison Review on prosthetics, and we would like to see the project plan and timetable for the establishment of the specialist centres and the arrangements for ensuring support health authorities in England and in the Devolved Administrations. (Paragraph 89)

24. We note that other costs relating to long term mobility issues, for example cars, housing and other aids and adaptations, need to be considered and resourced by other Government Departments. In response to this Report, we ask the Government to set out its proposals to ensure that these matters will be properly resourced. (Paragraph 90)

25. We are not convinced that the Department of Health and the health authorities in England and the Devolved Administrations fully understand the costs and implications of long term medical care and social care for ex-Service personnel with brain injuries. Our visit to the US defense center for excellence for traumatic brain injury highlighted their assessment of the links between traumatic brain injury and PTSD and mental health problems. It is very important that former Service


personnel whose health has been seriously mentally or physically undermined in the service of the country be given the best possible treatment. In response to this Report, we expect the Department of Health, the Devolved Administrations and the MoD to set out how they intend to provide such services and ensure the appropriate quality of the treatment and the necessary support. The Government should commission a review into the needs of ex-Service personnel with brain injuries and examine research which considers the long term effects of traumatic brain injuries and the mental health needs of veterans. (Paragraph 93)

26. We regard it as essential that the support of ex-Service personnel suffering from mental health problems should be treated as being as important as that for those with physical injuries. The MoD told us that it did not expect PTSD to develop in an overwhelming number of troops after they left the Service but we remain to be convinced. We recommend that the MoD works with the Department of Health, the NHS and the Devolved Administrations to ensure that GPs and other service providers are aware of the support available to former Service personnel with mental health problems. The MoD should work with the charities to communicate with former personnel and their families about the availability of support. (Paragraph 97)

Relationship with the charitable sector

27. The MoD told us, and we accept that it was slow to take advantage of offers of additional funding from the charities and has been reviewing the way it responds to offers of additional funding. In response to this Report, the MoD should tell us the outcome of this work. The MoD now appears to be better at engaging with those charities providing funding for capital projects. (Paragraph 101)

28. We recognise that there is a long and honourable tradition of the charitable sector providing support for our Armed Forces, for their families and for veterans. This is not only valuable in material terms but also helps to keep the people of our country connected to the Armed Forces. Nevertheless, we are concerned the charities may be paying for projects that the MoD should more properly fund. We are also concerned that the MoD may not have planned for the future replacement and maintenance of some of the additional facilities provided by such charities. We recommend that, in response to this Report, the MoD sets out its policy with regard to what it should properly fund and how it will work with the charitable sector and what its current plans are. (Paragraph 103)

29. We believe that there is a possibility that charitable donations will begin to reduce when the Armed Forces no longer have personnel in combat roles in Afghanistan and recommend that the MoD’s future plans for projects should not depend on such funding. We would suggest to the Armed Forces charities that now is the time to be raising money to be held in reserve for when future funding for Armed Forces projects declines. (Paragraph 104)

30. Whilst we recognise the work done by COBSEO and the MoD to improve the coordination of the charities supporting Service and ex-Service personnel, more needs to be done. We also exhort the charities to co-ordinate their efforts and in some cases to consider the merger of appropriate charities serving similar groups of people. The MoD should consider building on the COBSEO cluster system for


charities whereby a suitable organisation is given responsibility to co-ordinate efforts in a particular area, for example, housing. COBSEO should encourage charities to use some of their reserves as it is now “a rainy day”. (Paragraph 108)

31. The MoD should help to address the possible confusion as to where those affected can find support from the charitable sector. In particular, the MoD should publish on its relevant websites a clear description of where help can be found for different groups of personnel (for example, those in the individual Services or even Units). It should also as a matter of course provide such information to personnel when they leave the Services. (Paragraph 109)

Conclusion

32. We have been impressed by the courage, hard work and determination of those injured on operations to get well and, if at all possible, to return to active duty. The same may be said of the brave and skilful personnel, both military and civilian, who are providing the medical care that our Armed Forces need. The MoD is now providing first class medical treatment and rehabilitation both in theatre and back in the UK. It also provides other support for severely injured personnel in their journey to health and return to duty or to civilian life. It is too soon to say whether the individual Service recovery pathways and the transition protocol with health authorities are working well but they represent steps in the right direction. (Paragraph 110)

33. Our major concern is whether the support for personnel when they leave the Services will be sustainable over the long term when operations in Afghanistan have passed into history. In particular, we are concerned about the number of people who may go on to develop severe and life-limiting mental health, alcohol or neurological problems. We remain to be convinced that the Government as a whole fully understands the likely future demands and related costs. (Paragraph 111)

34. We note that the charities and Families Federations are making a significant contribution to the support of injured Armed Forces personnel and veterans and their families but fear that their contribution may be constrained if the level of charitable donations reduces substantially. We urge the charities and the MoD to work even more closely together and explore ways of ensuring that new capital projects provided by charities can be sustained into an era when current levels of donations may no longer be relied upon. (Paragraph 112)


1 Introduction 1. We wish to pay tribute to all the British personnel, both military and civilian, who are currently serving or have served on operations in Iraq, Afghanistan, Libya and elsewhere but, in particular, to those who have lost their lives, and the many more who have sustained life-changing injuries as a result of these conflicts. We have witnessed the courage of those severely injured working determinedly to return to active Service. We would also like to express our deep gratitude for the vital contribution made by the families of Armed Forces personnel. We also wish to recognise the dedication and skills of regular and reservist medical personnel, both in theatre and in the UK, in treating and rehabilitating those injured in action, often at some risk to their own lives and mental well-being.

Scope of the inquiry

2. In February 2011, we announced an inquiry into the support given to members of the Armed Forces including reservists wounded in the Service of their country and to their families. This inquiry is to be the first in a series of inquiries covering the Armed Forces Covenant. We are grateful to the staff of the Committee for the work they have put into helping us to produce this Report.

3. The Armed Forces Covenant between the People of the United Kingdom, the Government and all those who serve or have served in the Armed Forces and their families was set out by the Government in May 2011:

The first duty of Government is the defence of the realm. Our Armed Forces fulfil that responsibility on behalf of the Government sacrificing some civilian freedoms, facing danger and, sometimes, suffering serious injury or death as a result of their duty. Families also play a vital role in supporting the operational effectiveness of our Armed Forces. In return, the whole nation has a moral obligation to members of the Naval Service, the Army and the Royal Air Force, together with their families. They deserve our respect and support, and fair treatment.

It covers a range of issues including, terms and conditions of service, healthcare, education, housing, benefits and tax, responsibility of care, deployment, support after Service and recognition.1

4. Since 2003, the Armed Forces have been operating in two very hostile environments in Afghanistan and Iraq, resulting in many personnel being put in harm’s way, and many Armed Forces personnel have been killed or seriously injured in action. Since the start of the mission in Afghanistan in 2001 to 15 November 2011, 385 members of the UK Armed Forces and civilians have been killed and a further 544 seriously injured or wounded.2 In Iraq from January 2003, 136 Armed Forces personnel were killed as a result of hostile

1 The Armed Forces Covenant,

www.mod.uk/DefenceInternet/AboutDefence/WhatWeDo/Personnel/Welfare/ArmedForcesCovenant/

2 Defence Analytical Services and Advice, British Casualties – Afghanistan, as at 15 November 2011, www.dasa.mod.uk


action and a further 222 seriously injured or wounded.3 An unknown number of personnel have also suffered mental health problems, in particular, post-traumatic stress disorder (PTSD). The Armed Forces and the MoD have a responsibility to ensure that Armed Forces and civilian personnel are provided with the best treatment and support, including rehabilitation, and that their families are also supported.

5. We examined the following:

• how the Armed Forces and the Ministry of Defence (MoD) treat and rehabilitate injured personnel once they are evacuated from the battlefield;

• how they treat and rehabilitate personnel in the longer term;

• the effectiveness, or otherwise, of the processes involved in supporting personnel when they either return to work within the Armed Forces or, if being medically discharged, require support finding work, accommodation and further medical support;

• how effectively the MoD works with local authorities and health authorities to put the right level of support in place and whether different levels of support are provided in different regions of the UK;

• the role of the charitable sector in providing support to personnel and their families, in particular, whether the demarcation between the state and the voluntary sector in the provision and funding of services is appropriate;

• how well the MoD and the Armed Forces identify and treat mental health problems which develop in personnel returning from areas of conflict;

• how the MoD and the Armed Forces support the families of those wounded in action, in particular, those families of bereaved personnel; and

• if there are differences in the way that members of the Reserve Forces are supported.

6. As part of our inquiry, we took oral evidence from a number of external sources including the Families Federations, the King’s Centre for Military Health Research, the Royal British Legion, the Soldiers, Sailors, Airmen and Families Association (SSAFA), Help for Heroes and British Limbless Ex-Service Men’s Association (BLESMA). On the Government side, we took evidence from MoD officials responsible for policy matters and for the delivery of the policy and from officials at the Department of Health. A full list of witnesses is given on page 48. The Rt Hon Andrew Robathan MP, Minister for Defence Personnel, Welfare and Veterans, and the Rt Hon Simon Burns MP, Minister of State for Health, also gave evidence to us. In addition, we asked the Devolved Administrations for information on their approach and practices in support of discharged Armed Forces personnel. We had written evidence from the MoD, some charities, the Royal College of Physicians and the Royal College of General Practitioners and a number of other organisations and individuals who are listed on page 49. We are very grateful to all those who provided evidence to us whether orally or in writing.

3 Defence Analytical Services and Advice, British Casualties – Iraq, www.dasa.mod.uk


7. We visited the Queen Elizabeth Hospital and the Defence Medical Rehabilitation Centre at Headley Court, Hasler Company in Plymouth and, as part of a wider visit to the USA, visited the Walter Reed Hospital and the US defense center for excellence for traumatic brain injury in Washington. We also visited Norton House where SSAFA provide support and accommodation to the families of personnel in the Queen Elizabeth Hospital. We are grateful to staff and users of these facilities who took the time to brief us on their work and relevant issues.

Other reports

8. In producing this Report, we took account of several reports including work done by the previous Defence Committee, the NAO, the Committee of Public Accounts and the reports by Dr Andrew Murrison MP MD:

• Defence Committee report: Medical care for the Armed Forces Seventh Report 2007-08;4

• National Audit Office Report, Treating Injury and Illness arising on Military Operations, February 2010;5

• The subsequent Committee of Public Accounts Report, Ministry of Defence: Treating injury and illness arising on military operations;6 and

• Dr Andrew Murrison MP MD-two reports on the medical care and support: the first one, Fighting Fit, into the mental health needs of serving personnel and veterans published in August 2010;7 and the second on the provision of prosthetics for veterans, A better deal for military amputees, published in October 2011.8

4 Defence Committee, Seventh Report of Session 2007–08, Medical care for the Armed Forces, HC 327

5 National Audit Office, Session 2009–10, Treating Injury and Illness arising on Military Operations, HC 294

6 Committee of Public Accounts, Twenty-seventh Report of Session 2009–10, Ministry of Defence: Treating injury and illness arising on military operations, HC 427

7 Dr Andrew Murrison MD MP, Fighting Fit, August 2010, www.mod.uk

8 Dr Andrew Murrison MD MP, A better deal for military amputees, 27 October 2011, www.dh.gov.uk/health/category/publications/


2 Medical treatment and rehabilitation

Background

9. We recognise that more Armed Forces personnel become sick or are injured in training or other peacetime activities than those injured or killed on operations and that the treatment given to them is identical to that of personnel injured on operations and is commensurate with their needs. The MoD provides medical support to injured or sick personnel until their condition is stable and has improved as much as possible. Alongside the medical treatment and rehabilitation, Armed Forces personnel are supported by the Services in other practical aspects of their recovery. After the medical conditions of individuals have stabilised, decisions are then made as to whether the person wishes to remain in the Armed Forces and whether there is a suitable role for the person or whether they should be medically discharged.

10. The MoD described the Defence Medical Services (DMS) and the role of the Surgeon-General in the following figures:

Defence Medical Services9 The uniformed medical and dental personnel from all three Services are known collectively as the Defence Medical Services (DMS). The DMS are grouped under the Headquarters Surgeon General (HQ SG), Joint Medical Command (JMC), Defence Dental Services (DDS) and the three single Service medical organisations. Medical, dental and related support services are delivered to armed forces personnel by the Ministry of Defence (MOD), the NHS, charities and welfare organisations. Overview The primary role of the DMS is to ensure that service personnel are ready and medically fit to go where they are required in the UK and throughout the world – generally referred to as being ‘fit for task’. The DMS encompass the entire medical, dental, nursing, allied health professionals, paramedical and support personnel. It is staffed by around 7,000 regular uniformed medical personnel and provides healthcare to 196,000 servicemen and women. Personnel from all three services, regulars and reservists, work alongside civil servants and other supporting units providing healthcare to service personnel serving in the UK, abroad, those at sea, and in some circumstances family dependants of service personnel and entitled civilians. It also provides some aspects of healthcare to other countries’ personnel overseas, in both permanent military bases and in areas of conflict. The range of services provided by the DMS includes primary healthcare, dental care, hospital care, rehabilitation, occupational medicine, community mental healthcare and specialist medical care. It also provides healthcare in a range of facilities, including medical and dental centres, regional rehabilitation units and in field hospitals.

9 Defence Medical Services, www.mod.uk/DefenceInternet/MicroSite/DMS/WhatWeDo


The DMS has 15 regional rehabilitation units (RRUs) across the UK and Germany, 5 Ministry of Defence hospital units (MDHUs) embedded into NHS acute trusts, the Royal Centre for Defence Medicine (RCDM) in Birmingham, and 15 military-run Departments of Community Mental Health (DCMH) in the UK with 5 DCMHs at the major permanent overseas bases.

The Surgeon General10 is the 3* professional head of the DMS and the Process Owner for end to end Defence healthcare and medical operational capability. He is accountable to the Defence Board, reporting routinely through the Defence Operating Board and Service Personnel Board, both of which he attends as required.

The SG is responsible for:

• Defining the boundaries and processes, organisational structures and composition of forces, and the standards and quality needed, to deliver advice on health policy, healthcare and medical operational capability in consultation with top level budget holders

• Setting the overall direction on all clinical matters relating to the practice of medicine within the military

• Setting and auditing the professional performance of all medical personnel Setting clinical and medical policies and standards, and auditing compliance by military organisations across Defence

• Developing the science of military medicine to develop approaches and treatments that will best counter threats to the health and well being of Service personnel

• Providing deployable medical operational capability • Building and maintaining the medical infrastructure and cadre of people • Delivering a comprehensive healthcare system that provides the appropriate timely healthcare to

Service (and other entitled) personnel • Ensuring coherence of health plans between Defence and the NHS • Chairing the Defence Medical Services Board, the forum for providing strategic direction and

guidance to the DMS

The stages of medical treatment and rehabilitation

11. The seven stages of the medical pathway for personnel injured11 are as follows:

1. Battlefield – A soldier is wounded in Afghanistan. He carries his own field dressings and morphine, and will be attended initially by the team medic who is trained to deliver “enhanced” first aid. If too serious to be dealt with in the field, a call for assistance will be flashed to Bastion.

2. Evacuation – A medical emergency response team, including an anaesthetist, A&E specialist, medics and force protection soldiers travel to the scene in a Chinook helicopter. Two Apaches provide security. The median time from injury to arrival at Bastion is 99 minutes for the worst injuries.

10 Defence Medical Services, www.mod.uk/DefenceInternet/MicroSite/DMS/WhatWeDo

11 Defence explained: The seven stages of medical pathway, www.mod.uk/DefenceInternet/PictureViewers/DefenceExplainedTheSevenStagesOfTheMedicalCarePathway


3. Field Hospital – Bastion’s hospital offers an intensive care facility, surgery, A&E, physiotherapy, dental and mental health care. It has CT and X-ray equipment and can provide blood transfusions. An even more capable coalition hospital is located in Kandahar.

4. Aeromed flight to UK – If the patient needs more care or if a period of recovery prohibits return to duty, he is evacuated to the UK aboard specially equipped RAF aircraft. The aeromed teams are trained to deal with medical conditions that may be exacerbated by high altitude.

5. UK Hospital – In the UK, patients needing more treatment are usually taken to the Queen Elizabeth Hospital in Birmingham. NHS staff are augmented by about 240 clinical military staff, delivering the whole range of medical care. When clinically appropriate, patients are cared for in a military managed ward.

6. Rehabilitation – Patients recovering from orthopaedic and neurological problems may be removed to Headley Court, which hosts the unique Limb Fitting and Amputee Centre, that ensures prosthetic limbs are correctly fitted. Patients may then be transferred to regional rehabilitation units.

7. Return to Duty – The goal is always to return injured personnel to duty. That may not always be possible, in which case continued support eases their return to civilian life. The majority of patients return to duty and increasingly even amputees are finding that their careers are not over.

12. Mental health medical care for Armed Forces personnel psychologically injured on operations is predominantly through Community Mental Health Teams in the UK and Germany. If personnel require in-patient treatment, the MoD has a contract with Staffordshire and Shropshire NHS Trust who place patients in hospitals in nearby NHS Trusts.12

The provision of medical treatment

Resources

13. We asked the Minister for Defence Personnel, Welfare and Veterans, the Rt Hon Andrew Robathan MP, if the MoD could sustain the right level of resources for the Defence Medical Services (DMS). He told us that the MoD would like to increase funds in some areas and that DMS had improved over the last ten years:

[...] it was not until the invasion of Iraq in 2003 and subsequently the war in Afghanistan that we have been in a position where we had casualties and injuries such as we sustain now. [...] Although there was provision for field hospitals and so on, the casualties who have come back from Iraq and Afghanistan have completely changed the nature of what we have to deal with in the Defence Medical Services. That rather sets the scene.

12 Ev 149, Q 371


Do we have the resources? I am tempted to say that we would always like more, but actually we do have the manpower to sustain the treatment that we are giving. We have the same work force needs, if I can put it that way, as the NHS, particularly in what is quite a new speciality—emergency medicine. [...] emergency medicine is a new speciality and we would like more of it. But we are able to manage it. We certainly are managing, but we would like to increase it in one or two areas .13

14. Surgeon Vice-Admiral Raffaelli, the Surgeon General, told us that medical care was one of the few areas which had received extra funding as a result of the SDSR:

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, [...].14

Advances in medical care resulting in more personnel surviving injuries

15. More Armed Forces personnel are surviving injuries which would have been fatal in previous conflicts because of advances in medical treatment in theatre, on evacuation and in hospital. Admiral Raffaelli told us that it is not possible to be precise about the proportion but he estimated some 210 additional people had survived:

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. [...] 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.15

16. The very severe nature of the injuries experienced by some personnel in Afghanistan and Iraq means that they have very complex medical and rehabilitation needs with the consequence that the period of their recovery can be extensive. The average time spent in medical care is normally greater than 12 months and can be two years or longer depending on the needs of the individual, hence many personnel have yet to be discharged. The MoD told us that, as at September 2011, only 300 personnel injured on operations since 2006, some 8.7 per cent, had been discharged and only 21.5 per cent had left specialist medical care.16 Admiral Raffaelli told us that it was important for individuals to get the most appropriate treatment:

13 Q 474

14 Q 345

15 Q 310

16 Ev 138


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 [...]. 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.17

17. Admiral Raffaelli stressed the importance of end to end treatment for wounded personnel and the need for partnerships with international military partners and the NHS. He also detailed some of the recent medical advances such those to reduce blood loss:

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 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.18

18. He also described the importance of evacuation procedures in theatre:

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 casualty retrieval helicopters are tremendous. We have a different, but complementary, approach to the US—we don’t have the quantity of assets that they have, though as I say we do work in partnership, and we have the Medical Emergency Response Team capability, which is deployed in the 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

17 Q 311

18 Q 304


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. 19

19. He then told us about the importance of the work done at the hospital in theatre and in the evacuation of personnel back to the UK:

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.20

20. The Families Federations told us that the medical support received by injured personnel was very good:

Dawn McCafferty (Chair of the RAF Families Federation): Certainly, the feedback that I get from family members and from those who are serving is that the medical support that they get, if they are injured on operations, is second to none. Indeed, many people are probably surviving on the battlefield who might not have survived years ago. They are brought home to the United Kingdom and they are given first-class treatment right the way through to, hopefully, recovery and rehabilitation.

Kim Richardson (Chair of Naval Families Federation): I would say that families feel that their serving personnel are being cared for very well; [...] One of the things I don’t think we’re doing is going back to the families to say, “Where could we have done better?” [...]

Julie McCarthy (Chief Executive of the Army Families Federation): I absolutely agree. Nobody doubts the quality of medical care that soldiers are receiving. [...]21

21. In written evidence, SSAFA told us that “the Armed Forces and the MoD, together with NHS and other Agencies, now have in place world class facilities for clinical treatment and rehabilitation”.22 The Royal British Legion told us that “the quality of trauma care on

19 Q 304

20 Q 304

21 Q 23

22 Ev 159


operations in Iraq and Afghanistan has progressed to allow an unexpected survivor rate of 25% which compares to some of the best NHS hospitals in the UK”.23

22. In its report of February 2010, the National Audit Office said that:

The Department’s (MoD) clinical treatment and rehabilitation of the seriously injured is highly effective. The Department has a clear focus on providing a high level of care and rehabilitation to seriously injured personnel on operations and in the UK, and outcomes achieved are good relative to the seriousness of the injuries sustained.24

23. The evidence of Admiral Raffaelli, supported by that of the Families Federations, sets out the extraordinary quality of care given to our Armed Forces almost from the point of wounding. We commend the Armed Forces medical services for the improvement in all aspects of the medical treatment of injured personnel in theatre from emergency treatment by comrades and then the Medical Emergency Response Team followed by staff in the hospital and then evacuation back to the UK. We note, however, that this greater survival rate of very seriously injured personnel has serious implications for the quality of life of these personnel and for the resources required to maximise this quality.

Queen Elizabeth Hospital

24. Since the opening of the new Queen Elizabeth Hospital, Birmingham in June 2010, the majority of Armed Forces personnel have been treated in a military-managed ward. Surgeon Commodore MacArthur told us that the arrangements with the Queen Elizabeth Hospital were working well:

[...] we have learned a lot over the last three or four years. We have injected more military personnel into Birmingham, and there are now nearly 400 people working there. We have learned too to increase the welfare administrative support to soldiers, marines and airmen coming to Birmingham with increased J1 [in theatre] support. We have very close engagement with University Hospital Birmingham NHS Foundation Trust to make it work, and I believe it is working well.25

25. Admiral Raffaelli stressed the need for a combined approach at the Queen Elizabeth Hospital:

[...] 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.26

23 Ev 165

24 HC (2009–10) 294, para 17

25 Q 349

26 Q 311


Defence Medical Rehabilitation Centre at Headley Court

26. The Defence Medical Rehabilitation Centre (DMRC) at Headley Court provides a mixture of hostel beds for those undergoing less serious rehabilitation and in-patient beds for those more seriously injured. The number of hostel beds has remained constant at 110 over the last 10 years. The number of in-patient beds has risen from 36 before 2007 to 122 in October 2011 with a further planned expansion to 144 by July 2012.27 We asked the MoD if this level of support was sustainable, particularly when the UK no longer has troops in combat roles in Afghanistan. Admiral Raffaelli told us:

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 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.28

27. The National Audit Office reported that Headley Court provided unique rehabilitation facilities:

Headley Court provides rehabilitation facilities for complex trauma, neurological injury and other complex injuries. There is no NHS equivalent for general rehabilitation from trauma and limited civilian provision for specialist rehabilitation such as neurological injuries. Seriously injured personnel needing rehabilitation are admitted to Headley Court, first as inpatients to the ward where they receive intensive support. [...] However, military commanders told us the quality of care at Headley Court was very good. Patients also considered the quality of care and support to be good, including from mental and occupational health specialists and rehabilitation staff.29

28. We note the significant advances in treatment resulting in a higher proportion of injured personnel surviving than in previous conflicts. We were impressed with what we saw and heard about the medical treatment in the Queen Elizabeth Hospital and rehabilitation services at the Defence Medical Rehabilitation Centre at Headley Court. We commend the MoD for improvements in the medical treatment and rehabilitation given to injured Service personnel and seek assurance that the new arrangements will be adequately resourced so they may be maintained over the longer term.

29. During our visit to the Walter Reed Hospital, we were impressed by the liaison and co-operation between the USA and the UK in their work supporting those with life-

27 Ev 144

28 Q 312

29 HC (2009–10) 294, para 2.18


changing injuries. We would encourage the MoD and the Department of Health to continue collaboration between the UK and USA defence medical services.

Transfer of lessons between the MoD and the health services

30. The relationship between the health services and the MoD is symbiotic. In the past, the MoD has drawn on the expertise of NHS personnel with greater experience in treating traumatic injuries. More recently, medical personnel working within Afghanistan and Iraq and at the Queen Elizabeth Hospital have unfortunately had far greater experience of emergency medicine. Claire Phillips, the Department of Health, told us that there were opportunities to learn from each other:

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.30

31. Claire Phillips also told us of the very recent creation of the National Institute of Health Research Centre for Surgical Reconstruction and Microbiology in Birmingham which would help in providing opportunities to learn from the work done by the Defence Medical Services and the NHS.31 The Centre will carry out research to help people recover better and faster from severe injuries resulting in improved trauma care in the NHS. The contract is funded by the MoD (£10 million over ten years), Department of Health (£5 million over five years), and the University Hospital Birmingham NHS Foundation Trust and the University of Birmingham (£5 million over five years).32

32. There are significant opportunities for the NHS to learn from the experiences of the MoD in dealing with traumatic injury. In response to this Report, the Department of Health should tell us what mechanisms, other than medical personnel returning to the NHS after operational service and the recently created Centre for Surgical Reconstruction and Microbiology, it uses or intends to use to ensure the transfer of such valuable experience and advances in medical treatment, both in England and in the Devolved Administrations.

The provision of treatment for mental health problems

Incidence of mental health problems

33. Admiral Raffaelli told us post-traumatic stress disorder (PTSD) was seen in those who have served on operations but, in general, the numbers were very low at between three and

30 Q 309

31 Q 309

32 Ev 144


seven per cent, compared with the general UK population. Much more common were general mental health problems such as depression and anxiety although these were still in line with the non-deployed personnel and the general population.33

34. Armed Forces personnel are still reluctant to come forward with concerns about their mental health because of worries about the impact on their careers and how other people might perceive them, and guilt that their condition is not the same as a physical injury. Professor Wessely, Head of the King’s Centre for Military Health Research,34 told us that this was probably no different from any other occupational group and indeed the military is now slightly more accepting of mental health problems:

[...] the majority of people with mental health problems do not present either in Service or after Service—only around 40% do, and 60% do not. As I say, there is a lot of undetected morbidity that we know about but no one else does, apart from the person themselves. [...] that is probably no different from any other occupational group. If we take a group of doctors—my wife runs a sick doctor service—it is very similar. If we took a group of MPs, I suspect it would be very similar as well. It is a much bigger social problem. Our own original, rather naive, view was that it was to do with the nature of Army culture. I think we have changed our mind; if anything, the military is now—we have some nice data on this—slightly more accepting of mental health problems than it was, and many problems with veterans begin when they leave, not when they are in Service. It is not that there is a bullying military culture, and then they join the touchy-feely, cuddly NHS and everything is fine. It certainly does not work like that.35

35. General Rollo, Deputy Chief of Defence Staff (Personnel and Training), told us that mental health was a priority for the MoD:

[...] 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.36

36. In May 2010, Dr Andrew Murrison MD MP was asked to develop a mental health plan for servicemen and veterans and on 31 August 2010 he published his report, Fighting Fit, the Government accepted his recommendations. Key recommendations included incorporation of a structured mental health enquiry into existing medical examinations for serving personnel, mental health follow up of veterans 12 months after leaving the Services

33 Q 317

34 The King’s Centre for Military Health Research is a collaboration between three parts of King’s College London-the Institute of Psychiatry, the Department of War Studies and the Medical School. Professor Wessely is the Director of the Centre and of the Academic centre for Defence Mental Health, a partnership between the MoD and King’s College London. The mission of the academic Centre is to be a resource of research excellence and expertise within Defence Medical Services Mental Health Services and to act as a catalyst for the promotion of a strong research-based culture within Mental Health Services

35 Q 147

36 Q 345


and the development of an online service, called “the Big White Wall”.37 Admiral Raffaelli told us:

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.38

37. Claire Phillips told us that they were working with the MoD on mental health issues for those leaving the Services:

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.39

The Big White Wall went live in September 2011 and the site is staffed by professional counsellors who can be contacted 24 hours a day, seven days a week.40

38. The number of calls to the recently established helpline demonstrates the high level of need for mental health support for veterans. We welcome the MoD’s increased attention to mental health issues. In response to this Report, the MoD should update us on progress on the implementation of the Murrison Report, Fighting Fit.

Research into the level of mental health problems in the Armed Forces

39. In 2003, following lessons learned from the first Gulf War, the MoD asked Professor Wessely, now the Head of the King’s Centre for Military Health Research, and his team to start a large scale study into the physical and psychological health of those who were about to take part on the invasion of Iraq. The study was later expanded to include those deployed to Afghanistan. The first set of findings was reported in 2006 with the results of the further study in 2010. 41 In 2004, the King’s Centre for Military Health Research was formed from the Gulf War Illnesses Research Unit of King’s College London.

40. Professor Wessely told us that results of their studies in 2006 and 2009 of 10,000 Armed Forces personnel showed that the rate of PTSD was unchanged at some three to four per cent with those having been in combat roles (some 25 per cent in 2009) at seven per cent.42

37 Dr Andrew Murrison MD MP, Fighting Fit, August 2010, www.mod.uk

38 Q 317

39 Q 328

40 Ev 145

41 King’s Centre for Military Health Research: A fifteen year report, September 2010, www.kcl.ac.uk/kcmhr/publications/reports.aspx

42 Q 137


The King’s Centre research found more depression, anxiety disorders and alcohol problems than Post Traumatic Stress Disorder (PTSD) in the UK Armed Forces. Professor Wessely stressed that for a diagnosis of PTSD, the person had to be suffering from some impairment of function:

The first thing to say is that some of the symptoms of Post-Traumatic Stress Disorder are not, by themselves, abnormal. We would not say that coming back from a deployment with poor sleep, or being more irritable or a bit more angry and difficult, were signs of a disorder; that is a normal emotional reaction. [...] The best way of understanding a psychiatric disorder is that it is when it is not just that you have good or bad memories of your military Service, but when that impedes your function; because of those memories, you cannot work, you cannot keep down a marriage, you start doing drugs or drink—in other words, your performance is impaired. In cases of PTSD, everyone remembers symptoms such as flashbacks, anxiety and such things, but they forget that there is also a requirement that someone is impaired in their function. When someone is impaired in their function, they are moving towards a formal psychiatric disorder that may require treatment. Simply having memories of war is almost a sine qua non of having been deployed, and we go out of our way not to medicalise or pathologise that.43

41. Professor Wessely also pointed out that the relationship between exposure to trauma and PTSD was not a simple one:

The point from that is that the relationship is not a simple one between exposure to trauma and Post-Traumatic Stress Disorder. When Marines had high levels of exposure, but lower levels of stress, the general view, which I think is the correct one, is that it was mitigated by high esprit de corps, training, professionalism, cohesion and leadership—all things that the military is good at. It is not a linear relationship between trauma and outcome in mental health.44

He also found less PTSD in the UK Armed Forces than in those of the USA following deployment. The reasons for this are not certain but American troops do longer tours, typically one year and are on average younger than UK troops.45 We also note that they are also more likely to be reservists.

Reservists

42. The King’s Centre research showed that reservists experienced more problems on return from deployment than regulars. Professor Wessely told us that the reasons for this were complex:

We know that they have worse mental health problems. [...] that these figures are not like some of those we have seen from the USA, where one third come back with neuropsychiatric problems. For us it is about 6%, so 94% do not come back with

43 Q 140

44 Q 145

45 Q 218


mental health problems. Nevertheless, Reservists are more vulnerable. We have had a long look at this in various ways, with various different studies and data sets. It is not to do with what happens to them in theatre. In particular, we showed that, between 2003 and now, morale and satisfaction with their role in theatre had increased from Telic 1 [first phase of the Iraq conflict] right through to now. It was a bit disappointing to see that that had not led to an improvement in mental health problems.

The problems are particularly to do with support and homecoming issues. Reservists are more likely to have problems with their employers; they are less likely to feel that the military is supportive; they are less likely to feel that their families are supportive; and they are more likely to have problems from their peer group. Let’s say that the Reservists come back to King’s. For two days it is great, and they tell their war stories, and you start telling them about the latest NHS reform and how terrible it has been while they have been away, or whatever the current problems are. We are clear that it is to do with different homecoming experiences, different support structures and different family structures.46

Research

43. In 2009, the King’s Centre for Military Health Research found no relationship between mental health problems and the number of deployments undertaken by personnel although Professor Wessely stressed that this was only “at that moment”.47 Professor Wessely told us that they had also completed research into the impact on mental health of physical injuries and had found that physical injury increases the risk of psychiatric disorder but the full results are not yet available.48

44. The King’s Centre found that pre-deployment screening for the likely development of mental health problems would be ineffective.49 It is currently carrying out research for the Armed Forces of the United States on the efficacy of post-deployment screening using the UK Armed Forces as a control group.50

45. We look forward to hearing the results of the King’s Centre current research on the impact of physical injury on mental wellbeing and the effectiveness of post-operational screening. The MoD should review its practices in response to the results of this research. We also recommend that the MoD continue to fund research into the mental health of those deployed on operations, in particular, the impact of multiple deployments and the stress of being in a combat role.

46. We recommend that the MoD should commission research into the homecoming experiences of reservists and the support and understanding of families and employers.

46 Q 150

47 Q 156

48 Q 173

49 Qq 172, 178

50 Q 178


47. We recommend that the MoD should monitor Armed Forces personnel who have been deployed on operations to determine if PTSD or other mental health problems emerge while personnel are still serving. The MoD should respond to any indication of future problems rapidly and effectively.

Mental health problems in theatre

48. Professor Wessely told us that the mental health problems which emerge in those deployed in theatre are a reflection of what is happening at home:

We know that many of the mental health problems that present in theatre are a reflection of what is going on at home. We also know that where the person in theatre feels that the family is not being supported, their own mental health is worse, and they are more likely to develop traumatic stress symptoms. It is not just a matter of being kind to families; we would suggest, and the data suggest, that it is an operational requirement to have good support and welfare for families of Reserves and Regulars, because that will improve mental health in theatre.51

General Rollo, told us that support for families when personnel were deployed was important in maintaining operational effectiveness:

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.52

49. Dr Fear of the King’s Centre told us that they were doing research into military families:

We are looking at 600 fathers from our military cohort, and we are interviewing them about their military experiences but also their relationships with their families and in particular with their children. We are asking how they feel that they relate to their children and how their children cope with them being in the military. We are also contacting their partners, or their wives, to get their views on how the father interacts with the family and with the children. For those children who are 11 or older, we are contacting them directly to ask them about what it is like having a father in the military and how they cope—what are the pluses and minuses of being a military child? That is work in progress.53

50. We recognise the importance of support for the families of deployed personnel, not only because it is right to look after the families but also because Armed Forces personnel are less likely to develop traumatic stress symptoms if their families are supported. We recommend that the MoD review its support for families when

51 Q 199

52 Q 321

53 Q 159


personnel are deployed on operations in the light of the results of the King’s Centre Research.

Alcohol misuse

51. Dr Fear told us that alcohol misuse was substantially higher in the military than in the general population, but not all of this was related to operational service:

[...] 13% of the Armed Forces are reporting levels of alcohol misuse compared with [...] between 3% and 4% with PTSD. Yes, there is perhaps some co-morbidity there—people with PTSD are misusing alcohol—but, obviously, not everybody who is misusing alcohol has got PTSD. We think there is some level of co-morbidity, but we do not believe that those 13% of people are harbouring mental health problems.54

Alcohol misuse within the military is substantially higher than we would expect with the general population. Obviously, the general population comprises people of all ages, and those who are occupationally inactive. If we take all those differences into account, the latest figure for the prevalence of alcohol misuse in the general population is 6%, compared with 13% in the military.55

52. General Berragan, Director General Personnel, Land Command MoD, told us that there was not a problem of alcohol dependence in the Armed Forces but there was significant misuse of alcohol in personnel under 35 years old—about twice as high as in the broader society with an even higher difference for women. He explained that the Armed Forces recruited risks-takers, put them in a stressful situation and then returned them home with money and free time when they drank excessively. He described what their approach to such problems were:

On what we are doing about it, it is another pillar in our whole strategy. The first pillar of any strategy is awareness. On a cyclical basis, we go through a process of posters, awareness and briefings on the dangers of alcohol misuse. The first point about solving any problem is giving people the facts. That is what we try to do.

Beyond that, the second stage is informal warnings and counselling. Beyond that, there is administrative action and counselling. If you like, there is a clinical intervention and a disciplinary intervention. If the problem does not go away and they fail to control it, they can ultimately be discharged from the Army. If the problem affects their operational effectiveness and their ability to do the job, the ultimate sanction is discharge.

There is a four-stage treatment process involving both the chain of command and the clinical chain. [...] We also have pricing policies, where any alcohol sold in camp has to reflect local market prices, so we do not encourage people to drink by cutting

54 Q 162

55 Q 163


prices. The pay-as-you-dine contractors have to provide non-alcoholic facilities in camp, like internet cafes or Costa Coffees, so that there is an alternative to the bar.56

53. General Berragan explained the available treatments for those with severe problems:

I would say, however, that it is about trying to prevent the situation reaching the stage where you have to put the soldier or sailor into a formal treatment programme. Education is terribly important. That is a routine thing through all units in the Army, Navy and Air Force. There is an ongoing education programme. It is about mentoring, through the chain of command on a division basis, a squadron basis or a flight basis, trying to nip it in the bud if a guy is drinking too much.

Ultimately, treatment, can be provided if required, through the Department of Community Mental Health [MoD community mental health teams], which I mentioned before. Not every Department of Community Mental Health can put on an alcohol treatment programme, but some do. By and large that it is a week-long programme, with group-based activities and a good success rate. I will say from my perception as a medical officer who has served for many years, that the level of alcohol abuse and misuse, as the General said, has markedly gone down.57

54. General Berragan said that the MoD recognised the issue of other risk-taking behaviour:

We are very conscious of it so they do get briefed on it [in decompression] and they are made aware of it. I think it still happens. The other aspect is that they have been living on an adrenalin rush for the best part of six months. Coming off adrenalin is like coming off any other form of substance; you have to do it in a measured way. That perhaps explains why people do risky things after operations, because they are still seeking part of that adrenalin rush that they have become accustomed to on operations.58

55. It is unclear to us whether the MoD regards the misuse of alcohol and other dangerous risk-taking behaviour as part of a pattern of reprehensible behaviour which requires punishment or discouragement, or a manifestation of stress which requires treatment, or indeed a combination of both. We recognise that the MoD has been trying to tackle the over-consumption of alcohol but there is more that should be done. We recommend that the MoD carry out a study into what is driving the misuse and abuse of alcohol in the Armed Forces and what more could be done to modify behaviour which is significantly at variance with that of the general population. The MoD has yet to recognise the seriousness of the alcohol problem and must review its policy in this area.

56 Q 374

57 Q 374

58 Q 375


Decompression for those returning from operations

56. The MoD told us that that by their very nature, military operations are stressful for all involved and that individuals deal with their experiences in different ways. All troops returning from operational theatres go through a decompression period lasting 24 to 36 hours in Cyprus with mandatory briefings on mental health issues, including the misuse of alcohol, which might arise on their return to the UK. Personnel are given time to unwind to facilitate adjustment to non-operational duties and to home.59 General Berragan told us that the Armed Forces had learned the lessons of previous operations and used decompression to identify people suffering from stress and put in place appropriate support.60

Trauma Risk Management

57. In 2008, the Armed Forces introduced a non-medical response to traumatic events, starting with the Royal Marines and now used in all three Services, called Trauma Risk Management (TRiM). Traumatic events include sudden death, serious injury, near misses and overwhelming distress when dealing with disaster relief and body handling.61 When asked how effective TRiM was, Admiral Raffaelli told us that personnel reported that they found it a very useful process but it had not been possible to formally evaluate it as having a control group not receiving such support would have been unethical. However, the MoD was confident it did no harm and believed it resulted in good mental health outcomes. As the trained TRiM counsellors are often warrant officers, TRiM reduces the stigma of seeking help.62

58. Whilst we recognise that it is not possible to do a formal piece of research on the Trauma Risk Management system, we recommend that the MoD evaluate the use and benefits of TRiM and compare it with other similar systems. In response to this Report, the MoD should tell us what it is doing to minimise the number of personnel who are not picked up by the use of TRiM, particularly reservists and those deployed as single augmentees.

Mental health issues for medical staff

59. In 2006, medical staff deployed in theatre showed higher levels of mental health problems than other deployed personnel although this might be due to their greater willingness to come forward for help with psychological distress.63 Medical personnel work in very difficult circumstances treating people with very serious and life-threatening injuries both in the theatre of operations and in the Queen Elizabeth Hospital and at Headley Court. The Defence Medical Services has introduced greater support for those employed in the Queen Elizabeth Hospital and Headley Court. For example, all

59 Ev 127, Ev 149, Q 375

60 Q 361

61 Ev 126–127

62 Q 325

63 Q 145


professional groups are briefed on psychological issues and have confidential access to psychological support.64

60. We commend the MoD for its recognition of the impact on medical staff in working with very severely injured Armed Forces personnel and for the introduction of greater support for such personnel. Such support for medical staff should continue and similar support should be introduced for those staff deployed in theatre and continued when they return home, particularly for reservists who are demobilised on return.

Support for families

61. As noted in paragraph 48 above, it is important that families are supported whilst their family member is deployed. It is even more vital that they are supported if that person is killed or seriously injured on operations. We were told by the Families Federations and charities that the MoD had involved them in improving the support for families since the start of operations in Iraq and Afghanistan.65 Mr Robathan told us that the MoD took the support of families of injured or killed personnel very seriously:

[...] That organisation [the Directorate Children and Young People, MoD] is closely involved with supporting children and young people, particularly when their parent has been killed in action. That is one of its focuses, besides the broader education system—indeed, it also deals with situations where a parent is medically discharged after an operational injury.

[...] For bereaved children, I have mentioned scholarships, and we also work closely with the charitable sector—SSAFA, in particular, and the Child Bereavement Charity, to ensure that Service children, of both the injured and killed, are given as much help as possible.66

62. General Cumming, controller of SSAFA, told us that the MoD had asked SSAFA to run a number of family support groups:

[...] Those groups have been going for about two years. They originally focused on those families who had been bereaved by bringing them together to enable them to talk, but they have expanded into another group for the families of those who have been wounded. Interestingly, out of that we found that the children of those who have been either killed or wounded did not want to do things with their parents but wanted their own group, so it is quite complicated with several such groups. They enable people to talk to each other, and we take them away for weekends and so on.67

63. We asked the Families Federations whether there were issues on family support which needed to be addressed. Julie McCarthy, Army Families Federation, told us:

64 Ev 151–152

65 Qq 13, 15, 29–30, 247–248, 256, 409, 415

66 Q 549

67 Q 247


Can I give you a quote to illustrate the sort of things that families come up against? “My doctor told me to have a hot chocolate and not watch TV late at night when I told him I was struggling to cope and not sleeping well.” Her husband was deployed, and it is not just about bereavement or somebody coming back with injuries. It is about coping sometimes with multiple deployments and seeing your friends getting knocks on the door telling them about their husbands. I spoke to a young wife the other day whose husband’s best friend had been killed, and she just did not know how to cope. She said, “What do I say to him?” She needed support in knowing how to deal with it. How do they tell their children that their daddy’s friend is dead, or that their friend’s daddy has lost their legs? It is about that whole wider family. Too often I get told, “That’s an NHS issue.” Actually, no, it is because of military Service that that is being impacted, and we should be addressing that.68

64. Dawn McCafferty, RAF Families Federation, told us:

I have certainly had evidence from one family where the individual in uniform was getting medical and mental health support through the MoD as required, and it was spot on, and just what he needed. She and the children were suffering in their own way. She was finding it very hard to adjust, went through to the NHS support, and found very little empathy or support available for her, because the perception was that it was an MoD responsibility. She couldn’t get across to them that she doesn’t come under the MoD for medical or mental health care. Someone must help them, and particularly the children. She was really looking for counselling support for the children, and all she could find was charitable support. There’s an identified gap. I am not saying that it’s a massive issue. It’s probably a minority, but where it exists, there’s a need to address it.69

65. Julie McCarthy, Army Families Federation, further told us:

That is notwithstanding the fact that specialist support may be required, which is not immediately forthcoming, such as if young children were involved. Sometimes specialist counselling and advice are needed, and again, we are relying on families going out to look at the charitable sector. Winston’s Wish is doing a lot of work with the military at the moment particularly to address children who are bereaved. There is very practical support, but emotional support such as counselling is an area that we need to look at.70

66. When asked about support for the families of those severely injured, General Berragan told us that the MoD accepted that this was an area where they needed to improve:

The first point is that part of the responsibility of the personnel recovery units [...] is to look after the needs of the family and to ensure that the family are dealing with it. It is a really sensitive area, [...] I was talking about this very subject with one of our seriously wounded only yesterday. We talked about how the impact of his injury on

68 Q 32

69 Q 33

70 Q 84


his family, particularly on his children, took him by surprise. His wife was with him in terms of dealing with it, but they had not realised the impact on the children.

It is an area where we continue to learn lessons, but in our case the first point of contact is the PRO [personal recovery officer], who is our interface with the family. What we need to do is to bring in the other agencies—SSAFA and perhaps some qualified social workers—where necessary to support where the family are not dealing with it very well. That is an area where we probably need to improve.71

67. In the rest of this Report we have set out the many areas where the MoD is providing outstanding care in relation to military casualties. The MoD rightly recognises, however, that this cannot always be said for the support it gives to families, and in particular children, in the event of the loss or severe injury of a member of their family or someone else the family knows well. The impact of such an event can be widely and deeply felt. While the MoD does in other circumstances acknowledge that it is often the families left behind at home that bear the brunt of the difficulties caused by deployment, it is time the Department turned that acknowledgement into action, and we urge it to look again at the support services it provides for the families and children of Armed Forces personnel.

71 Q 403


3 Return to military service or civilian life

Recovery Pathways

68. In addition to medical support and rehabilitation, Armed Forces personnel are supported by the Service to which they belong to ensure that they are given help with practical problems in returning to military service or civilian life. This support, called a “recovery pathway” includes resettlement advice and assistance in finding employment and accommodation. Each Service has its own recovery pathway designed to meet its needs, see the MoD memoranda for detailed descriptions.72 Those in the Royal Navy and the Royal Air Force have existed for longer than the Army recovery pathway. Individuals who are injured or sick agree with the Service what their non-medical recovery pathway should be. Staff supporting recovery pathways provide the individual with support and a structure within which to get better and return to service or to leave the Armed Forces.73 For example, Royal Marines and other naval personnel are posted to Hasler Company in Plymouth where their “duties” are to assist in their recovery to the fullest extent possible and where they are supported on their road to recovery by a range of professional staff.74

69. Problems in identifying and supporting those on sick leave in the Army led to the establishment of the Army Recovery Capability (ARC) in order to deliver the Army recovery pathway for the most severely injured or sick personnel. The capacity of the ARC is still increasing its size, currently 600 to rise to 1,000 by April 2012. Colonel Mason, head of the Army Recovery Branch, told us that even with the expanded capacity, the ARC would not be able to deal with all sick and injured Army personnel but only those with the greatest need.75

70. The concept that it is a duty of employment to return to health is one which shows clear benefits. This approach combines peer support and a structured military competitive environment which is best designed to aid recovery.

71. We commend the development of the recovery pathways for promoting the recovery of injured and ill personnel. In particular, we are pleased to see that the Army is now managing its injured and sick personnel better although we recognise that the ARC was only recently established and the Army has yet to see its impact. We are concerned that the ARC might not have sufficient capacity to deal appropriately with the number of sick and injured personnel in the Army. In response to this Report, the MoD should tell us the latest position on the numbers covered by the ARC and whether the ARC will reach its target capacity of 1,000 by April 2012. The MoD should also inform us whether this capacity will allow all seriously sick and injured personnel to be supported.

72 Ev 117–119, 121–124

73 Ibid.

74 Ev 119

75 Q 384


72. Whether an injured member of the Armed Forces should remain in Service or be medically discharged and return to civilian life is a difficult issue. The Armed Forces have to balance the need for a fit fighting force with the needs of the individual who has been injured in the service of his or her country. Some Service charities pointed out that some personnel may be opting to stay in the Armed Forces because it is their chosen career and they have worries about access to future medical treatment when they would be better returning to civilian life and a more fulfilling career.76

73. We recognise the difficulty faced by the Armed Forces in determining which injured personnel should remain in the Armed Forces and those who should be medically discharged, especially as many personnel wish to remain in the Armed Forces because it is their chosen career and of worries about future access to treatment. We recommend that the needs of the individual should be taken into account when deciding on medical discharge and that those for whom a civilian career would be more rewarding should be encouraged to consider the benefits to themselves of leaving.

Redundancies

74. In response to our concerns, the MoD assured us that no one on a recovery pathway would be made redundant until their treatment and rehabilitation was completed and that redundancy was not being used in place of the established medical discharge process. The MoD also told us that there were a number of personnel who were medically downgraded in the first tranche of redundancies but none of these people had been downgraded as a result of operations:

As at 1 September 2011, of those selected for redundancy in the Army, 34 individuals have been identified as permanently downgraded. [...] in the Navy, 310 individuals selected for redundancy were identified as permanently or temporarily downgraded. In the RAF 247 individuals selected for redundancy were identified as permanently or temporarily downgraded.77

We agree with the MoD’s policy that those in medical treatment or rehabilitation should be protected from redundancy.

Transition protocol

75. Transition from the military and return to civilian life has not always been as smooth as it might be. The MoD is working with the health authorities in England and the Devolved Administrations to improve matters and they have agreed transition protocols. In particular, the MoD is working to make the transition of personnel from military care to that of the health services more gradual. It does so by being in contact with the relevant health and social services before Armed Forces personnel are discharged. As yet very few injured personnel have left the Services and so the protocols have yet to be tested.78

76 Ev 161, 168

77 Ev 157

78 Ev 138


76. The re-organisation of health services in England may lead to the abolition of Primary Care Trusts and Strategic Health Authorities and the creation of NHS Commissioning Board. The re-organisation could undermine the relationships already between MoD and NHS staff.

77. We are concerned that the arrangements put in place by the MoD for the transition of personnel may be disrupted by the future re-organisation of the health service in England. We wish to be kept informed by the MoD of the results of its work with the providers of health and social care. In particular, the MoD should tell us whether medically discharged personnel are receiving consistent services, no matter where in the UK they live.


4 Support for former Service personnel 78. At present, with the Armed Forces actively engaged in Afghanistan, there is considerable interest in and sympathy for injured Service personnel. One of our deepest concerns is that when the conflict in Afghanistan has moved into history, the UK will still have a large number of people with serious physical and mental injuries who may no longer be at the forefront of people’s sympathy in this country. We wish to ensure that, in 20 or 30 years’ time, former injured Service personnel are treated as they fully deserve to be treated and money is laid aside now to cope with that.

Compensation

79. Compensation for injuries, paid from the Armed Forces Compensation Scheme, was not designed to pay for social care. Currently however, compensation is taken into account when determining means tested benefits. Mr Robathan told us that the MoD is advising personnel receiving compensation to put it into a personal injury trust which should be disregarded for the purposes of assessing entitlement to income related benefits:

That is an important issue that is being looked at. There have been incidences where people have been asked to contribute, [...]. Actually, what we advise is that the lump sum payment from an Armed Forces Compensation Scheme—compensation for the injuries they received in the Service of their country, not to provide a walk-in shower or whatever—is put in a trust that is exempt from social care cost contributions, so that it is not taken into account. That is the current situation: it is in a trust. It is a problem that is arising[...].79

80. The Rt Hon Simon Burns MP, Minister for Health told us that he expected that the Social Care White Paper due next year would consider the determination of means-tested benefits in this context:

Perhaps I could give you an answer about the whole social care issue, once someone leaves the Armed Forces. As you will know, there is going to be a social care White Paper next year, which will deal with the whole sensitive subject. It is not possible at the moment to anticipate what may or may not flow from that process, once there has been a White Paper, consultation and debate on the whole future of how social care is going to move forward.80

81. The Government should exclude Armed Forces compensation from consideration when determining means-tested benefits without the need for each person to establish a personal injury trust. We agree with the Veterans Minister that the lump sum payment from the Armed Forces Compensation Scheme is intended to be compensation rather than earmarked to be spent on social care. We therefore conclude that this is not a matter for debate but one which should be dealt with urgently. If it is left to be dealt

79 Q 522

80 Q 521


with following a consultation and debate in the country, there is a risk that in the short term some members of the Armed Forces might be disadvantaged.

82. We recognise that payments under the Armed Forces Compensation Scheme are borne by the MoD and there is, therefore, a risk that they are competing for funds against other defence needs such as weapons systems. We shall consider this subject further when we undertake an inquiry into the needs of veterans.

Priority health treatment for those leaving the Armed Forces

83. Veterans are entitled to priority health care for conditions acquired due to their Service. The MoD has been working with the NHS and the Devolved Administrations to educate GPs about the needs of veterans and the priority system.81 Mr Burns explained how this works:

We recognise the debt that we owe as a society to those who are selflessly prepared to defend freedom and our country in difficult circumstances that can lead to horrendous injuries and, sadly, death. We believe, as the previous government did, that former members of the Armed Services, if their medical condition is directly related to their service in the Armed Forces, should have access to treatment—not in a crude way of automatically queue-jumping—that is clinically decided, because no one would want someone who was an absolute emergency to be pushed aside by a former member of the Armed Forces, least of all the individual concerned. We believe that, as long as it is subject to clinical necessity, where appropriate, veterans will be seen more quickly.82

He also agreed that ensuring this system worked was dependent to a large extent on the education of GPs but insisted that “there was a commitment to honour the system”.83 He also said that Armed Forces personnel also needed to be educated about the priority system for medical treatment:

Most of it is through the GPs, because it is the GPs who will make the referrals when a veteran goes to see them with whatever the medical complaint is. What we have been doing since we came to office is ensuring that GPs are aware of this requirement and are familiar with what it actually is, because in the past there has been some misunderstanding around it simply being for anyone who has been a soldier, regardless of the nature of their medical condition and how they got it. It applies only to a medical condition that is a result of them having served in the Armed Forces. They believed that they were automatically allowed to, to put it crudely, queue jump. That is not the system; it is more refined than that. Doctors have been contacted by the NHS to make them more aware and more understanding of the requirement. Veteran organisations have also been more active in explaining to former members of the Armed Services what they are entitled to, so that they can

81 Q 483

82 Q 509

83 Q 518


make use of it. There is a degree of ignorance of what it is on both sides, and we are seeking to address that.84

84. Claire Phillips told us that they were developing a mandate between the Government and the NHS Commissioning Board, which will be responsible for commissioning services for the population in England. He explained that the mandate would include something about the Armed Forces 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.85

85. The policy on the provision of priority treatment to veterans is not clear. We would like to see tangible evidence that the education of GPs is working in regard to the provision for priority treatment for veterans with conditions as a result of service in the Armed Forces especially when it comes to treatment for mental health problems. The MoD should institute an education programme to inform Armed Forces personnel leaving the Services about what they are entitled to with regard to health services. We look forward to seeing coverage of the Armed Forces Covenant in the mandate between the Government and the NHS Commissioning Board and the establishment of similar arrangements being agreed with the Devolved Administrations.

Long term support for injured Armed Forces personnel

Prosthetics

86. Many Service personnel have survived injuries which in the past would have proved fatal. These personnel are often otherwise fit young men who can hope to live for many more years. The Royal College of Physicians and charities have raised concerns about the sustainability of future support for injured Armed Forces personnel when they leave the Services as many personnel have complex and difficult medical and social care needs which are likely to worsen over time.86

87. The Royal College of Physicians pointed out that the provision of prosthetic limbs and related support to Service personnel is much better than that provided by the health services. If this increased provision were to continue after they leave the Services, it might

84 Q 510

85 Q 334

86 Ev 176–178


lead to tensions especially with other young fit people, in particular, with those who have been injured whilst working for the emergency services.87

88. At the request of the MoD, Dr Murrison MD MP conducted a review into the continuing provision of services to those needing prosthetic limbs. Since we completed our oral evidence sessions, his report was published with the Government’s acceptance of his recommendations. In a press notice announcing the Report, the Government said:

In response to Dr Murrison’s key recommendations, the Department of Health will now introduce a number of national specialist prosthetic and rehabilitation centres for amputee veterans across the country. The Government will work with service charities, including Help for Heroes and BLESMA (The British Limbless Ex-Service Men’s Association) as well as specialists within the NHS to ensure high quality NHS facilities are available to our military heroes.

The Department of Health will also use the experience and feedback from providing these specialists services to veterans and apply these to the wider NHS, so that all patients will benefit in the future.88

89. In respect of those who have lost limbs, there are likely to be significant medical resource costs, not just costs of prosthetics but also in provision of qualified and experienced staff. We regard it as essential for former Service personnel to receive the same level of support after leaving the Services as they did whilst serving. We are pleased to see that the Government has accepted the recommendations of the Murrison Review on prosthetics, and we would like to see the project plan and timetable for the establishment of the specialist centres and the arrangements for ensuring support health authorities in England and in the Devolved Administrations.

90. We note that other costs relating to long term mobility issues, for example cars, housing and other aids and adaptations, need to be considered and resourced by other Government Departments. In response to this Report, we ask the Government to set out its proposals to ensure that these matters will be properly resourced.

Brain injuries

91. Many Service personnel have received severe brain injuries on operations and will require long term medical care and social care. Others with less severe brain injuries may not develop full blown symptoms until some years after they have left the Services. Diagnosing and treating people with such conditions can be difficult and demanding.89 These people may also require long term medical and social care. The Royal College of Physicians told us that they were concerned that the cognitive problems of those people with neurological injuries were often under-recognised and inadequately treated.90 The

87 Ev 177

88 Dr Andrew Murrison MD MP, A better deal for military amputees, 27 October 2011, www.dh.gov.uk/health/category/publications, and associated press notice, “New NHS centres for amputee veterans” Ministry of Defence, 21 October 2011, www.mod.uk

89 Ev 177, Q 514

90 Ev 177


College also told us that there were concerns as to whether statutory services could absorb the needs of ex-Service personnel:

Finally, there is the question over Vocational Rehabilitation. The British Society of Medicine has published a report specifically on the vocational needs of those with long-term neurological disorders. Again, provision of specialised services required is patchy, whether from statutory or independent sector providers. If existing services were adequate, the needs of those disabled through conflict could probably be absorbed; but currently we feel these services, taken in the round, are insufficient.91

92. When we asked Mr Burns about vocational rehabilitation services for those with long term neurological conditions as a result of service in the Armed Forces, he said:

I certainly cannot give a firm commitment today in response to that, but we will consider that whole area of care post-Murrison. You can have that commitment from me. I would also like to say, on the question of integrated care and continuity of care, which is crucial, sadly you are right. There is currently, and there has been for some time—this problem isn’t the responsibility of one government—too much disjointed provision of care, rather than a seamless pathway.92

93. We are not convinced that the Department of Health and the health authorities in England and the Devolved Administrations fully understand the costs and implications of long term medical care and social care for ex-Service personnel with brain injuries. Our visit to the US defense center for excellence for traumatic brain injury highlighted their assessment of the links between traumatic brain injury and PTSD and mental health problems. It is very important that former Service personnel whose health has been seriously mentally or physically undermined in the service of the country be given the best possible treatment. In response to this Report, we expect the Department of Health, the Devolved Administrations and the MoD to set out how they intend to provide such services and ensure the appropriate quality of the treatment and the necessary support. The Government should commission a review into the needs of ex-Service personnel with brain injuries and examine research which considers the long term effects of traumatic brain injuries and the mental health needs of veterans.

Mental health problems

94. It is commonly accepted that many ex-Service personnel go on to develop mental health problems many years after they leave the Armed Forces. Mental health support for veterans is available through certain charities. However accessing such support can be difficult and often requires the local GP to understand the support services available.93 Claire Phillips told us that GPs were crucial in providing support to veterans:

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

91 Ev 176–177

92 Q 524

93 Qq 279–284


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.94

95. PTSD Resolution told us that the treatment of mental health issues should be based on evidence and results:

[...] we suggest that the DoH and MoD should respond by inviting all providers with an interest in this area, to collaborate in a new, open practice and research network, free from dominance by any individual vested interests or therapeutic dogma, where evidence from outcomes in individual practice and cases, is used to guide treatment. We also suggest that all funding should be outcome-based, and that a central fund should be made available to conduct independent outcome research so that we can know, for the first time, whether the charitable and state funds used to support service personnel are being spent usefully.

Additionally, we look forward to the outcome of the DoH consultation on treatment acceptability—it is understood this will include the expressed wishes of the Surgeon-General, COBSEO and Combat Stress to find some method of “approving” or “accrediting” third-sector treatments.95

96. The MoD cannot estimate the number of ex-Service personnel who will go on to develop mental health problems such as PTSD, depression or alcoholism or when such problems may emerge, although for many it is likely to be many years after leaving the Armed Forces.96 The emergence of such mental health difficulties can result in the breakdown of relationships, loss of employment and possible criminal behaviour. Admiral Raffaelli told us that they monitored levels of PTSD and other mental health problems in serving personnel:

[...] 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.

94 Q 328

95 Ev 175–176

96 Qq 142, 167–168, 280, 334


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.97

97. We regard it as essential that the support of ex-Service personnel suffering from mental health problems should be treated as being as important as that for those with physical injuries. The MoD told us that it did not expect PTSD to develop in an overwhelming number of troops after they left the Service but we remain to be convinced. We recommend that the MoD works with the Department of Health, the NHS and the Devolved Administrations to ensure that GPs and other service providers are aware of the support available to former Service personnel with mental health problems. The MoD should work with the charities to communicate with former personnel and their families about the availability of support.

97 Q 317


5 Relationship with the charitable sector

How the MoD works with the charitable sector

98. The MoD works with the charitable sector in various ways. It funds some to provide services in support of Armed Forces personnel, their families and veterans, for example, SSAFA provides support to serving personnel and their families, including short stay supported accommodation for families visiting injured personnel (Norton Homes). More recently, the Armed Forces have been the recipient of charitable funds, for example: Help for Heroes funded a new swimming pool at DRMC at Headley Court and the Royal British Legion provided the running costs of the pool. The Families Federations provide an independent voice for the families of Armed Forces personnel to improve their quality of life.

Increase in charitable funding

99. There has been an increase in the amount of charitable donations going to Service and ex-Service charities, possibly due to the high intensity operations in Afghanistan and the injuries experienced by some Armed Forces personnel. In its written evidence, the MoD recognised the step change in the level of charitable funding (some £200 million since 2008) being offered to it and that it had not responded well to the early offers and needed to adopt a reformed and improved process.98 Air Vice-Marshal Murray, Assistant Chief of Defence Staff (personnel), told us that it could now make use of money from the charitable sector in a sensible way:

There has been a significant change in both the amount of money available and how we have addressed the use of it. [...] 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 [...] We have those conversations in terms of priority and of focusing the money where it is best needed for social and medical reasons.99

100. When we asked the charities if they thought the MoD was using the available funds sensibly, Bryn Parry, co-founder of Help for Heroes, told us the situation had improved but needed further development:

98 Ev 125–126

99 Q 339


[...] When you have an extraordinary amount of public support, which, in turn, provides an extraordinary amount of extra funding, it is very important that that is properly targeted and directed. [...]It should be the decision of experts, whom I would take to be the MoD. In an ideal world, I would be working on a series of targets or projects. That is what I always wanted. I ended up finding that I was second-guessing, because there appeared to be a vacuum of ideas, so instead of working down a list, I was creating one.

Now, we have the beginnings of the three Services, and their principal personnel officers, looking at lists of what they want to do, then bringing that up to the defence recovery steering group. They sift through and decide what they think could, or should, take third-sector support. Ideally, that is then passed out to the third sector. I do not believe that we should be working in parallel; we should be working in partnership and support. I would be very interested to see that area developed.100

101. The MoD told us, and we accept that it was slow to take advantage of offers of additional funding from the charities and has been reviewing the way it responds to offers of additional funding. In response to this Report, the MoD should tell us the outcome of this work. The MoD now appears to be better at engaging with those charities providing funding for capital projects.

102. We noted that Help for Heroes was supporting the establishment of several Army Recovery Capability Centres as well as providing the capital funds for a swimming pool at Headley Court. We asked Mr Robathan if the charitable sector was providing resources for projects that should properly be funded by the Government, he replied:

[...] it is important to realise that it is not new for the charitable sector or the voluntary sector to be involved in providing assistance with, for example, casualties from wartime. [...] Headley Court itself is a charitable trust that was given to the Nation.

The voluntary sector’s involvement should be applauded. What it really does is provide assistance, and such things would not necessarily be done so well or so thoroughly otherwise. It is almost about luxuries on top—not luxuries; it is the additional bonus on top. [...] The voluntary sector should be applauded, but that does not exempt the State from its responsibilities at all. There is a balance to be struck, if I can put it that way.101

103. We recognise that there is a long and honourable tradition of the charitable sector providing support for our Armed Forces, for their families and for veterans. This is not only valuable in material terms but also helps to keep the people of our country connected to the Armed Forces. Nevertheless, we are concerned the charities may be paying for projects that the MoD should more properly fund. We are also concerned that the MoD may not have planned for the future replacement and maintenance of some of the additional facilities provided by such charities. We recommend that, in

100 Q 416

101 Q 551


response to this Report, the MoD sets out its policy with regard to what it should properly fund and how it will work with the charitable sector and what its current plans are.

104. We believe that there is a possibility that charitable donations will begin to reduce when the Armed Forces no longer have personnel in combat roles in Afghanistan and recommend that the MoD’s future plans for projects should not depend on such funding. We would suggest to the Armed Forces charities that now is the time to be raising money to be held in reserve for when future funding for Armed Forces projects declines.

Organisation of the charitable sector

105. It is difficult to identify how many Service and ex-Service charities exist but they are many and range in size from the large to the very small. Bryn Parry, told us he understood that there were over 450 such charities, including the Regimental Associations, collectively worth some £1.9 billion.102 He also told us:

We have a lot of overlap and a lack of co-ordination. There is an awful lot of money, but at the moment there is an awful lot of need. I heard one wonderful comment: somebody said that a Regimental Association was asked how much money the regiment had. When he was told, he asked, “What is it there for?” and he was told, “It is there for a rainy day.” His comment, which came from the back of the hall, was, “As far as I can see, it is raining very hard” [...] “so who is putting up the umbrellas?” The umbrellas need to go up. This is when the money should be spent—at the moment. The idea of sitting on vast sums, with a reducing community who will ultimately need it, should be looked at.103

106. The multiplicity of providers creates difficulties for the MoD, the charities themselves and individual users in getting the most value out of charitable funds. In particular, individual Service personnel and veterans can find it hard to find the most appropriate available support. The Confederation of British Service and Ex-Service Organisations (COBSEO) exists to facilitate co-ordination between its members and with the MoD and the Armed Forces.104 Air Vice Marshal (retired) Tony Stables, Chief Executive of COBSEO told us that there were some positive examples of the charities working together and, in particular, that they had been developing a “cluster system”:

We have eight cluster groups at the moment, and I will give you three examples. The first is residential care, which is a topic that has been in the headlines for other reasons recently. There are some 17 within the Service charitable sector. Many Service charities operate a single care home, and they have been quite rightly focused on making ends meet at that single care home. Little thought has gone into where they want to be within the sector: should it be care in the home; should it be care at a

102 Q 425

103 Q 425

104 The Confederation of British Service and Ex-Service Organisations (COBSEO) was established in 1982 and its memberships consists of 181 Service and Ex-Service organisations including 65 regimental associations


home; should it be residential; or should it be nursing? The Royal British Legion took the lead on that, and it has done some extensive research into its own five homes. It shared that with me last week and will now share with the other members. I see that moving together for a very positive outcome.

We have done the same with housing, with Haig Homes chairing the cluster for housing. We have done a very successful one in resettlement, which the Regular Forces Employment Association has been running. That has up to 20 members now, drawn from way outside the Service charitable sector. They are coming together to deliver a far better transition and resettlement service. There are some very positive examples within the umbrella of this confederation of charities being able to work together, notwithstanding the boundaries.105

107. PTSD Resolution, a charity providing support to sufferers of PTSD, told us that the MoD channelled its funding through well-established third sector organisations which made it difficult for new charities offering innovative treatments to be funded.106

108. Whilst we recognise the work done by COBSEO and the MoD to improve the coordination of the charities supporting Service and ex-Service personnel, more needs to be done. We also exhort the charities to co-ordinate their efforts and in some cases to consider the merger of appropriate charities serving similar groups of people. The MoD should consider building on the COBSEO cluster system for charities whereby a suitable organisation is given responsibility to co-ordinate efforts in a particular area, for example, housing. COBSEO should encourage charities to use some of their reserves as it is now “a rainy day”.

109. The MoD should help to address the possible confusion as to where those affected can find support from the charitable sector. In particular, the MoD should publish on its relevant websites a clear description of where help can be found for different groups of personnel (for example, those in the individual Services or even Units). It should also as a matter of course provide such information to personnel when they leave the Services.

105 Q 248

106 Ev 174–176


6 Conclusion 110. We have been impressed by the courage, hard work and determination of those injured on operations to get well and, if at all possible, to return to active duty. The same may be said of the brave and skilful personnel, both military and civilian, who are providing the medical care that our Armed Forces need. The MoD is now providing first class medical treatment and rehabilitation both in theatre and back in the UK. It also provides other support for severely injured personnel in their journey to health and return to duty or to civilian life. It is too soon to say whether the individual Service recovery pathways and the transition protocol with health authorities are working well but they represent steps in the right direction.

111. Our major concern is whether the support for personnel when they leave the Services will be sustainable over the long term when operations in Afghanistan have passed into history. In particular, we are concerned about the number of people who may go on to develop severe and life-limiting mental health, alcohol or neurological problems. We remain to be convinced that the Government as a whole fully understands the likely future demands and related costs.

112. We note that the charities and Families Federations are making a significant contribution to the support of injured Armed Forces personnel and veterans and their families but fear that their contribution may be constrained if the level of charitable donations reduces substantially. We urge the charities and the MoD to work even more closely together and explore ways of ensuring that new capital projects provided by charities can be sustained into an era when current levels of donations may no longer be relied upon.


Formal Minutes

Tuesday 6 December 2011

Members present:

Mr James Arbuthnot, in the Chair

Thomas Docherty John Glen Mr Dai Havard Mrs Madeleine Moon

Penny Mordaunt Sandra Osborne Bob Russell Bob Stewart

Draft Report (The Armed Forces Covenant in Action? Part 1: Military Casualties), proposed by the Chair, brought up and read.

Ordered, That the draft Report be read a second time, paragraph by paragraph.

Paragraphs 1 to 112 read and agreed to.

Resolved, That the Report be the Seventh Report of the Committee to the House.

Ordered, That the Chair make the Report to the House.

Written evidence was ordered to be reported to the House for printing with the Report with written evidence reported and ordered to be published on 15 and 29 June, 7 and 14 September and 19 October.

Ordered, That embargoed copies of the Report be made available, in accordance with the provisions of Standing Order No. 134.

[Adjourned till Wednesday 7 December 2011 at 2.00 p.m.


Witnesses

Wednesday 30 March 2011 Page

Dawn McCafferty, Chairman, RAF Families Federation, Julie McCarthy, Chief Executive, Army Families Federation, and Kim Richardson, Chair, Naval Families Federation Ev 1

Wednesday 15 June 2011

Professor Simon Wessely and Dr Nicola Fear, King’s College London Ev 23


Air Vice Marshal (rtd) Tony Stables, Chairman, Confederation of British Service and Ex-Service Organisations, (COBSEO), Major General (rtd) Andrew Cumming, Controller, Commodore Paul Branscombe, Deputy Controller (Services Support), and Cathy Walker, Deputy Controller (Branch Support), Soldiers, Sailors, Airmen and Families Association (SSAFA) Forces Help Ev 40

Wednesday 6 July 2011

Claire Phillips, Deputy Director, Violence, Social Exclusion, Military Health and Third Sector Programme, Department of Health, Air Vice-Marshal David Murray OBE, Assistant Chief of the Defence Staff (Personnel) and Defence Services Secretary, Surgeon Vice-Admiral Philip Raffaelli, Surgeon General, and Lieutenant-General Sir William Rollo KCB CBE, Deputy Chief of Defence Staff (Personnel and Training), Ministry of Defence Ev 54


Major General Gerry Berragan, Director General Personnel, Land Command, Commodore Michael Mansergh, Director, Naval Personnel, Colonel Andy Mason, Head of Army Recovery Branch, and Surgeon Commodore Calum McArthur, Commander, Defence Medical Group, Ministry of Defence Ev 66

Wednesday 7 September 2011

Sue Freeth, Director of Health and Welfare, Kevin Shinkwin, Head of Public Affairs, Royal British Legion, Bryn Parry OBE, Chief Executive and co-founder, Help for Heroes, and Jerome Church, General Secretary, British Limbless Ex-Service Men’s Association Ev 81


The Rt Hon. Mr Andrew Robathan MP, Minister for Defence Personnel, Welfare and Veterans, Ministry of Defence, and the Rt Hon. Mr Simon Burns MP, Minister of State for Health, Department of Health Ev 99


List of printed written evidence

Page

1 Ministry of Defence Ev 114

2 The Royal Navy and Royal Marines Widows Association Ev 158

3 Soldiers, Sailors, Airmen and Families Association (SSAFA) Forces Help Ev 159

4 Help for Heroes Ev 160

5 The Royal British Legion Ev 164

6 PTSD Resolution Ev 174

7 Royal College of Physicians Ev 176

8 Lesley Griffiths, AC / AM, Minister for Health and Social Services, Welsh Assembly Government Ev 178

9 Nicola Sturgeon MSP, Deputy First Minister and Cabinet Secretary for Health, Wellbeing and Cities Strategy, Scottish Government Ev 179

10 Jeremy Harbord, trustee of a regimental charity Ev 182

11 Kevan Jones MP, former Parliamentary Under Secretary of State and Minister for Veterans Ev 186

12 Edwin Poots, MLA, Minister of Health, Social Services and Public Safety, Department of Health, Social Services and Public Safety, Northern Ireland Government Ev 187

List of additional written evidence

(published in Volume II on the Committee’s website www.parliament.uk/defcom)

Page

1 British Medical Association Ev w1

2 Big Lottery Fund Ev w3

3 Jessica Cheeseman Ev w5

4 Royal College of General Practitioners Ev w6

5 Action on Hearing Loss Ev w8


List of Reports from the Committee during the current Parliament

The reference number of the Government’s response to each Report is printed in brackets after the HC printing number.

Session 2010–12

First Special Report The Comprehensive Approach: the point of war is not just to win but to make a better peace: Government response to the Committee's Seventh Report of Session 2009–10

HC 347

Second Special Report The contribution of ISTAR to operations: Government response to the Committee's Eighth Report of Session 2009–10

HC 346

Third Special Report Ministry of Defence Annual Report and Accounts 2008–09: Government response to the Committee's Fifth Report of Session 2009–10

HC 353

First Report The Strategic Defence and Security Review HC 345 (HC 638)

Fifth Special Report Defence Equipment 2010: Further Government Response to the Committee’s Sixth Report of Session 2009–10

HC 898

Second Report and First Joint Report

Scrutiny of Arms Export Controls (2011): UK Strategic Export Controls Annual Report 2009, Quarterly Report for 2010, licensing policy and review of export control legislation

HC 686 (Cm 8079)

Third Report The Performance of the Ministry of Defence 2009–10 HC 760 (HC 1495)

Fourth Report Operations in Afghanistan HC 554 (HC 1525)

Fifth Report Ministry of Defence Main Estimates 2011–12 HC 1373 (HC 1528)

Sixth Report The Strategic Defence and Security Review and the National Security Strategy

HC 761 (HC 1639)

Defence Committee: Evidence Ev 1

Oral evidenceTaken before the Defence Committee

on Wednesday 30 March 2011

Members present:

Mr James Arbuthnot (Chair)

Mr Julian BrazierMr Jeffrey DonaldsonJohn GlenMr Mike HancockMr Dai Havard

________________

Examination of Witnesses

Witnesses: Dawn McCafferty, Chairman, RAF Families Federation, Julie McCarthy, Chief Executive, ArmyFamilies Federation, and Kim Richardson, Chair, Naval Families Federation, gave evidence.

Q1 Chair: Welcome to the Defence Committee. Youare the first evidence session of the inquiry that weare doing into the Military Covenant and militarycasualties. Welcome back. I know that you arefrequent visitors to Select Committees, so thank youfor coming to give us evidence. Despite the fact thatyou are frequent visitors, I wonder if you couldpossibly introduce yourselves, and say very brieflysomething about your organisations.Julie McCarthy: My name is Julie McCarthy and Iam Chief Executive of the Army Families Federation.We are a group that represents the voice of Armyfamilies. We collect issues, and we talk to and helpfamilies to solve individual issues and to also lobbythe MoD, the Army and other Departments to ensurethat the needs of Army families are taken intoaccount, particularly in policy making.Kim Richardson: I’m Kim Richardson and I chair theNaval Families Federation. We do much the same asJulie’s organisation, except that we represent thewhole Naval Service family, so we speak to servingpersonnel as well. We are the smallest of the threefederations—there are only six of us, based inPortsmouth—and we offer a voice to Naval Servicefamilies. On a personal note, I’m an old stateregistered nurse and my husband and I met just beforethe Falklands when he was on board HMS Coventry,which was sunk, so we go back a long way. Irepresented the three Federations on the Armed ForcesCompensation Scheme Review, led by Lord Boyce.Dawn McCafferty: I am Dawn McCafferty and I chairthe RAF Families Federation. I could say, “Ditto,ditto.” Obviously we do the same role, but on behalfof RAF families. Our organisation is quite small, andwe’re the youngest of the three. There are only eightpeople in my team, and we’ve been established fornearly four years. We are parented by the RAFAssociation. Similarly to my colleagues, we representRAF families in terms of solving individual issuesthey may bring to us, but also in terms of gettinggeneric evidence on themes and issues of concern tothem, and bringing those to people who can perhapsmake a difference.

Mrs Madeleine MoonPenny MordauntSandra OsborneBob StewartMs Gisela Stuart

Q2 Chair: Okay. Thanks very much. So, clearly youwork with the Ministry of Defence and with differentunits within the Armed Forces. How do you workwith Reservists?Julie McCarthy: We have a TA and Reserve Forcesspecialist, and one of her main roles is to get out thereand connect with the TA and with Reservist families,and we also make sure that any policies apply equallyto the TA and Reserves. It is very difficult, because alot of TA and Reserve families won’t be interested inthe fact that their partner may put green on until theyget those call-up papers and know that they are goingaway. So engaging with them is an ongoing process,and trying to keep them engaged after deployment isvery difficult.Kim Richardson: We would offer our services toReservists and to the RFA. The challenge we have isthat our families are very dispersed. They don’t tendto live in Service family accommodation; they tend tolive in their own homes, which fits in with whatReservists do. But we do get contact from Reservists,and we would speak to them in the same way as wewould any Naval Service family.Dawn McCafferty: From an RAF perspective, theFamilies Federation represents Reservist issues. Werun what we call interactive evidence workshopsaround the Air Force to gather evidence, and weinclude the Reservist squadrons in those evidencesessions. Certainly the serving members of theauxiliary squadrons can give us their views. As theothers have said, it is quite difficult to reach the familymembers because they live beyond the wire. The otherway we connect with the Reservists is that we go totheir annual Squadron Commanders’ Conference andtake evidence from the Reservists there as well. Sowe have a good link with them, and also we getupdates on reservist policy matters when we go onvisits to Air Command.

Q3 Mr Brazier: Sorry, could you repeat the partabout the conference? I didn’t get that.Dawn McCafferty: The Reservist Auxiliary SquadronCommanders have an annual conference, when theygather together to share best practice and presumably

Ev 2 Defence Committee: Evidence

30 March 2011 Dawn McCafferty, Julie McCarthy and Kim Richardson

get policy updates. We’ve been invited to the last two,and will be going this year as well.

Q4 Bob Stewart: You are not an executive arm ofthe Ministry of Defence, but who pays for you?Dawn McCafferty: We are paid for by the AirMember for Personnel’s budget, but it is essentially acontract through the RAF Association. It’s currently afive-year contract, and is paid for through the MoDbudget.

Q5 Bob Stewart: So, the MoD budget pays for allthree of you, one way or another.Dawn McCafferty: It’s different for the others.Kim Richardson: We have a contract. We arecontracted through a naval charity under grant-in-aid,but the money originates with the Second Sea Lord’soffice.Julie McCarthy: We don’t have a contract; we’re anindependent charity. We get 57% of our budget fromgrant-in-aid, so it comes from the HQ Land Forcesbudget but it is ring-bound by the Treasury. The other43% of our funding is the Army Central Fund, theDuke of Westminster’s fund—which supports RTAwork—or the Army Benevolent Fund. Various othercharities support particular projects that we run.

Q6 Bob Stewart: So you are pretty independent. Youwould class yourselves as utterly independent—batting for the Service families.All witnesses: Yes.Dawn McCafferty: Certainly, when I set up ourFederation three and a half years ago, I went to seethe Air Member for Personnel at the time, and said,“What do you mean by ‘independent’, as you’repaying for this service?” He looked me in the eye andsaid, “Independent with a capital I. I need to knowwhat the families’ views are, raw and unfiltered.” Thatis what he sees the Federation as delivering.Julie McCarthy: For all of us, all of our services verymuch support that and value the fact that we areindependent.

Q7 Bob Stewart: And you are fearless.All witnesses: Absolutely.

Q8 Chair: Why is there a difference in the fundingbetween the three of you?Kim Richardson: It’s just the way we’ve been set up.The Army Families Federation are the old guys onthe block.Julie McCarthy: Over 30 years old.

Q9 Chair: So you have built up fundraising eventsand organisations and things?Julie McCarthy: Absolutely. The grant-in-aid was putin place about 10 years ago to secure our future, butit’s set up as a charity from many years ago. We aremuch bigger; we are 65 staff, so we need that as well.That is why we are set up as an independent charitygoverned by the Charity Commission.

Q10 Chair: Does it matter that you don’t have acontract?

Julie McCarthy: No, because we are a charity; andbecause it is grant-in-aid in terms of the way that weapply for funding. Because the MoD sees our value,funding has pretty much been guaranteed. Because werely on other charities for our funding, our future isnot dependent, either, on grant-in-aid.

Q11 Mr Havard: Does the way you’re set up meanthat you can attract other funds from other places,whereas the other organisations might not be able to?Julie McCarthy: Quite possibly, yes.Dawn McCafferty: I think we can seek somesponsorship, but if I want sponsorship for an event,for example, or to support the marketing of mymagazine, I would need to go to the MoD—the RAFcontracts branch—and seek its consent to do that. Icannot just go out and seek funding, because I amfunded through my contract. We have had limitedfunding from some other organisations.

Q12 Chair: So does that mean that you can’t raisecharitable money as you wish?Dawn McCafferty: Well, I don’t, because we are partof the RAF Association, which is a charity in its ownright. It is a fundraising charity in support of thewhole of the RAF family. Our role is purely to meetour contract. The contract is quite specific about whatwe are supposed to do, and that is what the RAF ispaying for.Mr Havard: So you couldn’t get, for example, fundsfrom something like the Joseph Rowntree Foundationor European funding initiatives, or something else thatyou might be able to.Julie McCarthy: Yes, we have made various thingswith that. We wouldn’t get money from Help forHeroes because we don’t specifically do something tosupport, but we apply to various other grant-makingcharities.

Q13 Sandra Osborne: How do you fit in with theother organisations such as the British Legion,Support Our Soldiers, and all these organisations thatare on the go? How do you co-ordinate with them?Also, do you operate throughout the whole of the UK?Do you have staff in Scotland, for example?Julie McCarthy: We do. We have a network of co-ordinators based in most of the major units around theUK. We have a branch in Cyprus, Northern Irelandand Germany, and we rely on volunteers in BATUS,in Naples and various other places. We try to work ascollaboratively as possible with other charitieswherever we can, particularly with SSAFA and withthe Army Benevolent Fund.We feel that we are unique—I think all three of uswould agree—in solely representing the views ofserving personnel and their families. That is uniqueamong all of the organisations, which tend to crossover between serving and veterans. I am the wife of aserving officer, so I am doing it from the point of viewof, “This is my life as a serving person and these arethe things that impact on me.” I think that cansometimes get lost in the noise of charities that rightlysupport a whole spectrum of the military community.The veteran and serving community is estimated atsome 10 million people, and it is very difficult to get



a consistent voice if you are trying to address all thosepeople. We focus on serving families, and we do thatvery well.Dawn McCafferty: All three of us work together veryclosely, and we are invited to gatherings and meetingswhere we are asked to represent the familyperspective. For example, if you take the ExternalReference Group on the Covenant, we arerepresenting the family perspective, but you will alsohave members of RBL, SSAFA and COBSEO, whoare representing not only the family perspective wherethey are involved in that, but the veteran perspective,with which we tend not to get involved.

Q14 Chair: Are you part of COBSEO?Dawn McCafferty: My parent charity is a memberof COBSEO.

Q15 Mr Hancock: When we carried out a report onDuty of Care in this Committee, one of the problemswe experienced was the fact that your organisations—not the RAF, because at that time it was not inexistence as it is today—had great difficulty, from theArmy’s perspective, in getting heard within the MoD.Has there been a significant change for all three ofyou over the last few years to reward this Committeefor the work it did in getting that issue raised with theMoD in a positive way? I would be interested to knowfrom all three of you about how you have seen theclimate and the receptiveness of the MoD to yourpoints of view, particularly as the issues affectingfamilies have grown so significantly.Kim Richardson: I have been in post for seven years.I was there at the start of the Naval FamiliesFederation, and I can honestly say that theGovernment paid lip service to the voice of thefamilies seven years ago. We did not have theconnections and the direct access that we have now.What I have is the luxury of being able to see that wehave evolved into something that has become quitewell respected. Our views are sought and I am verycomfortable that there is nowhere that we can’t go.When I say “where we can’t go”, where our familiescan’t go. So in the seven years, huge change,absolutely.Dawn McCafferty: There are some examples we cangive—the Armed Forces Pay Review Body. When westarted giving evidence to that a few years ago, it wasvery much on an informal basis, and now we are partof the formal evidence team, which is another step inthe direction that says, “This is a respected andcredible team that gives evidence”. Also, in terms ofour access to the Ministry of Defence, we have justleft a meeting where we have been briefed on ongoingprojects with a family perspective, and we have beenbriefed on the review of the Children’s EducationAllowance. We have been brought into the MoD tobe brought up to date. I don’t think that would havehappened seven years ago.Kim Richardson: It didn’t happen seven years ago. Tobe fair, it probably didn’t happen even five years ago—I think that it is probably the last four years that thingshave gone like this, and they are staying that way. Weekon week we are being asked to contribute to things liketoday, that we wouldn’t have been five years ago.

Chair: If you’re wondering if you are respected, youare. I’ll come back in a moment.

Q16 Mrs Moon: I wonder how much families havebeen placed in a position of not only being the sourceof information about the impact of Service life onfamilies, but also becoming the mouthpiece for theserving Forces, in the sense of the nervousness that ifyou say something and it is negative, it might affectyour career chances. How much are you the safetyvalve?Dawn McCafferty: I think I can almost counter that,in that 65% of the people who come to us for support,advice and signposting are in uniform. I think thatthat is an encouraging sign that people are prepared toengage. When I first came into this organisation, ourpredecessor organisation did not represent the servingfamily member. I found that quite difficult to get myhead around, and I challenged the RAF and said, “Thefamily is the whole family, and the person in uniformas well.” The RAF quickly agreed to that, and said,“Yes”. But there is an issue there, about chain ofcommand and responsibility for welfare and I have tobe very sensitive to that. But having served myselffor quite a period, I understand that sensitivity, andtherefore I am very comfortable engaging with servingpersonnel.But you are right. There are those who perhaps don’twant to come to us because there is fear of anyrepercussion or concern, and perhaps it is then thepartners who are bringing evidence to us.

Q17 Bob Stewart: I want to ask about your mandate.All Services have squadrons, companies, whatever.How far down do you go? Who are therepresentatives, and what is the structure—so thatwhen you speak, you actually have a mandate fromyour people that you are representing?Kim Richardson: We are all structured slightlydifferently—

Q18 Bob Stewart: In principle?Kim Richardson: We have a team of six—five full-time equivalent jobs—and we have a worldwidecommitment to Naval Service families. I would see itthat we offer a voice. There will be some families outthere who do not require someone to stand up andspeak for them. I was probably one of them a fewyears ago, because I have a voice myself.

Q19 Bob Stewart: Forgive me, that is the wrongtrack. What I mean is, do you have a representative atunit level? Do you go down? You have your staff ina headquarters somewhere and my question is: wheredo you get your authority to speak, beyond the factthat people ring you? Do you actually haverepresentatives in, say, a battalion, a squadron or aship?Julie McCarthy: We don’t go down that far. Of our65 staff, we have 63 Army wives, one Army husbandand a male Army civil partner. Most of them are basedwithin large garrisons, apart from probably 25 whoare in offices. But they are all Army spouses as well,so they will be living on a patch and you canguarantee that wherever we go, if the person you are



meeting knows you work for the Army FamiliesFederation, you come and get spoken to.

Q20 Bob Stewart: So presumably all three of you goto wives clubs. Representatives go to a wives clubmeeting and then you hold the meeting.Kim Richardson: We go into mess decks. I will goand sit and talk to submariners in mess decks, and goto families days at sea. Wherever the Service or thefamilies ask us to come, we will come.

Q21 Bob Stewart: That will work, too—that meansthat you are actually down at unit level talking andyour staff go down and talk to units there.Kim Richardson: We can’t do it otherwise.

Q22 Bob Stewart: I know. I suspect I understand thereason why you wouldn’t have a unit representative,because they just wouldn’t get round to it. But actuallydoing that is a very good way.Dawn McCafferty: What I think we do have at unitlevel is a very good linkage in with the HIVEorganisation. I am sure you are familiar with whatHIVE does at unit level. We will link in with those,but also when we go out and do our evidencegathering—what we call our workshops—then we aregathering evidence from LAC right the way throughto Air Chief Marshal. Our evidence last year coveredevery rank and partners of most of those ranks. So Iam comfortable that, when we sit in front of you andgive evidence, we are giving as best a representativevoice as we can, bearing in mind Kim’s point that notall families want to come to us and give evidence.Chair: So that’s what you do and what you are. Wehad now better get on to our inquiry.

Q23 Ms Stuart: On physical injuries—separatingphysical and mental for the moment—if I look at thefigures, in Operation Telic we had, between 2003 and2009, more than 1,900 aero-medical evacuations—quite significant numbers. Can you give us a senseof how the families feel about the medical treatmentfollowing injury, and whether they are being lookedafter as well as the individual? I am also trying tounderstand whether you think there is a differencebetween the three Services, because I find it quitedifficult to get my head around why there are threeof you.Dawn McCafferty: Certainly, the feedback that I getfrom family members and from those who are servingis that the medical support that they get, if they areinjured on operations, is second to none. Indeed, manypeople are probably surviving on the battlefield whomight not have survived years ago. They are broughthome to the United Kingdom and they are given first-class treatment right the way through to, hopefully,recovery and rehabilitation. If they can’t berehabilitated back into full-time Service, then there isso much work going on now to help them transitioninto life beyond the Armed Forces. I think my onlyconcern—probably shared by families—is whetherthat is enduring. Does that carry on not just for twoyears or five years after Service, but the rest of thelife of that injured person? There is also the widersupport for that family. I am not sure if we have

evidence to suggest—we’ve not had long enough—that that is enduring and will be there for the rest oftheir lives.Chair: We will come on to that particular issue in thenext hour or two.Kim Richardson: I would say that families feel thattheir serving personnel are being cared for very well;I would not dispute that at all. Where I think we havea part to play, and certainly the role that I feel wehave, is where people fall through the cracks. We willonly start seeing that as time progresses. I havecertainly spoken to families of serving personnelwhere there have been things that we can do better.One of the things I don’t think we’re doing is goingback to the families to say, “Where could we havedone better?” I think it is early days at the moment. Ithink everybody is learning. I would not sit heresmugly and say that we are getting it absolutely rightfor everybody. There are areas where we could dobetter.Julie McCarthy: I absolutely agree. Nobody doubtsthe quality of medical care that soldiers are receiving.In terms of support for families, the staff at QueenElizabeth Hospital—and Selly Oak before it—and thepatient support services work as hard as they possiblycan to ensure that families are supported. Thosesoldiers who are less severely injured can inform theirkin themselves. I think the unknown version of whatis happening is that those who were telephoned by thesoldiers themselves and told about an injury were thenfilled with fear about what had happened, and therewasn’t necessarily the same follow up—that is whatwe picked up in a recent deployment survey. I knowthat issue is being addressed by the Army to ensurethat doctors are able to phone families back at homeand explain about injuries.

Q24 Ms Stuart: How easy is it to define what thefamily is? I know that Selly Oak has had someproblems.Kim Richardson: It is broad. In my view, who thefamily are comes down to the serving person. Forsome young Royal Marines, their mates are theirfamily. They don’t necessarily have normal parentarrangements, and it is not our place to determine whosomebody’s family are. That is the place of theserving person. It must be done on an individual basis.

Q25 Mr Hancock: This is really to you, Kim. It wasinteresting to hear what you said about your husbandbeing on the Coventry when it was lost. My brother-in-law was on a ship that was lost in the Falklands.He was in the Royal Navy and he suffereddramatically from that. He was rescued from onesunken ship and put on another that was then bombed,and he has never recovered from that. The Navylooked after him remarkably well and kept him in theService for as long as it could, but the trauma was sogreat that it finally had to let him go. When it let himgo, he got no support and was desperately looking forhelp. He went to SSAFA and all sorts of organisations.My question is about the length and endurance ofsupport given.Chair: We are coming to that point in due course.



Mr Hancock: I was just following up on what thelady said.Chair: I know. That is why I said then that we willcome on to it.Mr Hancock: I would be interested if we could getan answer about the endurance of that support. TheFalklands war was not that long ago, and these peoplehave been forgotten.Chair: We will get an answer to that; we have nodoubt.

Q26 Mrs Moon: You said that you work closelytogether. I was interested in your comment about notgoing back and asking the families whether they thinkthat the support that they received was the rightsupport. How much do you compare and contrast thedifferent schemes in each service? Have you identifiedgaps in your own schemes, and support services thatmake you think, “I wish we had what the Navy has”,or, “I wish we had a bit of what the RAF has”?Kim Richardson: We all compare notes. On thequestion of why there are three of us here, we wouldeach answer that in our own way. We all feel verystrongly about our own Service, and we need that atthe moment. We compare notes, and we probablywork together better now than we have ever donebefore. I see that as a real positive. I also see that wedo some cherry-picking. If somebody does somethingparticularly well, I’m very happy to sit outside theSecond Sea Lord’s office and say, “Why is it that theArmy are doing that and we’re not?” In the same vein,if the Navy is not delivering what our families wouldlike us to deliver, I am equally comfortable telling himthat we ought to be looking at that as well. It can beany aspect of doing what is best for our families.Dawn McCafferty: One of the challenges for us isthat because we represent the views of families on amassive range of issues, it is actually a challenge justto keep up with the processes of one Service. I havebeen out of the Service for four years, having servedfor 23. Things have moved on dramatically,particularly in this arena. I have spent the past coupleof weeks trying to get my head around exactly whatis provided now and what the policy is. I have anawareness of the Army and the Navy’s processes andprocedures. As Kim has said, we will point out wherewe think there is best practice in another Service, andideas that perhaps we could follow.To be honest, with a small team, trying to keep up todate with what the RAF is doing is enough of achallenge. I am grateful to the RAF because it allowsus to go to Air Command on a regular basis to getupdates on what is happening. There is a lot to takein because it is not just this issue, but housing, childcare, education and employment. There are so manythings to get our heads around. You could ask, “Couldwe understand each other’s business in-depth?” Thatis probably one reason why it is good that you haveone from each Service. We are specialists on our ownService and our own families’ experience.

Q27 Chair: That reminds me of something that Ishould have said right at the beginning of the evidencesession. At the end, we will ask you to suggest issuesthat we should consider in other inquiries—not just

medical issues. I am giving you the chance to thinkabout that. We want brief pointers as to why weshould look at x, y or z.

Q28 Sandra Osborne: Could I ask you a practicalquestion about support for families whose loved ones,having been injured, are in hospital in Birmingham?This has been brought up with me in my constituency.People have difficulty travelling down to Birminghamfrom Scotland to visit their family, and paying foraccommodation and travel. Are you aware of anyproblem with that? Are there any issues that need tobe dealt with on a practical basis?Kim Richardson: There are structures in place to helpfamilies with those sorts of practical costs. The way Iwould say that families struggle is that their whole lifegoes on hold when they are supporting someone inhospital. I have certainly spoken to more than onefamily member whose job has taken a back seat andtheir business has closed down because they havededicated their time to supporting their son in hospital.The impact, which is not just on the immediate familybut, like a ripple effect, on the wider family, can beenormous. The Service recognises that it needs to putin place support, such as practical financial support.We do have a good support structure at QE inBirmingham. Could we be doing more? I am sure thatwe could. This is where we need to come back andask families, “What would you have liked to see thatyou didn’t have before?” That is absolutely key to usimproving what we are doing. It is not just thefinancial side of things; it is bigger than that.Dawn McCafferty: I’d like to highlight the role of theVisiting Officer. If someone is hospitalised, long term,a Visiting Officer will be appointed and they are thefamily and the patient’s point of contact for any issueslike that. They should then be able to take back anissue to the parent unit and say, “There is a problemhere.” It could be as simple as arranging transport,booking accommodation or liaising with SSAFA to gointo Norton House at Selly Oak.

Q29 Chair: Sorry, liaising with SSAFA? SSAFAprovides some of this?Dawn McCafferty: Absolutely. It should not be forthe family to search around all those agencies. Thereis a dedicated person trained to do that liaison role onbehalf of the family, and they are appointed in all suchcases. They are trained up to do this, so the familyshould be guided. The Visiting Officer should go outand find the support that is required.Julie McCarthy: It is important to remember that inthe immediate aftermath of somebody coming back toQE, the issue is not with resources then. People areescorted to the hospital and accommodation isprovided. It is the issue of the long term. As somebodyis downgraded in their illness, that support is steppeddown. It is quite difficult for families to understandwhen they know that they still need to be there, butthere is not necessarily the resource for them, becauseother people are coming in who are very seriouslyinjured and who need to use up that accommodation.The issue is with the long term. Families still have tocome down to QE, but the patient is rehabilitating.



Q30 Chair: Now that you have mentioned SSAFA,will you say what the difference is between what youdo and what SSAFA does?Dawn McCafferty: There is a contract between theRAF and SSAFA to provide professional qualifiedsocial workers, which is not what we in the FamiliesFederation provide. We are a group that represents theviews of the families. SSAFA is there to provideprofessional welfare social services support tofamilies who are going through any sort of welfarecrisis, so it is part of the welfare support team withinthe chain of command at unit level; it is part of thatwelfare connection. The Visiting Officer would tapinto the SSAFA support to help any family or casualtywho is in need of support. There is quite a distinctionbetween what we do and what SSAFA does.

Q31 John Glen: Can I turn to mental health issues?It is probably fair to say that in the last few yearspublic awareness of mental health issues has risen,and so, too, probably has awareness on the part ofpoliticians and Government. We have had theMurrison report, which has made somerecommendations. I have two questions. What is yourassessment of the effectiveness of the MoD, in termsof identifying mental health issues? If you think it isdeficient, what more do you think it could do?Secondly, in terms of the families, there is a directimpact on them when someone has mental healthissues. What is your assessment of the preparation andeducation that the MoD or different forces provide inguiding families to understand what might happen ifa mental health issue is presented?Kim Richardson: When somebody goes away, if I ambeing honest, I don’t think the family is planning forthem to come back with mental health issues. A lot ofplanning takes place before they go. I have to admitthat it’s an area I have some concern about—aboutwhere families are going to seek guidance and help. Ican probably focus on the Royal Marines as a goodgroup to focus on. They are roughy-toughy guys andtheir families don’t ask for very much. They ask forless than the Navy blue side does. Will they go andseek help through the chain of command if theyrealise that there is a problem at home? Possibly not.So I am very grateful to be here today and to have anopportunity to say that I think this is where we needto engage more with GPs and the civilian side, whoperhaps don’t actually get us. I am not convinced theyunderstand who we are.Sometimes a wife realises that there is a problem, orshe has a problem herself. I have spoken to somemums of serving Royal Marines who have seen theiryoung men come back and they are not the samepeople they were when they went out. They are likelyto go through the civilian GP, or to speak to somebodyon that side. While I am comfortable with what weoffer within the Service, with Naval Personal andFamily Service and Royal Marines Welfare doing afantastic job, do they necessarily see everything? No,I don’t believe they do. We must make sure that thatarea is resourced properly, but that we starttransitioning across into civvy street as well. We can’tjust do it all within the Service.

Q32 John Glen: Just to be clear, is there anyproactive attempt by the MoD—Kim Richardson: Yes.John Glen—to evaluate families’ needs?Kim Richardson: Families’ needs, no. For the servingperson, we have something called TRiM—trauma riskmanagement. We again come back to the RoyalMarines. All their welfare experts are Royal Marines,so they understand the person that they are dealingwith. The family, on the other hand, tend to get onwith it on a day-to-day basis. They are probablyseeking support from their wider family or theirfriends and the people around them. They are notnecessarily as likely to approach the chain ofcommand to ask for help.Julie McCarthy: Can I give you a quote to illustratethe sort of things that families come up against? I havea quote from a wife in North Yorkshire: “My doctortold me to have a hot chocolate and not watch TV lateat night when I told him I was struggling to cope andnot sleeping well.” Her husband was deployed, and itis not just about bereavement or somebody comingback with injuries. It is about coping sometimes withmultiple deployments and seeing your friends gettingknocks on the door telling them about their husbands.I spoke to a young wife the other day whose husband’sbest friend had been killed, and she just did not knowhow to cope. She said, “What do I say to him?” Sheneeded support in knowing how to deal with it. Howdo they tell their children that their daddy’s friend isdead, or that their friend’s daddy has lost their legs?It is about that whole wider family. Too often I gettold, “That’s an NHS issue.” Actually, no, it is becauseof military Service that that is being impacted, and weshould be addressing that.

Q33 John Glen: So you are making the distinction,I think, between an ongoing need, regardless of what’shappening operationally, versus a response to recentevents in Afghanistan, which is perhaps whatprompted the greater awareness. You’re arguing for itto be embedded in, regardless.Julie McCarthy: It should be. The pressures ofService life are not just about operational service. Theguys are away a lot anyway, never mind when they’rein Iraq or Afghanistan. I think something should bebuilt in to support families much better.Dawn McCafferty: There is also an issue around thetransition protocols between the MoD and the NHS.Transferring support out for the Service person ispretty well understood, and it is being tested andtrialled at this time. No doubt lessons will be learned,and it will be enhanced. It is the transition of thefamily members who, as Kim says, are registeredwith GPs.I have certainly had evidence from one family wherethe individual in uniform was getting medical andmental health support through the MoD as required,and it was spot on, and just what he needed. She andthe children were suffering in their own way. She wasfinding it very hard to adjust, went through to the NHSsupport, and found very little empathy or supportavailable for her, because the perception was that itwas an MoD responsibility. She couldn’t get across tothem that she doesn’t come under the MoD for



medical or mental health care. Someone must helpthem, and particularly the children. She was reallylooking for counselling support for the children, andall she could find was charitable support. There’s anidentified gap. I am not saying that it’s a massiveissue. It’s probably a minority, but where it exists,there’s a need to address it.Chair: It’s a very important issue to get right.

Q34 John Glen: I am conscious that on thisCommittee we have representation from NorthernIreland, Wales and Scotland. Given your national role,do you see any different interpretations of this needand response to it among different parts of theUnited Kingdom?Dawn McCafferty: I think the exposure we’ve hadthrough the External Reference Group, the Covenantissues and, before that, the Service PersonnelCommand Paper, probably drew the differences to myattention for the first time, and to the fact that althoughEngland might make legislation, we would be lookingto the Devolved Administrations to support us on that.I think our representation is absolutely spot on,because where best practice is being recognised, it isthen being followed through. [Interruption.]

Q35 John Glen: I think you were saying that youhad become aware of the differences.Dawn McCafferty: Absolutely. Let’s say we wantedsomething done in one part of the Administration;we’d be following through whether Scotland,Northern Ireland and Wales were able to replicate thatservice. We’ve spoken before in this Committee aboutseeing really good support from the DevolvedAdministrations. We’ve been to the Expert Group onthe Armed Forces in Wales, where they’ve reallytaken some of the issues forward. There aredifferences because, rightly, we must allow thoseDevolved Administrations to make their owndecisions, but when they see that it’s the right thingto do, they all get behind it.Julie McCarthy: It’s important to consider that thereare also differences across England because of theindividual PCTs. I’d always assumed that in placeslike Catterick and Colchester, where there are bigpopulations, things would be okay, but sometimesthat’s where there is the most ingrained belief that“That’s all right; the Army deals with that” or “theMoD deals with that.” The issue is down at groundlevel among individual practices and PCTsthemselves.

Q36 Chair: It is very good to get this evidence. Ifyou are hoping that a report by politicians will resolvesome of the misunderstandings in this issue, you maybe a little optimistic.Kim Richardson: We can hope.Chair: It’s a long-term process, I suspect.Kim Richardson: We are cup half full.

Q37 Ms Stuart: In a sense, it is the oldest problem—Penelope and Odysseus. Someone goes away and youdon’t know what will happen with the family whenthey come back. There is uncertainty. Have you

looked at how other countries deal with what isessentially a problem you can’t resolve—it just is?Julie McCarthy: I stupidly look atMilitaryHOMEFRONT and a lot of other Americansites. We look at the amount of things that theAmericans are given and at the American model.For example, with counselling in mental health, thereis automatically a pre-paid scheme that families canuse to get access to professional counselling; there isnot a limited budget that they have to seek out if theyhave problems. The approach is a lot more joined-upin some areas. I know that they have much biggerbudgets, and much bigger problems, than we do, buttaking one of Kim’s themes, if a parent has to give uptime to care for their son, there is an obligation bylaw in America to keep that job open and to allow theparent to take a break from employment, which wejust do not seem to take account of in this country.

Q38 Chair: I think that the Committee has heard inprevious years that the American outcomes on mentalhealth issues are not as good as the British outcomes.I do not know whether that is true, or whether we aresimply not looking at them.Julie McCarthy: I think a comparison is possiblebetween serving personnel, but of course we havenever compared what the Americans do for familieswith what we do, because you couldn’t do anythingfor families. We can’t compare what perhaps shouldbe provided in support for families, although we couldcompare what they do for serving personnel.Dawn McCafferty: I think what’s encouraging is thatresearch is beginning to be done. From ourperspective, we have been banging on the table for 3years saying to the researchers, “Could you pleasehave a look at what impact there is on families of thestress of deployment?” I think that King’s College hasalready started some work on Army fathers, orpossibly a tri-Service study of fathers who aredeploying and the impact on the children and thefamily. It will be interesting to see what that throws upin terms of potential mental health issues for families.

Q39 Penny Mordaunt: I have a quick questionfollowing on from that. Are there particular challengeswithin individual Services? I am thinking aboutpeople who are currently in Service and the dispersalaround the UK of families. You pointed out that thereare hotspots where you could focus on sorting out theGP stuff. Are there different issues that you have asindividual Services about how you might tackle that?Kim Richardson: I would like to say, and perhaps itis something that you could do something about, thatdata protection makes it very difficult to contact ourfamilies. We had an aspiration that we would be ableto amend the system that pays all three Armed Forcesto allow us to have a sort of opt-out box, so that wecould contact families directly. I am completelycomfortable with saying that many families out therewill not know that we exist because they set up homein their own communities and live their own lives.The time that they need us, or somebody else, is whenthey have a problem and an issue. It is challenge toreach those families.



Q40 Penny Mordaunt: And your families would befairly dispersed?Kim Richardson: They are across the country. Wehave hotspots in Liverpool, Birmingham—not aroundthe traditional naval ports. For us in particular, it is ahuge challenge because I am convinced that there arepeople out there who are not particularly sympatheticwith Afghanistan—with Afghanistan, we are not backto where we were with the Falklands. Some peoplewould like to seek some help and they are not surewhere to go. That is a challenge for all of us, but moreso for us because our families are more dispersed.Dawn McCafferty: We’ve got similar challenges inthat our families can be very dispersed. A largeproportion of the RAF families now decide to live intheir own communities and not necessarily on thebase. So we have families in Birmingham, Scotlandand Wales, as Kim has.The challenge if that family is in need is to identify atrained Visiting Officer who is close enough to makea real difference to that family. If, for example, thecasualty is a regiment gunner from Honington, but thefamily are in Scotland, there’s no point appointing aVisiting Officer from Honington because it will bereally difficult for them to provide the necessarysupport, so staff will then look to the nearest RAFunit to provide support locally. They try to match thatsupport, recognising that our footprint is small andgetting ever smaller.

Q41 Chair: Would it be fair to say that these mentalhealth issues are still more difficult to deal with inrelation to Reservists?Julie McCarthy: Absolutely, because they may begoing back to a GP who has no idea how to deal withthat, and the soldier may be away from a unit whereTRiM can be conducted. We have had families cometo us saying, “I know there’s something wrong. I don’texpect it’s PTSD but there is perhaps a transition issuegoing on with my soldier having come back and Idon’t know how to deal with it. What do I do?” Unlessthat soldier seeks help himself or herself, the familyfind it difficult to know what to do.We rely on the charitable sector to point peopletowards PTSD Resolution, Combat Stress, that sort oforganisation, to get help. Where it is not PTSD, whatdo you do? Providing information to families beforesoldiers come home would be useful, so that theyknow that some things are perfectly normal and asoldier will get out of. They can be told what to lookfor so that they know there is a problem and that it isnot just a transitional condition.

Q42 Chair: And it is more likely, isn’t it, to bealcohol than PTSD?Julie McCarthy: Absolutely.Dawn McCafferty: Reservists when they aremobilised have the same access to the same level ofsupport as the Regulars. It is just that a physical injuryis quite apparent and they will not be demobiliseduntil everything has been done to get them as fit aspossible. The challenge is that mental health issuesmight not become apparent. They will try to assessthat, but if it is not apparent and they are demobilisedand it comes out three or four years downstream, there

is then an issue of how to get back into the systemfor support.Kim Richardson: I think we need to differentiatebetween those who are injured and perhaps havemental health issues, and those who have come backand have potential issues that have not beenrecognised. Dawn touched on Visiting Officers. Ifsomeone has been injured, the Visiting Officernetwork springs into action. I am comfortable thatthey do a fantastic job. They also do it on top of theirown jobs. The Navy sticks with that family until thefamily determines that they are ready for it to leave.I come back to your question about dispersed families.That is a family where someone comes home who isnot injured. They are going back into the homeenvironment, perhaps with issues. I heard from ayoung mum with a Royal Marine son who is quiteconcerned about his behaviour. She came to us to talkabout where to go for help for that. He is not seekingany help. We need to recognise that these are youngmen going back out again and again and again. It isnot going to get any easier. We need to separate thetwo things: between those who have a care pathwaythat is defined and they are being looked after, andthose who perhaps have not yet, because it has notraised its head.

Q43 Mr Hancock: After the first Gulf war, whentroops were coming back, one of the big problems—and this Committee found it—was that GPs could notget the right information back from the MoD. Therewas a big, big problem ensuring that medical notes—and even unit notes about someone’s behaviour notbeing properly helpful—were being put towards GPs.I would like to know whether there has been a change.Are medical records of serving personnel who havebeen on operation—maybe not physically ill, but havesuffered a mental setback while they were away—being transported to the GPs, so that the GP cansupport the family?My second point is about the chain of command. Kim,you rightly said that for a lot of these young Marinestheir real family is the unit they serve in. That isapparent when you meet them on a regular basis. Theydon’t have significant ties at home.Do you think the chain of command is properlyequipped to spot the sort of issues that these youngmen are facing when they come back, having servedon two or maybe three tours in Afghanistan and onein Iraq? They are coming back and the chain ofcommand isn’t prepared to give them the benefit ofthe doubt. They just think, “You’re a tough Marine,get on with it.” Is there a sense that more work needsto be done, that unit officers and NCOs need to betrained to recognise the problems that these youngmen are facing?Kim Richardson: Starting with your first questionabout GP notes, I am not in a position to comparehow things were with where they are now. I actuallydon’t know how that works, when they move to acivilian practice. I am conscious, with my work that Idid with the Armed Forces Compensation Scheme,that we have different methods of recording medicalnotes in the Services. Can I sit here and say that I amconfident that absolutely everything gets recorded? I



am not sure that I can say that, because they havedifferent methods of doing it.Dawn McCafferty: I agree with you, but I think thetransfer of records was one of the key parts of theTransition Protocol. The transfer recognised thatpeople were potentially leaving the Armed Forceswith medical conditions still outstanding and needingsupport, but who were lost off the radar because GPsweren’t picking up those conditions as the notesweren’t being transferred.A big part of the Protocol is to ensure that suchinformation gets passed across—whether it is thenunderstood, because it is written in a differentlanguage or a different way, I don’t know. But I amsure that one of the key themes of the TransitionProtocol was to ensure that all available records werepassed across so that there was no break in the supportthat was needed.

Q44 Chair: The chain of command?Kim Richardson: If somebody doesn’t want to beidentified, they have ways and means of hiding theirproblems. I am confident that, particularly where thereis the core ethos that perhaps the Royal Marines or aship’s company have, they look after one another. Ifthey see somebody who is struggling, I amcomfortable that they would do something about it.The problem is that we are seeing young men who arestruggling, but who are perhaps not presenting in theway you would expect. So a young Royal Marine whoI spoke to had come back from Afghanistan and takenup 10 mobile phone contracts. He then had moneyworries and was getting himself into a real old hole.He couldn’t explain why he had taken up 10 mobilephone contracts, but some of it was the buzz. Theyare still looking for that buzz and that thrill. So whodecides that that is not normal behaviour? If they wantto hide it, they will.Dawn McCafferty: Again, the introduction of TRiMand having TRiM practitioners at unit level has beena big step forward in ensuring that flight commandersand senior NCOs are at least aware of how to watchout for any symptoms that might be a cause forconcern.Julie McCarthy: I think that TRiM works very well.My concern for the chain of command is: who isTRiMing them? Actually it is our senior NCOs andour officers. The families that feed back to us whenthere are issues are those where the guy says, “Well,no, I’m looking after my guys, my squadron, myregiment.” They are not seeking help, but they areseeing their men injured and lost, and they feelresponsible for that. They’re under a lot, but there isan assumption that as a senior NCO, a warrant officeror an officer, “You won’t suffer from that becauseyou’re in command. So crack on.”

Q45 Chair: And the Chaplains?Dawn McCafferty: The RAF has certainly addressedthat issue quite recently and said that there is a needto “train the trainers” to ensure that they watch outfor themselves and recognise any symptoms of beingoverwhelmed. I must say that the Visiting Officer rolemust be one of the most difficult in the Military.Absolutely, it is a real challenge to take that through

and do it professionally. And there is a danger ofbeing overwhelmed by the responsibility of it, and,therefore, as you say, we need to support those peopleso that they can deliver to best effect.

Q46 Mr Hancock: You have probably answered partof this, but how are those trained practitionersselected? Who are they in units? Who is it who getsthat job?Dawn McCafferty: Some years ago—this is since Iserved, so I am not as familiar with it as I should be—the RAF decided to create a trained Visiting Officercadre. There is a pool of individuals who are selectedon the grounds of their maturity and their ability totake on what is, as I have just said, a very challengingrole. They are then put through comprehensivetraining. Some of that training is tri-Service, and Iknow that they share best practice in how to deliverthat training.If there is an injury or a casualty in a unit, thePersonnel Management Squadron will look at the poolof available people and determine who is best suitedto that particular family. For example, it wouldn’tnecessarily choose somebody who is well known tothe family—a friend on the squadron—because thatmight not be a very clever thing to do. So they mightchoose someone who is a little bit more distant, butwho perhaps served on the squadron and knew theindividual but wasn’t close. What the RAF is tryingto do is provide capacity on a unit to cope with anycasualties or injuries that come along.Mr Hancock: I will get in trouble if I ask youanother question.Chair: You will.

Q47 Mr Brazier: I want to take you back to thequestion on Reservists, to which you gave very fullanswer in so far as we can go on that. It seems to methat it is worth turning it the other way round. In ourconstituency postbags the common problem withmental health cases is that, on the whole, they don’tpresent. We hear about them indirectly becauseneighbours are complaining about being harassed,because parents or siblings are worried, or whatever.In that respect, there is a parallel with civilian life.The fact that more than half of our medical output atthe moment in Afghanistan and elsewhere is throughthe Reserve Forces offers an opportunity for mentalhealth for the Armed Forces as a whole—regular andreserve—that is currently untapped. In a way, I shouldbe putting this point to Ministers rather than to you,but you may well have views on it.It seems to me that, through the use of large numbersof NHS personnel in the reserve forces inAfghanistan, we now have quite a large ceiling acrossall regions of the NHS, of people in civilian jobs whoare primarily civilian doctors and nurses, who have apretty good idea of what it is all about because theyhave been out there and served. Would you support agreater role for trying to find a way of picking upand identifying these people, who may not present tillseveral years later, whether they are ex-regulars orReservists?Chair: I wonder if that is more of a policy question,although you may have a view on it.



Julie McCarthy: I suggest that those medics that weretaken from TA aren’t necessarily in primary healthcare—they are taken from secondary health care, fromhospitals—so they wouldn’t necessarily see the initialpresenting symptoms. I think it is a good idea, but Iam not sure it would still address the issue.

Q48 Mr Hancock: We are still talking about peoplesuffering from traumatic stress and other mentalhealth issues. So when the problems are identified,how effective is the treatment that they themselvesreceive? Secondly, are the families given enoughsupport once these difficulties have been identified?In other words, is it explained to the families howthis will transmit itself over a fairly lengthy period oftime?Julie McCarthy: As far as I can see, from thefeedback I have had from the few families I know thathave experienced treatment for mental health, it isvery good. Certainly, in terms of the chain ofcommand, they have tried to reduce the stigma ofmental health as much as possible. But I think soldiersand families still feel that there is a stigma. It is not avisible injury, and they may compare themselves tosomeone else and say, “Well, they lost an arm or aleg.” They have these traumas where you can’t see aninjury. I think they feel that it is not a real injury, andthere is some guilt associated with that, but I don’tthink the support is any less.

Q49 Mr Hancock: Where would they get thesupport, then? There isn’t a Headley Court, is there?Julie McCarthy: No, but there are mental health unitsregionally. Actually, in some terms, the provision isslightly better, in that they go regionally to be treatedrather than to a single—

Q50 Mr Hancock: To a military unit?Julie McCarthy: It is a military NHS partnership, asfar as I understand. I think that’s right.Dawn McCafferty: I think that there are militarypractitioners in mental health who will follow throughthose who need that support.Julie McCarthy: Yes. The help is definitely there, andit is not my area of expertise, but there is help and Ithink that it is very good help. I know that it hasrecently changed from being treatment at the Prioryto these regional centres.

Q51 Chair: And you also mentioned Combat Stressand Resolution.Julie McCarthy: I think that there are many charitiesdoing a lot. Veterans Aid picks up a lot when peopletransition into civilian life. The difficulty is in gettingpeople to seek help for mental illness. I don’t thinkthe issue is about the treatment—it is getting peopleto own up that they have an issue. Families haveraised the point that they can’t get somebody treateduntil the person admits to having an issue. That is stillvery much where the problems are.

Q52 Mr Hancock: What happens for soldiers whoreturn to units in Germany, for example, who aresuffering in this way, who are in Germany becausetheir families are still there? Is there a facility inGermany?Julie McCarthy: There are mental health clinicians inGermany, yes.Dawn McCafferty: SSAFA will be there as well.Kim Richardson: I don’t know how big the problemis, because it is not something people are necessarilycomfortable talking about. I have had very littlecontact from families who have had an issue withmental health. It would be interesting to know fromthe Service—I think it is only the Service that cananswer—how big a problem it actually is.Chair: I am afraid that apparently there is going to bea vote in the House shortly. If there is, there is; wewill just have to vote as quickly as we can and comeback, because we’ve got a lot of ground we still wishto cover. Sorry about that.

Q53 Mr Havard: On the question of rehabilitation,in its broader sense—there is physical rehabilitation,but concentrating on rehabilitation in the sense thatwe’ve just been discussing it—how does a familyrecover as well as an individual, in terms of theirwhole presentation and their mental health? You aredescribing ways and services that support individuals.You seem to be saying, as somebody said earlier, thatfamily needs are not catered for in that sense. Can yousay something about how you see the way in whichthe family and the extended family—however itdefines itself—is supported? The family is part of therehabilitation, but it needs support to rehabilitate itselfat the same time.Dawn McCafferty: One thing that I find veryinteresting in working with Air Command and gettingto understand what is now in place is learning howthey now track our individuals who are seriouslyinjured or ill through what they call the ClinicalPathway or recovery process. While that covers theService person in uniform through rehabilitation andrecovery, there is also a parallel pathway of welfaresupport that looks at the broader welfare needs of thewider family as well. That certainly wasn’t in placewhen I was serving 10 or 15 years ago and doing thissort of work as my bread and butter. It’s really helpfulthat there is a post in Air Command dedicated totracking all those individuals through their recoveryand then using that as a trigger to the unit welfarestaff to ensure that those questions are being asked. IsSSAFA involved? Does the unit welfare team knowabout this family’s needs? Is anything furtherrequired? There’s now a system in place to trackthem through.On whether that support is then delivered, like theothers, I don’t have that much contact from familiesof seriously injured or ill personnel, but I can onlyassume that some of that lack of contact is actuallybecause it might be working quite well and they aregetting very good support. At unit level, there’s awhole team of welfare support staff ready to help. Thekey thing is connecting them to family members tomake sure they understand what the need is.



So there is this parallel pathway where the individualwho has been injured is transiting through all his orher treatments, rehabilitation and recovery. Obviously,a decision is made at some stage about whether he orshe can stay in the Service or has to transition tocivilian life. Along that parallel path, the family arebeing looked after. I am reassured that that is beinglooked at. We’re probably not all the way there yet—there’s probably more to be done on that side—but atleast they’re asking the questions of whether there’s awider need than just clinical recovery.Julie McCarthy: I think there’s a lot of hope,particularly in the Army environment, that the ArmyRecovery Capability will pick a lot of that up andensure that rehabilitation of the family provides themwith the information they need. That’s the mostcommon complaint that I’ve heard. It’s justinformation. It’s knowing what’s going to happen; it’sthe “what if?”.There’s one organisation—the Defence CareerPartnership. We may have spouses who suddenly haveto become the main breadwinner. It’s about equippingthem after years in the Service. They may have to goout and work or, at a very young age, become a full-time carer. It ensures that they understand what futureimplications for them will be available and what isthere for them. If the spouses of our Foreign andCommonwealth personnel don’t have indefinite leaveto remain at the moment, they have no recourse topublic funds, so they can’t get a carer’s allowance.That’s the question for them: what will happen tothem? There are implications depending on eachfamily’s circumstances. It’s not that there is no desireto support families; it is just knowing exactly whatfamilies need. If any of the Services know whatfamilies need, they will do their best to meet that.Kim Richardson: All I would add to that is that to getreally good, firm evidence, you need to be talking tothe experts. They are organisations such as CombatStress, who would be able to give you that feedback.I don’t believe it is something that families wouldnecessarily see us for. We are not experts in anything.I would not necessarily expect them to come to uswith concerns unless the system was not delivering,and I am certainly not seeing evidence that the systemis not delivering.

Q54 Mr Havard: You have partly anticipated one ofthe questions that I was going to ask about the relevantsupport organisations, whatever they might be, andwhether families have got sufficient information tounderstand what those are. You are speaking aboutnavigators, mentors or guides who can help throughthe process. How well is that applied generally acrossthe piece?Julie McCarthy: There are so many organisations outthere that sometimes it is very difficult for people toidentify who that is. We were saying earlier that bythe time a family has got up the courage to make aphone call, if they are told, “It’s not us; you need tophone so-and-so,” and then the next organisation says,“No, no. It is not us,” at that point the family says,“Do you know what? I’ll sort myself out. Don’tworry.” It is about knowing from the off. In somerespects, COBSEO, or an organisation such as that,

has a role to play in identifying the right people todirect families to in the first instance. There is a rolefor that.Kim Richardson: I also think that one size does notfit all. People choose their support by what works forthem. Some people find that their friends and familyare enough. We could sit here and say that if you havea mental health issue, Combat Stress is where youneed to start, but that might not necessarily be thecase. So an element of what we do is signposting andoffering choice. There is a lot out there—there is a lotavailable—but I counter that by saying that I am notconvinced that our families know the extent of whatis available to them.

Q55 John Glen: You have seen a massive increasein the amount of charity activity in this space overthe past five or 10 years. How do you feel about thedistribution of what is offered by the MoD and thecharitable side? Linked to that question, you have saidthat there is a wide array of organisations, but theremust be a lot of overlap, too. How do you feel aboutthat?Dawn McCafferty: It is a very confusing area for allconcerned, be they the charities, the MoD or theService person and their family. The boundaries arenot at all clear—there is a grey area. All credit tothe charities, which step in straight away if they seesuffering and deliver what is needed. They willperhaps ask afterwards whether they should be doingso. They will then go back and negotiate, perhaps withthe MoD or the Government, saying, “Perhaps youshould have delivered that capability.”People step forward to help because of the inherentwish not to let people suffer. If families are in need ora Service person is suffering, those charities will stepin and help. But the boundary between whereresponsibility lies—from the MoD, the Governmentand charity—is a blurry line, not just for theindividuals who are offering support, but for all thefamilies in the middle, who are looking out and seeinga plethora of provision and not knowing to whom theyshould turn. We cannot guide easily either, because Iam not sure that I understand the boundaries betweenthose areas.Perhaps this Inquiry might shed a useful light on theboundary issue. Perhaps it will try to provide someclarity—working with the charities, the MoD and theGovernment—and say, “Let’s try and draw someboundaries here.” Everyone could still contribute, butit would make a little clearer who had a lead and whowas responsible for certain areas.

Q56 Chair: Am I right in thinking that CombatStress does not provide support to serving personnel?Julie McCarthy: It does not. It is for veterans whoare suffering from PTSD, so it could not help peoplewho have other mental health issues.

Q57 Sandra Osborne: When a partner is sufferingfrom PTSD or some other mental health issue, thereis a possibility that domestic violence will occur. Inthat case, the spouse, whoever they may be, may needto seek support or protection for themselves and



sometimes their children. Is there a mechanism withinthe Armed Forces for that on a confidential basis?Julie McCarthy: The MoD has just published a joint-Service publication on its policy on domestic andsexual violence. I am sure that it would provide a copyto you if you needed it. The lead in the RAF, for anydomestic violence issues, concerns or allegations, isSSAFA, the professional social workers. They wouldget involved on a formal basis and support the familyif needed. We have been approached by familymembers who feel at risk of domestic violence andwe signpost towards the professionals, because that isnot something that we are qualified to support.Chair: I am sorry to conclude there, but you willunderstand that we have a lot to cover before we gooff to the Chamber.

Q58 Mr Havard: I want to address the matter oftime and late presentation of certain issues. Forexample, Barnardo’s has worked with fathers in thecommunity and discovered that some of theirproblems are due to their being ex-serving men.However, those problems might arise and causefeedback into the family 10 years on, so latepresentation is an issue. As some of these things moveaway from being acute problems and perhaps becomechronic ones that need treatment over a long term,could you say something about what you think ishappening in terms of how we could address thisbusiness of late presentation for families who mightnot now be part of the immediate military communitybut have the same root problem?Kim Richardson: I took a phone call from a manaround the time of the Falklands 25th anniversary.There were a lot of celebrations and there was a lotof talk in the press about it, and it took me two and ahalf hours on the phone to work out that this chap hadserved on a ship that had sunk. He’d spent 25 yearscoping and managing, and he went to pieces whenit was being revisited and highlighted. So I do haveconcerns that there are going to be people like that outthere, and we have to take into account that this couldbe a very long-term issue for them. Combat Stressprobably would say that it is already seeing thatanyway. Where are those people going to be pickedup? There’s a very good chance that by that stage theywon’t be in the Services.It is about our using all the resources that we have toinform those people out in civvy street that this ispotentially what’s going to happen. This is where Ithink it is about engaging with PCTs, GPs and thehealth experts who are likely to come across people inthat situation later on. Perhaps their families approachpeople for help. When families need help they willfind someone, but it would be nice if they knewbeforehand where to go.Dawn McCafferty: There is also a role for the Servicecharities here—[Interruption.]Chair: I think that we had better stop and go and vote.Sitting suspended for a Division in the House.On resuming—Chair: Again, I am afraid, we were interrupted midflow. Was there anything that you wanted to say inresponse to that last question, if you can rememberwhat it was?

Kim Richardson: Yes. Where can we get that bell?My husband would welcome it.

Q59 Mr Havard: I was asking about how you dothings over time.Julie McCarthy: Picking up on what John Glen saidabout the charity, one thing that concerns me is that,over time, we may see a number of charitiesdisappear. We might see Afghanistan go out of theheadlines, and what concerns me is that, if it ischaritable provision, that charitable provision mightfall away. Many of the people whom we speak to donot understand why, not necessarily the MoD, but theGovernment are failing to provide something. Takingthe American model again, it is provided by the State,full stop. I don’t think that people understand that, andthey fall through the cracks because of it. Because itis not statutory provision, they are dependent on thosecharities and on catching them at the right time inorder to get provision.

Q60 Mr Havard: That was partly what I was drivingat—sustainability. We seem to have two cohorts. Wehave people who are currently serving, for whom wemight be putting in place a lot of support. We alsohave people who have served who may come backand present, but they are a much more problematicgroup to even identify. But sustainability of provisionover time is clearly something. These are not acuteproblems that will be solved in two or three years, sothat is why I wonder whether you will be able, theway you are structured, to actually support what islikely to be a growing community of need.Julie McCarthy: For us, it is about the people whomwe deal with, so the answer would be no, because itis not in our charity objectives.

Q61 Mr Havard: So once they stop being militaryfamilies proper and they move into a veterancommunity, how do you hand them over?Dawn McCafferty: We would signpost them to thekey charities with which we are linked. Before thebell went, I was saying that there is a role for Servicecharities in terms of picking up, further downstream,people who perhaps come out of the Service and didnot feel that they needed support or to ask for help atthat stage, but who, maybe 10, 15 or 20 years later,might present. I think that the big charities, like theBenevolent Funds, the Royal British Legion andSSAFA, which have caseworkers out in thecommunity, may well be able to identify those. I knowthat the RAF has put in a lot of effort, through theBenevolent Fund and the RAF Association, to findwhat it calls “the lost generation”—those who havenot become members of that organisation but who areout there, are veterans and who may well be in need,if not now, in the future. It wants to make them awarethat there is support there for them. So I think there isa role for the charity sector to be the “eyes and ears”on the ground, out in the community, to find thoseveterans. As somebody said earlier, GPs need to betrained to ask, when somebody presents, “Do you byany chance have a military background?” It mighthave been 15 or 20 years ago, but it may still berelevant to why that person is now presenting.



Mr Havard: I am having that discussion with mylocal health trust to try to deal with that very problemas to whether they are aware, continue to be aware,and how that will be refreshed. We will be takingevidence from the charities, obviously, so you canthink about things we could do later. You have givenus some ideas about what we need to gain from them.Thank you very much.

Q62 Chair: If it is difficult now to ensure that GPsare aware of and are empathetic towards formerService personnel, how much more difficult will it bein 15 years’ time if there isn’t a conflict going on andthere is nothing in the headlines?Kim Richardson: That is why we have to start now.Dawn McCafferty: I think that’s where the Covenantwill have to play its part. The test of the Covenantitself, as to whether or not it delivers that awarenessand mutual regard between those who are not serving,those who have served and those who now serve, willbe connecting them together and saying, “Werecognise the fact that you have served.” I know thatthe Covenant is still only in draft, but we will not bemeasuring its success in five years’ time. It will be in10, 15, or 20 years’ time when we measure whetherthose enduring obligations that we are trying to set inconcrete now will endure right the way through, sothat people serving now who transition out will besupported right the way through to the end of theirlives if necessary.Mr Havard: And they may have a new, differentfamily by that point.Chair: There are a couple of questions we would liketo ask about bereaved families, and about whathappens when people remain in Service. While we arewaiting for people to come back from the vote, couldPenny Mordaunt ask about leaving the Service?

Q63 Penny Mordaunt: Do you think that personneland their families are getting the level of support thatthey actually need, considering everything fromongoing medical treatment to help findingemployment and accommodation—a very broad rangeof issues—and looking at all agencies that might beinvolved in that? Not only the MoD and the ArmedForces, but also the NHS and local authorities. Thequestion to all of you is, are people getting what theyneed? If so, what is it, and if not, what is it?Kim Richardson: It is still early days. I think thatthere is a structure in place and that the Servicerecognises that it has a job to do. For some of ourpersonnel there is still that sense of uncertainty aboutwhether they will go or not, and when they do gowhat package they will leave with. I think there issome sense of uncertainty there. The people whoworry me the most are those who have injuries thatare not so obvious. I have spoken to a number ofRoyal Marines who have hearing loss. They areactually fit young blokes and you would not know thatthere was a problem, but there is. We are at thebeginning of this and need to be careful how it ishandled, but I also think we need to get feedbackwhere it is not working, because some people willundoubtedly fall through the cracks.

We also have a group of people who do not want toleave; they do not want to transition out. Thechallenge to families—and it might not be a wife orpartner; it could be a mum or dad—of someone thenreturning home could be quite significant. So for meit is early days.Dawn McCafferty: One organisation that we haven’tmentioned is the Service Personnel and VeteransAgency, which has a welfare role as well, in terms ofthat critical two years of transitioning out from theService into civilian life. There is a remit upon thosewelfare staffs to make regular contact with thosepersonnel and families and make sure that they aremaking that transition, and if they’re not, why not?What problems do they have? Again, it is early daysfor that. I cannot say that I’ve had any feedback oneway or the other on whether it is working. I have hadoccasional contact from guys and girls who havetransitioned out and fallen through the net, and wehave connected them to the SPVA Welfare Service. Ihave heard nothing afterwards, so I hope that that hasput them back on the right track. So there is anotherlevel of support there; they don’t just drop off theradar. The SPVA are there to support their transitionfor two years.Julie McCarthy: I agree with everything mycolleagues said. In terms of ongoing work and lookingat what will be done in the future, encouraging allService families to think about things like homeownership earlier in their careers may mean that ifsomething does happen then they are better preparedto move on. I think some of it is about getting peopleto think about transitioning before anything happens,and that will perhaps make them better prepared ifsomething does.People like the Defence Career Partnership arelooking at putting people into worthwhile jobs. That’sa key thing, because I think that is one of the scariestthings. Families have asked us what they will do; theycan actually still do a huge amount, perhaps oncemedical care is finished. Organisations like that havea huge role to play, as do local authorities. Bigorganisations throughout the country could help byemploying and providing employment prospects, forboth veterans and their spouses.

Q64 Penny Mordaunt: One issue that we discussedwhen we were thinking about how to gather evidencefor this inquiry was potentially doing survey work ata local level across the UK. For example, withexisting and emerging local NHS structures, with localauthorities, potentially with some big agencies thatmight be looking at employment services and the newthings that are happening on that front. Sorry to putyou on the spot and please feel free to come back tous on this. If we were going to do that, would therebe some questions that you would particularly wantus to ask of the NHS or a local authority or anotherbody?Dawn McCafferty: I am sure that we would come upwith some questions if you gave us a little bit of time.Kim Richardson: I live and work in the Portsmoutharea and I met with some representatives fromPortsmouth City Council. It was a really interestingconversation because about 20 minutes in I realised



that although we have a naval base on their doorstep,they do not actually understand us. It is behind a wire.So my plea would be, “What more can we do to getyou to understand us? Do you get us or is it just theodd programme that is on the telly, the bit of news?Is it another death in Afghanistan and the familiesbeing informed and you move on?” I feel we have arole to play here in engaging with people like that totell them what we are all about. I can only see thatbenefiting our families in the long term.Julie McCarthy: There are some very good examples,particularly in Wiltshire and North Yorkshire.Wiltshire has a military-civil partnership. They evenhave part of their website dedicated to the Militaryand talking about what the local government will dofor the Military. It is about looking at examples likethat and how it works and encouraging those councilswith relatively low numbers of Service personnel toadopt that model as well, because the issues occurwhere there is not that understanding and perhapswhere there are lower numbers as well, although thatflies in the face of Portsmouth, possibly.Kim Richardson: Wales has done that. We engagewith Wales and one of the things we did was paint apicture for the Welsh Assembly of what a Servicefamily is. We are all different. They followed throughin a really positive way. I am sure we have an opendoor at the moment. We have to be knocking on itbecause it’s not going to last forever.Penny Mordaunt: Could you follow up with us? Itcould be about what is in place or even whethersomeone is a point of contact, not just with the NHSand local authorities, but with other big agencies andservices that you would like us to look at.

Q65 Mrs Moon: We have asked a lot of questionsabout mental health recovery and rehabilitation. Howmuch frustration with the pace of action are youpicking up from families at the moment? How greatare their concerns that family members are not gettingadequate rest, leave and space? That may notnecessarily be before deployment back out to theatre;it could be deployment to the next job. Do they getthe time to recover from a deployment, or to unwindwith the family in a different rhythm, before they haveto move on? Is that an issue?Kim Richardson: I think so. Our families can’tunderstand how the Navy is downsizing when theysee less of their serving person than they ever didbefore. Even periods of time at home that used to betraditional jobs, where somebody would perhaps beable to take an early day to collect a child from school,are not happening so much now. Although we focuson Afghanistan, Iraq and now Libya and the biggerthings, the jobs at home were the downtime. Icertainly would say that our families are not seeingthat anymore. We cannot ignore that.Dawn McCafferty: I support Kim: it is the downsizingthat is causing the real ripple of concern. We are onlyjust coping now, from a family perspective. It is, “Iam not seeing much of my husband or Dad, orwhoever, and now we are going to get smaller, yet wecannot see the commitments lessening”. Yes, there ispredicted withdrawal from Afghanistan, but whopredicted that Libya would come up? What’s next?

The families feel that if they are stretched now, whatis life in the RAF or the Armed Forces going to be in2015 onwards? Do they want to be around to be partof that? If they’re feeling the stress now, what will itbe like then? I think it will be the families who putthe pressure on the guys and girls to say, “Enough isenough.” We’ve said that before. It is one of thebiggest factors in exit surveys. The reason why peopleleave the Armed Forces is not to do with jobsatisfaction, pay or anything like that. It is to do withthe family. People say they need to give their familybetter support; they want to spend more time withtheir family.It was only a small sample, but last year we asked ourfamily audiences a question about work-life balancein the RAF. Last year, 60% said, “Yes, broadly, wethink we have a reasonably good work-life balance.”This year it was 60% the other way—60% saying,“No, we haven’t got a good work/life balance.” Thatwas a really marked change in just two years of askingthe same question. That’s a really strong indicatorthat, again, people are feeling very stretched.I think the stats that are provided will indicate thatService personnel haven’t lost a great deal of leave,and perhaps working hours are down. I’ve just readthe Armed Forces Pay Review Body report. The statsare there, and you can’t deny them if they’ve beenproduced. The question is what they really mean,maybe not in terms of losing leave, but in terms ofgetting leave when you wanted it. In terms of stretch,how do the families actually feel? There is stressthere, and I am concerned about what it will be likeonce we have gone through the phases of redundancythat we are about to go through. How much harderwill it be?

Q66 Bob Stewart: What happens when bereavementoccurs? What’s the current procedure? Let’s just takethe Army, because that’s probably most—Julie McCarthy: In terms of notification, a notifyingofficer will be appointed. They will be a warrantofficer or above, not a subaltern or a young captain.

Q67 Bob Stewart: There’s no release of nameswhatever until the family have heard?Julie McCarthy: No. There’s Op Minimise in theatre,so that the name can’t get out, although we have hadexperience of the name leaking out for variousreasons.

Q68 Bob Stewart: In theatre, you normally have anews black-out. You tell everyone they’re not to usetheir phones, right?Julie McCarthy: Yes. There are no phones. Theinternet will go down. That’s Op Minimise.

Q69 Bob Stewart: I want to get through this quicklybecause we don’t have much time. The notifyingofficer approaches the house, where there willnormally be a wife, whether she’s on base or not.Julie McCarthy: Or a parent. It’s whoever is theemergency contact that the soldier has left.

Q70 Bob Stewart: The next of kin on the next-of-kin form. Who goes to the house?



Kim Richardson: It’s not necessarily the next of kin.Julie McCarthy: No, it may not be the next of kin;it’s the emergency contact.

Q71 Bob Stewart: I understand: it’s whoever thesoldier, sailor or airman designates. Who goes to thehouse?Julie McCarthy: The notifying officer.

Q72 Bob Stewart: On his or her own?Julie McCarthy: No, there are two, I believe. Theymay be male or female, but they will have beentrained to visit people. They will go to notify theperson and will stay for a short period and then theVisiting Officer takes over. So they’ll see that persononly once and it should not be a person who is veryclose to them.

Q73 Chair: It should not be.Julie McCarthy: It should not be.

Q74 Bob Stewart: The notifying officer is normallya stranger. Are they normally with a Padre?Julie McCarthy: It can be a Padre.

Q75 Bob Stewart: Or a families officer.Julie McCarthy: No, it wouldn’t be the unit welfareofficer, because they will then have contact. When thehusband of a previous staff member of ours waskilled, her emergency contact was taken—hernotifying officer contacted her friend and took her tomake sure that she had support.

Q76 Bob Stewart: And that person is thenresponsible for notifying the family? Who goes on tonotify the family, if the emergency contact is not thefamily?Julie McCarthy: I believe that’s the notifying officer,the Visiting Officer—it will be the unit. I think that’sa question for the MoD.

Q77 Bob Stewart: So the first person is there, andthat happens. I’ve done it, so I understand. Normallyit’s quick; someone goes in, says, “I’m very sorry, MrsSmith. Brian has been killed.” She collapses. Whocomes and looks after her?Dawn McCafferty: The Visiting Officer and thePadre.

Q78 Bob Stewart: The Visiting Officer is rightbehind, immediately?Julie McCarthy: They should be, yes.

Q79 Bob Stewart: And the other person clears out.Julie McCarthy: Yes.

Q80 Bob Stewart: The real question is this: for howlong are bereaved families looked after from thenonwards?Kim Richardson: I have to pick you up on this. Yousaid, “Go to Julie because it’s an Army issue.” It’s notan Army issue.

Q81 Bob Stewart: I know. I said that because it’smore—I’m sorry—

Kim Richardson: No, it’s not more. The other twoServices feel very sensitive, and this is something thatI would like you all to pick up. It is not just the Armyin Afghanistan losing people; it is the other twoServices as well. It is one of the things that ourfamilies feel very strongly about, so I hope you don’tmind, but I need to say that.

Q82 Chair: You need to say that. And the RoyalMarines—there were more Royal Marines inAfghanistan at one stage than there were people fromthe Army.Dawn McCafferty: Can I just make this point, aswell? I know this is focused on operational deaths, butactually a death is a death. If your guy has just beenwiped out in a motorbike accident, it is exactly thesame process, in terms of notifying and support.

Q83 Bob Stewart: I entirely agree. We are justtalking about procedures here, and I am going shortly.Kim Richardson: Each of the three Services has aslightly different way of doing it, and I think it wouldbe helpful for the Services to explain it to you. Forour Visiting Officers, they stick with families all theway through until the families determine that theywant that to finish. Each of them does it slightlydifferently. It is not because that is wrong, but becausethey are tailoring it to what is right for ourindividual Service.Dawn McCafferty: The guidance from the RAF is thatthe Visiting Officer will be that key link for a goodsix to eight months, and then might try slowly butsurely to withdraw the support. If the family need himor her, however, they will be back there, particularlyif there are things such as Inquiries and Inquests totake them through, which might be two yearsdownstream.

Q84 Bob Stewart: Forgive me, but the Army wasnot very good at it. Maybe the RAF and the Navy arebetter at it. I am not trying to point-score; I am justtrying to ascertain the system. The question really is:how long do people get proper support?Kim Richardson: For the Navy, as long as they wantit.Dawn McCafferty: I would say the same for the RAF.Julie McCarthy: That is notwithstanding the fact thatspecialist support may be required, which is notimmediately forthcoming, such as if young childrenwere involved. Sometimes specialist counselling andadvice are needed, and again, we are relying onfamilies going out to look at the charitable sector.Winston’s Wish is doing a lot of work with themilitary at the moment particularly to address childrenwho are bereaved. There is very practical support, butemotional support such as counselling is an area thatwe need to look at.Dawn McCafferty: We have examples as well of theRAF Benevolent Fund, for example, helping bereavedfamilies to purchase a house and funding educationfor the children, either ordinary schooling oruniversity. The support can still be in place years afterthe actual bereavement, so it is an enduring support,but it is very much guided by what the widow or thewidower and the family want.



Bob Stewart: That is good, isn’t it?Dawn McCafferty: Gone are the days when youwould say to a family that you were withdrawingsupport at too early a stage.

Q85 Bob Stewart: What about money? I am so sorryto ask embarrassing questions, but one of the keythings that people always panic about is money. I willbe brief; for example, who pays for the funeral?Julie McCarthy: The MoD.

Q86 Bob Stewart: What happens if the family saythat they don’t want the MoD to pay?Dawn McCafferty: A grant is made towards aprivate funeral.

Q87 Bob Stewart: What happens if the family say,“We don’t want you to identify that my son has beenkilled, by an MoD spokesman saying so”?Julie McCarthy: If the family ask that the name is notreleased, it will not be released.

Q88 Bob Stewart: No; if the family say, “We don’twant the MoD to release the name. He’s ours; wewill say.”Kim Richardson: I think if the family ask forsomething, everyone will bend over backwards toaccommodate it.

Q89 Bob Stewart: I have not seen that happen; it hasalways been an MoD spokesman. I would think thatif it were my boy, or my girl, I would say, “Whythe heck?”Kim Richardson: I don’t think our families are verycomfortable challenging systems, often. You have anindependent serving person, who goes away and maynot contact the family from one month to the next,and all of a sudden you are making decisions forsomeone who has lived an independent lifestyle. Youdo what you think is best. A lot of families gain a lotof succour from having that support from the Service.I can’t speak on behalf of the Service, but I would bevery surprised if a family said to the Service, “Wewant to do it in this particular way,” and the Servicesaid, “You can’t, because we want to do it our way.”

Q90 Bob Stewart: The biggest problem is who toidentify, because of the system, isn’t it? I mean, howfar do you go out telling people, and what is theresponsibility of the Service to tell extended family?Julie McCarthy: Having spoken to the aftercare cellfor the Army yesterday, their responsibility is theemergency contacts, and that is it. They will, however,make every effort. They have instances where theyhave appointed three Visiting Officers, because theyhave visited a spouse, and she doesn’t speak to the in-laws, who are divorced and don’t speak to each other.

Q91 Bob Stewart: Or a common-law wife.Julie McCarthy: Absolutely.

Q92 Bob Stewart: This is a serious problem, which,of course, is impossible to solve, isn’t it?

Julie McCarthy: You never get any policy thataddresses every make-up of family and allows thatflexibility.Bob Stewart: I don’t want to run this all the waydown, because the Chairman has told me that I haveto shut up.

Q93 Chair: I have not told you to shut up, but I doknow that you have another engagement that you haveto move on to. We haven’t been rushing through thisbecause it is, in any sense, an unimportant issue. It isprobably one of the most important issues that weface.Dawn McCafferty: One support area that hasn’t beenmentioned yet in terms of the bereaved is the WidowsAssociations. They have an important role to play interms of a neutral support group. Each of the Serviceshas one. They are there because they have lived andbreathed it themselves. They offer a unique supportnetwork to those who wish to use it. It may be thatnewly bereaved are not comfortable joining in the firstfew months after the bereavement, but furtherdownstream, they might welcome that support. Thatis a really good thing to have for the people who arebereaved and, indeed, the children. Again, SSAFA isdoing some great work with some support groups forbereaved families and siblings, and, again, we areleaning towards the charity sector, but there is somegreat stuff happening there, and that support will beenduring.

Q94 Bob Stewart: Can I just put one thing on therecord that I want your reaction to? I think that theElizabeth Cross has been an outstanding success.What is your reaction?Julie McCarthy: You are absolutely right.Bob Stewart: It is the most wonderful thing that theprevious Government brought in, because widows andfamilies wear it with real pride.

Q95 Chair: By the way, while Bob Stewart is stillhere, he said that he didn’t think the Army did thisvery well, and I think he was speaking as an Armyman. What is your view?Julie McCarthy: I think that the Army haveimproved massively.Bob Stewart: I am old hat.Julie McCarthy: The Army are absolutely desperateto learn from their mistakes, and they review policyregularly. I am happy that they will do their best. Ifsomething falls down, it is because of the familysituation, not because of policy.

Q96 Bob Stewart: One of the problems is that youmust identify the people who will actually do thevisits, and in a very small Service it is difficult forthem to do it.Julie McCarthy: What we find is that, if you look atsomebody, perhaps the Rifles, who have lost a hugenumber of men, they would very much like to providesomebody from within the Regiment, who understoodthe Regiment. One of the bones of having a familyRegiment is that if you want your Visiting Officer tobe of that Regiment, that has a huge impact, and theyare now looking to go out again.



You mentioned money. The Army Dependants’ Trustis a membership organisation that, within 24 to 48hours of a death, whether operational or non-operational, will pay a grant of up to £10,000 tofamilies to alleviate immediate financial concerns.

Q97 Bob Stewart: That is non-returnable.Kim Richardson: Absolutely.Julie McCarthy: It doesn’t have to be spent onanything in particular. The money is given to thefamily to alleviate financial concerns.

Q98 Bob Stewart: That was one of the biggestworries in my time. I was panicked about how muchmoney these people would get.Dawn McCafferty: The other concern that theimmediately bereaved will have if they are living inquarters is, “Am I going to be kicked out veryquickly?” Again, things have moved on to give themthe reassurance that, pretty much, that quarter is therecertainly for the foreseeable future through to a goodtwo years out. By that time, they will hopefully havemade that transition themselves, and many of themmove out of quarters before that point. Even at thetwo-year point, if that family still feel the need, theywill review that with the Service.

Q99 Bob Stewart: They want to be in a communitythat they know.Dawn McCafferty: I think so. For those who havelived within that community, moving out is almostanother bereavement, because they have to leave thatother family behind. Again, there is a real sensitivityfrom Defence Estates and the chain of commandabout making the family feel that they are not beingrushed. This isn’t something that is going to happenovernight. They are saying, “Take your time, makeyour plans, and we will support you as you transitionout.” That has changed dramatically since my earlydays in the Air Force.Chair: This is all extremely good to hear.

Q100 John Glen: I have two observations aboutwhat you’ve said so far. You seem to be very loyal toeach other, in that you are all doing similar things.You also observed, Julie, the experience that ourtroops have, in terms of being aware of a differentoffer from what American troops might achieve. I waswondering if you could explain what the drivers areof different expectations between the Forces. Youseem to be saying that, broadly speaking, you alldeliver about the same. But are there any tensions?Are you aware of specific best practices that the othershave that you can’t have because of any constraints?Also, do you not think it would be better for thereto be one offer that is the same? When somebody isbereaved, why would there be a different expectationfrom different Services, given that bereavement isbereavement?Dawn McCafferty: I wouldn’t like to try to explainthe different culture and ethos of the Services, but thereason they have evolved differently is that the lightblue look after the light blue, the khaki look after thekhaki and the same for the dark blue. The terminologythat we use is different. For example, if we were

asking an Army unit welfare officer to look after abereaved RAF family, they potentially would notknow what a unit welfare officer was because theydon’t use that language. They are very comfortablebeing supported by their own Service. People have thefeeling that that is the Service they belong to, and thatis the Service that will look after them.We could have a tri-Service casualty informingprocess and a tri-Service pool of Visiting Officers andsay that anybody in any uniform could go and visitany family, but I’m not sure that would work. Peoplehave a very strong bond not just to their Service, butright down to squadrons and units. That is why localsupport where possible from a Visiting Officer fromthat unit is important. The chain of command and theparent unit of that family are critical to that ongoingcare for the next couple of years—from organisingthe funeral to support networks and engaging with thecharities. If that were in some way centralised andharmonised, we would lose out somewhere along theline.Chair: Yes; particularly at a time of bereavement,you’ve got to get it right.Kim Richardson: Each of the Services has a slightlydifferent structure. Our welfare set-up is differentfrom Dawn’s and Julie’s. It is about each of theServices using the resources that they have in a waythat they think works best for their people. It is goodfor a Royal Marine to have a Royal Marine VisitingOfficer, and it is even better for a Royal Marine’sfamily. It is about using your own resources.Julie McCarthy: There should be minimum standardsacross the board. Everybody should expect the same.

Q101 John Glen: Do they exist?Julie McCarthy: I think they do. In terms of treatmentfor injuries and bereavement, we don’t hear that thatis one of the areas about which people say, “But theNavy or the RAF get it.” As far as they can, peoplegive a top-class service.

Q102 Mr Havard: We are trying to cover all thecategories. We’ve done bereavement, rehabilitationand leaving the Service. Can I ask you some questionsabout people who have a problem—an accident orwhatever—and return to Service? Could you saysomething about the adaptations or things necessaryto rehabilitate someone back into Service life? Howdoes that process work with families?Kim Richardson: I have not seen any evidence thatthe Service hasn’t made it work. Sometimes theserving person needs some time to determine what isgoing to be right for them. That is a good thing. Someserving personnel feel that they are going to returnto the Service and then perhaps realise that it is notnecessarily right for them. I go down to HaslerCompany in Devonport.Mr Havard: The Chair has told me not to ask youabout that.Kim Richardson: We would be here for another hourbecause I think they’re fab. I go down about every sixweeks to talk to the lads in Hasler Company abouteverything and anything.



Q103 Chair: They are the Marine trauma unit, arethey?Kim Richardson: They are not just Marines; the Navycan use it and it is being opened up to the otherServices as well. It’s a recovery pathway and is wherethey get together. It is predominantly Royal Marinesat the moment.

Q104 Mr Havard: It’s sort of self-sustaining andself-supporting.Kim Richardson: Yes. So they come out of their unitand it becomes their unit. I have contact with RoyalMarines who are in a position where they are not—

Q105 Mr Havard: Are these largely people who aremaking this very transition of getting back intoService activity?Kim Richardson: Yes.Dawn McCafferty: There is a process that certainlythe RAF will go through. The medics will take thelead on assessing to what extent the injured individualcan return to work and determine what fields ofemployment they are still able to do. That informationwill be passed to the manning staff who willdetermine whether there are opportunities for theindividual to be still employed. As Kim said, we donot have evidence that that is not working well. If,en route, adaptations are needed to Service families’accommodation, a process is now in place to workwith Defence Estates. It might not be the quickest wayof getting things done, but at least a process is in placeto make it as smooth as possible.

Q106 Mr Havard: How does that work if they arenot in Defence Estates accommodation?Dawn McCafferty: There is even a protocol in placenow to do adaptations to private homes, such as aparental home to which a single guy is returning afterhe has been injured and has to be discharged from theRAF. He can have his family home adapted so that hecan return with whatever disability he might have.Kim Richardson: The biggest challenge is for thosewho would like to stay but cannot—for whateverreason. For the serving person and the family, thatmight be something that they had not considered.They probably have the biggest challenge.

Q107 Mr Havard: Is the Army experience different?Julie McCarthy: I am similar, in that we do not get alot of that. As far as I know, that is what the ArmyRecovery Capability will pick up

Q108 Chair: What have you heard about that?Julie McCarthy: The units will assess the carepathway as they go along, and whether that personwill return to Service. They will establish at whatstage they would do that, or whether they weretransitioning out, and ensure that they and their familyare equipped to do it. My concerns are about adaptinghouses with perhaps a reducing estate and pressure onbudgets. I would like to make sure that we maintain aquick turnaround in the adaptation so that people canget back home and start living as normal a life aspossible.

Q109 Mr Havard: Have you had any, “Well, he ispretending that he is getting on with it when he is notreally getting on with it,” from the families?Julie McCarthy: We have not, but that is not to saythat it is not happening.

Q110 Mr Havard: The family might be affecteddifferently from the individual.Julie McCarthy: Absolutely.

Q111 John Glen: I have a couple more questions.Let us consider one year after discharge from theForces and mental health issues. One of the concernsthat has arisen is that there is no attempt then tounderstand where people are at. Do they receive moreassistance? Do you have any understanding of whathappens post-discharge and whether there isassistance to the person’s mental health and for thefamilies?Dawn McCafferty: As far as I understand it, theSPVA has a requirement to make contact with theService person—if not at the year point, then a two-year point after they have left—to check how they aredoing and if they have particular needs in any area.Whether or not that is happening on a regular basis, Ido not know. You would have to ask the SPVA.

Q112 John Glen: Do the families get in touch withyou and say that they have mental health issues thatthey did not know about a year previously?Dawn McCafferty: Not on mental health issues.Families, and indeed ex-Service personnel, come backto the Families Federation once they are out if theyhave been in touch with us during their Service. Wedo not tend to deal with the veterans’ issue so much.We signpost veterans on to SPVA, SSAFA, the RAFBenevolent Fund or the RAF Association, whicheverwe feel is appropriate. We just then monitor and makesure that they have linked up with the right people,but it is not really our area. It is not what we are hereto do. We are here to represent the serving andfamilies of the serving. It sounds callous to say thatwe draw a line and say, “No,” but so many otherorganisations look after veterans that we have to drawa line somewhere.

Q113 Chair: Are you aware of any problems withthe Armed Forces Compensation Scheme or with itsadministration? I am not asking you to tell me if thereare lots. I am just asking whether there are any.Kim Richardson: The whole process under LordBoyce was very good. I welcomed the opportunity tobe there representing all three of us because that wasquite a step forward. I welcome the findings. There isstill some ongoing work. Professor Sir AnthonyNewman Taylor’s work is very welcome because heis focusing with his independent medical expertsgroup on things such as hearing loss and genitalinjuries, which need extra work. I would like to seethat continue, and I’d like to see him and his medicalexperts stay in place until well after we’re out ofAfghanistan. I think it would be appropriate for thatto happen.So, the Armed Forces Compensation Scheme, as aconcept, is doing a good job, but the process takes too



long. After going to Hasler Company, I know that theposition of some of the lads down there is that theyare reaching a point where they will possibly betransitioning out of the Service, and they do not knowwhether they will get money, and if so, how much thatwill be. That adds extra pressure when they are tryingto plan for leaving the Service or deciding whetherthey will stay. There is an aspiration or a request fromserving personnel that they would like a dedicatedpoint of contact in the SPVA so that they have somecontinuity. Once they have filled that paperwork in,they know a name, and the SPVA will keep in touchwith them.People also have some concern—and we are back tomedical records again—that everything that they haveexperienced and the injuries that they have arecompletely recorded on their medical records. I havebeen asked on several occasions why personnel haveto complete paperwork, and why they can’t physicallysit in front of somebody and start their claims processwith them. I realise that there is a huge resourceimplication for that, but I wonder whether some sortof sample testing should take place. One in 10 peoplecould actually sit in front of somebody independently,who says, “Right, you tell me what happened to you,and let’s make sure that it correlates with what we’reseeing in the medical records and what you’reclaiming for.” So, among personnel who are claiming,there is a sense of nervousness about the process andhow it takes place. That comes back to how manydifferent methods there are of recording medicalinformation.Another aspect of the Armed Forces CompensationScheme, which is a side issue, is that some of theseyoung lads are being given huge wodges of money,and they are going out and spending it on fast cars,for example. Should we be considering financialadvice and offering it to them when they are in receiptof what are big sums of money?People talk about the scheme. It is a subject theydiscuss, and I’m sure that if you are even consideringa visit to Hasler Company, they would tell you exactlywhat they think about it. They compare notes and theycompare injuries. It is a topic for discussion. Theprinciple is good, but I think we could be doing better.That would be my feedback, direct from the peopleI’ve been speaking to.

Q114 Chair: One quick question. I mentionedalcohol before, and the fact that there is more of aproblem with alcohol than there is with PTSD. Is thatsomething that the Armed Forces CompensationScheme should be looking at? It doesn’t at themoment, because alcohol is considered to be a matterof personal choice, but is it something that should bean issue for the Armed Forces?Kim Richardson: I don’t know how you determinewhether somebody comes back from operation anddrinks more. How is it decided whether they weredoing that to the same extent before they went? I’mnot sure how you would manage that.Chair: It is difficult.Kim Richardson: Hearing loss is something that isclose to my heart, and I am not even convinced thatour personnel have a benchmark or a standard for

hearing before they go to Afghanistan. Are webenchmarking their hearing properly before they evengo? How do you determine whether somebody comesback and has a drink problem?

Q115 Chair: I think we are, aren’t we? You have topass a medical before you go.Kim Richardson: You do, but I would ask whether itis doing what it says on the tin. That is the question Iwould ask, because I have been led to believe that thatis not necessarily the case.

Q116 Mr Havard: So you are saying that thereshould be a proper audiometric test that is recorded,with a graph, rather than somebody banging the oldtuning fork and asking questions.Kim Richardson: I do, because it is acknowledged asbeing a problem. It is difficult to determine how youwill make an award for hearing loss—tinnitus is aproblem. That is why this extra work by Professor SirAnthony Newman Taylor is so important, but if youhaven’t got something to start with, it makes it evenmore difficult to come out with a firm diagnosis andput people into the right categories.Chair: I warned you that it was going to be a catch-all question.

Q117 Penny Mordaunt: As the Chair said, we willdo further inquiries, so this is your opportunity to flagup any specific issues that you are concerned about orthat you want to make us aware of—the cumulativeeffect of things, for example, or how morale is.Julie McCarthy: I shall mention two. On thebereavement side, I would like to see greater advicefor our Service personnel on putting their willstogether. Too many of our Service personnel are goingout on ops without a will. There was the case of LucyAldridge whose rifleman son was killed and she wasgiven his death-in-Service payment. She was oninvalidity benefits, which she has now lost, and shefeels that she is wasting the money that her son leftand isn’t able to give it to his two half-brothers to helpthem in the future. She has lost her benefits when avery simple provision in his will of a discretionarytrust could have solved that. I would like to see theMoD forms revised, which I know they are lookingat, and solicitors being made much more available toour young personnel, who think they’re invincible andare not going to be killed. It should be much higherup their list of priorities to look at their familysituation and write a proper will before they go onops.The other thing I would like to see relates to theMilitary Covenant. A very strong arm in the diagramsI have seen of the Military Covenant is the terms andconditions of Service for our Service personnel. I feelthat these are being eroded, with no unionrepresentation, and that very much affects us asfamilies, not least because of mobility. We are largelysingle-income. I have not been able to start a pension.I spent seven years in Germany when I couldn’t, andhave never caught up. I feel that, in terms of theMilitary Covenant, we should be looking much harderat what people are given. Is it fair? Do we labelService personnel and families under a misconception



that we are badly done to, or are we actually very welldone to? I would like more light shed on that.Kim Richardson: I have a couple of points. I knowthat some of the lads I have spoken to have taken outinsurance with PAX or Service Life Insurance—thosesorts of things—and when they have got down to thenitty-gritty and had the conversation about what theythink they’re going to get, it is actually nothing likewhat they thought they had taken out. I wouldwelcome some questions being asked about how thoseprocesses work, because they are being taken out withthe best intentions. I spoke to a young chap who said,“I thought if anything serious happened to me, myfamily would get £250,000 and I would be able to buya house and sort them out,” but when it comes downto the bottom line, it is nothing like he thought.The other thing is that you have engaged with us andasked us, but if there are any ways and means toengage with the families and people who are ready totalk to you, I would welcome your finding some wayof doing that. They are not always asked for a view;you would find they would give you very goodfeedback if they were asked, but it is very much downto them when they choose to tell you.

Q118 Chair: How would we do that?Dawn McCafferty: You could, for example, seek, ifnot oral evidence, then written evidence from theWidows’ Associations and ask widows for their viewson how they were supported. They will have somestories to tell; hopefully, many of them good stories,because this is an area that the Armed Forces arereally focusing on and getting better at, but there isalways something they can learn. That would be agood area, as would be using SSAFA and the supportgroups that they have as a connection to families whohave either been bereaved or have members who areseriously injured—through Hasler Company, forexample; through Personnel Holding Flight with theRAF and the Army Recovery Centres—to see whetherthere is a linkage, through the chain of commandlinks, to anybody who would like to contribute toyour Inquiry.As Kim says, we try to represent what the familiesbring to us. Hand on heart, I have to say that we donot have a great deal of evidence on our issuesdatabase from these particular groups. I have done mybest to understand what the RAF is doing todaybecause it is different from what it was when I wasserving. The best people to talk about it are those inthe chain of command who deliver the process, andthose who are in receipt of it. Through the varioussupport groups, you might get some really goodevidence.Kim Richardson: Could I make a plea? Could wedifferentiate between the bereaved and the families ofthe seriously injured? The families of the seriouslyinjured find it quite difficult sometimes. We have agood website, RNcom, where bereaved families seeksupport and help from other people. Often, thefamilies of the seriously injured feel that they havegot their person and they are not in the same place asthe bereaved family. Their experiences will be quitedifferent and, in some ways, more illuminating for youthan those of the bereaved families. We need to keep

them as very clearly defined groups with their ownneeds.Dawn McCafferty: You might also—I don’t knowwhether the chain of command could help facilitatethis—get feedback from the Visiting Officers whohave carried out the role because they are living andbreathing this with the families of those who areseriously injured or the bereaved. Their experience oftrying to deliver this might be a useful indicator backto you of where it is going really well and wherethings might be enhanced from their perspective. TheVisiting Officers do regular reports back to the chainof command on any issues that they have come acrosswith their families. Perhaps you could ask the chainof command to pull this together to identify any keythemes. I am sure that the chain of command wouldbe giving that sort of evidence anyway.I see the Visiting Officer as such a key player in thedelivery of this. Their experience of what they arebeing asked to deliver will provide some really goodevidence. For example, is their training good enough?Did they come across any problems? Are the familiesfeeding back to them?Kim Richardson: Are you going to talk to SPVA? Itmight be interesting to hear its perspective and how itfeels that it is delivering.

Q119 Penny Mordaunt: Just a comment followingon from that. Mrs Richardson had previouslymentioned to me about Members of Parliamentvisiting family days. Would that be a welcome thingfor a body such as this Select Committee to do?Kim Richardson: We said that we would take you outon board a ship with a group of families. It is not quitewarm enough to be doing that yet, but it is on ourradar. I am sure that that will be a welcome way ofgetting a very different perspective. We don’t havemany ships now to take you out on, but we will doour best.

Q120 John Glen: Slightly linked to that, the SDSRthrew up some issues around basing and the basesreview. As a member of the Family Federation, howare you preparing for potential significant moves oftroops back from Germany or just generally? Haveyou been consulted on such things?Julie McCarthy: Not as yet. The Services themselvesare still trying to work it out, given the big picture.Hearing that half will be out of Germany within fiveyears is a shock, particularly to Germany. We have aconference in Germany in June and that is when thefamilies will be hoping that the chain of command,including the General, will be there. There are a lot ofquestions. Families are just really uncertain about thefuture. They want some answers. They want toknow—it does not matter whether it’s good or badnews—what is going to happen five or 10 years downthe line.Dawn McCafferty: From an RAF perspective, we arewaiting for, hopefully, an announcement in June ofwhen the next base closures will be confirmed. Thereis a media feeding frenzy going on out there in termsof campaigns—for this unit not to be closed or thatunit not to be closed. That has a huge impact on thefamilies living on that base, because they will be



hoping that their unit will be spared the axe. It will begood to have, as soon as possible, certainty overwhich RAF bases will close as part of the StrategicDefence Review. Then we will help the families copewith that transition.The redundancy package is something that we mustkeep an eye on—exactly how many people areapplying and how many people will be madecompulsorily redundant. There is so much going on atthe moment with the families. We are just trying tokeep a weather eye on what is happening and keep intouch with the MoD or the RAF. We are saying tothem, “As soon as you have some confirmedinformation, pass it on. Use us as part of yourcommunications strategy back to the families becausewe owe them clarity. We do not want them readingabout it first in the newspapers or hearing it on thenews.”

Q121 Mr Havard: On several occasions, Kim, youhave said that you felt that the experience of thefamilies might be collected better than it is beingcollected—we have gone through different aspects.The MoD runs surveys and does a lot to try to captureinformation from serving personnel. Do you have anyparticular comments you would like to make, or arethere things that you think should be happening in thatarea that are not happening?Kim Richardson: I have recently become aware thatwe are perhaps not so good at asking people what theythink, although it is early days. I am talking probablyabout the bereaved family, who can be taken up bythe—

Q122 Mr Havard: Yes. You said that there may bedifferent categories whose experience you want tocapture.Kim Richardson: There are. The bereaved familieswill be able to connect with widows associations, ifthey choose to do that. Some of the injured and theirfamilies are still going through a process years on, andI think we need to learn from that. I have met youngpeople who are some considerable way down theirline of treatment, but they still have a long way to go.There will still be an impact on that family. They areprobably at a point where they may still have aconnection with the Service but they think thatperhaps their views are not views that would be aswelcome now as they would have been at the initialinjury. Actually, I think that they are more valuable,because what we are seeing is the pathway and whereit could have been made better.

Q123 Mr Havard: Who should do that, and howshould it be done?Kim Richardson: There are ways and means. I thinkDawn covered quite a few of them: engaging throughHeadley Court and Hasler Company, and tellingpeople that if they have a view, we will welcome it.

Q124 Mr Havard: So there needs to be a continuoussurvey process.

Kim Richardson: I think so, and not even necessarilya survey.Julie McCarthy: Just giving people the means, evenif it’s a website.Kim Richardson: They can come to us, but theymight prefer to sit and type something at 11 o’clockat night. It’s about asking what would work best forthem. Would they prefer to sit down and talk tosomebody, or would they prefer to know that there issomewhere they can go where they can say, “Youknow what? We’ve had a really rubbish few weeks.This could have been better”? We could learn fromthat. I’ve learned a lot since I started doing thisparticular area of work from some really good people.It tells you that you don’t know everything, and weactually don’t.

Q125 Chair: I am conscious of the fact that we mayhave cut you off, Dawn, without asking you to giveus your thoughts.Dawn McCafferty: I think we have covered a massiveamount of ground this afternoon. The focus of thisinquiry is obviously on support to those who havebeen injured and bereaved. I think we’ve covered justabout all the areas I would have wished to raise. Myenduring message is that the RAF would agree thatone size does not fit all. It is working really hard inthis area at the moment, and has improvedsignificantly since I was serving in the Air Force. Iam actually very impressed with what I’ve beenbriefed on recently. I would like to think that it is awork in progress that will be taken forward. The staffare taking it very seriously, and I would commit toanything that we can do as a Federation to support thechain of command in delivering it.As well, my message is that this is not just about thehere and now—it is about the long term. That is whereit cuts across from the MoD into the transitionprotocols and Government authorities. It goes into theDepartment of Health and also into the charity sector.That is the area in which I have less confidence in thelong term. At the moment, there is some fantasticwork going on, but, as Julie pointed out, some of thosecharities may not survive in the longer term. If theyare the main support to a family or an injured Serviceperson, when they fall over, what is there for them?There has to be a safety net.I think it’s about long-term support. It’s about thetransition, and I think as well a focus on where theboundaries are between all the different players, andtrying to get a little more clarity there so thateverybody understands what they can bring to theparty. Hopefully, everybody is working to the sameagenda, which is to give Armed Forces personnel andtheir families the best support that we can.I was asked in a radio interview just yesterday whywe should be putting in all this effort. If somebody isinjured and they are in an ordinary civilianorganisation, why would we not want to give them thebest support? I think this comes back fundamentallyto the Covenant. It’s about the unique nature ofService life and the sacrifices that we ask our peopleand their families to make. That is where we can stand



up and say, “There is a real need here. We need tolive up to that and deliver as best we can.” There isa difference.I would like to emphasise that all of us would backup how very special the families are who werepresent. We are very pleased and privileged to be

allowed to come to this sort of gathering and representsome of the views that they bring to us.Chair: What a wonderful closing statement. I won’tadd to it, except to say thank you very much indeed.It was fantastic.



Members present:


Mr Julian BrazierThomas DochertyMr Mike HancockMr Dai Havard

________________


Witnesses: Professor Simon Wessely, King’s College London, and Dr Nicola Fear, King’s College London,gave evidence.

Q126 Chair: Thank you both very much for comingto give evidence to us for our inquiry entitled “TheMilitary Covenant in action? Part 1: militarycasualties”. Might I ask you to introduce yourselvesand say what you do?Professor Wessely: I am Simon Wessely. I am aconsultant psychiatrist and epidemiologist at King’sCollege London. I set up and look after the King’sCentre for Military Health Research. I’ve been doingthat since the middle days of Gulf War syndrome andhave looked, latterly, at Iraq and Afghanistan. It is aunit within King’s, and we specialise in militaryhealth. That is what I do, among other things.Dr Fear: I am Dr Nicola Fear. I am a reader inepidemiology in the King’s Centre for Military HealthResearch, based at King’s College London. I havebeen involved in military research since 2002. I spenttwo years working with the Ministry of Defencebefore moving to King’s in 2004.Professor Wessely: I should add that I’m the HonoraryCivilian Consultant Advisor in Psychiatry to theArmy.

Q127 Chair: Will you tell us about the King’s Centrefor Military Health Research—what it does and howyou ensure that the research is independent of theMoD?Professor Wessely: Yes, sure. It is a research unitwithin King’s College London, so it is an academicunit. Its main purpose is to carry out research andpublish it. Our main customer is the MoD, but it isnot the only one. We also have funding from the US,the Medical Research Council, the ESRC and theLeverhulme Trust. Do we have funding from theWellcome Trust? I can’t remember—no, we haven’t.

Q128 Chair: ESRC stands for what?Professor Wessely: The Economic and SocialResearch Council. We also get funding from the RoyalBritish Legion and so on. Our main projects revolvearound military health surveillance that began in Telic1 in 2003. We have periodically looked at the healthof 10,000 or so members of the three Services, andare following them up now as they continue to deployor as they go into veteran life. Around that are avariety of other studies, looking at stress management,different ways of managing and preventingoperational stress, screening in the Armed Forces andlots of other things, all of which at the moment escapeme but will come back in a second. We work with

Mrs Madeleine MoonPenny MordauntSandra OsborneBob Stewart

other colleagues around the medical school indifferent disciplines when we need them, likeneurology, immunology and so on, when we do stuffon vaccines and Forces health protection. We alsohave a full-time professor of history in the unit,because we are very interested in historical aspects ofmilitary health.The relationship with the MoD has developed over theyears. We have two rules. One is that everything thatwe do, we publish, so we have never done anythingthat has not been published—or at least when it hasnot been published, it has not been our fault; it hasbeen because of journals. The MoD has no censorshippower over the results and the papers that we publish;nor, to be fair to it, has it ever tried to exercise any.The only rule is that we do not look at Special Forces,so we have never had any dealings with SF. That waspart of the deal. The MoD sees final copies of ourpapers and reports, so that it can look at them for anyfactual errors and so that it knows what is going tocome out in the press, but as I said, it does not haveany veto over it. That relationship has developed overthe years and, I think, has been reasonably successful,but as I said, the right of publication is unequivocallywith us at KCL, and as you can see from the reports,we do publish quite a lot, including some stuff that isfavourable and some stuff that is not.

Q129 Chair: Special Forces are an interestingexclusion. Do you want to tell us why they areexcluded, or would you prefer not to?Professor Wessely: It has nothing to do withpreference. I don’t actually know; they just said at thestart, “No SF.”

Q130 Mr Havard: May I ask the question slightlydifferently? Do you know what, if any, special otherarrangements there are to deal with—Professor Wessely: I genuinely have not a clue.

Q131 Chair: Who pays for what you do?Professor Wessely: At the moment, about 50% of ourfunding comes from the MoD. The rest, as I said,comes from a variety of sources. We have two bigstudies, on screening and on children of militaryfamilies, which are funded by the US Department ofDefense. We have other funding for work looking atveterans and Service leavers from the Royal BritishLegion. We are looking at public attitudes to themilitary with funding from the Economic and Social


15 June 2011 Professor Simon Wessely and Dr Nicola Fear

Research Council. We have also had MRC grants. Wehave a big project at the moment looking at crime,violence and incarceration. What we have done is this:for all the people in our study, we have obtained theircriminal record data from the Ministry of Justice tolook at the impact of deployment, Service andvulnerability on patterns of offending. That is fundedby the Medical Research Council.

Q132 Chair: If you are doing all this research intopeople, presumably you have open access to thepeople you need to have access to within the Ministryof Defence.Professor Wessely: Within reason, yes we do, butobviously even though you have open access, findingthem is still incredibly difficult, not least becausewhen you are dealing with serving personnel, they dohave jobs to do, but we do work in theatre. We havedone two studies, and we are now doing a third, ofvarious operational mental health issues in Iraq andAfghanistan. We go out to theatre. Two or three of usare going out in two weeks’ time to Afghanistan to dothat. Funnily enough, we have incredibly good accessthere. The problems are often when they come homeand when they leave. Tracing people after they haveleft the Armed Forces is not easy. They are a young,mobile population. We are very good at it, but it isalways a struggle. If you asking whether there areinstitutional barriers to us, no. Chair: Tracing peopleafter they have left the Armed Forces is somethingthat I think we will have to come back to during thecourse of the afternoon.

Q133 Mr Hancock: In two of your studies, in 2006and 2009, your results showed no increase in themental health problems of those being deployed, asopposed to those not being deployed. Were yousurprised at that result?Professor Wessely: Yes.

Q134 Mr Hancock: How big a core group were youlooking at?Dr Fear: In the 2006 study, we had more than 10,000study participants. In the subsequent study, we hadjust under 10,000 participants—a relatively largesample size. Professor Wessely: Remember, that isRegulars only. That was not the finding for Reserves,but for the Regulars only.

Q135 Mr Hancock: When you discovered that,where did you take that research? What happened tothose fellows later on when some of them did start todevelop problems? Was it that the problems did notarise as quickly as you anticipated they would?Professor Wessely: No, it wasn’t that. Let us be clear:3% to 4% of them did have Post-Traumatic StressDisorder, so it was not that they were not havingproblems; it was that the rate had not changedbetween 2003 and 2009, despite the increased optempo—that was the surprising fact. They were notfree from problems; they just had not got worse withincreasing numbers of deployments. There was not anincrease to explain, and we cannot explain the absenceof something, but we clearly think that certain issues

are important, such as a shorter tour length comparedwith those of our US colleagues.

Q136 Chair: How does that 3% to 4% compare withthe population as a whole?Professor Wessely: No one knows the true prevalenceof PTSD in the UK population, because there hasnever been a population-based study. We know thatoverall, from work that we have done using data upto the beginning of 2000, the mental health of theArmed Forces is very similar to that of the generalpopulation, with the exception of alcohol, but thosedata really date to the National Service, Cold War andNorthern Ireland generations. The problem is thatthere isn’t good population data on PTSD in the UK.We tried to get it done in a thing called the nationalpsychiatric morbidity study, but it was not included inthe way that we wanted; other studies have not lookedat veterans. We think that it is probably around thesame, but it might be slightly more or slightly less.

Q137 Mr Hancock: You studied a group that had notbeen in combat; had they never been in combat, andso possibly had spent only relatively short periods oftime in the Armed Forces?Professor Wessely: There are two separate things tothat. Those who were in combat, which was about25%, had higher rates of PTSD. For them, it wasaround 7%, which to be honest, did not surprise us.Had we not found that, it would have caused us towonder. The other group are mainly in combat supportand all the other roles, but they have deployed. Theproblem is that by the second study it is almostimpossible to find a non-deployed control group; theybarely exist. When they have not deployed at all, theyare either very new or they have medical problemsthat mean that they are not a very good comparisonanyway. I have now forgotten the first thrust of yourquestion.

Q138 Mr Hancock: I was interested to know howthat group was made up, and you have given us theanswer to that. There were those who were in combatroles and those who were in support roles. For somepeople, just being in a support role would be stressful.You don’t have to imagine the situation; lots of peoplehave seen a situation where there are riskseverywhere. Did you not get the same sort of responsefrom them?Professor Wessely: For the ones who were clearlybased in Bastion and Kandahar and really did not getbeyond the wire, we did not see much impact oftraumatic incidents. Mental health problems weremore things like depression and family problems; thatcame out more. The further you got from the mainbases, the greater the increase in traumatic symptoms,some of which are not disorders, and there was moreto judge.

Q139 Mr Hancock: May I ask about going back?Prior to Iraq, British soldiers were deployed toNorthern Ireland for much longer deployments, andsome were there for 18 months or two years. Did youstudy what happened to those people on return?



Professor Wessely: No. The very first ever follow-upstudy on the UK Armed Forces was the Gulf Warstudy. Prior to that, there had been no tradition ofdoing those kinds of studies. They only really beginwith Vietnam and the US.

Q140 Mr Havard: Perhaps you could help me, if noteverybody else. We talk about Post-Traumatic StressDisorder and the identification of it; it presumably hasa definition, and you therefore either fall within it oryou don’t. You then said something like, “Well,they’ve got these problems but they’re not disorders.”Will you help us with some problems of definition?What is in Post-Traumatic Stress Disorder and whatis not? How are those different things accounted for?Professor Wessely: That is a vitally important issue.The first thing to say is that some of the symptoms ofPost-Traumatic Stress Disorder are not, bythemselves, abnormal. We would not say that comingback from a deployment with poor sleep, or beingmore irritable or a bit more angry and difficult, weresigns of a disorder; that is a normal emotionalreaction. My father still has nightmares involving theRoyal Navy in 1944, and he is 85. You will have totrust me: he is not disordered, but that is the way it is.There is sometimes a tendency in modern culture toequate having bad memories and nightmares withhaving a psychiatric disorder. The best way ofunderstanding a psychiatric disorder is that it is whenit is not just that you have good or bad memoriesof your military Service, but when that impedes yourfunction; because of those memories, you cannotwork, you cannot keep down a marriage, you startdoing drugs or drink—in other words, yourperformance is impaired.In cases of PTSD, everyone remembers symptomssuch as flashbacks, anxiety and such things, but theyforget that there is also a requirement that someone isimpaired in their function. When someone is impairedin their function, they are moving towards a formalpsychiatric disorder that may require treatment.Simply having memories of war is almost a sine quanon of having been deployed, and we go out of ourway not to medicalise or pathologise that.

Q141 Mr Havard: That was my fear—that a lot ofthings that would be normal, in a sense, were beingmedicalised in a way that they do not need to be.Where does the definition come from?Mr Hancock: Following on from what Dai said, ifsymptoms extend over a long period of time, wouldn’tyou consider that?Professor Wessely: At the risk of being personal, myfather has had nightmares about the Royal Navy allhis life. He has never forgotten about it, but he is notdisordered and does not need treatment. The idea ofhim now having counselling—I don’t think you wouldget very far with that. One would not dream of sayingthat he is disturbed.There is a very nice study from America and theSecond World War that followed up very, very highlyexposed combat veterans over 50 years. Nearly all ofthem continue to have memories—often verytraumatic memories—about the war. They are alsomore likely to be in “Who’s Who in America” than

those who have not had combat exposure. That isprobably to do with a selection of reasons. You wouldnot go around saying that those veterans had adisorder. There were some who did, however. Somecommitted suicide, some were murdered and somehad tremendous problems with drugs and alcohol.Those people had clearly moved intopsychopathology, as we would call it.

Q142 Mr Hancock: In your studies, do you find thatthat group does lead in some instances to the othercategory?Professor Wessely: Yes, we do. We find that somepeople have symptoms, and then gradually develop adisorder over time—sometimes called delayed-onsetPost-Traumatic Stress Disorder. It is not like cancer,where you are okay, and then suddenly get it. It ismore gradual, and there comes a point where youcross a line and then fulfil the criteria, usually whenyou cannot function. Other people do the opposite,so there is a changeover with people who graduallyimprove and get better. There is a natural history tothese things, which is why the overall rate is stableover time. That is because some people are gettingbetter, and some people are getting worse, but theoverall rate remains pretty static over the years.

Q143 Mr Havard: Remembering some of thosethings and contextualising them might be cathartic. Iunderstand now, but I would like to know whetheryou think some of this is over-medicalised, or notmedicalised enough. Are these definitions right asthey stand at the moment for the sort of research thatyou are doing?Professor Wessely: I think in the Armed Forces theytry very hard not to over-medicalise. The TRiMsystem—the trauma risk management programme—inwhich we played a large part and did the big trial tolook at its effectiveness, came out of precisely a desirenot to medicalise these issues. Previously, there hadbeen post-incident debriefing—psychologicaldebriefing—and as soon as something bad happened,you talked about it with trained counsellors. A seriesof studies, including our own, conducted by mycolleague Surgeon Commander Neil Greenburg, thenshowed that not only did that not work, but it madeyou worse, so we moved away from that. In my view,that was inappropriate early medicalisation ofsomething that was a normal reaction. The militaryare very good at that; the idea is: “Yeah, you’re shakenup or whatever, but that’s normal and should be dealtwith your mates,” within the TRiM system and so on,and only if things get bad should you be referred toan RMO or a mental health professional. These thingsare not psychiatric disorders.In society as a whole, it depends. I agree with you ingeneral: I think there has been a tendency sometimesto trivialise PTSD and move away from the originalconception, which came out of Vietnam and then theFalklands, of grossly abnormal situations where youare in fear of your life—situations where anyonewould develop problems—to sometimes quite trivialthings. We all have a collection of stupid Daily Mailstories, and I keep them as well. I find them irritating,



because they demean those people who have comeback with real psychiatric disorders.

Q144 Mr Havard: They devalue the coinage.Professor Wessely: Yeah. People who trip on pavingstones, and things like that. I find them annoying, tobe frank.

Q145 Mrs Moon: You talked about those who hadbeen in combat having a higher incidence—I thinkyou said 7%. Did you find that any professions orparticular roles had a higher incidence? I believe thatin America, for example, they found that thoseinvolved in medical teams had a higher incidence. Didyou uncover any such difference?Professor Wessely: We did. We originally foundexactly the same, and that the medics had slightlyhigher rates in 2003 to 2006, but for whatever reason,by the follow-up they were back with the others.Dr Fear: Simon mentioned the medics, and that wasthe main sub-group that we looked at. We also lookedat Marines as a separate group, and paratroopers andinfantry personnel, to compare those groups. Wefound lower rates of PTSD among the occupationalgroup of Marines, compared with the infantry andthe paras.Chair: Than the paras, or and the paras?Dr Fear: Than the paras.Mrs Moon: Could Dr Fear move the bottle of water?It is blocking the microphone.Professor Wessely: The point from that is that therelationship is not a simple one between exposure totrauma and Post-Traumatic Stress Disorder. WhenMarines had high levels of exposure, but lower levelsof stress, the general view, which I think is the correctone, is that it was mitigated by high esprit de corps,training, professionalism, cohesion and leadership—all things that the military is good at. It is not a linearrelationship between trauma and outcome in mentalhealth.

Q146 Penny Mordaunt: On the rare occasions whensomeone has a crisis episode and might cause injuryto themselves or others, there have been suggestionsof broader welfare factors, such as someone’saccommodation, how they are living with people, andbeing supervised, which have either exacerbated thesituation or led to something not being picked upwhen earlier intervention might have prevented atragedy. You draw out things such as leadership, trustand confidence. In this time of great change for theArmed Forces and change to how people are livingand how units work and live together, do you thinkthat they are detrimental factors to someone’s mentalhealth to the ability of people looking after them topick up problems?Professor Wessely: I think we would be speculatingon that one; I don’t really know. We know a lot abouthow it is managed in theatre, because we see it andlook at the outcomes. In general, things are picked upvery quickly there. You are in such intimate contactwith people in such an abnormal situation that youquite rapidly notice, to be honest. We have not donemuch on accommodation changes, have we?Dr Fear: No.

Professor Wessely: I can’t really answer that.Certainly, with the increased work load that peopleare under, you would think that some things getmissed, but what we are seeing is an increase inpeople presenting now to mental health services. It isstill not big—let’s not exaggerate this—but thereseems to be a slow cultural change of increasingrecognition and acceptance. There is a huge way togo, for sure, but if anything, I would hazard a guessthat it is going slightly in the other direction. Well, Iknow that, but I don’t know precisely why.

Q147 Chair: So decreasing stigma?Professor Wessely: Possibly. Let’s be clear: themajority of people with mental health problems do notpresent either in Service or after Service—only around40% do, and 60% do not. As I say, there is a lot ofundetected morbidity that we know about but no oneelse does, apart from the person themselves. Weshould also say that that is probably no different fromany other occupational group. If we take a group ofdoctors—my wife runs a sick doctor service—it isvery similar. If we took a group of MPs, I suspect itwould be very similar as well. It is a much biggersocial problem. Our own original, rather naive, viewwas that it was to do with the nature of Army culture.I think we have changed our mind; if anything, themilitary is now—we have some nice data on this—slightly more accepting of mental health problemsthan it was, and many problems with veterans beginwhen they leave, not when they are in Service. It isnot that there is a bullying military culture, and thenthey join the touchy-feely, cuddly NHS andeverything is fine. It certainly does not work like that.

Q148 Sandra Osborne: Do people presentsymptoms years later? I have Combat Stress in myconstituency. It sees people come forward maybe 20years after they have left the Forces. Is that becausethey have not come forward, or is it something thatjust happens?Professor Wessely: No. I am a trustee of CombatStress, so obviously I am familiar with what we do.Usually, 12 to 13 years is the average time it takes forpeople to present, but that does not mean that they arefine for 12 years and then, after going to a reunion orwatching a TV programme, it all comes back to themand then they are in trouble. They have been in troubleduring that time; it has just taken 12 years for them todo something about it or, more often, to be told by thewife in particular that they have to do something aboutit. It is not that you are fine and then suddenly godownhill. That does happen, but it is very unusual.What is not just common, but the norm, is that it takesyears before you will accept it and finally admit toproblems. That is the norm; hence the figure of 12years that Combat Stress mentioned.

Q149 Mr Brazier: On the point you made about theRoyal Marines being more resistant in your studiesthan other groups, presumably that is quite heavilyrelated to the fact that the corps of Royal Marinesdeveloped the decompression technique ahead ofeveryone else. For quite a while, they were the only



people going through a formal decompression process.That is right, isn’t it?Professor Wessely: I should know, actually. I am sureyou are right.

Q150 Mr Brazier: I am pretty sure that I am right,because Royal Marine officers have told me about it.What is now happening was largely originallydeveloped by them. My question is: do you think thatReservists experience more problems on return fromdeployment, and why?Professor Wessely: The answer to that is a categoricalyes. We know that they have worse mental healthproblems. Again, let’s be clear that these figures arenot like some of those we have seen from the USA,where one third come back with neuropsychiatricproblems. For us it is about 6%, so 94% do not comeback with mental health problems. Nevertheless,Reservists are more vulnerable. We have had a longlook at this in various ways, with various differentstudies and data sets. It is not to do with what happensto them in theatre. In particular, we showed that,between 2003 and now, morale and satisfaction withtheir role in theatre had increased from Telic 1 rightthrough to now. It was a bit disappointing to see thatthat had not led to an improvement in mental healthproblems.The problems are particularly to do with support andhomecoming issues. Reservists are more likely tohave problems with their employers; they are lesslikely to feel that the military is supportive; they areless likely to feel that their families are supportive;and they are more likely to have problems from theirpeer group. Let’s say that the Reservists come back toKing’s. For two days it is great, and they tell their warstories, and you start telling them about the latest NHSreform and how terrible it has been while they havebeen away, or whatever the current problems are. Weare clear that it is to do with different homecomingexperiences, different support structures and differentfamily structures.

Q151 Mr Brazier: I have two short supplementaryquestions on that. One of your colleagues—I cannotremember who it was—gave testimony to a meetingof the all-party mental health group, in conjunctionwith the all-party Reserve Forces group, three or fouryears ago. It was a joint meeting. I think you werethere, Chair. Your colleague said that there was someevidence that Reservists in Reservist units were lesslikely to have problems than those who went over asindividual augmentees.Dr Fear: Recently, we have used our data to lookat whether deploying with your parent unit or as anindividual augmentee impacts on mental healthproblems. We have looked separately at Regulars andReservists. Our latest data show that there is nodifference in mental health outcomes.

Q152 Mr Brazier: Interesting. The other thing I wasgoing to ask was on the fact that mental healthproblems are something that emerge, as you have said,over a much longer period. You mentioned at the verybeginning the difficulty of tracking people who haveleft the Armed Forces. Presumably that is a big factor.

If it is difficult for the regular Armed Forces, it mustbe even more difficult for Reservists.Professor Wessely: Yes.

Q153 Mr Brazier: That might suggest that thedisparity is slightly greater than it appears, because itis harder to catch up with Reservists.Professor Wessely: It is harder to catch up withReservists. I will not go through all the details, but weare fairly confident that those are the true rates andthat we are not missing a big pit of morbidity that wecould not find, because we can look at the influenceson response rates. We think it is more that they aredifficult to find. Their links with the charities and thevarious regimental associations are weaker. It isharder for us to get valid addresses. Plus, some ofthose have lost contact with the military and are notbothered any more. Those who are still serving areeasier to find. I do not think that we are missing abigger problem. We are missing, in all our studies, avery hard group to find, which includes, for example,the homeless, but it would be highly improbable thatReservists were more likely to be homeless thanRegulars. If anything, it would be the other wayround.

Q154 Mrs Moon: May I ask Dr Fear to go back tothe statement that she started to make and amplifyit? You talked about soloists, whether Reservists orRegular. You found that there was no differencebetween soloists who were Regulars and Reservists,but there was higher incidence among Reservists. Areyou saying that there is also higher incidence amongthose who go as soloists, say someone from the Navyor the RAF who is embedded in a formed regiment,where the majority are the Army and where they goback to their Navy or RAF unit without the supportnetworks? Are you finding higher incidence amongsoloists from other Forces as well?Dr Fear: I would have to come back to you on that,I am afraid. I cannot remember those details off thetop of my head.Professor Wessely: We didn’t on OMNHE, did we?Dr Fear: We didn’t, no.Professor Wessely: We did studies in theatre, andthere was not any difference overall betweenindividual augmentees and those who formed units,irrespective of whether they were Reservists orRegulars. I cannot remember the details either; wewill have to look that one up.

Q155 Penny Mordaunt: You made the observationthat if harmony guidelines were exceeded, there wasan increased risk of PTSD, psychological distress andsevere alcohol problems. Why was that?Professor Wessely: We think that it is to do withexpectations. It is very hard to think of any otherreason because you would say, “Well, what’s thedifference between six months and seven months? It’snot that much really; why would you suddenly get adoubling of alcohol problems?”I think it is because people expect to go home on acertain date, RAF permitting. If that is denied them,they suddenly get quite demoralised and the family dotoo—remember that there is now instant



communication between home and theatre. Thatwould be our explanation. I should say in defence thatit does not happen very often, but when it does wenotice that impact. I know that the MoD has acceptedthose findings and tries very hard to stick as much asit possibly can with the tour length that people aregiven.

Q156 Penny Mordaunt: Did you notice anydifference in the 2009 results for those who hadmultiple deployments?Professor Wessely: No, we didn’t—in direct contrastto the USA, where there is a linear relationshipbetween the number of deployments and mentalhealth, obviously going up quite dramatically. Again,you might come back to the previous question aboutwhether we were surprised by that, and I think wewere. But no, there is no relationship at the moment—we have to say “at the moment”—between the numberof deployments and current mental health.

Q157 Penny Mordaunt: You think that that comesback to the expectation issue. People being deployedagain and again are—Professor Wessely: The only nation that we cancompare with is the US, which has a one-yeardeployment and then a one-year down time. As soonas they come back, they do not even have post-operational leave; they wait until they are due theirleave and a year later they are back on deployment.You do not really need to do much research to knowthat spending all that time in a rather difficult place,where people are trying to kill you, is not very goodfor your mental health. The obvious explanations aresometimes the correct ones.Chair: We will be coming back in a moment to lookat the comparison between ourselves and the UnitedStates.

Q158 Mr Brazier: I have a very quicksupplementary about the system that we have inBritain of sending people back for a short period ofleave in the middle of deployments. I had a rathercurious complaint from an officer, who said that hethought that it was bad for the families rather thangood for them. His leave happened to fall at the verylatest possible point. He said that he was in the absurdposition of having done more than five months of asix-month position, going home—he had youngchildren—and seeing all his family, and then goingthrough the trauma of saying goodbye to them allagain to return to operations for two and a half weeks.He said that it would have been much better for hisfamily if he had gone straight through the six months.It is a difficult thing to study, but has anybody madethat sort of remark to you?Professor Wessely: Yes, very much so. It is a verydifficult thing to study; you would have to do arandomised controlled trial, giving half of them leaveand half not, and I suspect that that would not beacceptable. Our data show that R and R is popularwith people. We are aware of a couple of other studiesthat show the opposite, and we are trying to reconcilethose two data sources as we speak, so we do notknow.

Things like decompression—we don’t know whetherthat is successful. We know that it is popular the firsttime around, but we do not know whether it preventsthings because we do not have a group who do notdecompress. One of the reasons why we are zealouslypushing a randomised trial of screening, which is whatwe are doing at the moment, is precisely because thenwe can give you real answers about whether it makesa difference or not. On R and R, we are aware ofboth points of view and we find it a little difficultto reconcile.

Q159 Bob Stewart: As an ex-commanding officer, Ithink that it is extremely difficult to make people takeR and R early or late. We do not need to study that;people totally understand it straight away. If they goearly, they are not into the tour and if they go late,they are at the end of it.My question is this. Having been the object of a four-month tour and six-month tours thereafter, what isyour opinion—both of you—of the best length for anoperational tour in an operational theatre such asAfghanistan, which is quite intensive? What length oftime do you reckon is the best?Professor Wessely: I don’t think it is for us to giveyou a specific answer to that because there are somany other issues beyond the area that we look at,which is the impact on health.Bob Stewart: I am thinking of it from the point ofview of mental state.Professor Wessely: I am aware that there are many,many other equally important operational issues.Bob Stewart: I accept that.Professor Wessely: We know that the UK systemseems to be working. We don’t know whether that isby luck or judgment or whether it is just because onceyou have a rule, you stick with it and people acceptit. You could lengthen it, provided that you havemanaged expectations without undue problems. Weare reasonably confident that the US system is notideal, and most of our colleagues in the US wouldagree.It is not just the tour length; as I am sure you knowvery well, it is the down time as well. You have tomanage that as well, so the two are not independent.For what it is worth, my view is that we have got thebalance about right, but I really caveat that by sayingthat we look only at the health effects, not everythingelse—we do not look at anything strategic oroperational, and we know that there are views theother way. But at the moment, the UK seems to havethe balance reasonably well. [Interruption.]Chair: I am afraid that we now have to go and vote.We are nowhere near finished, so we will return. Wewill be back within 10 minutes, if possible, unless wehear news that there is to be a second vote, in whichcase we will be longer.Sitting suspended for a Division in the House.On resuming—

Q160 Mr Hancock: On the civilian side of theharmony guidelines, have you been commissioned todo any work on the reaction of the wives, girlfriendsand partners of Service personnel who have beenaffected in one way or another and what they are



going through. The MoD has a duty of care to thewhole family, but nothing I have read mentions anyresearch that has been carried out about the effects ofthese types of deployments on the husbands of thewives who have been deployed. Have you done anywork on that?Professor Wessely: We have, yes. We did a study onthe Welsh Guards, talking to the wives before, duringand after deployment, and also to—it was always thehusbands in that particular study. It was interestingthat in general the wives were pretty resilient, but thehusbands didn’t think that they were. The husbandshad a tendency to say, “No, no, she’s not doing verywell at all,” but the wives would say, “He keepssaying that, but actually I am doing reasonably well.”We have a big study now looking at children, in whichwe will be interviewing—well, Nicola you are the PI.Dr Fear: We are looking at 600 fathers from ourmilitary cohort, and we are interviewing them abouttheir military experiences but also their relationshipswith their families and in particular with theirchildren. We are asking how they feel that they relateto their children and how their children cope withthem being in the military. We are also contactingtheir partners, or their wives, to get their views onhow the father interacts with the family and with thechildren. For those children who are 11 or older, weare contacting them directly to ask them about what itis like having a father in the military and how theycope—what are the pluses and minuses of being amilitary child? That is work in progress.Professor Wessely: We also have work published onhome-coming experiences, and on rates of maritalbreakdown as a result of deployment. It is a big issue.

Q161 Chair: That is continuing work—you haven’tfinished that research yet.Professor Wessely: No, we have finished the earlyones. We haven’t done the family ones, but we havedone the impact on marital relationships.Mrs Moon: I am sure Bob Stewart would love tovolunteer for that.Bob Stewart: I would feel like it was a report on me,and I think I would fail. I would be at the bottomlevel, according to you guys. Failed in all senses. Justimagine my children commenting on me—I’ve got sixof them. They would say that I’m done for.Chair: Moving rapidly on—Professor Wessely: Let’s hope you are not in thesample, then.Chair: The next topic is risk-taking behaviour andalcohol misuse.

Q162 Mrs Moon: Your research shows an increasein alcohol use in those returning from deployment.That is after a period of no alcohol use while intheatre. Sometimes, one of the early indicators ofmental health problems is increased alcohol use asself-medication. Is that why there is an increasedalcohol use? Is it being used as self-medication to dealwith the trauma of engagement in theatre?Professor Wessely: Nicola is our resident alcoholic,so she can answer this one.Dr Fear: The report that we recently publishedshowed that 13% of the Armed Forces are reporting

levels of alcohol misuse compared with, as Simon hasmentioned, between 3% and 4% with PTSD. Yes,there is perhaps some co-morbidity there—peoplewith PTSD are misusing alcohol—but, obviously, noteverybody who is misusing alcohol has got PTSD. Wethink there is some level of co-morbidity, but we donot believe that those 13% of people are harbouringmental health problems.

Q163 Chair: How does that compare with thepopulation as a whole?Dr Fear: Alcohol misuse within the military issubstantially higher than we would expect with thegeneral population. Obviously, the general populationcomprises people of all ages, and those who areoccupationally inactive. If we take all thosedifferences into account, the latest figure for theprevalence of alcohol misuse in the general populationis 6%, compared with 13% in the military.Professor Wessely: That applies equally to men andwomen.

Q164 Mr Hancock: Does it apply to individualServices?Professor Wessely: Yes. The Army and Navy are theworst; the RAF is slightly better, but they are all bad.

Q165 Mr Havard: And there is no differencebetween men and women?Professor Wessely: Not much. The men drink morethan the women, but the women drink far more thannon-military women—quite substantially so.

Q166 Mrs Moon: Among those who are ultimatelydiagnosed with Post-Traumatic Stress Disorder, isthere usually in their medical history a period ofexcessive use of alcohol? Is that something that is alsocommon in their medical histories?Professor Wessely: Yes.

Q167 Mrs Moon: So there is a link for those who goon to have Post-Traumatic Stress Disorder, but of the13% only 3% generally go on to do so.Professor Wessely: Yes. Certainly, we know thatalcohol increases the risk of subsequent PTSD. Thatis a stronger relationship than the other way around—of PTSD increasing alcohol.

Q168 Mr Hancock: But isn’t that because it leads toother problems?Professor Wessely: Yes; there is new work nowsuggesting that is actually the results of commonvulnerabilities to both, and that they are notcompletely independent factors. It is not like heartdisease and cancer, which are separate things. Theyare related. In terms of prediction, we know that pre-Service vulnerabilities, such as time in care or havinga poor family history and things like that, predict bothalcohol and PTSD quite strongly.

Q169 Mrs Moon: You also talk about increased risk-taking behaviour and violence.Professor Wessely: Yes.



Q170 Mrs Moon: Alcohol abuse is also associatedwith increased risk-taking behaviour and violence,especially domestic violence.Professor Wessely: Yes.

Q171 Mrs Moon: Is the common factor again thealcohol misuse?Professor Wessely: Alcohol is associated with bothaccidents and domestic violence. It is not that Acauses B causes C. These things tend to congregate inthe same people so they have a degree of vulnerabilitywhich leads to multiple things. It is the same withearly Service leavers, for example. They have a rangeof poor outcomes. It is not just one outcome—alcohol;they are also more likely to have unstable jobs,unstable relationships, be in trouble with the law, andhave debt problems and mental health problems.Those are not visited on them singly. It is a range ofsocial adversity problems that they experience. It isquite hard to separate out the impact of one overanother.

Q172 Mrs Moon: Are you going back to look at pre-military engagement issues in terms of early lifeexperiences and how that relates to their subsequentbehaviour after theatre?Professor Wessely: Yes. We know it does. We havepublished on that. Pre-Service adversity is the singlelargest risk factor for post-Service adversity, but not ina way—it is important to emphasise this—that wouldenable you to screen out those who are going todevelop problems. So these are risk factors, but theyare not sufficiently good for you to be able to say,“You can join the Forces. But you can’t, because weknow you are going to break down because you havecome from a broken home. You have not, so you can.”There we know that you would be wrong more oftenthan you would be right, which is why we havepublished showing that pre-deployment screening formental health problems is singularly unsuccessful andwhy the MoD don’t do that.

Q173 Mrs Moon: Is there any correlation at all withany of this and physical injury?Professor Wessely: We can say immediately thatphysical injury increases the risk of psychiatricdisorder. We have much more on that. We have aslight problem with that because we would rather tellyou off record because it is with a major journal andthey get very upset if we leak the findings. There ismy friend from the News of the World behind us. Wecan tell you privately, but we can’t do so in opensession. It is not because we have anything to hide; itis just that the journal will kill the paper and we’ll bein big—

Q174 Mrs Moon: When do you expect the paper tobe published?Professor Wessely: We don’t control that. I wish wedid.

Q175 Mrs Moon: How long is a piece of string?Professor Wessely: Yes.

Q176 Mr Hancock: A paper we were sent by theMoD in answer to some questions talks about traumarisk management—TRiM. It says that TRiM has beendeveloped to identify, manage and minimise theeffects these events have on Service personnel. Yousaid that it is useless. You said that trying to screenpeople in advance—Chair: That is a different issue.

Q177 Mr Hancock: Where does this come into itthen?Professor Wessely: There are two separate things.First, there has been an idea for years that it would begreat if you could spot people before they developproblems and then you wouldn’t put them in harm’sway.There is a wonderful thing in Ben Shepherd’s book onthe Second World War, where he found a letter in theWar Office from a commander writing back to Londonsaying, “Please stop sending me these people. Theyare already breaking down in the brothels of Cairo.God knows what will happen when they meet theAfrika Korps.”There has always been this idea that if you could justselect better, then you wouldn’t get mental healthproblems. That is what we studied. We showed thatalthough you can statistically predict the risk ofbreakdown—so that with a large group of people youcan say that one group is twice as likely to break downas another—with an individual you would be wrongfour times out of five. That is before they aredeployed. They have not gone into harm’s way yet.It is really not surprising that we have found thatbecause one of the biggest things is what on earthhappens to them in theatre—and that has nothappened yet. TRiM is about something that hashappened and then it is about how you manage thingsin the field. It is a very different thing. Something badhas happened. They have now made TRiM into averb, so to TRiM is now a verb in the Army. Horrible,isn’t it? But they talk about TRiMing. We can’tcontrol their use of language.That is where the system is at its best, because it isnot medicalising. It is using the people within thegroup and culture—not people like us or even mentalhealth people—to spot who is having difficulties, andwhen they are really having difficulties to help themor say, “You really do need to see the MO.” That is avery different thing, intended to do very differentthings. TRiM is very popular and is being rolled outacross the Armed Forces.My colleague Neil Greenburg led the original studyin the Royal Navy of the randomised controlled trialof TRiM. Unfortunately, that did not work very wellbecause the Navy did not do anything that year, sothere was not much trauma. It was a bit of a dampsquib because not much happened. It has been rolledout and has very good face validity and is popular.People seem to like it as a process, whereas they didnot like some of the things that had been done before,such as the post-trauma counselling.

Q178 Chair: Was the fact that you found itimpossible to do the pre-screening partly because thelevel of mental health issues is lower than one might



expect? If it is only 10% among the whole of that at-risk population, you will still be wrong nine times outof 10. Is that essentially it?Professor Wessely: Yes. It is not the only thing, butyou are right. The more common a disorder is, theeasier it is to screen. The US does screening and saysthat it is because it has a lot more PTSD than we do.There is still no evidence that it works, but that is onething. You are right: screening for an unusual disorder,where your instruments are not great and where youhave a big overlap between normal emotionalreactions, as we were talking about, and psychiatricdisorder, is always going to be a sticky wicket.So far we have said, first of all that we are doing thetrial of post-deployment screening to see if it works.However, if, for example, there was a majordeterioration in the mental health of the ArmedForces, we would revisit that. The area where they—not we—do the screening is in the physically ill withserious injuries, where the prevalence of psychiatricproblems is much higher, and therefore the chances ofthe system being effective are much higher. That wasquite a turgid answer, but nevertheless you areabsolutely right.

Q179 Chair: Not at all.Professor Wessely: It is very difficult to screen forunusual problems unless you have an incredibly goodtest, such as for cervical cancer. In psychiatry we donot have measures that good.

Q180 Chair: But you say you are doing a trial intopost-deployment.Professor Wessely: We are doing a trial into post-deployment screening as we speak.

Q181 Chair: How is that going? Or is that againsubject to the News of the World?Professor Wessely: We are just starting it; it will betwo years before we have a result. That is funded bythe US, because in the US it is policy to screen. Nowin the US they are wondering whether it was a goodpolicy, but of course once you make something policyyou can’t study it. Because it is not policy in the UK,we are able to do a randomised trial.

Q182 Chair: Could you say that again?Professor Wessely: If it is policy, everyone gets it,because it is policy. In the US, everyone gets screened.Therefore, you have no way of knowing if it isworking. You have no idea; you just can’t tell.

Q183 Mrs Moon: No control group.Professor Wessely: Yes. It could be making peopleworse; it could be making people better. You cannotsay. It might look better because the war is finishing,or it might look worse. We do not know. In the UK,because it is not policy, we are doing a study and wecan properly not screen half the people and screen theother half, and later see which group did better. Wegenuinely do not know whether it will be useless,good or bad.

Q184 Chair: Why would that be of much use to theUS, if it has such different deployment policies?

Professor Wessely: It is just that they would likesome evidence.Mr Hancock: Maybe they should change their policy.

Q185 Chair: So they would get some evidence—notideal evidence, but some.Professor Wessely: It would give UK evidence. Asthe US does not have that evidence at all, it is fundingit, and it does not do so out of charity.

Q186 Chair: What about mental health issuesemerging in those who have left the Armed Forcesaltogether, as opposed to those who have recentlydeployed? Are you getting evidence of that causingmental health issues?Professor Wessely: We are looking at that at themoment. In the latest follow-up study with the RoyalBritish Legion, we had a lot more Service leavers thanwe had before. I half said it earlier, but we know thatit is not so much deployment, but the early Serviceleavers group which seems to be over-represented inmost of the outcomes. It is those who served for lessthan four years, and often leave for health reasons orwhatever, who are clearly the most vulnerable. Theyseem to be the most likely to have poor outcomesacross the board. In general, the longer you serve, thebetter you do.

Q187 Chair: Or is that a self-selecting sample?Professor Wessely: Of course it is. Obviously, thelonger you serve, the more robust you are and themore you integrate with the Army and the ArmedForces, the greater social support you have and thegreater rewards you get. There is an interestingdilemma: the way things are set up at the moment isthat the more you give, the more you get. As I amsure you know, those who serve 25 years get verygenerous resettlement and, as we have shown in ourdata, they rapidly walk into jobs and do very well.They get the most reward, whereas those who havenot been in for very long get the least, but are the mostneedy. Having stated the dilemma, obviously that isnothing to do with us, but it is a policy issue. But thatis the problem.Chair: Yes, I can see that.

Q188 Mrs Moon: Can I clarify your comment aboutthe early leavers? Is that Nav Patel’s work fromManchester to which you referred?Professor Wessely: That is in it as well. He has lookedspecifically at suicide, and we are looking at deliberateself-harm. All of it triangulates—sorry, that is ahorrible word; I hate it. All of it is compatible withwhat I have just said.

Q189 Mr Hancock: Just to follow on, the earlyleavers really do have a problem. One of the biggestproblems is that most of them leave with a lot of debtbecause they have got into financial difficulty. A lotof Service personnel who leave within two to fouryears leave with horrendous debts hanging round theirnecks. They cannot get jobs. What studies have youdone to see what can be done better within theServices to prevent young Service personnel from



getting into serious trouble, which inevitably lead tothe other problems that you have talked about?Professor Wessely: We are doing a report on debt forthe Legion at the moment, but I do not think that wehave looked at what interventions can be made.Dr Fear: We are looking at resettlement, and peoplewho have gone through the resettlement process. Thatobviously does not apply to early Service leavers.They miss out on that, but we are looking at that asan intervention. We have no other plans on the way tolook at what can be done for the early Serviceleavers group.

Q190 Mr Hancock: For early leavers, debt is abigger problem than alcohol or anything else.Professor Wessely: They all go together, but you areright: debt is a huge problem.

Q191 Mr Hancock: Debt is the biggest problem. Isee it all the time in my constituency.Professor Wessely: It is important that we stick withinthe limits of our competence. If the Armed Forcesstarted to do something on debt, we would be in anexcellent position to evaluate it. But it is not for us totell it what to do. It is their Army.

Q192 Mr Havard: Before I ask about what you dowith the people who have been identified with theproblem, can I just follow up on something? AndrewMurrison did a study with which you would befamiliar. He recommended that people who leave—both Reservists and Regulars—are followed up after12 months. That would be presumably in the contextof their mental and other health issues, but you seemto suggest that there is a follow-up that is broader thanthat. Is any work being done about that?Professor Wessely: Murrison has been implemented,and it will be interesting to see what impact it has. Weare not implementing it, obviously.

Q193 Mr Havard: No, but do you do any workaround it?Professor Wessely: Well, it will come up naturally ifwe are in a position to continue the study that we aredoing at the moment and look in another two or threeyears’ time at what has happened. Obviously we area slightly interested party, so let us assume that wedo. Yes, we would be able to see if it has made adifference or not. At the moment, we do not know. Itis a difficult thing to implement. It is a lot easier tosay than it is to do, based on our own experiences.Andrew knows very well that the problem is that theones you most need and who need you are always, bydefinition, the ones who are an absolute sod to find.As for the ones you find really easily—why? Becausethey are married and have jobs. We could talk aboutthat until the cows come home—it is always theproblem.

Q194 Mr Havard: Is the Ministry effective inidentifying those people who have mental healthproblems and difficulties because of operations? Whatare the barriers to doing that? What is your assessmentof how good the process is?

Professor Wessely: We know a lot about this issue.The main, biggest barrier remains stigma. People donot come forward because they are worried aboutwhat their mates will think of them and the impactthat it will have on their career. It is not that they donot know that Services are available; we have shownthat they do know, but they choose not to access them.The biggest single problem is reluctance to comeforward because of stigma. The sad thing is that thepeople who have the problems are the ones who feelthe most stigma. Those who are fine say, “It’sperfectly okay—it’s all totally acceptable. Thatdoesn’t really matter.” But the ones who haveproblems with depression, PTSD or drinking feelacutely that coming forward would end their careers.They think, “People would think that I was uselessand I would be discriminated against.” That is thebiggest barrier.

Q195 Mr Havard: So it is not that the Departmentis not doing the right things to try and identify people,but that people are selecting for themselves not to usethe services.Professor Wessely: You cannot force people to havetreatment—unless they go psychotic, but that is notmuch of an issue in the military. They must want tohave treatments. You can do things to make servicesmore attractive, and the military have done well byswitching to community mental health teams andbringing in a much more modern version of mentalhealth, which is good. You can put the mental healthteams where the trouble is with field mental healthteams, which we have shown to be very effective.They get good results and treat people quickly intheatre with no waiting list or anything like that. Notsending people home is a good policy and is astandard doctrine that teams try to follow as much asthey can. They do pretty well on that and in theatrethey do very well.It is a difficult problem and the truth is that there isnot an organisation on the planet that has solved theproblem of stigma. I go back to what I said: it is a bigproblem for doctors, Members of Parliament—everyone. The military do well; they do not havewaiting lists. As I say, we have shown that folks inthe military know more about how to get treatmentthan those who are not in it. They are better informednow, but they still do not do it.

Q196 Mr Havard: You said that when people areidentified it happens in theatre. We visited HeadleyCourt recently and it was a similar experience,because people were still in work—they were in a job.Is that very important? The people there, even thosewith physical injuries and, maybe, associated mentalhealth problems, were arguing that it was importantthat they were still part of the military—that they werein work and part of things.Professor Wessely: The importance of that wasestablished in 1917. People should be kept in uniform,as close as possible to their mates with an expectationthat they will return to decent service—that has beenthe doctrine since 1917. No study that we have everdone suggests that that is the wrong way of doingthings.



Q197 Mr Havard: So that is endorsed by yourstudies, essentially.Professor Wessely: Absolutely, yes. It is sometimesmore difficult to do than people think it is. There areissues, particularly around firearms and suicide risk,which are really difficult to deal with. There is no easyanswer to that. But that is the policy, and certainly ourevidence suggests that it is the right one.

Q198 Chair: Is that why there is such difficultywith Reservists?Professor Wessely: Not in theatre, no; but when theycome back, yes. I go back to what we were saying.We have shown an association between PTSD and notfeeling supported by the military. Reservists are morelikely to feel that they have been left and that theyand their families have not been supported in the waythat Regulars are. Having made that finding, it is hardto know what to do about it, because it is difficult.That is part of the picture—homecoming experiences,social support, military support and support tofamilies are important for mental health in theatre andafter it.

Q199 Mr Havard: I was going to ask you about theeffectiveness of the treatment, and so on. You aresaying that advising and preparing families is veryimportant, so it is not just about the treatment of theindividual. What are your observations about thepreparedness, and the advice and support that familiesreceive as part of the process?Professor Wessely: There are two issues. We knowthat many of the mental health problems that presentin theatre are a reflection of what is going on at home.We also know that where the person in theatre feelsthat the family is not being supported, their ownmental health is worse, and they are more likely todevelop traumatic stress symptoms. It is not just amatter of being kind to families; we would suggest,and the data suggest, that it is an operationalrequirement to have good support and welfare forfamilies of Reserves and Regulars, because that willimprove mental health in theatre.

Q200 Mr Havard: I saw a report yesterday fromAmerica, where schemes are being run out of WalterReed for families of people who are returning to tryto help them deal with these questions. There was adebate about whether such schemes could continue tobe financed and be made universal across the wholeUnited States. There was a discussion about theirintrinsic value or otherwise. Do you think particularthings should be done?Professor Wessely: Again, I am not going to go downthe route of telling them what to do. What I can sayis that where families feel better supported, mentalhealth in theatre and post-theatre improves. It is worthlooking at whether we can improve the support.

Q201 Mr Havard: But this was a scheme to help thepartners to understand the problem that they weregoing to confront specifically in relation to mentalhealth.Professor Wessely: That is a specific question, andyou would need to do a trial on that; you would need

to know whether it made a difference or not. You areasking a very specific question, and I do not know theanswer to it. I know that they are doing that, but theyare doing lots of things, and one hopes they areevaluating them to see whether they made a differenceor not. What we can say is that this is an importantissue, which the MoD should be looking at.

Q202 Mr Havard: We visited Walter Reed recently.The US does brain scans, because they see arelationship with head injuries of various sorts, suchas mild traumatic brain injury; they argue there is acausal relationship. You seem somewhat scepticalabout that. Could you say what you feel about that?Is it useful to do such things?Professor Wessely: All I can say is what we find. Letus put to one side traumatic brain injury—people withmajor head injuries. We are looking at somethingcalled mild traumatic brain injury, which we callconcussion, because that is what it is. The rate ofconcussion in the UK, if we use exactly the samemethodology and criteria as the US—the US isrunning at 20% to 24% in all the studies they do—isrunning at about 4% to 7%. Either we have thickerskulls, which seems unlikely, or there is some culturaldifference here, and we would suggest it is possiblythe latter, although tour length also plays a part. Weget concussion, but although we are fighting the samewar and taking the same risks, and although we havethe same casualties now and face the same IEDs andall that, it seems to be a smaller problem for us. It isthere—I am not saying it isn’t—but it seems to be amuch more major issue in the US.

Q203 Mr Havard: Yes, it’s playing football withtheir helmets on—they shouldn’t. Anyway, that is adifferent argument. Can you tell us what you thinkabout the general process of the treatment? Is iteffective? Are there barriers? If so, what are they?Professor Wessely: I have said what the main barrieris: it is getting people into treatment—that is thebiggest barrier. The data we have from the fieldmental health teams suggest that treatment iseffective. As for the data from secondary care, by thattime, it is a harder problem, and the outcomes are notso good, at least not until two years ago.

Q204 Mr Havard: And there are no problems withrelationships with the NHS?Professor Wessely: Yes, there are some.

Q205 Mr Havard: And is it a devolved format?Professor Wessely: That is too complicated.[Laughter.] No, genuinely, we have not looked at that.

Q206 Mr Havard: That is beyond your pay grade.Professor Wessely: We could look at it. We did try toin Scotland and Wales, but we did not get very far.Dr Fear: We did not get very far with that.Professor Wessely: We tried with the Cardiff unit andJon Bisson, but I cannot remember what the problemwas.

Q207 Mr Havard: I think there is a real issue hereabout a uniformity of approach from a central



Department, such as the MoD, and the deliveryagencies, which are becoming much moredifferentiated. We have to deal with that relationship,even you cannot particularly help us with it today.Professor Wessely: We should have my wife here. Sheis the chairman of the College of GPs.Chair: I am going to move on. Madeleine Moon.

Q208 Mrs Moon: There are two separate things. Ivisited the specialist unit that has been developed tolook at Post-Traumatic Stress Disorder. I asked aboutmedical notes being passed between the military andhealth service providers and about the compatibility oftheir systems, because they cannot read across. That isa major issue in the States. Is that a major issue in theUK as well, that is impacting on people being able toget acknowledgement of their Service in the military,and acknowledgement and awareness of the injuriesthat they may have received in the military, and just aread-across?Professor Wessely: Yes, it is an issue, still. It is a verywell known issue. I think it is proving quite hard todeal with technically, both within and without themilitary; and without going into the saga of electronicpatient records, they are certainly not proving aseffective as we would like them to. I think you wouldhave to ask the Surgeon General specifically whatprogress they are making. I know they are acutelyaware of it, and we know it is a problem.

Q209 Mrs Moon: I understand that the MoD islooking at eye movement desensitisation andreprocessing as one of the major therapies that itwants to use. How widely available is that going tobe for people who have left the military? It may wellbe generally available within the military, but giventhat a lot of people who are getting Post-TraumaticStress Disorder get it post-Service, how widelyavailable is that going to be?Professor Wessely: Evidence-based psychologicaltreatments are not widely available, whether you areex-Forces or not ex-Forces. The big issue there iswhether or not Improving Access to PsychologicalTherapies (IAPT) will pick those up. We will just haveto see. That is what it is supposed to do. At themoment it remains the case, and our study shows, thateven with those who have left the Services, themajority of those who have mental health problemsare not getting good treatment.

Q210 Mrs Moon: This is a fairly new therapy.Professor Wessely: It is a fairly new study as well;but to be fair IAPT is still being rolled out anddeveloped. In five years’ time we will have a muchbetter handle on whether or not that has done what itis supposed to do. It is supposed to pick up these kindsof problems. I think it will always be a bit difficult,because I think ex-Service populations are difficult.They are not that great at psychologisation; they havea lot of comorbidity—particularly the ones in trouble.I do not think that that alone will solve this problemand I think that a lot of people will need quitecomplex care over a long period of time. I do notthink it will be a quick fix.

Q211 Mrs Moon: Is there a risk that, if you like,the diagnosis of choice will be Post-Traumatic StressDisorder, rather than, say, bipolar disorder or someother mental health diagnosis—as an easier diagnosisto live with, as being something that is a result ofService?Professor Wessely: Well, it is a risk. One would hopethat any decent service appreciates the necessity tomake the appropriate diagnosis. I do not see anyevidence that IAPT would not do that. I am muchmore worried about the growth in the voluntary sectorbeyond the good brands. There is a huge number oforganisations springing up, who contact us on aregular basis, where I have more reservations aboutissues of clinical governance, diagnostic practice,outcomes, audit and all those kinds of things. I do notthink the problem is going to lie with NHS servicesor RBL, Combat Stress or the big brands like them;but I think there is an issue with some of the otherthings that are happening.

Q212 Chair: We are just about to come back to thecomparisons with the United States, with MikeHancock. I should like to open by saying I amastonished by the difference that you report in relationto concussion—24% in the United States and 2% to4% here. Are you using the same tests?Professor Wessely: Yes.Dr Fear: Yes.Professor Wessely: We said that together, so wemust be.

Q213 Mr Havard: Is it something to do with anequipment difference? Is it a different deploymentprocess?Chair: How can you extract this?Professor Wessely: It is a diagnosis that they aremaking in a lot of people. The symptoms are verycommon. The symptoms of this are fatigue, headache,feeling dizzy. These are very common symptoms thata lot of people have, and a lot of the Armed Forceshave. In the UK the tendency is not to attribute it tohead injury, and the US now there is a tendency toattribute it to head injury. Remember, neither of ushave got good data on actual exposure in theatre, sothe diagnosis is made retrospectively when peoplecome home. “Do you have these symptoms?” “Yes.”“Were you exposed to blast?” “Yes, I was.” A lot ofpeople, both here and in the States, therefore thinkthat a lot of misdiagnosis is going on.

Q214 Mrs Moon: It might be helpful if I say thatwhen we went to the specialist unit they said that itwas virtually impossible to have served in theatrewithout having a mild traumatic brain injury.Professor Wessely: That is exactly my point, isn’t it?Exposure is very common.Now we are getting to difficult territory, but there aretwo things. First, we don’t like the term “traumaticbrain injury”, because it is a scary term. I have beenconcussed and I bet you have. My kid certainly hasplaying sport. When you get a call from the schoolsaying that your kid has concussion, you don’t call ina helicopter and everything. You pick him up at theend of the day. But if you had heard that he has a



traumatic brain injury, you probably would. The nameis a misnomer and it was a mistake. A lot of the USthink that, too. We have stuck with “concussion”,which is less scary. We know that the label has animportant effect on outcome. It is not a neutral thing,and we know that it impacts on outcome.

Q215 Mr Hancock: It probably leads to other things,because the person feels that they have something thatis probably serious.Professor Wessely: You are absolutely right.

Q216 Mr Hancock: Before I ask a question aboutthe comparison, I want to go back to your point aboutthe importance of people who have injuries remainingin the Service. With the Services being reduced, thecapacity for the Armed Forces to hold on to peoplewill be dramatically reduced. I remember asking thisquestion of the then Chief of the Defence Staff twoyears ago, and he said that the Armed Forces werealready coming close to the point at which they simplycould not allow the situation to go on. What is theadvice that you are giving them?Professor Wessely: We are not going to give adviceon that. They know the issue. It is not that they arestupid and don’t know the issue, they do know theissue.Mr Hancock: They are doing well, really.Professor Wessely: What will happen is that morepeople with mental health problems will be dischargedwho might have done better in Service than out ofService. There is a much bigger picture there thanfor us.

Q217 Mr Hancock: They will probably realise thatthe stigma attached to that will travel out of theServices with them.Professor Wessely: Possibly.

Q218 Mr Hancock: Can we go back to thedifferences between the mental health outcomes herecompared with the United States?Professor Wessely: That’s a tricky one, isn’t it? Atfirst sight, the US has more PTSD than we do. Well,not at first sight–they have more PTSD than we do.There are various reasons for that, some of which arerather obvious. For the first few years, 2003 to 2005,they had higher rates of combat exposure. That hasnot been the case since 2005–06, but it certainlyaccounts for some of the original differences. Theirforce structures are different. They have three timesas many Reservists. Given that Reservists on bothsides of the Atlantic are a little more vulnerable, themore Reservists you have, the greater the impact onoverall PTSD will be.We have talked about age, too. The Americans areyounger than the UK Forces, which is an importantissue. Then you have tour length, which is a very bigissue. It is impossible to study, because we have onetour length and they have another, but most peoplethink that that has a big impact.Then you have the other issue, which is reallydifficult. The American rates are going up. When youcome back from theatre you have a certain rate, thensix months or 12 months later it has increased,

sometimes dramatically. Our rates are not doing that.They have gone up by maybe 1% over some years.What is the reason for that? Well, it is very hard tosay. We find it difficult to think that it is going to beabout what happened in Iraq and Afghanistan, becausethings are very similar there.

Q219 Mr Hancock: Is their ability to hold on topeople after they have come back and been diagnosedwith a psychological disorder greater than ours? Or isit the fact that they are very well compensated if theyleave the Service with a medical condition?Professor Wessely: I do not know the answer to that.We are trying very hard to co-operate with WalterReed in particular, because if we were to share datasets some of the answers might become clearer. At themoment we do not know. I do not know the answerto your question on retention.

Q220 Mr Hancock: We have just had 6,000American Service personnel in my city, and I talkedto some of them. Some pilots who had been flying inthe Navy were saying that if you left the Service earlywith a medical disability, your compensation packagewas quite considerable. The guy in charge of the airwing on the carrier said that a number of his pilotswere leaving, but what they did not imagine was thedifficulty of getting civilian jobs when going out withthis medical complaint that they had claimed. But itwas the financial package that led many of them toseek medical advice, so they could get out of theService with a greatly increased package.Professor Wessely: I am aware of that. I do not knowwhether that is the explanation. We know there aredifferences between the US and the UK in how youcan access health care after you have left the Services.We can speculate that that is an issue. We think itmight be, but it is difficult to prove. It would be greatto randomly allocate people to serving in the Britishor American Armed Forces. That would be awonderful study. Again, that is unlikely to go through.We wonder whether those are issues, and we wonderif access to health care, particularly after two or fiveyears, is impacting on this, and that is a very big issuefor an American Service family.

Q221 Mrs Moon: At the unit that I visited, the focuswas on treating and working with the whole family.They brought the whole family to the unit for twoweeks of intensive therapy. They set about writing acare plan, which was then sent back to the unit, andthe person would be discharged to the unit only if theunit could carry out that care plan. Are we workingon a whole family treatment plan, or are we workingexclusively with the serving personnel?Professor Wessely: I think you have to ask theuniformed Services that. I am not aware of that. Ingeneral, they are aware of family issues, but I do notthink there is a set-up like you have just mentioned.This was the US you were talking about?Mrs Moon: Yes.Professor Wessely: You would have to ask them, butI do not think so.



Q222 Mr Havard: That is partly why I asked youthe question earlier about preparing, advising andenabling the family to deal with the problem. On thesituation in the US, I saw a report last night. It seems86,000 military people have come back with PTSD.But then the Military Chiefs seem to be saying, “Thatcould be an underestimation. There could be800,000.” That was the figure on CBS last night. Thisseems to me much more to do with the socialisedmedicine process that they have if you have been inthe military than anything else. What are thecomparators? Is any of this stuff that we are seeing inAmerica of general relevance to us in making policydecisions?Professor Wessely: You are asking us to go a bitbeyond our competence. I think it is a mistake toassume that what happens in America will inevitablyhappen here. I know some people say that. We shouldnot necessarily use the Americans as an example ofwhat we should be doing. They have unbelievablestrengths, as anyone who has been out there and metthem knows—their medical care, support for theForces, support for families. There is a huge amountthat we can learn—I wish we did—and I wish we hadone tenth of their research dollars. But that does notmean that everything is working over there. Ourcircumstances are different.

Q223 Mr Havard: Is it not the case that they arelooking in the totality, including their veterancommunity? What you are studying are the people inactive Service.Professor Wessely: We study the veteran communityas well. We have no equivalent of veteransadministration, but we do not need an equivalent.They need a veterans administration because these arepeople who would otherwise not get health care. Theyreally would not get it, because they come from astratum of society that does not get it. We do not havethat system, so we need to interpret carefully what theUS are finding, and we should not assume it willhappen over here.

Q224 Mr Hancock: The military covenant issupposed to give that through life care, not just to theArmed Forces personnel but to the family. That is partof the commitment. We heard evidence from the threeServices’ welfare organisations; three ladies came andpresented their case. They actually answeredMadeleine’s question about whether there was acontinuity of care to the family as well as to theService personnel, and they said that the plans werebeing developed so that the family was involved. Theywere involved as well, particularly with soldiers whowere not coming back to the UK. In Germany, inparticular, where it started off, there was a great dealof the sort of support that Madeleine was talkingabout.Professor Wessely: That is in-Service.Mr Hancock: Yes.Professor Wessely: I thought we were talking aboutex-Service now. Of course a huge amount goes onfor families; we have said that. That is why we havehighlighted the problem of Reservists, where there isa difference and less is done, and of veterans. Much

of the support networks that you described do notextend so much to veterans—at least not to the onesin trouble, funnily enough. The ones who are wellhave tremendous networks, as I am sure you know.

Q225 Mrs Moon: Carrying on with the issue of aveterans agency ethos, the Sheffield University studylooked at people with mental health problems whohave served in the military. Six pilots have beenrunning. The study that looked at that said that one ofthe priorities that people said they were looking for inturning to the health service was people who hadmilitary background and an understanding of militaryService. They said that they felt more at easediscussing the problems that they were experiencingand more able to be honest and open about them ifthey were talking to people who had also served. Haveyou found the same sort of desire? Is that productivein helping to achieve a positive outcome?Professor Wessely: We don’t know whether it willachieve a positive outcome. We know that a lot ofpeople would prefer that, and we certainly know thata lot has to be said for assessment to be done bypeople who are militarily informed. I do not think thatyou can insist that they are ex-Service personnel,because there just will not be enough, particularly inmental health, but it is clearly very important that theyare informed. However, we should not forget thatthere are other Service personnel who do not want youto know that they have been in the Forces, and that isalso their right. I am slightly nervous about policiessuch as all notes should be flagged that you have beenin the Forces, because quite a lot of people do notwant you to know. You hear about the ones who dowant you to know, but you do not hear about the oneswho do not. Assessment, in particular, by military-sensitive people who basically understand thelanguage and also like them is very important. I donot think you need to be treated by people who havebeen in the Forces, but I think for assessments, yes,that’s a good idea.

Q226 Bob Stewart: When we look at the UnitedStates and the United Kingdom, I seem to recall thata long time ago, I looked at a study of resistance tointerrogation in the Korean War, which you probablyread when you were a student. It came out thatTurkish prisoners of war did not give in. Britishprisoners of war did a bit, but Americans did most ofall. I cannot remember the percentages. Do you thinkthat there is an element of—I am not sure that this ispolitically correct to say—greater mental resilience inthe UK than the US, or even Turkey? Is there anythingfrom a societal point of view, from where they havebeen brought up and that sort of thing?Professor Wessely: No. I don’t.Bob Stewart: I’ll take that as a no.Professor Wessely: I like to tease Americans bysaying that it is about the essential superiority of theBritish character. It is great fun.Bob Stewart: I did not mean that.Professor Wessely: To be serious, when you meet theAmericans, they are exactly the same. I think it has todo with the different systems, particular of health care.People will behave differently in different



circumstances. Do I think that they are fundamentallymore or less resilient than UK Forces? I don’t at all,and there is no evidence that they are. I just mentionedReserves and combat exposure. When you equalisethose, the rates and the differences between ournations become much smaller. I think that nearly allof it is explained, first of all, by rather boringdemographic things, and secondly, by the impact ofdifferent health-care systems. Do I think that we arefundamentally more resilient? No, I don’t.

Q227 Bob Stewart: How much does the branch ofservice and leadership within that branch have animpact?Professor Wessely: Of course it does. The US did theoriginal study showing the importance of good andpoor leadership, and we replicated those studies.Where there is poor leadership in both militaries, wehave worse mental health, and where there is goodleadership, you have better mental health. The samefactors that impact on US units impact on ours. If youcompared a poorly led US unit with a well-led Britishunit, you would conclude that we were much tougher.If you did it the other way round, you would concludethe opposite.

Q228 Bob Stewart: My own observation, incommand, was that those people who tended to haveproblems, such as PTSD, which we did not recogniseat the time, were those people who were in isolation—drivers of trucks in convoys—much more than thebasic section in the front line that really went throughit, with serious casualties and horrific things to do.Those people tended not to have PTSD as much asthe guys who were on their own or isolated.Professor Wessely: I am completely with you on thatone. First, what we, and others, have shown is that theparticular jobs you are mentioning are those whereyou have very little control over what is happening toyou. It is like bomber pilots in the Second World War,where you have a much greater sense of danger andthere is nothing that you can do to mitigate it, even ifit is an illusory mitigation.The second point is that we and others have shownthat the issue is not the really bad things that happen,because we are dealing with professional soldiers, weare not dealing with a conscript Army. For most ofthem, that’s the job. It is errors of omission andcommission: either when the side lets them down,which is why friendly fire is so psychologicallydamaging—it is one thing being shot by the Taliban,being shot by your own side is completelypsychologically different—or when you let the sidedown and you feel, rightly or wrongly, that you didnot behave as you should have done.Those are the issues that differentiate everyone whogets the various emotions that we have talked about,which are normal, from the smaller number who geta psychiatric disorder. It is errors of omission andcommission. It is misleading to think that it is merelyseeing bad things—no, people are pretty tough andresilient in both militaries about that. It is where therules were violated or you did not behave as youthink, in retrospect, you should have done.

Chair: Moving on now to the final area ofquestioning—further research.

Q229 Mr Havard: This is where you can make yourpitch, and rightly so. What are the most pressing partsof real research, because research gives us someprecision, but there is still a lot of supposition in anumber of these questions? Despite what you havedone already, which you have outlined, what are themost pressing questions that should be beingresearched, and can you do them in the same way?Professor Wessely: The biggest issue for us is that itis still early days. The war is continuing, and we don’tknow what is going to happen. A lot of the concern isfor what will happen to people at five, 10 or even 15years, and we don’t know. Will we see a change inthe patterns? We don’t know. Will some of theassumptions that we have made continue? We don’tknow. Will there be an impact of some of the goodthings that are going on? Will they actually make adifference? We don’t know.Obviously, we are interested parties here—I am sureyou will have taken that—but I think that it is reallyimportant to get evidence on the effectiveness ofinterventions and to follow trends. People talk abouta time bomb or a tidal wave. We have not seen thatyet, but is that because it is far too early? I cannot tellyou the answer to that. It is important to continue tocollect good, accurate data on the impact of Iraq,Afghanistan and current operations. Having done sosince 2003 has made a substantial difference in a lotof areas. We would not have had the Reserves mentalhealth programmes if we had not shown increasedvulnerability. We would not have all the various otherthings that have gone on, nor would we know the realbalance of problems, like the importance of alcohol,so that is important.It is also important to know the effectiveness ofinterventions; this would not be us. We are assumingthat the kind of treatments that work in the NHS, andin NICE, good randomised controlled trials done bymy colleagues at the Maudsley, are appropriate in theArmed Forces, and we do not actually know that. Weare assuming EMDR is appropriate, because it worksin civilian settings. We do not know if it works inmilitary settings, and it is important that we look onthe ground to see whether these treatments areworking. We are making an assumption.

Q230 Mr Havard: I was just about to ask you that.Earlier on, you said that there is a number of groupsand organisations coming forward with their own styleof interventions and processes, which are verydifferent one from another. We are trying to evaluatewhich ones we should look at and see how theycompare and so on. There are agreed methodologiesin the college or wherever it is, but then there areother things. You seemed to suggest earlier that youhad some sort of role in helping the MoD to decidethat. Was that the case, or was that some role youfulfilled with the Royal College of Psychiatrists, orwhat? What is the mumbo jumbo and what is theuseful stuff?Professor Wessely: This is just a general duty onprofessionals. I am a boring psychiatric academic. I



believe in evidence, I believe in randomisedcontrolled trials, and I believe in NICE guidelines. Ithink that that is the way forward. People should knowwhat is effective. We cannot stop people having non-effective treatments—of course we can’t. They shouldat least know. I worry that at the moment people aregetting treatments where there is no evidence that theywork, and they do not know that.

Q231 Mr Havard: So what should be the processof validation?Professor Wessely: Please God, we are not advocatinggreater regulation. In the talking therapies market it islike trying to regulate water. It cannot be done.Information can be regulated, however. People needto know, when they are using treatments, that there islong-term evidence of effectiveness, good governance,good outcomes, good audit and good clinical practice.They need to know that, and they need to know wherethere isn’t that.

Q232 Mr Havard: You are saying that this is animportant area that the MoD needs to turn its attentionto, as much as anyone else, to decide what is effective.Professor Wessely: That is slightly harsh.

Q233 Mr Havard: I’m putting words in yourmouth—sorry.Professor Wessely: The MoD can and does regulatewithin Service. It is very good at that, actually. Mostof its practitioners have been well trained and thetreatments that they offer are validated. They do notdo non-validated treatments. It is not a problem inService. It is for those who have left.

Q234 Mr Havard: And the funding of this necessaryresearch for the Ministry of Defence.Professor Wessely: I repeat: I do not think that itshould come from the MoD, because that would beunfair. I happen to think that the duty is on those whooffer treatments to have shown that they are effective.They always say, “Oh, we can’t do that”, but we doit, so they can do it. It is hard, but you can do it. Thatis me speaking personally.

Q235 Mr Havard: So this is a responsibility for theNational Health Service.Professor Wessely: No. It is a responsibility forpeople offering treatments. If they are not wellaccepted or well validated already, they have a dutyto show that those treatments are safe and effective.

Q236 Mr Hancock: Just one question. I aminterested as to whether this is a question that you ask,or will consider asking. Do you ever ask returningsoldiers whether they feel what they have done wasfulfilling and rewarding for them? Soldiers who gavean awful lot in Iraq maybe feel disillusioned that theirefforts were not rewarded by the outcome. Howimportant is that for the future of the work that youwill have to do to help soldiers?Dr Fear: We have asked, in our latest survey, whetherthe people who went to Iraq and Afghanistan felt thatthe mission was beneficial to the citizens in either Iraqor Afghanistan and how they feel that the British

public have viewed their role in that mission. We askwhether they feel that the public have been supportive.We also ask them about the attitudes of the publictowards them since they have been home. We havenot looked at the data yet, but, as Simon mentioned atthe beginning of this session, we have recently hadsome money from the ESRC to look at public attitudestowards the military.We are also going to ask the general population whattheir views are on the mission, on the success of themission and on Service personnel who have served onthose missions. We will then be able to compare thedata to look at how the soldiers’ attitudes and thepopulation’s attitudes compare. Obviously, from thesoldiers’ perspective, we can look at how that impactson their readjustment into life back in the UK and atsubsequent mental health problems.

Q237 Mr Hancock: I think the public perceptionwould be that the military are top of the tree, if youasked people for their views. I am interested in theyoung soldier who saw friends die and who comesback. What end result and effect does that have onhim?Professor Wessely: We are interested in that as well.We ask those questions. I am afraid that time alonewill tell what the impact of that issue is. If you areasking whether we have asked those questions, yes wehave. Most actually still see it in very professionalways, and they feel that, okay, things in Iraq may havegone to hell in handcart, but they did well. That seemsto be very important. Again, it comes back to whetherthey behaved professionally.

Q238 Mrs Moon: Two things. One is that I havefound this session extremely interesting and veryinformative, so thank you. I just wonder whether wecould set up a system where a copy of your researchis automatically sent to the Clerk when it is published,so that we are kept abreast of your research andfindings, and also whether we could perhaps ask for aprivate conversation between yourself and one of ourClerks in relation to the issue of physical injury, sothat we could know those findings on a confidentialbasis.Professor Wessely: On the second one, yes, that isfine. On the first one, we give our research first ofall—

Q239 Mrs Moon: When it is in the public domain.Professor Wessely: Of course. That is absolutely fine.I am sure that we can do that.

Q240 Chair: Final question. We have to produce areport at some stage. Do you have any suggestions forrecommendations that we might like to make to theMinistry of Defence?Professor Wessely: No.

Q241 Mr Havard: That is going to be part of ourconfidential discussion, is it?Professor Wessely: To be honest, we are veryconscious about the limits of what we do. It is not forus to tell them how to run the Armed Forces. Weproduce evidence and then some they incorporate and



some they do not. As I have said, it has been verysatisfying, because they do listen to what we say. Theydo not always act in the way that we might think thatthey should act, but they often have reasons that arewell beyond the areas that we are considering, so wedo not tell them what to do.

Q242 Mr Havard: That is fair. You are part of theirevidential base for making decisions.Professor Wessely: Absolutely. We would be upset ifthey did not read what we did.

Q243 Mr Havard: I respect that. Could I ask you aslightly different question? Are there things that weshould have asked you about that we have beenneglectful in asking you about, which would help usin making the decisions?Professor Wessely: No. I think you have covered thewaterfront pretty well, to be honest.Dr Fear: No.Professor Wessely: One area that really intrigues us iscommunication between families and servingpersonnel. That is an issue where we have had a glibassumption that more is always better, which issomething that I am wondering about. We see in ourstudies that the impact of bad news from home can bequite profound, and now it is so unregulated and sofast that I do not know whether people areconsidering that.

Q244 Bob Stewart: A telephone call that goes wrongbetween a wife and a husband can be prettydangerous.

Professor Wessely: Nothing is private out there, andyou can hear conversations with people almost tryingto sort out the washing machine and so on. We knowthat too little communication has a terrible effect onmorale, but should we wonder whether you can havetoo much as well? That is an area that we have toexplore.

Q245 Mr Havard: I visited one of the submarinesrecently, along with others. Their view of how theyhave to deal with communications, which bits of itare useful to them and whether delays and so on aredetrimental, is interesting. They have a particularview—they are in a very different position fromsomeone on the ground in Helmand, but there aresome comparative groups that you might be able tostudy in relation to that, are there not?Professor Wessely: Yes. It is possible. There is an areaof debate to be had, so this can be thought about in alittle more depth. What is the right level ofcommunication? Certainly, the biggest impact onmental health in theatre is not what is going on intheatre; it is events at home. We are very clear aboutthat.Chair: Thank you very much for that fascinatingevidence.



Members present:


John GlenMr Mike HancockMr Dai Havard

________________


Witnesses: Air Vice Marshal (rtd) Tony Stables, Chairman, Confederation of British Service and Ex-ServiceOrganisations, Major General (rtd) Andrew Cumming, Controller, Soldiers, Sailors, Airmen and FamiliesAssociation (SSAFA) Forces Help, Commodore Paul Branscombe, Deputy Controller (Services Support),SSAFA, and Cathy Walker, Deputy Controller (Branch Support), SSAFA, gave evidence.

Q246 Chair: Thank you very much for coming.Some of you have given evidence to this Committeein the past, and I know you have given evidence tothe Armed Forces Bill Committee as well—you areall most welcome. This is another evidence session inour inquiry “The Military Covenant in action? Part 1:military casualties”. We expect to finish by about 4pm, if that is okay by you, so you will know thatthere will be an end to your misery. We will have lotsof questions.Air Vice Marshal Stables, may I ask you to tell uswhat COBSEO does?Air Vice Marshal Stables: In its present format, itdates back to 1982. It is the Confederation of Servicecharities. It has a membership of about 180 and rising,as about two or three charities seek admission on amonthly basis. What are its principal outcomes? Weprovide a focus for dealing with Government—notonly the Ministry of Defence, but other GovernmentDepartments—so we are an external focus of thedefence charitable sector. We provide a mechanismwhereby the Service charities can work in a morecomplementary way. We seek to avoid duplication ofeffort and to enhance the outcome of the charitablework. That, in a nutshell, is what it is about. Its workis driven by an executive committee of 13 members,who are the chief executives of the 13 large fundsand charities. The major players form the executivecommittee, which drives the business, and my goodfriend the controller of SSAFA Forces Help is amember of that executive committee.

Q247 Chair: That leads us on very nicely. MajorGeneral Cumming, what does SSAFA do?Major General Cumming: It does an awful lot, sir,and I shall try to give you the three-minute version.We pride ourselves on the fact that we work with theArmed Forces from the time a person draws one day’spay until the time he or she departs this mortal coil,together with the dependants they gather on the way,so we look after people both in-Service and ex-Service. Very simply, Paul Branscombe runs the in-service side and Cathy Walker runs the ex-Serviceside. On the in-Service side, principally, we run anumber of contracts and a couple of grant-in-aid bitsof business for the Ministry of Defence, providing thehealth and social work services for our Armed Forcesoverseas, broadly speaking. We also run the Royal AirForce’s Welfare Service, which is the equivalent of

Mrs Madeleine MoonBob StewartMs Gisela Stuart

the Army Welfare Service, or the Naval Personal andFamilies Service. We run the same thing for the RoyalAir Force.Aside from that, we have a number of volunteers andin-Service committees. We contribute to victimsupport programmes abroad. We have carers and soon and so forth. We are an accredited adoption agency.We run a thing called the Forcesline, which is paid forby the three Services. It was originally a confidentialsupport line, but now it is slightly broader—it has anew manifestation. We organise to pick people up ifthey are travelling with families from airports orwhatever—that is called the Family Escort Service—to take them wherever they are going, such as if,interestingly, somebody is coming from Germany onthe news that someone has been taken to Selly OakHospital as a result of operations.We run a number of family support groups at thebehest of the Ministry of Defence. Those groups havebeen going for about two years. They originallyfocused on those families who had been bereaved bybringing them together to enable them to talk, but theyhave expanded into another group for the families ofthose who have been wounded. Interestingly, out ofthat we found that the children of those who havebeen either killed or wounded did not want to dothings with their parents but wanted their own group,so it is quite complicated with several such groups.They enable people to talk to each other, and we takethem away for weekends and so on.On the cusp of in-Service and ex-Service, we run twoparticular types of home. One is what we call astepping stone home, which is for those sad occasionswhen families become estranged. Generally speaking,the husband is welcomed back into the bosom of theregiment and the sergeant-major hugs him, and thefamily is given 12 weeks to leave the quarter. Most ofthe time that works perfectly well, but sometimes itdoes not and we provide the stepping stone home—there is one in London and another in the North—tohelp them through that difficult stage. It is literally astepping stone to find housing, education for thechildren and so on.Another type of specialist home has been running forabout three years. Again, we did this fully in concertwith the Ministry of Defence. We suggested to it thatwe could help with the families of the wounded, ifthat would be suitable, and the then Veterans Ministeragreed that we should do something. We raised an


29 June 2011 Air Vice Marshal (rtd) Tony Stables, Major General (rtd) Andrew Cumming,Commodore Paul Branscombe and Cathy Walker

appeal and started two homes. One is at Selly OakHospital—Chair: Which we are going to visit tomorrow.Major General Cumming: I am pleased to hear thatyou are going to the one at Selly Oak tomorrow—Ihope you enjoy it. I think it will be very good value.The other home is down in Headley Court. We areworking closely with the Hospital Trust inBirmingham and with the Fisher Foundation, which isdoing the same sort of thing in America on a muchbigger scale, to see whether we can help with anextension near Selly Oak. That is quite interestingwork, and Paul can tell you more about it in a minute,if you want.On the ex-Service side, very broadly speaking, we arethe trusted agents for not only the military benevolentfunds, but the civilian benevolent funds. We do thecasework for those who say they are in need.Somebody in need will come to SSAFA—they go toother organisations, too, but they mostly come toSSAFA—and we assess that need. It could be anyone:an ex-Serviceman, a widow or a family member.Having done that assessment, our caseworkers willdecide from where to, as we call it, almonise themoney. Where will they send the assessment claim?They will send it to the regiment, the Royal BritishLegion, the Army Benevolent Fund or maybe the PrintWorkers’ Fund, if that is the trade that the person wentinto later in life.Last year we shifted, if I might put it that way, some£18 million or £19 million either from benevolentfunds, or from Government statutory funds, into thehands of those who needed and deserved it. Therewere some 47,000 cases and visits.Chair: We will go into that sort of thing—Major General Cumming: And a few houses andhomes—that sort of thing—around the country. I thinkthat is enough, but it is quite a big business.

Q248 Chair: As you say, you do an awful lot.Mrs Walker and Commodore Branscombe, please feelfree to come in if you think you can help us withour evidence. If you think the answers are completelywrong, just jump in.Air Vice Marshal Stables, I will start with you. Whatdifference do you think you have made to the co-ordination of the work that your member organisationsand the Ministry of Defence do to provide help forArmed Forces personnel—both serving and former?Air Vice Marshal Stables: I first came into thisappointment some five years ago, and I would betempted to say that the fact that we sit around a tableand talk to each other is a significant improvement onwhat might have been before. I can say now—you hadbetter confirm this with my good friend on my right—that there is openness and transparency across thecharitable sector. There are many good examples ofService charities working together. I could cite theRoyal Air Force Benevolent Fund and the RoyalBritish Legion working to offer debt advice, and youwill find other initiatives by charities workingtogether. Other benefits include the fact that we havestarted to co-locate, particularly with those charitiesbased in London. We now have five based in

Mountbarrow House in Victoria. Plans are afoot, asleases expire in London, to seek greater consolidationthere, which clearly brings benefits.In terms of absolute examples, I think that Andrewreferred to casework management. There is no doubtthat some five years ago each charity took a ratherisolated view of casework management and welfare.That has been brought together under a caseworkmanagement group chaired by SSAFA Forces Help,which ensures a quality assurance for those seekinghelp. In other words, they are now working from thesame protocol—from the same format—and they areable to transfer people from one charity to another, orto transfer funds from one charity to another tosupport that person.We have done exactly the same thing with therepresentation of appellants before tribunals.Appellants have been represented free of charge byService charities before appeal tribunals in respect ofwar pensions or compensation. Again, the level ofrepresentation was a bit patchy. The lead was takenby the Royal British Legion, and that has developed aprotocol and training so that, again, there is greaterquality assurance.I think probably more recently—in the past year—wehave been recognising that it is sometimes difficult forcharities to work outside the boundaries of their trust.One of the great limiting factors of getting charitiesto work together is that they are all individualorganisations that are bound by a deed of trust, withtrustees who have a legal responsibility to ensure thattrust, so it is sometimes difficult. A year or 18 monthsago, we set up a series of topic clusters. In otherwords, we brought together those charities that had aninterest in specific subjects. We did not prescribe atimeline or an endgame; we merely said, “Let us sitaround a table and see where it takes us.”We have eight cluster groups at the moment, and Iwill give you three examples. The first is residentialcare, which is a topic that has been in the headlinesfor other reasons recently. There are some 17 withinthe Service charitable sector. Many Service charitiesoperate a single care home, and they have been quiterightly focused on making ends meet at that singlecare home. Little thought has gone into where theywant to be within the sector: should it be care in thehome; should it be care at a home; should it beresidential; or should it be nursing? The Royal BritishLegion took the lead on that, and it has done someextensive research into its own five homes. It sharedthat with me last week and will now share with theother members. I see that moving together for a verypositive outcome.We have done the same with housing, with HaigHomes chairing the cluster for housing. We have donea very successful one in resettlement, which theRegular Forces Employment Association has beenrunning. That has up to 20 members now, drawn fromway outside the Service charitable sector. They arecoming together to deliver a far better transition andresettlement service. There are some very positiveexamples within the umbrella of this confederation ofcharities being able to work together, notwithstandingthe boundaries.



Q249 Chair: Your funding comes from your memberorganisations, does it, as opposed to directly from theMinistry of Defence?Air Vice Marshal Stables: There is no externalfunding. All the funding is internal from the memberorganisations.

Q250 Chair: Thank you very much.Major General Cumming, how much of your fundingcomes from the Ministry of Defence?Major General Cumming: The only funding we getfrom the Ministry of Defence is for the work we dofor it.

Q251 Chair: So what proportion is that?Major General Cumming: The turnover is about £29million. Is that right, Paul?Commodore Branscombe: It is of that order. We arepaid for the services that we provide, Chair, but weprovide those under contract. There is no subsidy tothe charity.

Q252 Mr Havard: Is that grant in aid?Commodore Branscombe: Some of it is still old-fashioned grant in aid, meaning that we are paidpurely for what we do. With the one under thecommercial contracts, we are allowed to make a smallmargin, but of course that small margin passes to thecharity to fulfil our charitable objectives.

Q253 Mr Havard: So it is a mixture of the two.Commodore Branscombe: It is, yes.

Q254 John Glen: We have heard from the MoD in amemorandum that it seeks to investigate better waysof co-ordinating and prioritising the activities ofdifferent elements of the voluntary and charitablesector. Are you familiar with that investigation, andhow are you engaging with it?Major General Cumming: The answer is no, althoughI have heard of it. In many ways they would be doingwhat is already being done very successfully, in myopinion, by COBSEO. Tony has talked very modestlyabout what he has achieved over the last three or fouryears, but prior to that, very little was going on. Ireally think that there is a very broad understandingnow within the charitable sector about where we standwith each other, and we are also far better informedabout each other’s activities, so less trespass is goingon. Where we think that there might be a bit oftrespass, or a bit of inadvertent treading across theline, we can use the good offices of COBSEO tostraighten things up.It is a jigsaw puzzle—the military third sector—but itworks, and the pieces fit. In the way that it is beingrun at the moment, we are fitting neater and neater allthe time.

Q255 John Glen: That seems to imply that youperhaps think that this investigation and work by theMoD is not necessary, because you are almost self-regulating the co-ordination of all your memberorganisations. Is that true? What are the challengesfacing the MoD?

Air Vice Marshal Stables: If I may say, I think this islargely driven by the success of Help for Heroes andby the Chief Executive, Bryn Parry, saying to theMoD, “We have raised this money by publicsubscription for veterans of Afghanistan; what do youwant me to do with it?” I think that when he askedthat, there were some blank looks at the MoD, becauseit is not the way that we have conducted our businesstraditionally—and how the charitable sector conductsits business. When he first went to the MoD, theoutcome, of course, was the swimming pool atHeadley Court.Certainly the view of Help for Heroes, although youwould be better off asking Bryn, was that—John Glen: We are.Air Vice Marshal Stables: Its view was, “Ministry ofDefence, please prioritise. Come up with some kindof list that you feel charitable money could assist.”The rest of the charitable sector does not generallyoperate in the same way as Help for Heroes. If I maysay, it would be better to ask Bryn and the MoD. I amaware of the initiative, which I thought at first mightbe some kind of wish by the Ministry of Defence tohave greater control of the charitable sector. I suspectthat it is not actually, and that it is a wish by Help forHeroes for the MoD to put some priority to projectsthat could be funded from charitable sources.

Q256 John Glen: May I come back in on that? Ihave talked to Bryn Parry about it. He is based in myconstituency, and I certainly recognise the dynamicthat you have spoken about. However, is there not adanger that, in a sense, the MoD responds to thatquestion and undertakes this activity to deal with theissues that he has thrown up, when you seem to besaying, “We are working very well”? Is there not adanger that there will be a disconnect between theestablishment, if you like, of organisations such asyours, which work quite well, and what he is doing?How will they interact well together? Is the MoDgoing to miss a trick if it does not look at what youdo alongside what he does?Air Vice Marshal Stables: I would be confident thatthe mechanisms in place at the moment allow forvisibility of that. I do not see the thing actually gettingout of hand. For example, Bryn Parry sits on ourexecutive committee, not as an elected member, but inattendance. So, he is there in the executive committee.I also meet regularly with the assistant Chief of theDefence Staff personnel. Cathy and I meet himregularly—three times a year, formally. I meetinformally with him and his staff almost monthly. Ithink that there is a genuine openness andtransparency, certainly between the personnel andveterans—sorry, whatever they call themselves thisweek. I think it is “patrons” and veterans, andourselves. We meet very regularly, and I would besurprised if things were stitched up.

Q257 Ms Stuart: Why is Help for Heroes not on theexecutive body?Air Vice Marshal Stables: Because our currentconstitution, within the Confederation, allows forbetween 13 and 14 members on the executive board.



There are six permanent members and six are electedon a two-year rotation, by twos, if you like, so everyyear two change over, and they are elected at theannual general meeting. There was a view, certainlyin the executive when Help for Heroes began, thatthis was a powerful charity, which was likely to beinfluential, and it was important that we included it.The only mechanism that we had to bring it withinour executive at that time was to ask Bryn to be inattendance.

Q258 Ms Stuart: Have they stood for election andnot been elected?Air Vice Marshal Stables: They have not stood forelection.

Q259 Ms Stuart: Are you encouraging them to?Air Vice Marshal Stables: I am.

Q260 Bob Stewart: I think I know most of theanswer, but I would like to hear your view, Air ViceMarshal, on why there has been an increase incharitable donations to Service charities. We have ageneral idea, but, for the record, we would like to hearwhat your view is.Air Vice Marshal Stables: Can we hear from SSAFAfirst? Then I will come back with a general comment.Major General Cumming: I think we all have a viewon this, but there are several factors involved. If youtake Help for Heroes, in particular, it is an exceedinglygood fundraising organisation. It is very streamlined,it has a jolly good message and a very good strap line.It is extraordinarily energetic. It has revitalised themoney-giving public, and it has found that it is able todo this at a time when the Armed Forces are, generallyspeaking, very popular. What it is doing is very wellsupported by the British public. Sorry, I do not meanthat what it is doing is popular; I think it is very wellsupported by the British public in what it is beingasked to do. There is a genuine sympathy for thosewho are killed, and sympathy for those who are verybadly wounded, who we see quite a lot of. So, it is acoincidence of a number of things. It has helpedeverybody.SSAFA per se is not a greedy organisation. It needsenough money each year to run itself. It is not a grant-giving organisation; it is a “doing” charity. We trundleon with our revenue sources, which is fine. But I dothink it has helped an awful lot of other people.Cathy Walker: I was going to say pretty much thesame. Society as a whole is very supportive of theArmed Forces community. All the Service charitieshave benefited from the impact since Help for Heroesbegan by raising awareness of the Servicemen andwomen and their families. How long that will lastremains to be seen, but certainly in the recent past wehave none of us struggled with fundraising.

Q261 Bob Stewart: Does Help for Heroes coverother conflicts apart from Iraq and Afghanistan?Someone told me that it was just concentrating ongiving money out for that, but not for NorthernIreland, for example.

Cathy Walker: No. Its objects allow them to helppeople who are sick, injured or wounded post 9/11.Commodore Branscombe: That has been part of thereason for its success, because it has been able tofocus on a very narrow theme—I do not mean narrowin any bad sense—that resonates with people rightnow. There is a downside to that, because much ofwhat SSAFA and the other specialist charities tend todo is less obvious. For every visibly wounded veteranwho attracts our sympathies and support, you canmultiply by 10, 20 or 50 the casualties elsewhere, notleast those who do not show a single mark on them.These days there are also the nearest and dearest, andsometimes the nearest and dearest are not the mostobvious. Sadly, most of the killed and wounded havebeen between the ages of 18 and 23, and those whoare most dependent upon them may not necessarily bea widow or a spouse. Many of the people whom weand others support are casualties and their extendedfamilies. They are casualties not only of war but ofthe stress leading up to peace. That very breadth issomething that also needs to be taken into account. Itis not always the most obvious target that takes themost effort and, in the end, money.

Q262 Bob Stewart: So any Help for Heroes moneycan go only to help people post 9/11?Major General Cumming: Theoretically, that is so.But that is not to say that charities like ours, whichare doing something very specifically for post 9/11,cannot help. For example, the two Norton houses havecontributed a fair amount of money. We are about tostart up another project, because we believe the Armyis about to ask us to do so. We should be going toHelp for Heroes with our cap in hand, saying, “Willyou fund this? It very much fits your post-9/11 objectsand your profile—here’s a good way to do it.” Weshall go to it.

Q263 Bob Stewart: I am sorry to keep on, butpresumably if you get Help for Heroes money in abatch for that project, you could dedicate it to that,but it would give you more money to look beyondthat—to look back.Air Vice Marshal Stables: I get terribly concernedabout this on the basis that, as I often discuss withBryn Parry, the one-legged veteran today is the sameone-legged veteran 30 years down the track. As longas you are dealing with Afghan veterans andsustaining that into the future, I am not too worriedabout a cut-off date.On your original question, I agree entirely with whathas been said. Help for Heroes changed the shape ofthe charitable sector. It most certainly raised the bar,and created far greater awareness. I am the Chairmanof Trustees of Headley Court. Our trust owns HeadleyCourt, which we lease to the Ministry of Defence formedical rehabilitation. We have never been afundraising charity—we have never gone out to seekfunds; essentially, we are a landlord, but because wehave funding, we make grants and assist withrehabilitation at Headley Court. We have received asignificant number of legacies in the past two years,



which we have not sought. I think that is about profile,and other charities will be in the same position.

Q264 Mr Hancock: You have answered part of myquestion, which was going to be about whether therewill come a time when you will go to Help for Heroesas a major benefactor for what you are doing. Thereis also a problem about where charities peak. I workedfor one that was involved in a very emotive issuerelating to children from eastern Europe. I understandthat there was a conflict, in the end, between many ofthe existing charities and those that came up—a bitlike Help for Heroes. In my case, the charity, whichwas set up to help children, creamed off a lot of theresources. A lot of good work that was done byexisting charities fell by the wayside. Do you feel thatthere is a downside to the popularity of one particularcharity? Does that create a risk for you?Major General Cumming: That is always apossibility. We have been around a very long time andwe aim to be around for a long time still, fulfilling, Ihope, a task that has thus far proved enduring, forwhich I believe there will be a need in future. Therewill always be peaks and troughs of interest andpopularity for the Armed Forces. With that will go theassociated new charities and old charities—funds willgo up, funds will go down, and so on.If I had a mission in life, it would be to say, “We doa very good job in support—entirely—of the ArmedForces. We do not exist except to do that; that is oursole aim, and we look after people and individuals.”If we are doing a good job now, my absolute intentionis that we will go through this hiatus of sharp growthsin the number of charities that are working for theArmed Forces doing what we do. I wish to come outat the far end, when things are going down into thetrough, still doing a good job that we believe isimportant—so long as the Armed Forces require us todo it.In other words, our philosophy would be that this isnot the time to invent or reinvent ourselves or to say,“We should be doing a bit of this,” when we knowthat others are doing it already. Instead, we shouldstrive to continue to do our job exceptionally well. Weshould always be seeking the opportunity, should itarise or should we be required, to do somethingnew—as we are about to be asked, which I alluded to.Essentially, we should do what we are doing and doit well—we should come out of it doing well and goon doing it well.Commodore Branscombe: There is a differencebetween the long-haul 125 years and doing thingsbehind the scenes for people. Raising funds for peoplewho are doing things for others—in other words,services—is not an easy or popular thing to do.Raising money for high visibility but relativelytemporary infrastructure projects is always mucheasier. So there is a downside—not that I am criticalone way or another, because you clearly needpremises in which to do things. But the rather moredifficult things, widely broadcast, such as gettingvolunteers to work with individual families, whereverthey may be, employing mental health social workersor paying the travel costs for someone who needs to

go to see somebody are not easy things to raise moneyfor. There is only a certain amount of money to goaround. As the controller said, we have not haddifficulties at the present, but when uncertain financialtimes come along, there may well turn out to be somekind of conflict.

Q265 Mrs Moon: It is said that organisations growto fill a vacuum. Was there a vacuum that requiredfilling by a new organisation such as Help for Heroes?If so, in what way has it been successful? What has itbrought to your field that has generated a new raft ofgiving and engagement?Air Vice Marshal Stables: Andrew referred to it. Thebrand caught the imagination of the nation at a timewhen there was a fair amount of media pressure aboutthe inadequacy of the Government to meet what manysaw as the responsibility of the Government and thestate, particularly regarding the care of the wounded.One can refer to many media articles about thecondition of people in Selly Oak and the lack offacilities at Headley Court.I have to tell you that most of that was ill-informed—I say that as Chairman of the Headley Court Trust—but I think that there was a perception among theBritish public that people who had served theircountry and been wounded in that Service were notbeing properly cared for and looked after. To someextent, there was truth in that, but by and large, therewas far more media speculation than there was fact.Nevertheless, there were some gaps. The moneyraised by Help for Heroes has certainly helped to fillsome of those gaps in a way that we probably couldnot have done otherwise. I do not believe that theService charitable sector, joined up as it may be,would have done so, and I certainly do not think thatthe Ministry of Defence would have done so. Thewhole of the recovery capability has been enabled bythe £100 million raised by Help for Heroes, and weshould not take that away. What it is setting up in thatrecovery capability is something that was not therebefore, which was needed, and it will enhance thequality of care and the transition of people out of theArmed Forces and into civilian life.Chair: Before I call Mr Havard, Major GeneralCumming would like to come in.Major General Cumming: Since SSAFA is here,following on from what Tony has said, I think wemight just blow our own trumpet. We go about whatwe can do to help the Armed Forces in a very differentway from Help for Heroes. It would say that it isgoing to raise money and build you a swimming pool;we would talk to the Ministry of Defence and ask,“What do you want?” Out of that would come arequest: “Can you do something for the families?” Atthe same time as it started, so did we. Within 18months we had raised what we had wanted to raise,which was about £5.5 million. We stopped at thatpoint because that was enough to fund the two homesand run them for a fair amount of time. There aremany ways of doing this business, and we are firmlyof the belief that we should not be thrusting somethingon people, but acting in concert with them to seewhere it is that we can fill the gaps that are appearing.



Q266 Mrs Moon: Forgive me. I was trying to clarifywhether there was a particular ethos within thefundraising of Help for Heroes that helped generatethose funds and public engagement in a way thatwould make you look back and say, “Gosh. That isthe way of doing it.”Major General Cumming: Absolutely. There were ofcourse organisations in existence, not least theprincipal benevolent funds—RAF, Army and Navy. Icertainly think that what Help for Heroes did was giveeveryone a kick up the backside and bring a new,modern and bright approach to the whole thing. Thatdid no one any harm at all.

Q267 Mr Havard: There was an interestingdiscussion on the radio earlier in the week about theRound Table and the way in which it presented itself.It was exactly this debate about whether the approachof Help for Heroes raises questions for all sorts ofcharities about the way in which they position, brandand market themselves.May I turn to a more prosaic thing? The Ministry ofDefence internal audit recognised that there had beena step change in charitable funding. It also looked atthe Department’s relationship with the charities.Given that there has been this increase in the money,how much of it is substitution for things that theMinistry of Defence should be doing?Major General Cumming: If I may just speak from aSSAFA angle, I do not believe that we have set out togenerate more funds to take over those things that theMinistry of Defence should be doing. At the risk ofrepeating myself, I want to reiterate that, for the veryreason that everything we do is in support of what theArmed Forces need, we do not do anything unlessthey want us to do it. We may, from time to time,identify what we see as a gap and ask whether we canhelp to fill it, but they can always say no. I do notbelieve that we are out there seeking funds to takeover something that the Government should be payingfor, and I am speaking there for SSAFA.Commodore Branscombe: I can only reinforce that.We should be putting our financial and humanresources into something that Government could not,or should not, do. There is a distinction between thetwo. I do not believe that we should be finding ashortfall in public funding when facilities should bepaid for by the Ministry of Defence, the Departmentof Health or whoever.Our Norton Homes were a prime example of that. Wechose to procure or to buy very high-quality housesoutside the perimeter of the MoD establishment,entirely run on civilian grounds, because they werefor the families. Actually, although the MoD has aresponsibility vicariously for families, in practice it isnot responsible for their accommodation. That is butone example. On top of that—because there are thingsthat we believe we have the expertise to do for apopulation that is largely civilian—most of theproblems that we are dealing with, whether theyhappen to be health, welfare or whatever, are theproblems of people, rather than being intrinsicallymilitary.

Q268 Mr Havard: It obviously falls to us to ask thesceptical questions, which was why I asked theprevious one. “Was the Ministry of Defence takingany advantage in some of this?” might have been abetter way of phrasing the question. The internal auditsays that “now”—in January—this is being done in amore targeted and co-ordinated way, which suggeststhat previously it perhaps was not. How much of thisis to do with capital projects?Major General Cumming: What—

Q269 Mr Havard: The increase in the funding andmore money coming in to do these different things.What is the balance between capital projects andrevenue? Is that significant? Is that something weshould understand better? It might not be.Commodore Branscombe: I can answer only forSSAFA. Our problem, as we have said, is raisingcosts—operating costs. On infrastructure, although, ofcourse, we needed to raise the money to purchase theNorton Homes, the majority of what we do is fundingour people, whether they happen to be paid-for staffor volunteers. It is not for me to speak for Help forHeroes, but its main thrust is to provide swimmingpools and gyms, and to build infrastructure. Thatcould be a capital programme on MoD or otherproperty.Air Vice Marshal Stables: Most charities—I certainlyspeak for the Headley Court trust because we astrustees took this view—think that they should not bea substitute for a proper call on the public purse. Thereare projects at Headley Court that we have refused toaccept as trustees because we felt that they were aproper call on the public purse. You have to measurethis with a certain amount of realism and pragmatism,inasmuch as the public purse is often empty. Whencharities are looking for a good outcome, and well-being and improvement to people, it actuallysometimes gets a bit blurred.

Q270 Mr Havard: The reason I interrupted earlier toask about the mixture of grant-aid money and othermoney is that the structure is changing. There is nowmuch more contracting—your ability actually to pitchfor contracts, the £10,000 limit and so on. I know thatyou now have a conference every year where youcome together to discuss strategy, practices and so on.How well do you think these processes are runningoverall, in terms of the MoD being able to make useof the money in the proper way you describe?Air Vice Marshal Stables: I should think that they arein their infancy.

Q271 Mr Havard: Right. What do you need to do?Major General Cumming: I think that we probably—all of us—have our own checks and balances withinour own organisations. We are a completelyindependent charity, and that means just what it is. Ithas its own board of trustees. It has its own charterand its own set of objects, and although it is of courseour job on a day-to-day basis to do the devilry, to dothe work, and to seek the opportunities and so on, intheory we cannot just go out and do things. We needto carry with us the board of trustees, who, honest



men and women as they are, will hopefully observethe objects of the association.

Q272 Mr Havard: I was thinking more in terms ofthe structures that you now face—how you interfacewith the MoD and how you collaborate. Is the processallowing the money to be used well, or are thereprocess issues to be addressed that could make itwork better?Commodore Branscombe: Perhaps I can answer that.The MoD is, of course, not like some of the otherGovernment Departments in terms of spending withcharities to let contracts to deliver services. It is notlike health and social care, or whatever. I guess thatwe are kind of unique, not least because of our longhistory of delivering health and social welfare servicesto the MoD, which we originally did whollycharitably, and then it paid us for that. If the questionis whether there is any kind of obstacle there, takinginto account that the MoD is different, its money tendsto run in a disaggregated way rather than being drivenby central policy. As a person who has to deal withthe MoD daily, that disconnect between central policyand the spending sections of the MoD can lead toinefficiencies.

Q273 Mr Hancock: May I take you back to thedifference when getting a large capital grant towardsequipment? We could use Headley Court as anexample. There are long-term revenue implications forthe staff who have to use that equipment and bearound to help Servicemen over a long period of time.Is it compatible that you just go on taking charitablegifts of equipment and what have you, but do not askfor the long-term revenue contributions needed tomaintain them? Who will pick up the price 10 yearsfrom now for the facilities that we have createdbecause of the largesse of the British people throughHelp for Heroes?Air Vice Marshal Stables: I think you have hit on oneof the difficulties, which the Ministry of Defencewoke up to rather late in life. In respect of personnelrecovery, the Royal British Legion has of courseundertaken to provide the long-term running costs ofthose services, so I think that, certainly 20 years out,their future is safeguarded. However, you raise a veryinteresting point with Headley Court, in myexperience there, in terms of people’s willingness todonate equipment and then look at the long-termrunning costs, which clearly fall upon the Ministryof Defence. I am not sure whether the Ministry ofDefence—and you should ask them, not me—actuallycomes to a judgment before accepting these kindoffers. Certainly we in the Headley Court Trust haveput in place people, such as recreational therapists,who we funded, but with an agreement with theMinistry of Defence that, were they successful, itwould assume the funding within two years ofstarting. Every time that we have acted, we have doneso with an agreement that it formally takesresponsibility at a point in the future, but I am notsure that that is true of all capital equipment that hasbeen put in there.

Q274 Ms Stuart: This is pretty much the samequestion, but with a slightly different outlook. Did youactually want the swimming pool?Air Vice Marshal Stables: I cannot tell you, but Ishould ask the Surgeon General in the Ministry ofDefence to answer that question.Chair: I am sure that we will have the opportunity.Mr Hancock: You could ask, but I won’t, although Iwill mention it.Chair: I was not suggesting that you do.

Q275 Mr Hancock: Perhaps because of the attitudeof the Ministry of Defence to what is happening atpresent, is there going to be an adverse reaction toyou?Major General Cumming: There could be, couldn’tthere? That is why I emphasise the importance thatwhat we should be doing as a charity is notreinventing ourselves on the back of currentpopularity, but continuing to do what we have doneso well before, although always aiming to improve theway in which we do it.In a slightly different way, we very quickly set up theappeal to buy these two homes for the families. Withinthe business plan of that, we built in the thought thatwe would certainly have to be running them for three,four or maybe five years, so that is all self-contained.Who knows what will happen in the future, but thereis always the anticipation that the need may no longerbe there in about five or six years’ time, in which casewe can sell them, move on and reinvest the moneyinto something else that the Armed Forces need. Wehave our own in-built flexibility. We do not expectthe Armed Forces or the Ministry of Defence to payfor that.Cathy Walker: May I just reflect slightlyphilosophically on some of these questions? I thinkthat the relationship between the Ministry of Defenceand the ex-Service sector broadly is slightly in itsadolescence, in that it was not really until a Ministerfor Veterans was appointed—in 2002, I think—thatthere began to be an engagement with the ex-Servicesector, at least over veterans.Clearly, there had already been a relationship, and wehave had a long relationship on our in-Servicecontracts. However, this engagement with the ex-Service sector and recognising that it includescharities—sovereign bodies with their own trustees;not agents of the Ministry of Defence that can be toldwhat to do, which it felt like a little bit at thebeginning—is a newish and an adolescentrelationship.I do not think that, corporately and historically, theMinistry of Defence or the single Services have hadexperience of being offered money and hearing,“What would you like us to do with this?” or, “Here’ssome money; can you prioritise it; and how would youlike to spend it?” It is extremely difficult for it toaccept even charitable money. Tony can tell the storyof the washing machine at the laundry at HeadleyCourt, which is quite entertaining. With everythingelse that is happening—the restructuring andredefining, the Strategic Reviews and everything elsegoing on in the Ministry of Defence—this relationship



with the ex-Service sector and the charities is stillbeing learned.

Q276 Mr Havard: That was why I quoted the word“now” from the internal audit in January. It states thatthis is “now” being targeted better, which assumes thatbefore it probably was not. I asked the questions aboutthe process for sustainability, because the process canchange to deal with the immediate, but it may nothave the longevity to deal with your questions ofsustainability.Cathy Walker: And sustainability for projects forserving personnel is obviously for the Ministry ofDefence. But the one-legged or three-limbed veterannow looks—dare I say—sexy, and we can fund raiseon the back of that. A Falklands veteran in awheelchair now looks like a sad old man, and today’sAfghanistan heroes are going to look like sad old mensitting in their wheelchairs in 20 or 30 years’ time,when people around them are going to say, “Whathappened in Afghanistan?” That is the burden on us;it is not a burden on the Ministry of Defence.

Q277 Mr Hancock: That is a very good point, andone that our Report needs to establish clearly. You seeit all the time. Living in a city like Portsmouth, I seemany of the victims of the Falklands war, includingmembers of my own family, who never recoveredfrom it and are just as you describe. To what extentdoes SSAFA work with those who have been injuredin current operations, if at all?Major General Cumming: The answer is yes we do,but at the moment there are not that many of them.Most of them are still being retained in the ArmedForces, so they are mostly being looked after by theMinistry of Defence, one way or the other. Of coursesome have left and those who need our help havecome to us. I will hand over to Paul in a secondbecause there are some very practical examples ofwhat we do, particularly through our health service inGermany. In fact, Paul, why don’t you pick up on thatpoint now?Commodore Branscombe: We do come into contactwith them while they are still serving because ourhealth services operate in the overseas bases. As wespeak, there are many people deployed from BritishForces Germany and sometimes from Cyprus, wherewe are responsible for many of the health services.We prepare them to deploy with immunisations,vaccinations and all those sorts of things in theirhealth checks. More importantly, we look after themwhen they recover, whether they recover injured or fit.One of the most significant things is that we run acommunity mental health team in Germany that isable to respond not only to those who have returnedfrom operations, but their families. That is a reallyimportant matter, particularly when we can look aftera family as a holistic unit.I make that point only because of the distinctionbetween what happens in the UK and overseas. We donot, obviously, operate health services in the UK, butwe have social work services, and it is for not onlythe Army but the RAF and others. We have directcontact with those who come back wounded. For all

those who end up in Headley Court or through thevery high visibility pathway, there are many withmuch lesser injuries. You can have all sorts of injuriesshort of needing a leg amputated. We deal with thosefrom a welfare as well as a health point of view. Theanswer is that we see those, but equally we see theirfamilies very freshly. The first place a family goeswhen they get the call that their nearest and dearest isin the Queen Elizabeth Hospital in Birmingham maybe the bedside, but within two or three hours they areprobably being accommodated in our home, which isrun by Cathy. It is not just a very comfortable placefor them to sleep and rest, but a place where they geta huge amount of pastoral and professional supportwhile they are going through that hideouslytraumatic experience.Chair: Given our intention to finish at about 4 pm, Iwould like fairly snappy questions, if that is okay, andfairly snappy answers, too.

Q278 Mr Hancock: What do you think about thesupport services that have been given to those whoare not injured or wounded on operational duty, butreturn to this country for various reasons or leave theService with long-term health issues? Where do youthink the State lets these people down? Where are thebiggest problems?Major General Cumming: I suspect that the biggestproblems lie among those for whom the wound isnot visible.

Q279 Mr Hancock: You meet these people, so whatis the group you meet most often?Major General Cumming: Still the people that Cathywould meet most often from the veteran community—those who have left and need help—are of the oldergeneration. Typically, your average client is a 70-year-old male from the Army, is he not? It is hard toprovide concrete evidence for this, but it seems thatthere are more younger people who are coming to seeus. That might be just as much as a result of suchthings as debt as anything else. We will know onlyabout the people who ask to come and see us. A lotof people get referred to us, but in the end it is theywho come to us.Cathy Walker: I would add that people come to us forhelp because of a problem that has not necessarilybeen caused by their Service. They will come to usbecause they have served and are therefore eligible tocall on us for help, but it might be because they havea mobility problem in their later years. You couldargue that their mobility problem was going to happenanyway because they are getting older, or you couldargue that their dodgy knee was caused by the factthat they fell down a hole while they were on exerciseor on operations. The situation becomes very blurredthe older people get. I know one example that Paulwould use of an old gentleman with Alzheimer’s. Isthe Alzheimer’s attributable to his Service, or is hecoming to us for help because he is an ex-Serviceman? The further away from Service you get,the more blurry the answer to that question becomes.Air Vice Marshal Stables: May I raise two issues?The first is that there are most certainly gaps in



transition. I think that we recognise that there needsto be a rather more holistic approach to the transitionfrom the Armed Forces into civilian life. That ishighlighted in the recent Howard League for PenalReform report, which looked at veterans in prison. Ithighlights that transition issue. The second issue alsocomes from the Howard League, which looked atveterans in prison typically 10 years removed fromService. Generally, those are custodial sentences, notService-caused or related. That is equally true of thosepresenting with mental health problems and withhomelessness in London. The Howard League findsno reason for that 10-year gap, so we have a group ofpeople at the 10 to 13-year point, but we also haveweaknesses in the transition part. We identified thatwhen we went to the Big Lottery Fund, and we arenow hopefully a matter of weeks away from a lotterygrant of £35 million, with which we will address thistransitional issue.Chair: We are just about to get on to psychologicalissues.

Q280 Mrs Moon: Just a thought that you might wantto carry with you. As an MP, when people come toyour surgery, there are two things that you usually tryto clarify fairly early on: whether they are in a tradeunion, and whether they served in the Armed Forces.You know that if the answer to one of those is yes,there is a whole gamut of support that you can goback to that you know you can engage on their behalf.I would like to talk about mental health difficultiesand your assessment of the MoD’s capability to assessthem while people are in Service. Is there a problemwith people who are identified with mental healthdifficulties almost being passported out and thattransition issue? Is the MoD is effective enough, inyour view, at picking up post-traumatic stress arisingbecause of Service, as opposed to a mental healthcondition that develops while in Service? Will yougive us your thoughts on those?Air Vice Marshal Stables: I will just pick up twopoints. I think there is an acknowledgment that theArmed Forces can do far better in transitioning peopleon a medical discharge with psychiatric illness intocivilian life. This comes back to the holistic view.Quite often somewhere to live is the most importantfactor, rather than seeking psychiatric care for thecondition. I do not think that the MoD hastraditionally taken that view. You could ask why itshould; after all, it is a war-fighting organisation, nota welfare organisation. There is a recognition of thesituation, however, and I am quite sure that we willcome to a better way of transitioning people throughthat care pathway. I am slightly more confident aboutthat. I sit on the War Pensions and Armed ForcesCompensation Appeal Tribunal, and I have to say thegenuine incidence of PTSD that we see is really quitesmall. The Howard League makes reference in itsreport to the low incidence of PTSD. That is not to saythat there is not a relatively high or larger incidence ofmental illness; there is, but PTSD itself is relativelysmall.

Q281 Mrs Moon: Commodore Branscombe, youtalked about the CMHTs that you operate. Do youoperate CMHTs within the UK?Commodore Branscombe: No, because overseas, inbases where families are, the MoD is responsible forthe health care and we do it alongside the MoD forthe benefit of the families, but of course we do notdivide between the families and the serving people. Tocome back to your question about whether the MoD isadequately providing mental health services forserving people, I think in general the answer is yes,and it is not just from the clinical, psychiatric andcommunity mental health point of view. Some of theself-help processes around TRiM, for example, andmutual support provided by individuals is pretty good.Having said that, there is no doubt that—I put it inwritten evidence—there will always be reluctanceamong some people to seek assistance from theirmedical officer when that medical officer is also anemployee of their employer, if I can put it that way. Ihave direct experience of that. That may not be thefault of the system, but there may be some reluctanceamong people to seek assistance. For example, if youare a fighter pilot and you need to go and say, “I thinkI might be a bit wobbly”, you will lose your job prettysoon, or it will follow fairly close on from that.Transition is very difficult, because nobody knowsexactly where the person is going to. But equally,although it was not part of your question, does theNHS pick up? Where it knows and it gets thathandover, it works. Reservists are a special case,because they are neither fish nor fowl in that sense.The area in which I have concern and directexperience is in the mental health of families—theyalso serve who watch and wait at home. There is nodoubt that the transmission of stress to wives andchildren, as a result of continuous operation,deployment, separation, uncertainty and, indeed, theworst happening, has a bad effect. Low-level mentalhealth problems and the problems of potentialdomestic violence and so on, which could be said tobe a by-product of these sorts of things, are difficult.In Germany, our combined social work and mentalhealth teams are able to work in a proactive andpreventive way, and we know that we head off anenormous number of problems that would otherwisebecome acute. In the UK, there is a difference.Whereas the serving soldier will be looked after bythe MoD mental health services, in general thefamilies will not be, because they are NHS patients.That is not to say that the NHS locally is not verygood. There are good examples where particularlytherapeutic services are good, but it is a postcodelottery. If you do not fit into the norm—this is part ofSSAFA’s theme—we tend to pick up the people whofall between the cracks for one reason or another. Ihave some concern that the holistic support forfamilies, in a proactive and preventive way, isprobably not as good as it might be. That is notbecause of a failure of either the MoD or the NHS. Itis a matter of logistics, geography and circumstance.I would also reflect on the statement that PTSD is notthe great bogey that we think it is. It happens, butthere are many other lower-level mental health



conditions. Depression and anxiety are the realproblem—and, finally, alcohol.

Q282 Mrs Moon: Are you happy with the range oftreatments that are available to both serving personneland those who leave the Services?Cathy Walker: Those who leave the Services comeunder the NHS.

Q283 Mrs Moon: I am thinking about those wholeave the Services and then need to be passported intothe NHS.Commodore Branscombe: We all know that mentalhealth services have often been the Cinderella of theNHS. However, there are exceedingly good mentalhealth services in different parts of the country,including therapies that are not just psychiatricservices. Again, it is variable. Remember that we arenot just talking about England. People pass from theServices to Scotland, Northern Ireland and whatever.Mrs Moon: I think “whatever” is Wales.Commodore Branscombe: Yes.Mrs Moon: Sorry, but I am a Welsh MP.Mr Havard: You are surrounded by Welsh MPs.Commodore Branscombe: I beg your pardon. So,there is not a general answer, but you can be lucky.Or unlucky.Air Vice Marshal Stables: Sitting on an appealtribunal, I see sufficient evidence that it does notalways work. In fact, in many instances, it is notworking at all.I think we have an issue with transitioning andpassporting people into the Service. I think it is better,but historically, we have had a large number of legacyissues with people who have mental illness. They areparked now, medicated and contained, and that is thebest you can say; their prospect of becoming fit againor being put into employment is very remote. If youwere to sit on the tribunal that I sit on, you would seethis almost every time we meet. We have not donewell in the past, to be honest, but I would be rathermore optimistic for the future. In fact, we could notdo as bad as we have done before, so we have got todo better.

Q284 Mrs Moon: I think that that is true of mentalhealth generally. How great is the difficulty of mentalhealth problems generated because of active Service?Is active Service creating an increased problem forpeople developing mental health problems?Commodore Branscombe: The King’s Collegeresearch and others show that the incidence is nohigher in terms of long-term effects. The incidence ofPTSD, if we are going to take that as the extreme endof the spectrum, is actually less, age for age, in theserving population, whether they have been in combator not, than it is in the general population.Air Vice Marshal Stables: The majority we see atappeal do not have the Service causation, but thenyou might reasonably expect that, because it wouldotherwise have been accepted by the MoD as acondition and the appeal would not have happened.

Q285 Bob Stewart: General Cumming, yourmemorandum suggested that alcohol in the ArmedForces was exacerbating mental health problems.What do you recommend should be done to try tostop this?Major General Cumming: Stop drinking.Bob Stewart: I have to say that they selected me forthis question, particularly that lady over there—theWelsh one.Major General Cumming: I don’t think it’s for us tocomment on that—Bob Stewart: Not personally.Mr Havard: Take more water with it, Bob.Major General Cumming: There is something aboutcasual drinking in the Armed Forces for a wholevariety of reasons, not least because, I guess, for themost part, there are a lot of men and women togetherand that is how it goes. I would not dream ofcommenting on how it should be handled. Theevidence would suggest that the less drink is taken,the fewer issues one has. I am not sure that I can saymore than that.Air Vice Marshal Stables: I spent 42 years as a pilotin the Royal Air Force, and I suspect that Membershere who have served in the Armed Forces willrecognise that it is considerably better now than it wasin the past. Maybe these are just incremental changes,and you may come to a totally different culture within10 or 15 years.

Q286 Bob Stewart: May I ask Mrs Walker thatquestion, because she has been not only a servingofficer herself, but the wife of a serving officer?Would you have any way of trying to cut down thedrinking further? It is true that the culture haschanged, but is there any other way of trying toencourage particularly young men to cut it down?Cathy Walker: Crikey. Probably not, because asAndrew said, it is a bit like playing rugby. You are allchaps together after a bit of an adrenaline high andwhat are you going to do? If there is drink there to behad and it is under control, it’s fine. It is just when itgets out of control that it is a problem. The momentthat it becomes a problem is when it gets out ofcontrol and when behaviours start to change becausethere has been too much drinking, or it is doneprivately or secretly. The character then changes. ButI do not know whether that is done. It has been a longtime since I served, and it has been long time since Iwas a Service wife. As Tony was saying, I see adifference now. For example, one does not see alcoholat lunch time anymore, certainly not in officemeetings; 10, 15 or maybe 20 years ago, there mighthave been.

Q287 Bob Stewart: So the culture is changing and itis bringing it down because people just do not thinkit is acceptable.Air Vice Marshal Stables: I cannot think of anysimple measure to reduce drinking. If there were one,the Armed Forces would have taken it in the past, andthey have not. Incremental culture change is probablythe only way. I agree with what Cathy said. If I go



back to my young day—perhaps I shouldn’t talk aboutmy young day.Major General Cumming: I understand that all theentertainment allowances are being reduced, so thebrigadiers’ dinner party on water and orange juicemay well lead the way in this respect. It has startedalready.

Q288 Ms Stuart: Paul Branscombe, you mentionedthe postcode lottery and unevenness in provisions. Tocome back to community mental health support,Andrew Cumming, do you notice any specificdifferences between England and the DevolvedAdministrations?Major General Cumming: If I may start very broadly,I will then turn to Paul, who is the expert on this. Ifyou want to go into old age in peace and comfort, youmight as well live in Scotland—it is not a bad placeto be at all. It is certainly probably rather better thanEngland and Wales, and even Northern Ireland mightbe better. Funnily enough, we run a branch in theRepublic of Ireland, but we have not tested it yet.Scotland has a reputation for its dealings with all sortsof things, so it would appear—with health andeducation and the way it handles its veterans. It is amuch cleaner, neater operation up there. It would beas well to be a Scot.

Q289 Ms Stuart: And of course there are far fewerof them. Tony Stables, what about members of yourorganisations? Do you provide support across theUnited Kingdom or is there a bias towards certainparts?Air Vice Marshal Stables: No. In fact, VeteransScotland is a member of our executive body, so weembrace it.If I have one concern, it is the delivery of service andsupport of veterans by other GovernmentDepartments, because postcode lottery is compoundedby Devolved Administrations. Someone said to merecently, “I lost my leg in the Service of my country,not in the Service of East Midlands, so why shouldn’tI have parity across the United Kingdom?” That isquite a political issue. The delivery is vested in trustsand other organisations—subject to Governmentguidelines, presumably—outwith direct Governmentcontrol. For example, how do you ensure that thestandard of prosthesis replacement is commonthroughout the United Kingdom?

Q290 Chair: We heard that as an issue when we wentto Headley Court. There was a worry that althoughfantastic artificial limbs are given to those who areserving, they might not receive such a good serviceafter they have left the Armed Services. Is that aconcern that you share?Air Vice Marshal Stables: It has been a concern.Together with the General Secretary of BLESMA, Icalled on the Minister, Simon Burns, some six monthsago. He put in place a study by Dr Andrew Murrison,who will shortly report. In fact, he very kindly sharedwith me last week his final draft on the issue ofprosthesis. He has been looking at the standard offitting, because as you rightly point out, it is a rather

more technical leg, which, frankly, the NationalHealth Service were not trained to deal with. He hasalso looked at the provision of future prosthesis.Where do you set the bar in a situation that ischanging technically almost by the month? It is acomplex issue, but I shall leave it for Andrew’s report.The draft that I have seen is extremely good and headdresses all the issues.It raises another interesting point about other deliveryof services by Government Departments, such as theDepartment of Health or the Department for Work andPensions, when there is a local issue. For example, Iwas talking with the mayor of Solihull recently. Hesaid that he had recently become aware that thepriority for the provision of social housing in Solihullfor ex-members of the Armed Forces was equal to thatof prisoners coming out of prison. He said, “Do youthink that’s right?” I said, “It’s a matter for Solihull,”but you realise that what is a matter for Solihull is amatter for a different council somewhere else.Priorities will be afforded differently.

Q291 Mr Havard: What do you take from that?Many of the things that will be in the Covenant mightnow have a more legally based authority. People willbe able to ensure that they get some consistentapplication across an increasingly disparatecommissioning and provision regime. People will betrying to deliver a central policy from the Ministry ofDefence across a disparate set of organisations.Air Vice Marshal Stables: The recommendations inDr Murrison’s report to address that might reasonablybe used as a blueprint in other areas.

Q292 Ms Stuart: Paul Branscombe, I cut you off.Sorry.Commodore Branscombe: No, not at all.Prosthetics is but one example of services that mayneed to be provided locally. One perspective of whatis different about Service personnel and, to an extent,relatively newly discharged veterans, is that they arehighly mobile. The postcode lottery would apply toyou if you were static in one place and going toremain there. The fact is that Service familiesconstantly have to move. Whether you need aprosthetic leg, you have a disabled child or you needto adopt a child, services will vary by local provision.The same will happen to an extent if you need mentalhealth services or anything else later on, becauseService personnel rarely end up where they are firstdischarged, for all sorts of reasons that should berelatively obvious.This is not a political point, but I have to say thatthe situation is not helped—this relates to health inparticular—by the fact that the money-spendingcommissioners are likely to be in a state of disarray.We are talking here about England, but we also havetalked about the Devolved Administrations. We arein a position to make some comparisons between thedifficulties of the north-east versus those of the south-west. There are fiscal and organisational realities. Iam not that optimistic about the outturn and whetherfunding will be available to ensure that a particularservice continues to be provided.



My only optimism is that the NHS, or the Departmentof Health through the NHS, has reacted prettyimpressively by setting up Armed Forces forums,which, for the first time, have representatives ofprimary and community health care trusts, communitymental health care trusts and charities. For the firsttime, we have truly local discussion about what theresources are. We have a visibility of the reality of theneeds of the serving and the ex-Service population. Ihope that those forums can continue, but they are onlyas good as having part-time representatives from thetrusts, some of which are being abolished as we speak.

Q293 Mrs Moon: Major General Cumming, can youtell us about the work you do with bereaved families?What support do you give and how long does it goon for?Major General Cumming: This is something that westarted as a result of conversations with the Ministryof Defence—on its initiative. It asked whether wecould do something to help bereaved families. As Isaid, several groups are involved. They run quitesimply on the basis of self-help. In the case ofbereaved families, the lead is someone who lost hisson—he is the appointed chairman. We simplyfacilitate what the groups do; it is they who give thetherapy—I don’t know whether that is the rightword—through the conversations they have with eachother to take them forward and so on.We run the groups for as long as they are needed, butthey are almost self-determining. I would rely veryheavily, for example, on that chairman to judge theappropriate moment to finish. He might say, “I thinkwe have achieved what we want to achieve.” Ofcourse, people are being bereaved all the time, so it israther hard to say how long they would go on for.SSAFA is such that whether you specifically align thisto the current operations going on, or you say there isa general need for such groups—indeed, somemembers of the group have not necessarily beenbereaved as a result of war; people might have beenkilled in motorbike or car accidents, or by falling offa mountain or while parachuting—this is open toeverybody and it gives them the chance to talk toeach other.

Q294 Mrs Moon: Family life can be messy, andrelationships are sometimes quite complex whensomeone dies. Who do you find yourselves workingwith? If it is a single young man, do you work withhis parents’ families or perhaps with his girlfriend andher family? If it is someone who was married, but hadseparated and at the time was with a girlfriend, whodo you work with?Major General Cumming: One hears the mosthorrendous stories about managing the bedsidemanner when the boy is brought out of his inducedcoma. There are terrible stories such as people saying,“You can’t put them together, because he’ll think he’sgone to hell,” or very complicated ones such as, “He’llthink he’s gone mad, because his parents haven’ttalked to each other for 20 years.” I will turn you overto Paul in a second, but we have a qualified socialworker who is very experienced in these matters and

is, if you like, the brains behind it—the mover andshaker, and the person who gets these things going.Cathy Walker: Before you hand over to Paul, may Iadd that you might get some examples of this whenyou go to Norton House tomorrow, because there theyare doing this all the time? They are recognisingthat—Ms Stuart: I understand the problems. Some of themend up at my constituency advice surgery.Major General Cumming: Our chairman was up therethe other day, and he had been warned that there wasa family there whose son had been very badlywounded, and that they were terribly angry and reallyout to get someone. He went with our president. Thetwo of them went into the ward, and before long theyfound themselves confronted by this family, who,rather than gripping them by the throat, said, “Do youknow, the very fact that we are in this Norton Househas made us realise that we are not alone and thereare other families we can talk to.” So therapy beginsquickly.Commodore Branscombe: If I may just add to that,the answer to your question is all of those, becausewe understand all the complexities of the family,whether its members happen to be legally married,partners or whatever. Interestingly enough, the groupswere started not necessarily for widows—in someways, the widow, if she is the next of kin, gets thepension, all the sympathy and everything else—butfor those who are not legally married, or who are themum, the grandparents or, most importantly, thechildren or siblings. I made the point earlier that ifyou are killed between the age of 18 and 23, you arelikely to have younger brothers and sisters.As Andrew pointed out, we also recognised that youoften have very subtly to separate these people. Youcannot just make the assumption that when we arehelping to look after the widow of somebody killed,the children will want to be in the same group,because the children want to talk to people of theirown age who have suffered the same kind ofexperience, but they do not want mum there, becausethat inhibits them. It is hugely complicated, and forthat reason it is relatively costly. Enabling means thatwe have to give them not only the social worker, whoworks subtly in the background, but the venue, andvenues often have to be at weekends, or at times andin places that are relatively costly to organise.Bob Stewart: The Elizabeth Cross must be anightmare to allocate sometimes.

Q295 Mr Havard: People going into the operationaltheatre are asked to nominate the person they wish tobe contacted—not necessarily the parent or whoeverhas immediate legal right—before they go. Youpresumably start from that process. Is that correct?Commodore Branscombe: Yes, of course, but there isa major difference between what we can call thebusiness of casualty notification and the legalistic stuffthat needs to be done, and what we are talking abouthere: pastoral support to the extended family—extended in both time and space.To answer Gisela Stuart’s question about how long, Iagain emphasise that it will be as long as it takes.



Nothing succeeds like success. Of course, although itstarted with a view to those who are most freshlyaffected, they then brought their friends, and wesuddenly had people from Northern Ireland and theFalklands, so we are just growing and growing.However, the experience is the same—or verysimilar—and in some ways that is a great strength. Ifyou have already been through it, you have anenormous amount to give to the person who is not yetthere. I hate using the expression “journey”—itsounds social work-like, doesn’t it?—but people areable to help each other at different stages through thejourney, and that is hugely important.Cathy Walker: May I give another example of theway we have supported bereaved families of formerand current operational casualties? For many years,we provided a sort of neutral platform through theDefence Widows Working Group. We were able tofacilitate discussions between the three Services’Widows Associations and the people in the Ministryof Defence or the single Services who wereresponsible for what happened to people on all thenitty-gritty issues that theoretically worked well, butdid not always do so in practice. That is an exampleof something self-effacing that we do: just helpingpeople to get together to sort out their problems. Thatworking group, which used to be chaired by us—thechairmanship was then handed over to the chair ofone of the widows associations—is now within theMoD. There was a recognised facilitation exercise thatwe did on some of the practicalities, such as whenyou tell a person that their husband had been killed.Those are all the sorts of things that do not alwayswork in the way you imagine that they will, such ashow the visiting officer is going to appear and help.That is another example of how SSAFA has beeninvolved historically with supporting bereavement inthe round.

Q296 Mrs Moon: Can you give us an idea of howmany people you have working in this field?Cathy Walker: In the bereavement field?Mrs Moon: Yes.Commodore Branscombe: We have one senior socialwork manager who co-ordinates the groups. We alsohave social workers and health staff working invarious places. Our volunteers are trained inbereavement and loss work. I cannot give you anexact answer, but the answer is that this is somethingthat we take seriously and are capable of doing atevery level that is needed.

Q297 Chair: Air Vice Marshal Stables, is thereanything that you need to add to that, or has it allbeen covered?Air Vice Marshal Stables: No, nothing.

Q298 Ms Stuart: To follow up, Cathy Walkerreferred to the relationship since the creation of theVeterans Ministers between the charitable sector thatwas giving and doing and the MoD. You said that, ina sense, both sides are learning. What would you do ifyou had one wish for how to improve the relationshipbetween giving and doing on both sides?

Cathy Walker: The Data Protection Act.

Q299 Chair: What would you do with the DataProtection Act?Cathy Walker: We do not want everyone’s data abouteverything, but we want to be able to help people whomight need help without there being a reason given,and that comes to the Data Protection Act. I think thatthe Ministry of Defence is working extremely hardwith us to try to allow the transfer of some data. Ithappens easily within the Service Personnel andVeterans Agency, but it is rather more difficult to refersomeone out to the charitable sector. Through thegood offices of COBSEO, in fact, we have been doingquite a lot of work with our colleagues inside the MoDto try to make this work better.There has been a lot of ignorance over the years aboutwhat the Data Protection Act means. Historically, youhear of matrons in wards who will not allow anyoneto be given any information about anything becauseof the Act. It is not just about the Act itself—Chair: But the understanding of it.Major General Cumming: To put it simply, we feelthat we could do so much more to help if we hadan introduction, rather than stumbling across someonewho needs help later, which is what happens at themoment. We feel that an introduction from in to exwould be better for everyone.Air Vice Marshal Stables: I think it is one of theissues that we will address in this transition piece,which we will do under the Forces in Mind Trust. Themain issue that I put to the Big Lottery Fund is thatwhile most of the components of transition are inplace, the real problem is that they are not joined up.The real weakness in the whole thing is leadershipand cohesion, because no single organisation has thatleadership and cohesion—from the point of leavingthe Armed Forces to death, almost—because somepeople never actually make that transition. They dieand they have never made a proper transition. Mostof the building blocks are in place. We have come along way in our interface with the MoD and with otherGovernment Departments. There has been significantprogress with the Department of Health in the pastthree years, since we became part of the ReferenceGroup that we referred to in our last session.Chair: That was in a completely differentCommittee—the Armed Forces Bill Committee.However, we will be able to take that evidence intoaccount in what we say in our Report on this.Air Vice Marshal Stables: I am relatively confident.As Cathy said, there are issues with data protection,where we have not come to an agreement or anaccommodation, but we are working at it. I do notthink there are any obstacles.

Q300 Chair: Are there any suggestions you wouldmake to the Ministry of Defence or to otherGovernment Departments about how they couldimprove their general treatment of those who arephysically or mentally injured, or the generaltreatment of families in relation to the Armed Forces?Are there any improvements you might suggest?



Commodore Branscombe: I think that the processesor the provisions are theoretically very good. Mycomments would be about process and continuity. Itis true that the Ministry of Defence at all levels suffersfrom the almost constant movement of militarypersonnel and civilians. That is a truism, of course,because the personnel themselves are constantlymoving, but those who are responsible for theirtreatment, welfare and other administrative supportare themselves constantly being posted, and this is anever-increasing spiral. I will give you a practicalexample. A casualty notification officer allocated tobe the first person to tell the family in this particularcase may well move on, because it is only a temporaryappointment. We keep talking about the journey.Nothing happens in snapshots, and nothing happensin comfortable two-year posting cycles.If we could have greater consistency among the staffwho are responsible for the administration of welfare,and in some cases clinical treatment, life would bemuch easier. One of our frustrations is that we learnto deal with the MoD at all levels, and no sooner doyou strike up a relationship with a very competent andwell-meaning person but you find that the next weekit is somebody different. That is as difficult for us aswelfare providers as it is for the people actually goingthrough the chain, but I guess that it is the sameeverywhere. It is the culture and the nature of theArmed Forces. I would say that there are certainthings for which you just need to have permanent staffwho do not change—I am only saying that becauseI’m getting really old now. I served 33 years in theRoyal Navy and changed my job every two years,probably because I was incompetent and kept beingmoved on. I am privileged to have been in my presentpost for 15 years. There is some merit in being in postfor a reasonable amount of time.Chair: I think that that message is being heard loudlyin the Ministry of Defence at the moment.Cathy Walker: If there was one thing I would wishfor—it is about not necessarily the Ministry ofDefence but other Government Departments as well—

it would be that if we want to be able to help veteransdownstream, we should know where they are and whothey are. If the community covenant is going to work,local authorities need to know who the veterans are.The question that Mrs Moon mentioned aboutsomeone in her surgery with a trade union or ex-Service background needs to be asked and recorded.

Q301 Chair: You have to remember, though, thatsome veterans do not want to be traced.Cathy Walker: I am not suggesting that we should betracing them, but if a local authority is asked by HaigHomes if there are any people in their area who mightbe eligible for a particular house, it would be good forthe local authority to be able to say, “Yes, we’ve gota few people you might like to approach”, rather thantracing them. I know that there is another issue aboutnational Service people who will never admit that theyare ex-Service, for example, so there is a lot ofcomplexity about what you mean by a veteran.Air Vice Marshal Stables: There is a broader issue. Ifyou go back 10 years, you would not have heard theword “veteran”. We have created a section of societynow—an identifiable group of people—called the“veteran community”, and I am not sure that we havecreated the overarching architecture to deal with them.There is an expectation now because people say, “Iam a veteran. I belong to the veteran community,” or,“I am the family of a veteran,” but what does thatmean? We have not answered all the questions, I’mafraid, and we have not put in the architecture to dealwith a group of people that we have created nationally.

Q302 Chair: Yes, and the word “veteran” impliesthat you are old, whereas a lot of these veterans arenot.Major General Cumming: They are very young.Chair: Thank you all for a fascinating evidencesession. You have been extremely helpful and we aremost grateful.



Members present:


Mr Julian BrazierMr Jeffrey M. DonaldsonMr Dai Havard

________________


Witnesses: Air Vice-Marshal David Murray OBE, Assistant Chief of the Defence Staff (Personnel) andDefence Services Secretary, Claire Phillips, Deputy Director, Violence, Social Exclusion, Military Health andThird 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 andTraining), gave evidence.

Q303 Chair: May I say welcome? Welcome back toGeneral Rollo. Surgeon General, very good to seeyou. Would you like to introduce yourselves, please?Air Vice-Marshal Murray: My name is Air Vice-Marshal David Murray. I am employed as AssistantChief of Defence Staff for Personnel, and have aparticular interest in charitable activities in connectionwith 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 andTraining.Claire Phillips: I am Claire Phillips, the DeputyDirector at the Department of Health, withresponsibility for military health as well as violencesocial exclusion and third-sector partnerships.Chair: Thank you very much. You are all mostwelcome to this session in our inquiry into militarycasualties. The questioning will be begun by GiselaStuart.

Q304 Ms Stuart: Welcome to the Committee. If Imay, I will start with Admiral Raffaelli. If you wereto look back at the past 10 years, we have madeextraordinary advances in terms of soldiers survivinginjuries. I wonder whether you can give us abreakdown of just what happened in terms of the rateof those injured and surviving in comparison withother conflicts we have been involved in.Surgeon Vice-Admiral Raffaelli: Of course. Wouldyou like me to start with why I think there may havebeen changes that have resulted in more survivors? Ithink it is the long-term thing, that there is a wholeend-to-end treatment package. We are now much morefocused on providing serious care, from the point ofwounding, through retrieval back to the forwardhospital, through the air to Birmingham—so, end toend. In all of that, we have been working inconsiderable partnership—that is partnership in manyareas, between the three Services, between theRegulars and Reserves, with our international militarypartners and with the NHS and the Department ofHealth in other areas.In quite specific terms, one of the direct focuses—working with Americans, in particular—was therecognition that catastrophic blood loss at the point ofwounding was the single biggest killer in the short

Sandra OsborneMs Gisela Stuart

time frame. In fact, 50% of the people were dyingfrom blood loss. So a lot of effort has gone into how todeal with that, by using things like combat applicationtourniquets, novel blood products and bandages tohold bleeding back. They are delivered not only bymedical personnel forward, but by the soldiersthemselves, who are trained, and by team medics. Sothe first thing is, at the very point of wounding, tosave the life and then rapidly follow that up with ourcombat medical technicians or our medical assistants,who are trained to a higher level, and for them totake forward the blood products and the rest to dealwith that.The next stage of course is to retrieve the wounded asexpeditiously as possible, and we do not just do thaton our own; we also do it with our internationalpartners, the Americans in particular; their PEDROand DUSTOFF casualty retrieval helicopters aretremendous. We have a different, but complementary,approach to the US—we don’t have the quantity ofassets that they have, though as I say we do workin partnership, and we have the Medical EmergencyResponse Team capability, which is deployed in theChinook. What that does is it takes to the casualties ahigher level of care, almost taking the emergencyroom to the casualty. So with a consultant-led teamon board, we can provide high-level resuscitation, wecan incubate people and we can provide bloodproducts—that is a big change, to deal with thatphysiological disruption that major trauma causes. Wecan reheat them and deal with acidosis, and we caneven put on aortic clamps if they are severely injuredhigh. We can certainly anaesthetise and bring themback safely.They get back to the hospital, and again it is acombined, consultant-led team approach. They knowwhat is coming in, as best they can—in terms of thenumber of casualties, the problems they have—sothey can prearrange the reception to deal with them,if necessary even bypassing the emergencydepartment and going straight into operating theatre.The job is very much focused on what we call damagecontrol surgery, which is that life-saving andphysiological stabilisation surgery, to get the casualtyinto the best possible condition.For UK-based and other multinational coalitionpartners, the next part in the chain is to get them backhome as safely as possible. The RAF is quite


6 July 2011 Air Vice-Marshall David Murray OBE, Claire Phillips, Surgeon Vice-Admiral Philip Raffaelliand Lieutenant-General Sir William Rollo KCB CBE

exceptional at that—the critical care support team andtransport system is quite remarkable. When I speak tocolleagues in other health care systems, theysometimes say, “We wouldn’t take that chap up threefloors”, but we bring them back 3,000 or 4,000 miles.That is again down to a consultant-led team, focusingspecifically on the patients.

Q305 Ms Stuart: Some of my colleagues will comeback and pursue that a bit further. Could you answertwo very specific things? The American system is stilldifferent. They take the patient to the doctors whereaswe take the doctors to the patients.Surgeon Vice-Admiral Raffaelli: Yes

Q306 Ms Stuart: And how does the ratio of injuriesto fatalities compare in the different systems?Surgeon Vice-Admiral Raffaelli: That is a very fairquestion that we keep asking ourselves. They havehelicopters for quick retrieval—scoop and run, if youlike. We use them slightly differently. We will use theMERT for whichever casualty demands it. So we pickup US soldiers and they also pick up British soldiers.It is a question of the right asset to the right casualtyat the right time. It is hard to compare. We know thatwe have saved people and had unexpected survivorsduring flight. So we believe there is an advantage, tosome extent. Last week, I was at the Institute ofSurgical Research in San Antonio and the Americansare taking to their Congress just now a proposal tointroduce a MERT equivalent to supplement what theyare doing. We must not in any way denigrate thePEDROS and DUSTOFFs. It is an essential part ofthe whole spectrum of retrieval of injured patients andin numbers. It is really resource intensive—both therotary wing asset requirement and the teams on boardto deliver MERT. We simply could not provide iteverywhere and nor could the Americans.

Q307 Ms Stuart: So are the medics still breakingharmony guidelines?Surgeon Vice-Admiral Raffaelli: We very rarely seeany breach of harmony guidelines among the medics.There have been one or two numbers and in almostevery case I am aware of, it has been voluntary by theindividual. When they do things like the ContinuousAttitude Survey, it does not arise at all. In fact, goingon operations is very much what they are about andwant to do.

Q308 Mr Havard: A friend of mine is a Reservistwho does this, too. You use Reserve Forces in thatactivity as well as full-time Forces?Surgeon Vice-Admiral Raffaelli: Absolutely. Theway we deliver our medical effect goes back topartnership. If you were to go into a field hospital inBastion, you would not know whether that man orwoman behind the mask was Navy, Army, RAF orReservist, or indeed whether they were American,Estonian or, shortly to be, French people. We also usesome people directly from the NHS in small numbersand their system supports operations. They may havea 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 ourarmoury.

Q309 Ms Stuart: That is very helpful. Could I turnto Claire Phillips? Ten years ago the NHS said that itneeded to support what the MoD did in terms ofmedical services because of the critical mass needingsupport. Now in some areas what happens within theArmy context is quite superior to what is happeningin the NHS. Are you content that we have sufficientcross learning from each other?Claire Phillips: Yes. Thank you. There are hugeopportunities for us to learn from each other and werecognise that the huge advances that have been madeare things that we can learn from in the NHS. So asthe Surgeon General said, the Reserves are obviouslyvery important because they are going back into theNHS and taking a huge amount of operationalexperience with them. It is often said that one Reservespending some time in Bastion will have more traumaexperience than he will see for months and months, ifnot years, in the NHS. So that is clearly important.As well as that we have defence medical staff who areembedded in the six Ministry of Defence hospitalunits that we have in this country. So they areconstantly working alongside each other, sharing thelearning and so on. Then we share research. We havea joint National Institute for Health Research inBirmingham now. NIHR has invested about £34million in the past few years. We have recentlyannounced that we are going to invest £20 million.That is a partnership between the Ministry of Defence,the Department of Health, the hospital in Birminghamand Birmingham University. That will look at surgicalreconstruction and microbiology to see what we mightshare and learn there. Obviously we are doing a lot oflearning internationally as well.

Q310 Chair: Can you say what proportion of troopsare surviving who might have died in earlier conflicts?Do you have any figures for that?Surgeon Vice-Admiral Raffaelli: We cannot sayproportion wise. The mechanism for calculatingunexpected survivors is dreadfully complex. It isbased on injury severity score comparators. Above acertain level, you begin to grade them as majorcasualties. With each case, we give them what iscalled a new injury severity scoring and then we sit ina peer group and compare with each other. In purenumerical terms we believe that about 208 or 210 inthe last five years would have fallen into the “notexpected to survive” group. It is a multivariateanalysis process and it is a predictive number. What Ithink we could say very confidently, and the NAOpicked this up when it audited us last year, is thatagainst all standard comparisons that we do—I amtrying to avoid giving an exact number because it doesnot really exist—one in 10, or one in 15 end upsurviving longer than we would have expected. But itis a case-by-case analysis; that is really what I amsaying.



Q311 Chair: Yes, it must be very complicated. Whatchallenges do you have in the physical care of troopswhen they come back to the United Kingdom?Surgeon Vice-Admiral Raffaelli: Once they get back?Chair: Yes.Surgeon Vice-Admiral Raffaelli: They do come backin a remarkably short period of time. It can beanything from 24 hours to 48 hours, or three days. Sothey are still extremely injured and seriously illpeople. The first challenge is to actually provide forthat high level of intensive care to continue. QueenElizabeth Hospital at Birmingham is, quite simply, afantastically well set-up unit.Chair: We visited that last week and we were mostimpressed.Surgeon Vice-Admiral Raffaelli: The other thing, ofcourse, is that it’s a completely combined approachwithin that unit now, and consultant led. It is verymuch an NHS lead by the time you get there, but ourpeople are well embedded. So I think that that is thefirst challenge, to actually secure that survival, andthey do very well. I’m delighted to say that very fewpeople have actually ended up dying in Birmingham.The longer-term thing, though, is with the level ofseverity of injuries that they’ve received, and is muchmore challenging in many ways. You’re well awarethat, with the high level of IEDs, the lower halves ofthe body are particularly damaged. That can be reallyquite high these days, and people are still surviving.So it’s about how to secure a good functional outcomefor these young men, how to help them to heal as bestthey can, and then, in the longer term, how to providethem with whatever support, be it at one endprosthetics, at the other perhaps, in some cases,longer-term nursing, particularly if there are headinjuries involved as well. The thing is to ensure thatthat support is delivered to them, and then carried onin the longer term.From our perspective, we will not look to dischargepeople until we’ve got them to the best level offunctional ability that we’d hope we would do. Thework we have been doing at Headley Court, where Iknow you have also visited, is an example. Some ofthe high-level casualties we would absolutely expectto be with us for, say, three years, to ensure that we’vegot them to that best possible level.

Q312 Chair: Yes, we did visit Headley Court, and,as ever, it’s breathtaking in its ability and scope. Is thelevel of activity at Headley Court sustainable? Whatdo you think will happen to Headley Court whenAfghanistan finishes, from the point of view ofBritish troops?Surgeon Vice-Admiral Raffaelli: Okay. Yes is theanswer on sustainability. The core business forHeadley Court, even today, remains dealing with thelarge number of soldiers, sailors and airmen who incurmuscular-skeletal and other injuries. That is still about70% to 75% of their daily activity, and that does andwill continue. We have been modelling with DASAover the last—well, we do it all the time. We regularlymodel on what the capacity and capabilityrequirements of Headley Court are. Last year, we putin a temporary ward to uplift the high-level beds to

96, and recently we submitted a new statement ofrequirement to the new Defence InfrastructureOrganisation, with the intent of increasing capacity intwo increments, between October and early next year,to 144 high-level beds.We are not pressurising that point just now, but wewere looking at the casualty rates and the in-patientrates to Headley Court. As the casualty spectrum haschanged, the critical new factor is the dwell time thatwe are keeping them in Headley Court before they’redischarged. This is partly because we’ve not hadenough time yet—we’re not discharging at the ratethat we will in due course—but also because some ofthe other arrangements are developing. As I said, wewill not let people go until we are comfortable thatwe’ve got them to a level that is appropriate. On thatbasis we are incrementing its size over the next yearto sustain it, and we will continue to take that view.

Q313 Mr Havard: This is a question about thosewho are injured on operations—including casualtiesin the field, as you’ve been describing—and thosewho are in Service and injured otherwise, or havedeveloped general health problems. Could you saysomething about the differences between those two, orwhether one learns from the other and helps to supportimprovements across the piece? What is happening?Surgeon Vice-Admiral Raffaelli: In terms of how wedeal with them or treat them, we treat them all exactlythe same. They get whatever they require medically.It’s a clinical driver; that’s the requirement. When itcomes to the discharge at the end point, again, theyare treated the same. General Rollo will be the one totalk about the Army recovery capability and the rest,but through the medical boarding systems, which I ranwhen I was in the Navy and have overview of, theyare treated in entirely the same fashion. Part of theprocess is for the medics to predict the outcome andhow long it will take to get there. But then it is thecommand side that takes the decisions on the longer-term employability of the individual.

Q314 Mr Havard: Yes. One thing that strikes you atHeadley Court is that the people there are at work.They are still in the Forces; there is the esprit de corpsand that sort of thing. That is great for those casualtieswho were injured on the battlefield. What about thesame sort of process for the rest of the people, whoare injured and physically unwell?Surgeon Vice-Admiral Raffaelli: That is a very goodpoint in terms of rehabilitation. There is something wedo differently from the NHS, which for very goodreasons focuses on the individual. Given ouroccupational and regimental approach to life, we havefound an approach that works for our people, thoughit is not necessarily transferable. We maintain thatcommand and control and use group dynamics tobring a lot on. That camaraderie and a little bit ofcompetition help them to use that class approach toall of the rehabilitation, whether in our primary carefacility, our regional units or at the top of the pyramidat Headley Court. That is the same for all of them.Even the seriously injured ones, though they oftenneed individual care at specific points during their



care pathway, as soon as they are able to get intogroup classes, that is what we move to do.

Q315 Chair: General Rollo, would you like to addanything?General Rollo: Not on the policy point, which hasjust been covered. Our view is that we should treat allour people the same, certainly as far as medical careis concerned, but also employment. It is too difficultotherwise. Your best man may be injured onoperations or he may come back and be injuredshortly afterwards—or before—in training. It wouldbe neither fair nor efficient to do anything else.

Q316 Mr Havard: One reason for the question isthat we are looking at the Covenant and a particularpart of it, trying to break it up. We have started withcasualties. We recognise that they are unwell and thatthey are casualties not just because of the things thatare obvious. Everyone concentrates on aspects. Wewant to try to deal with all the people who serve, if itis in relation to a general commitment to them, asopposed to when they are in a particular place.General Rollo: But I would emphasise the SurgeonAdmiral’s point. The vast majority of people atHeadley Court, now and when not on operations evenmore so, have non-operational injuries. They are theeveryday wear and tear you get from pursuing a prettychallenging lifestyle.

Q317 Sandra Osborne: Admiral Raffaelli, will yougive us your opinion on what types of mental healthproblem are emerging in those who have served onoperations?Surgeon Vice-Admiral Raffaelli: There are threegroups, if you like. The public perception,understandably, is of conditions such as post-traumaticstress disorder, which is a particular issue with us. Wemonitor this very closely. I know you have spokenwith Simon Wessely. There is also Defence AnalyticalServices and Advice, and our own departments ofcommunity mental health. The PTSD rates we areseeing just now are—in broad terms, as far as we cantell—very similar to those that exist in the generalpopulation, so somewhere between about 3% and 7%.My hesitation is partly because there is not great datafor the general public. It has not been looked at for agood number of years. Based on what we know fromprevious studies—there is nothing to suggest that haschanged—that is a true statement. We know thatwithin those numbers there are some groups that areslightly higher than others. Those who have beendirectly involved in combat—not in every particularcloth that they come from—are none the less higher.There have been some slightly higher levels in thosein the Reserve grouping, and sometimes youngerpeople and younger women. All are within that broadspectrum of general comparability with the generalpopulation. That is measured by the Simon Wesselyteam, who do it through a questionnaire process, sowe are pretty comfortable in saying that it is anindependent, scientifically rigorous approach.We also measure very regularly, putting it intoDASA’s hands, which does it independently. We look

at referrals to and diagnoses within our departmentsof community mental health. We have our consultant-led psychiatric teams. The numbers there are actuallylower. In our last group numbers, we had 66 casesconfirmed as PTSD, which is about a 0.3 per thousandrate over that three-month period. The reasons wethink it is lower are slightly speculative. We thinkthere are two reasons. Simon Wessely’s work involvesself-declaration, which brings a bit of fuzziness, butmay also be a more frank admission.One area where we are working hard across themilitary spectrum is to make it absolutely clear topeople that a mental health problem is no less worthy,if you like, than a broken ankle. We are working hardat ensuring that stigma is not an issue, so as toencourage people to come forward. There may besome people who don’t come forward to departmentsof community mental health. Using Simon’s measuresas a benchmark has given us a feel for that. As I say,we are doing what we can to de-stigmatise that. Wehave approaches to try to minimise it and use non-medical approaches, allowing people to comeforward.As a result of the work that Andrew Murrison did on“Fighting Fit”, we are working with the Departmentof Health and are in the process of introducingsomething called Big White Wall, which will be aself-referral into a carefully run, properly governedinternet facility that will be open to serving people,veterans and families. Within it, they will be able toget advice and be signposted to what is appropriatefor them. That will be the first issue.PTSD is certainly something that our people will see.However, despite what we are asking these men andwomen to do, it is at a low level. We take it seriouslyand monitor it both in-Service and thereafter. As longas we continue these high levels of operations, thereis a population that is continually at risk, so we haveto keep doing that and keep an eye on whether somepeople may present later, for whatever reason. At thisstage, there is no evidence that there is either a tidalwave or an iceberg, but we need to keep monitoringit and not relax until we are in a position to knowwhether that is appropriate.Much more common are general mental healthproblems, such as depression, anxiety and the rest.They are absolutely comparable to control groups ofex-Service people, non-deployed people and thegeneral population. The one area where we do seemto present more often in our age group—that is, belowthe age of 35, after which they return to normal—isalcohol 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 differentiatebetween them. There is a relatively low threshold inone sense at which you become a positive, but usingthat same marker, we are at about 13%. That is acouple of times above a comparable group in thegeneral population might find.When they deploy for six months, they don’t drink forsix months. When they come back, they have a go atit. There is a degree of binge drinking. What we arenot 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 timelapse for this younger group in developing thoseproblems is longer. We do know—again, mainly fromSimon’s work, but also from work that General Billand I do between us—that their drinking patternreturns to that of the general population by the timethey are about 35. It is a complex thing and we do nothave all the answers. We have a reasonable feel ofwhere it is, and we put a lot of effort into education.From the minute these young men join us from thetraining park, we make it absolutely clear that theyunderstand the danger of alcohol.The Forces have had a history of not being averse toalcohol in a lot of settings. We have moved on a fairbit from that, I think. A recent article in Soldiermagazine went back to the stigma thing, where peoplewith problems have come forward and spoken. We ofcourse retain the command ability. If someone iscausing problems, we can command them on to aneducation course. We can’t enforce treatment andwould never do that, but we are doing as much aswe can at present to ensure that they understand theconsequences for them, the regiment and their buddieson deployment, although they do not drink ondeployment. It is a complex issue, but that is one partwe still need to do some work on.

Q318 Sandra Osborne: Can I ask General Rolloabout the King’s research? It points to the fact that,where harmony guidelines had been breached, therewas a possibility of an increase in PTSD, alcoholproblems and so on. What account have you takenof that?General Rollo: The first thing to do is to try to avoidbreaching harmony guidelines. They are guidelines,and they can be broken if there is a good reason to doso. The current rate is, by historical standards, quitelow. I think it is 0.8% for the Navy, 5% for the Armyand 2.6% for the Royal Air Force. If you compare thatto the past, in 1998 and 1999, when we went intoKosovo, it was about 50%. Why would we do it wherethere are scare skills? We would use volunteerswherever we could, but it does sometimes happen.However, in overall terms the rates are quite low.The other point that Simon Wessely brought out wasthat in some cases it wasn’t the breach of harmonyguidelines; it was the unexpected breach of them. Ican think back to some American examples wherepeople who had just done their 12 months weresuddenly told, when their kit was on the ships, thatthey had to turn around and go back for another threemonths. That was clearly a tricky call, but luckily forus we are not normally in that boat.

Q319 Chair: May I interject here? You mentionedthe question of people volunteering to breach harmonyguidelines. Are there any data on whether there is lessconsequence for a voluntary harmony guidelinebreacher than for someone who is forced to breachharmony guidelines?General Rollo: Chairman, I am not aware of any, butI can come back to you on that one.

Q320 Sandra Osborne: Are people who have beenphysically injured more likely to suffer from mentalhealth problems as well?Surgeon Vice-Admiral Raffaelli: There is goodevidence from other sources that physical trauma, orindeed just general illness, leads to an increasedpotential for mental health problems. That wouldcover all of them. We do not have any direct evidence.Simon’s team have been doing some specific work forus to look at that, and I understand they’re on the edgeof publishing some more data. The peer journals thatpublish these things get very nervous of earlydiscussion of it.We have also been monitoring our seriously injuredpeople very closely from the time they get back, fromRole 4 at Birmingham through into Headley Court.Initially it was pure audit work to ensure that thesechaps were okay, and that was all very positive. It hasnow reached the stage where, about six months ago, Icommissioned a formal prospective study to look atthose high level casualties and chart their mentalhealth outcomes and how it goes through. It is timethat we did that. The hesitation previously was alwaysthat the psychological assessment tools are franklypretty broad brush. The sensitivity and specificity issometimes not as crisp as we would like, and not allof them have been validated either in our cohort, orin these kinds of high level patients.Of course, what we do see—you’ll have seen it atHeadley Court—is that life is labour for these chaps.But the overwhelming impression you get from ourclinical staff who are with them day in, day out, isthat their cup is actually more than half full more oftenthan the other way around. They are very positive.Following through in the longer term is where I thinkour particular duty and interest must lie.

Q321 Sandra Osborne: We were very impressed bythe morale—if I can put it that way—at HeadleyCourt. It was really quite humbling to see.May I ask about people who have been in multipledeployments? Some of the research from King’sshows that, for example, family problems at home andthe effects of family on people who’ve been deployedare big factors. What about people who have beendeployed on multiple occasions?Surgeon Vice-Admiral Raffaelli: One thing thatSimon Wessely and Nicola Fear’s research has shownis that these things are incredibly complicated, butadverse circumstances, or difficulty at home, isprobably one of the single biggest contributors to thechallenges that people then find when they aredeployed. It is very inter-relational. Indeed, one of theareas that we have had endless discussions about isthat today, in this communication age, the contact withback home is really, really regular. I spent my youngerdays in nuclear submarines; when you left the wall noone spoke to you for three months, and there were noother problems. It was remarkably easy to do. But it’snot that way today. It is a very complex cycle, andwhen you have that back-and-forth stress you can seethat if someone goes away multiple times, especiallyif there isn’t time to step down in between, that cancompound itself. But there are no really hard data;



that is a serious problem. We are certainly concernedthat you can see that being added to. I don’t know ifGeneral Bill wants to add anything?General Rollo: Common sense leads you to think thatthere would be a rise in PTSD, particularly for peoplein exposed places over multiple deployments. As faras I am aware, the evidence does not show that atpresent. In terms of families and the interaction thatAdmiral Raffaelli mentioned, I agree. The mentalhealth surveys we have done show clearly that asignificant factor in mental distress in theatre can beproblems at home, as you would expect, because youfeel very helpless stuck out in the desert somewherewhen you know there is a problem at home that youcannot do anything about. Knowing that families areproperly looked after is a really important element ofoperational effectiveness.

Q322 Mr Havard: People say that Reservists areworse off when they come back because perhaps theyare more isolated or have less support. I do not knowwhether there is any evidence of them being anyworse off. Have you done any work on that? If thereare particular difficulties for them, what preventivemeasures are being put in place to deal with it?General Rollo: Do you want to start with theevidence, and then I’ll come in with what we aredoing?Surgeon Vice-Admiral Raffaelli: Within the spectrumof mental health problems that I described at thebeginning, Reservists are one of the groups that showa higher level of problems. There is a measurableeffect, but it is relatively small.

Q323 Mr Havard: But there is a measurable effect?Surgeon Vice-Admiral Raffaelli: There is, but thereare Reservists and Reservists. Those who aredeployed in groups and in different commandstructures have a different spectrum from those whowould be completely on their own.

Q324 Mr Havard: One-off augmentees, orsomething?Surgeon Vice-Admiral Raffaelli: Absolutely.General Rollo: When the figures first showed thatthere was a slight increase in the instance of mentalhealth problems in Reservists, it was back during Telic1 in 2003. Our supposition then was that it hadsomething to do with the fact that we called peopleup at very short notice, landed them among groups ofpeople whom they did not know and with whom theyhad not trained. Perhaps not surprisingly in thosecircumstances, they had a greater instance of mentalproblems. Then you come back to the aftermath andthe fact that support mechanisms for individualscoming back into civilian society were not developed.Since then, we call people up on a much morestructured basis and do so well ahead, so they cantrain with the people with whom they will deploy andintegrate into teams. When they finish, they gothrough the Reserves Training and MobilisationCentre. There is a mental health briefing session there,where people who feel they have problems can puttheir hands up and that is followed up.

We are also better in terms of the focus by Reservists’commanding officers on looking after the Reservistswhen they come back. They have to have the samemandatory stress debriefing as Regulars, and there isan allowance within the number of training days forthat to happen. It is quite clear that it is forcommanding officers to ensure that it happens. Theyare much more focused than they used to be on thefact that individuals coming back really have to belooked after and have an arm put round them.None of that detracts from the fact that when they goback to work, they are among a group of people whohave not gone through the same experience. Thatapplies to a certain extent to the Regulars—if you arean individual augmentee, you go back into anorganisation that has not been deployed, which ismore difficult than when you come back with yourregiment.Surgeon Vice-Admiral Raffaelli: All I would add isthat even with recognition of that, we have put inplace some additional support mechanisms shouldpeople develop a problem later. There is a mentalhealth programme at Chilwell, to which the Reservistscan be referred at any time, and, if required, they canbe referred to the medical assessment programme atthe Baird Health Centre.We recently collaborated with the Department ofHealth, the Royal College of General Practitioners andthe Royal British Legion to give an informationbooklet to GPs, which does not focus solely onReservists, but includes them, so that GPs have awider perspective. Hopefully, if they turned upanywhere with problems, they could be linked back inand access the programmes. If they access anyprogrammes, they are entitled to come back to ourdepartments of community mental health, because wecan provide a level of expertise and empathy. That isopen to Reservists, should they be among theunfortunate ones who have a problem.Mr Havard: I want to come back to that on a laterquestion about the continuing arrangements,particularly with the NHS.

Q325 Sandra Osborne: Can I ask you about theidentification of people who are experiencing mentalhealth problems as a result of being in operations? Isthe MoD good at identifying that and how is the use ofTRiM working out? What has been the impact since itwas introduced?Surgeon Vice-Admiral Raffaelli: There is a wholeend-to-end approach here. Really from the minutepeople enter the Services there is a large educationalprocess to make people aware of what they may beexpected to face up to and the normal responses thatthey must recognise and not be frightened about. Thatis repeated in all parts of leadership training so thatpeople can first of all contextualise what is happeningto them. The trauma risk management programme wasintroduced initially with the Royal Marines and wasspecifically aimed at not medicalising what can justbe really quite large emotional responses, but onesthat are normal. If you lose someone in your familyin 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 peoplethrough the incident they have been in and analysesthat 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 beyondthe typical range and may require further help.All the evidence that we have is that it does not causeany harm. That is an important statement. People usedto do something called critical instant debriefing,when you would throw a counsellor at someone whois in a crash. We know that that caused problems.There is an eminent study in the states of survivorsof air crashes; a year afterwards people had greaterpsychological problems. We are categorically notgetting that. What is very difficult, however, is thatwe are not putting on a control group with this. Whenthey tried to do that some years ago, when I wasresearching in the Navy, we had a large number ofnaval ships that did not then do anythingoperationally. So it did not work. It would not beethical to do it today. So we are confident that it doesnot cause any harm. We are happy, as we havedescribed, that the outcomes that we are seeing interms of mental health are pretty good, given thecircumstances we are in, so it is something we arekeen to continue with. The feedback we get frompeople is that they feel it is a very useful process.General Rollo: May I build on that for a second? AsSG has said, the key issue is that it is a reduction instigma—a reaction to an unpleasant incident isnormal. Within the Army very frequently now it is theCompany Sergeant Major who is trained as the TRiMcounsellor. That in itself sends a very clear messagethat this is not something that is soft in any way: thehardest man in the company is responsible for it.When you talk to a group of warrant officers, they arevery focused on this, as indeed is the chain ofcommand. They want to know more. They understandwhat it is for and they understand very clearly itsbenefits. You are talking to people who have now hadrepeated operational exposure. They know what theydo. They know what they are going to have to faceand they know what they need to do to help people.When people come back—I won’t go through themechanics of the process—there is a system formonitoring those who have been exposed toparticularly unpleasant incidents and for checking upon them at regular intervals to see whether theyimprove or not. It is normal to have the reaction. It isnormal to improve. If you don’t improve then youneed help. The chain of command is very focused onproviding that. We are lucky. We have no queues foraccess to mental health care. The system works well,I think.

Q326 Mr Havard: In the process there is a sort ofthree-day thing? Somebody has been exposed tosomething and you say that that person needs anintervention. Then there is a review in three days’time. The process is that the management—the chainof command—makes an evaluation after three days.That seems to be a period in the process. Is that justan organisational thing or is there a particular reasonrelating to the manifestation of a problem?

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

Q327 Mr Havard: There is not a medical reasonfor it?Surgeon Vice-Admiral Raffaelli: It is not a medicalreason. It is just a sensible process time frame.Mr Havard: Okay.Surgeon Vice-Admiral Raffaelli: But then we have afollow-up system thereafter. Everybody who isdeployed is then interviewed by the commandingofficer 30 days after the deploy; not to go throughTRiM as such, though it would include those, but toask if there are any issues and problems at that kindof level.

Q328 Sandra Osborne: May I ask Claire Phillips,how effective is the National Health Service incomparison, in providing support to people who havebeen deployed?Claire Phillips: It is an area where we have madehuge improvements. The Government recentlypublished their mental health strategy, which is called“No Health Without Mental Health.” It gives equalweight to mental health as to physical health and thereis a separate section on treatment of veterans—asthere was in the previous Government’s mental healthstrategy. We have invested £7.2 million in thisspending review period to implement therecommendations 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 healthcapacity for veterans, so we are establishing specificposts all around the country with people who havespecific expertise in dealing with veterans’ mentalhealth. That is a partnership between the NHS and thethird sector. It is actually Combat Stress that we areworking with, so that is an important development.We recently established a 24-hour helpline throughCombat Stress. The contract was given to Rethink,who have a lot of experience in this field. We havereceived nearly 3,000 phone calls, which is quite alot, within the first three or four months. The SurgeonGeneral mentioned Big White Wall. That is an onlinetherapeutic community, if you like, that is open toveterans, to serving personnel and indeed to families.We are trialling that; that is at a fairly early stage atthe moment. Help for Heroes have put some fundinginto that, so it is at an early stage, but we will belaunching a full service for veterans on Big WhiteWall within the next couple of months. That will beimportant.We have commissioned the Royal College of GeneralPractitioners—who are absolutely crucial in this—todevelop an online learning facility to tell GPs far moreabout veterans and to be more aware of the sort ofissues facing them, and indeed those in the ArmedForces and their families in particular. We are settingup a Veterans Information Service, whereby veteranswill be asked 12 months after they have left how theyare feeling, telling them about what sort of servicesare available locally and asking them whether theyneed any help. We will be trying to do that in an openand engaging way and trying to overcome the



problems of stigma that have been identified alreadyand the delay in help-seeking that we know men inparticular are prone to. That is a problem for men inthe whole community, not just veterans, but veteransmay be even more prone to it.We are also doing specific work with veterans to makesure that they are able to access NHS services. So allof Dr Murrison’s recommendations were accepted infull and we aim to implement them very rapidly withour partners in the third sector, and of course in MoD.

Q329 Sandra Osborne: Finally, I believe there areongoing pilots with regard to supporting Reservistsonce they have been demobilised. Is that correct andcan you give us any feedback?Surgeon Vice-Admiral Raffaelli: In what particularsense?

Q330 Sandra Osborne: The pilots for the support ofReservists post-demobilisation, as I understand it.Claire Phillips: I think the Surgeon General hasalready mentioned that there is a mental health servicefor Reservists and that has been going for some time.Surgeon Vice-Admiral Raffaelli: In the last year orso we have run a number of veteran support pilotsaround the country. There is one in Scotland, whichwas Veterans First, for example, which was reportedon by Sheffield University. That was done incollaboration between the Ministry of Defence and theDepartment of Health and the DevolvedAdministrations in each area. They were all slightlydifferent models and they ranged from a veterans’drop-in service to a more specifically focused one inEdinburgh and the direct link into Midlothian’s mentalhealth services. They had military experience front ofhouse and people could get access to services. That iswhat you may have heard about.The report from that was really quite positive and weare now working with the Department of Health onhow to take the lessons learned from these quitedifferent pilots and decide what is the best model togo ahead. They are still running at present—I thinkvirtually all, if not all of them—General Rollo: They had a two-year life originally.Surgeon Vice-Admiral Raffaelli: Yes, so we areanalysing the lessons learned to carry that on.

Q331 Mr Havard: That chimes in partly with whatI want to ask about: return to civilian life. One ofthe questions that everyone struggles with is how yousustain these things over periods of time. The life-changing injuries that some people have mean thatthey will need particular support. You would get it thesame as I would. The people at Headley Court willsay that they have all these fantastic new limbs andstate-of-the-art equipment, but they are concerned thatin 15 or 20 years’ time they will have state-of-the-artstuff that is not state-of-the-art any more. How does a£15,000 limb get replaced? There are particularquestions of sustainability for such individuals, but itraises the broader question about the TransitionProtocol and the sustainability of all thesemechanisms.

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

Q332 Mr Havard: Absolutely, and one of thequestions that I would like to get to at some point isconsistency or coherence of application across theUK, given that there is a Devolved structure.Surgeon Vice-Admiral Raffaelli: The point isabsolutely critical. We recognised some time ago thatthe cliff-edge, immediate handover was simply notacceptable. We have been working in real partnershipto have an earlier reach in from the Department ofHealth so that there is a sloped handover. The focusis individual case management. We have been runningsome pilots to test that with individuals, and some ofthose have been completed. We have been triallingthings: for example, there were a couple of guys whono longer needed to dwell so much in Headley Courtbut were not yet ready to leave Service. We workedwith the relevant PCTs, which took up the communitycare, the ongoing physiotherapy and so on. There willnot be one answer for all cases, because they are allso different, and the family circumstances are differentas well. When we talk further about transition I willhand that over to General Rollo.If we talk about prosthetics, for example, after hisprevious work Andrew Murrison’s next target wasquite rightly prosthetics. Very helpfully, Mr MikeO’Brien had made the commitment that veteranswould get not only the same level of prosthetics, butwhatever was used in the future. That was a verypositive statement from our perspective, and clearly itwas 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, willbe partly similar: to work together so that everybodyunderstands what we are using, what the functionalbenefits are and what the outcomes are, and to workwith the Department of Health and the DevolvedAdministrations to ensure that that same level ofsupport can be provided. It is not just about thereplacement C-Leg at £15,000; there is the socket, anda skilled prosthetist is required.Although the gross numbers of trauma in the NHSare much greater, the number of multiple amputees isthankfully much, much lower. There will be a similarissue to the one that we have seen with major traumacentres. If you are really seriously injured, you oughtto go to a leading consultant who has seen a lot ofpatients like you in the past week. There will have tobe some kind of approach to it, and I know thatAndrew Murrison is looking very hard atrecommending a way ahead on that.General Rollo: Can I pick up on the TransitionProtocol? Over the past two to three years, as wehave—in many ways fortunately—had a number ofunexpected survivors who are really very seriouslyinjured, it has become clear that we really have to getthis right. The answer could not be to stay in theService forever, but equally we absolutely could nothave an unsatisfactory transition, hence the pilots.Claire will, I am sure, expand on this in a second, butthe key lessons learned from them are actually fairlystraightforward. You need to start early, you need



continuous engagement and you need to have singlepoints of contact who are there consistently rightthrough the process. I am absolutely sure that there isalso a piece about looking after the family as well asthe individual. That is really tricky stuff, and everycase is different. It is very hard to meet everybody’sexpectations, but that is clearly what we have to tryto do. I will pause there, but I would be very happyto come back to the wider subject of transition in aminute.Claire Phillips: We have set up a training system, andwe have had three or four joint sessions betweenpeople in the military, NHS people and localauthorities who are responsible for adult social care.We have applied the principle of continuing healthcare to people at an early stage, so, as soon assomebody is admitted to Headley Court, we should beplanning for their discharge. They need to decidewhere they are going to live and so on, once theyare discharged from the Armed Forces, if that is whathappens to them. As I said earlier, we have establishedthe Armed Forces networks all over the country. Wehave 10 such networks that bring together the militaryand the NHS. They are led by an Armed Forceschampion in every Strategic Health Authority and thatsituation will carry on, even when the SHAs areclustered together. That has been a very important partof the way we have worked.We have learned a lot from the pilots that we have runover the last year or so. Key things include havingthat single point of contact in the military, as well asfar earlier engagement, and there has been quite a lotabout language. We speak very different languages inthe military and in the NHS, so we have had to learnsomething about one another and to try to avoid usingabbreviations and so on. It is obviously amultidisciplinary approach. Clearly, the person in themilitary will have to engage with everybody—notonly within the NHS, but within local government—who will need to provide social care support. That isall very important, and communication is key.One of the challenges, as General Bill alluded to, iscare of families and managing their expectations.There is no doubt that their loved one, when they arestill in Headley Court, gets the most fantastic care,and all the transport is paid for and so on. There issomething about managing families’ expectations, sothat when that person leaves, the family is preparedfor the level of support that they will receive. That iswhat we are doing. We will have further training asrequired, but there is a lot that we are learning fromthe first few people—six or eight, I think—that wehave put through the protocol so far.

Q333 Mr Havard: Earlier, you alluded to GPs, anda booklet for them. We have other issues that we aretrying to discuss, such as how you track people overtime, or that some people do not want to be identified,while others do. There is a whole series of monitoringissues and so on that are bigger than just thisimmediate area, but questions are raised aboutenduring social care, particularly in a Devolvedenvironment.

The description you have just given is of the Englishhealth service. I wonder whether you can help me; Iam from Wales—I do not even understand Wales,never mind England. The question is that thecommissioning arrangements will be very different, aswill the enduring arrangements. If there is a centralcommitment in a Covenant to—at least—a consistentapplication, if not a uniform application, how will wesee that the transition model works for everyone wholeaves? It is not just those who are immediatelyseverely injured who have been through HeadleyCourt; there are also all those who have served,however injured, or however ill. Can you perhapshelp? I know you know will not have an exact answerto any of that.Surgeon Vice-Admiral Raffaelli: I think that I canpartly answer that. We have a Ministry of Defenceand Department of Health partnership board that isco-chaired by myself and Sir Andrew Cash, on whichthe Devolved Administrations sit. So, a lot of thesediscussions are also played out in that forum. Werotate our meetings and go, as I said, to the fourcountries. They are all different, as you say, but theyare all seeking to deliver the same effect. All of themare really quite different—in some ways, Scotland isa single, unified health care delivery system, and it isrelatively easy for them do it. Wales has had somechallenges, but the commitment level is the same. Iknow, because I have seen the draft, of the work ofAndrew Murrison, and he recognised those difficultieswhen it came to prosthetics provision. I would not liketo pre-empt his final proposal, but one of his optionsis to look for a central, Treasury-sourced allocation toeach of the four countries to address that veryproblem, because he was equally concerned that ifthere was an inadvertent diversion of committed fundsfor prosthetic support to veterans, that would beequally unfair. I think he has recognised that prettyclearly and come up with a proposal to address thatconcern.Claire Phillips: Could I also add that the DevolvedAdministrations, which, as the Surgeon General said,were represented on the partnership board, have alsosigned up to the transition protocols? We do workvery closely with them; we have several sub-groupsand there is a lot of ongoing contact, as health is aDevolved issue.Mr Havard: Our concern, as you rightly said, is thatit is an individual solution, an individual’s journey.Across all of that, they move around as well. They arenot all just from Wales or England or wherever. Someof them are in Germany at the moment. Theinterrelationships between the components aresomething we are particularly concerned tounderstand is put in place.

Q334 Chair: May I pass on a concern that has beenexpressed to us in this Committee, but also when wevisited Queen Elizabeth Hospital? It is an issue notjust for the NHS, but for the Armed Forces andsociety. There is a concern, quite strongly felt by someof the very badly injured veterans coming back. Theyfeel that it may be fine at the moment, while attentionis on Afghanistan, while the deployment is in place,



and it is in the headlines day after day. However, in20 or 30 years, when they are older and Afghanistanis an item in the history books—I should touch woodas I say that—and when the younger people doingmost of the funding were not alive at the time of theconflict in Afghanistan, how will they be sure thatthey continue to have the medical support, for bothmental and physical injuries, that they look to get inthe immediate future?Claire Phillips: At the moment we are developing amandate between the Government and the NHSCommissioning Board, which will be responsible forcommissioning services for the population in England.We hope that there will be something in the mandateabout the Military Covenant. The Military Covenantis obviously intended to be a long-term arrangementin place for some time. There are also long-termprovisions, such as priority treatment, that we aretrying to publicise and raise awareness of among GPs.There is often a long delay between somebody leavingthe Armed Forces and developing any of the problemswe are talking about. That entitlement to prioritytreatment remains, although it is subject to clinicalneed being appropriate.I hope that, by having something in the mandate andin contracts with providers through clinicalcommissioning groups and so on, those needs will bemet 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 mightoccur, though it is hard to predict exactly how thingswill work in 20 years. The Annual Report on theCovenant seems to be something that could easily beused to focus on that area, among others. It wouldrequire the Secretary of State to report annually onhow that is working. If that is something that endures,it could be a useful mechanism for keeping this in thepublic eye.

Q335 Ms Stuart: Thank you. With General Rolloparticularly, I want to explore a bit further the supportwe give to the families of the bereaved and injured.We visited one of the Norton Houses last week, andwe know that up at “the Q” they are going to build aFisher House. Provision has improved continuously.My two questions are: where do you think we couldstill make more progress? The second is more specific.There was talk at one stage of a specially dedicatedcoroner, which is now no longer on the statute bookas I understand it. Do you have any views on that?General Rollo: In reverse order, we have a clearinterest in supporting families through the inquestsystem, and we do that in conjunction with the BritishLegion and the lawyers it employs. We also have asystem for providing coroners with background intomilitary structures and the nature of operations. Wealso have—we have put in place, first in the Armyand then on a defence basis—the Defence InquestsUnit, which you may have come across and which isdesigned to make sure that, without rushing in anyway, we provide the evidence that the coroners requirein a timely fashion so that things do not drag out.

Q336 Ms Stuart: But my understanding is that whenthat was set up in 2008, it was meant to link up witha specifically dedicated coroner.General Rollo: I do not pretend to expertise on thatsubject. I have a general personal interest in acoroners system that works as well as possible. Howto do that is not my speciality.

Q337 Ms Stuart: On the more general question ofwhether we could do more to support the bereavedand the families of the injured, one thing that wasmentioned in Queen Elizabeth Hospital was fromsomeone in the Reserves, who said, “My companynever acknowledged the fact that I’m here as aninjured soldier.”General Rollo: By “company”, do you mean hiscommercial employer?Ms Stuart: Yes, his civilian employer.General Rollo: That is an interesting one. In general,how do we support bereaved families? You will befamiliar, I suspect, with the visiting officer system.Ms Stuart: Yes.General Rollo: That is a very personal relationship. Itcontinues 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 toremain, and I believe it tends to find its own level. Inaddition to that, there is a defence bereaved familiessupport group, which is run through SSAFA andwhich we support. They have focused on the thingsyou would expect them to, I think, including inquests.How could we do more, and what is the aim? The aimmust be, I guess, for people eventually to move on. Ithink that that is a very individual process, and thereare limits to what we as an institution can do to help.What we can certainly do is make sure that we do notget in the way. Over the years, we have moved a longway from the 1945-style treatment of casualties that,frankly, was still around even 10 years ago.

Q338 Ms Stuart: That is very helpful. A quickquestion to Claire Phillips. Do you notice an increaseof incidents of domestic violence in families whereone member has returned from operations?Claire Phillips: It is a subject that I am very interestedin, as I am responsible for policy on domesticviolence. It is something that I have discussed as Ihave gone around military bases, and it is somethingthat is taken incredibly seriously within the chain ofcommand, by welfare people on site and indeed bythe Military Police found on those sites, but theevidence is lacking, I am afraid. It is very difficult tosee whether that is the case or not. One expects someincrease in the general level of domestic violence inthe current economic climate anyway, but as I said,the evidence is lacking.The Ministry has just published a domestic violencepolicy for all three Services. That is in response tothe cross-Government action plan on violence againstwomen and girls, and there is a cross-Governmentinter-Ministerial group on violence against women towhich the MoD belongs, but as I said, what is lackingis the evidence, I am afraid, so it is quite difficult toanswer that question.



Q339 Mr Donaldson: Air Vice-Marshal Murray, theMoD memorandum said that there had been a stepchange in the amount of charitable funding on offerto the Armed Forces. How much additional fundinghave you received, and are you able to make use ofthat money from the charitable sector in a sensibleway?Air Vice-Marshal Murray: I think so. There has beena significant change in both the amount of moneyavailable and how we have addressed the use of it.Traditionally, our relationship with the charitablesector has really been one of dealing with charitiesthat deal with veterans. We now deal far more withcharities that are very interested in serving personnel.The money has not come to the MoD; traditionally, ithas been spent by the charities on their own peopleand their own constituents. Now that we have moreinterest in the serving Servicemen, we have set upmechanisms internally so that we can focus on whatwe actually need. For example, we run a smallorganisation within MoD with representatives at ahigh level from the Army, Air Force, Navy, themedical side and the charities—particularly Help forHeroes, the Royal British Legion, SSAFA and so on.When we recognise that there is need for a particularthing to be built or to happen, we see whether it canbe funded internally within the MoD. If it cannot, wehave a conversation with those charitableorganisations—in some cases they are very wellendowed—to see where that money should be bestspent to make sure there is no duplication, that we arenot spending charitable money when it should bepublic money, and vice versa, and that we are not, aswe almost did at one stage, about to build somethingfor the Air Force 10 miles away from a very similarfacility for the Army. We have those conversations interms of priority and of focusing the money where itis best needed for social and medical reasons.

Q340 Mr Donaldson: How much additional fundinghas been received from the charitable sector?Air Vice-Marshal Murray: In the context of thisparticular issue, we have received, or been promised,about £50 million from the British Legion, up to £100million from Help for Heroes—that is £70 millionactually promised, with another £30 million outthere—and approximately £10 million from othersmaller charities.

Q341 Mr Donaldson: So is that roughly £160million all together?Air Vice-Marshal Murray: I suggest that it will berising towards £200 million.

Q342 Mr Donaldson: For capital projects, how willyou cope with operating and maintenance costs? Willthe MoD be able to replace the capital assets at theend of their lives?Air Vice-Marshal Murray: Part of the conversationthat we have when we set up a facility is who is goingto be paying for it—who is going to pay to maintainit, who is going to pay to man it, what is its longevity,and what happens at the end of 10 or 20 years whenthat charity might no longer be around or might no

longer wish to fund or support that activity. That iswhere we bring in our infrastructure experts. We haveconversations with the Treasury to make sure that itis comfortable with what we are doing.

Q343 Mr Donaldson: Is the charitable sector nowfunding programmes that the MoD would previouslyhave funded?Air Vice-Marshal Murray: I would not say that. Iwould say that there are some activities that we wouldhave liked to have funded ourselves but for which wehaven’t got the money, and that is where they step in.

Q344 Mr Donaldson: So they are funding someprogrammes that you are not able to fund from yourown resources?Air Vice-Marshal Murray: That is what charities do.We look to see where we should be funding it andwhere we would expect to fund it. It is not the “niceto have”, but the going the extra mile stuff where theyget involved.Q345 Mr Donaldson: Vice-Admiral and General,what has happened to your budget for health care andsupport in the past few years? What are yourexpectations for future budgets?General Rollo: Just to make clear the split ofresponsibilities, ultimately the chain of command isresponsible for everything, but in particular it isresponsible for health policies—things that preventpeople getting ill. In many ways, that is normal chain-of-command activity. It is keeping people fit andhealthy, and the normal support systems will do that.There is no separate health budget in the way thatyour question might imply. The cross-over point issome aspects of mental health and mental health care.Ministers have repeatedly made quite clear to us that,despite the overall financial situation in theDepartment, mental health care is a priority and weare to say what we need.Surgeon Vice-Admiral Raffaelli: I am responsible forhealth care delivery and medical operationalcapability, some of it directly through my joint units,and some of them with process ownership across thethree single Services. I have visibility of the end-to-end piece. We are one of the few areas during theSDSR that actually had additional funds committed,for exactly the reasons that General Rollo referred to.

Q346 Mr Donaldson: Do you have a fund forresearch? If so, where do you spend that money, andare you still able to continue funding the King’sresearch?Surgeon Vice-Admiral Raffaelli: There is a mixture.There is not a single approach to research funding. IfI start with the last question first, we are going tocontinue—it is a shared responsibility. The King’sresearch is essential and will continue. We talkedearlier about what we have done recently. Inpartnership with the Department of Health and theNational Institute of Health Research, we have openedthe UK’s first NIHR Centre for SurgicalReconstruction and Microbiology in partnership withthe UHBFT and the University of Birmingham. Thatis a new initiative. It was formally opened at the



beginning of the year, but the actual doors will openthis month coming. I have a small research budgetwithin my medical director area.We also fund a large number of our people as part oftheir own development to be clinicians or seniornurses or whatever, and we have a programme totarget masters degrees and even PhDs in areas ofparticular relevance to us. We also bid through thescience and technology total research budget, whichis something in the region of £385 million a year. Alot of that goes on equipment, but a component of it,which is not set aside as such, goes on human factorsin their widest sense. That includes medical combatcasualty care, personnel matters and men fitting intoaeroplanes. We bid quite comfortably through that.We also collaborate very much with our internationalpartners, particularly the Americans. For example,their Department of Defence has recently invested inthe Simon Wesley team to look at some screening formental health purposes, families and post-deployment.

We are a non-screen population. There is amultiplicity 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 thatCOBSEO’s success in the lottery funding for a verysubstantial programme—Forces in Mind—which itintends to use for research in future, will clearly reachacross, particularly into the veterans area, and that willallow us to be much more evidence-based in thefuture.Chair: It sounds as though it helps to have a Secretaryof State for Defence who is a doctor.We had better bring this to an end. Thank you verymuch indeed to you all. I am sorry that we have notallowed more time, particularly for you, Air Vice-Marshal Murray. You did not have quite as much timeas you may deserve, but we have particular goals forthis evidence session and we are very grateful to youfor helping us to fulfil them.



Members present:


Mr Jeffrey M. DonaldsonJohn GlenMr Mike HancockMr Dai Havard

________________


Witnesses: Major General Gerry Berragan, Director General Personnel, Land Command, CommodoreMichael Mansergh, Director, Naval Personnel, Colonel Andy Mason, Head of Army Recovery Branch andSurgeon Commodore Calum McArthur, Commander, Defence Medical Group, gave evidence.

Q347 Chair: Gentlemen, welcome to the DefenceCommittee’s session on military casualties, and thankyou very much for agreeing to come and giveevidence. May I begin by asking you please tointroduce yourselves? Colonel Mason, would you liketo start?Colonel Mason: I am Colonel Andy Mason, and I amresponsible for the Army Recovery Capability.Surgeon Commodore McArthur: I am CommodoreCalum McArthur, and I command the DefenceMedical Group, which comprises our five Ministry ofDefence hospital units, RCDM in Birmingham andHeadley Court.Major General Berragan: I am Major General GerryBerragan. I am the Director General Personnel at LandCommand, and my responsibility includes the Armyrecovery capability.Commodore Mansergh: I am Commodore MikeMansergh. I am Director Naval Personnel, and I amresponsible for the executive and welfare support forall in the Naval Service involving the recoverypathway.

Q348 Chair: Let us begin with the issue of physicalcare of the Armed Forces; we will come in a momentto mental care of the Armed Forces. CommodoreMcArthur, could you tell us what sort of challengesyou face in dealing with the physical care andrehabilitation of troops when they come back home?Surgeon Commodore McArthur: I think most of youhave been to Birmingham and to Headley Court, andI am sure you have seen some of the people comingback to those units. What we have seen over the lasttwo, three and four years is soldiers and marinescoming back with increasingly complex injuries,which require a very multidisciplinary clinicalapproach. When a casualty—a soldier—comes backto Birmingham, various disciplines will be required tolook after them: surgical care, orthopaedic care,reconstructive surgery and so on.

Q349 Chair: You are right that the Committee visitedthe Queen Elizabeth Hospital a week or so ago. Howare the arrangements with that hospital working?Surgeon Commodore McArthur: They are workingwell. I think we have learned a lot over the last threeor four years. We have injected more militarypersonnel into Birmingham, and there are now nearly400 people working there. We have learned too to

Mrs Madeleine MoonPenny MordauntMs Gisela Stuart

increase the welfare administrative support to soldiers,marines and airmen coming to Birmingham withincreased J1 support. We have very close engagementwith University Hospital Birmingham NHSFoundation Trust to make it work, and I believe it isworking well.

Q350 Chair: What about the other medical defenceunits?Surgeon Commodore McArthur: The other unitssupport casualties when appropriate. Everyone comesto Birmingham in the first instance, and by and largemost medical support is carried out in Birmingham.Follow-on care may be done in other military unitscloser to garrisons if appropriate; for example, ifongoing support can be provided at Derriford forRoyal Marines in Plymouth, well and good. Similarlyin Aldershot, if support can be provided at FrimleyPark, well and good. But by and large, most of it isdone in Birmingham.

Q351 Chair: I visited Frimley Park on Friday, butthat was because it serves my constituency. Is thereany intention of reconsidering the role of medicaldefence units?Surgeon Commodore McArthur: We arereconsidering the way we place our secondary healthcare people in the NHS. We currently have five unitswhere we try to place people, and we also have manysingleton posts—about 65—dotted around the wholeUK.

Q352 Chair: But is there any suggestion that medicaldefence units might, for example, not continue toexist, and that everything might be sent to the QueenElizabeth?Surgeon Commodore McArthur: No, we plan tomaintain the five units that we have at the moment.As I said earlier, we have reinforced the unit inBirmingham. Our intention is to maintain the rest.

Q353 Chair: There is no study being done into that?Surgeon Commodore McArthur: We are looking atthe way we place people in the NHS. Why? We wantto make greater use of the emerging level 1 traumacentres in the NHS. Ideally, our people have acquiredso many trauma skills on operations that they havequite a lot to add to those units in the NHS, and wewant to try to maintain the skills. We seek to place


13 July 2011 Major General Gerry Berragan, Commodore Michael Mansergh, Colonel Andy Masonand Surgeon Commodore Calum McArthur

people in level 1 trauma centres where possible. Notall the military units that we have are level 1 traumacentres. That is not to say that we are going to closethose units; we are not. We would only seek todisperse people more widely in the NHS, makingbetter use of the level 1 trauma centres.

Q354 Chair: We were very impressed by HeadleyCourt, which we also visited. There is a high level ofactivity, and the obvious intention to expand. Is thatlevel of activity sustainable?Surgeon Commodore McArthur: Yes.

Q355 Chair: Is the expansion on track?Surgeon Commodore McArthur: Yes. We rose to 96beds last year in response to the volume of casualtiescoming back; not just the volume but the length oftime they spend at Headley Court and the admissionsin and out. Today we have 116 beds and the intentionis that by October there will be 120, and 130 by theend of the year. Ultimately, the plan is to build fulleraccommodation at Headley Court, so that by summer2012 we aim to go to 144 beds.

Q356 Chair: What happens when we leaveAfghanistan, or when combat troops stop operating ascombat troops in Afghanistan?Surgeon Commodore McArthur: Some of those 144beds are in temporary ward accommodation that wasestablished four or five years ago and has beenextended to maintain capability, but some of thataccommodation will come to the end of its natural lifeand could be closed. The 144 beds could shrink whenthe current case load coming back from Afghanistanstops.

Q357 Mr Hancock: What does increasing bednumbers do for the capability of what needs to bedone for people? It is one thing to increase thenumbers there, but you have to have the supportneeded. Is that easy to maintain? Can it advance at thesame level as you are expanding the bed numbers?Surgeon Commodore McArthur: You are right, ofcourse. Increasing the number of beds is not the entireissue. Along with that, added staff are required, andprosthetic support, gym capacity and all the otherthings that make up the holistic environment ofHeadley Court. We are doing that; we are meetingthat. Part of it is met through the injection of moneythrough the SDSR process. We are about to put £7.5million per year for 4 years into Role 4, by which Imean Birmingham and Headley Court.

Q358 Mr Hancock: That is quite a big jump, isn’t it,from where you are today to where you will be a yearfrom now? Could it mean that some of the personnelwill have to be there longer, simply because there arenot the facilities to give them the care, treatment andrehabilitation work that needs to be done? It will bedone for more people but over a longer period.Surgeon Commodore McArthur: No, we are not inthat situation. The rehab pathway is a long one formany people. That reflects the complexity of theinjuries. There is the need to spend time at Headley

Court, go on convalescence to regain strength andcome back to Headley Court, but there is noprolongation of treatment due to lack of capacity orresources. We are increasing those but it is a plannedevolution. I firmly believe we are meeting the need.

Q359 Mr Havard: You said that, for some people, itis a long process. One of the great enablers of HeadleyCourt is that they are at work. There is some ethosthere that helps them through and more people arethen retained in the Service. It is not so much whatwould be retained at Headley Court, but that morepeople are kept in the employ of the military farlonger that way. What about the sustainability of thatover time? It might not be in your immediate ambit,but it raises a question about the sustainability of theprocess.Surgeon Commodore McArthur: I am sure that theGeneral will want to comment on that. From my ownperspective and that of the people of Headley Court,it is a long pathway. Over the past three or four years,the majority of people coming back with complexinjuries have not yet been discharged from Servicewhether they are soldiers or Royal Marines. Why?Because as I said earlier, they spend time at HeadleyCourt. They go home; they go back to Headley Courtand then they might go back to Birmingham forfurther reconstructive surgery. We are talking aboutpeople who have lost a limb, two limbs or, in 16 cases,three limbs. It is a long process.Major General Berragan: Your point is absolutelyright, of course. The length of the clinical pathway forpeople with some complex injuries means, clearly,that they will stay in the Army for longer. The otherpoint is that advances in medical care mean that somecan continue serving afterwards. What does thatmean? It means that we need to expand our recoverycapability.It is worth my explaining that the rehabilitationpathway is the clinical pathway, while recovery is therest; and the rest is all about everything from mentalattitude to what they can do—to challenge, to welfareand so on. That is really what the recovery capabilityis about. It is absolutely congruent with therehabilitation pathway. While they are in recovery,people will go in and out of Headley Court for periodsof clinical intervention and, at other times, we willmake sure that their recovery pathway is absolutely inharmony. That is something that we have created inthe past 18 months or so, and something that we areseeking to expand as we get a better handle on theextent of the requirement.Clearly, as you say, eight years of two campaignsmean that we have built up a requirement over andabove what we would have already. The nature ofsoldiering is such that is tough. We injure people andwe have to deal with that. There is a steady staterequirement even when we are not conductingoperations such as we are at the moment.Chair: Commodore Mansergh, do you want to addto that?Commodore Mansergh: I think that the businessbetween the clinical pathway and the overallrecovery—what we are seeing and sharing very much



with the Army—is the process. Some of you mayhave seen at Hasler Company the ability to continuewith the recovery at the same time as there arefacilities to allow rehabilitation to take place in anenvironment where the facilities are made available.Hasler is an example of where we can continue thatrecovery pathway at the same time as the clinicalpathway, by having facilities at a recovery centre.Chair: We were most impressed at Queen ElizabethHospital, Headley Court and Hasler Company by thefact that those who have been injured treat it as partof their work to get better. That is something that wecould recommend to the National Health Service.

Q360 Mr Hancock: May I ask you about mentalhealth problems both for serving personnel and whenpeople have left the Service? Where are you with that,and what is being done at the present time? Whatmajor problems in the mental health field areemerging?Major General Berragan: If the Commodore startsby talking about the clinical aspects, I shall come inon the wider aspects.Surgeon Commodore McArthur: The immediatemental health issues are those that you might expectfrom someone who has suffered a life-changing injury.By and large, a soldier at Birmingham and at HeadleyCourt is very focused on recovery and trying to regainhis life and to rehabilitate. We have established a 2year screening programme for mental health issues,starting in Birmingham, and following that person allthe way through the pathway at Headley Court on therecovery process and beyond. If they are dischargedfrom Service prior to the 2 year point they would befollowed up until the two year point to try to trackemerging mental health issues. When a soldier is inthat fairly high tempo Role 4 pathway at Birminghamand Headley Court, he is focused, as I said, ongetting better.

Q361 Mr Hancock: What about the personnel whodo not come back with physical injuries, but comeback suffering from mental health problems? What areyou experiencing? What are the treatments available?Where is the pathway for those personnel?Surgeon Commodore McArthur: Part of it is tryingto prevent those problems from happening in the firstplace—making sure that deploying troops get theproper mental health brief before they deploy and thatwhen they come back into the UK, they go through atwo-day decompression programme in Cyprus. It alsoinvolves them having follow-on briefs when they areback in units after they have taken their leave. Do youwant to say more, General?Major General Berragan: Of course, there are mentalhealth professionals deployed forward in Bastion, sothere is, if you like, an immediate mental healthcapability in theatre, and there are clearly mentalhealth professionals within the Defence MedicalServices.I will just pick up on what the Commodore said,because we have learned a great deal fromexperiences of previous campaigns. What we aretrying to do is to get ahead of the problem, and to

do so by interventions which are non-clinical but aredesigned to flush out and identify where people havesuffered stress or are suffering stress as a result ofwhat they have been through in operations.It is quite important to recognise that much of that canbe done without any medical intervention whatever. Itcan be done by trained non-medical people—ideally,people within the cohesive unit that has undergonethat experience—by, in the first instance, goingthrough a process of talking about it.That is really what describes the TRiM process—theTrauma Risk Management process. Since 2008, wehave mandated TRiM as a capability. We have trained5,000-odd people in conducting it, and the people wetrain to do it are at the sort of company sergeant-majorlevel. They are respected people who soldiers look upto and trust, and who have been through the samethings they have and understand the pressures they areunder. They then train people within units to conductthis.If I take you through an example: let’s say that on anoperation there is an incident where someone is killedor wounded. The rest of that group of peopleinvolved—the patrol, the vehicle crew or whatever—will, within 72 hours, go through a formalisedstructured debriefing process with one of these trainedTRiM professionals.The purpose of that is to take them through theirexperience in the period in advance of that particularincident, and what happened during the incident andwhat happened after the incident. Why 72 hours?Because it takes 72 hours for people to overcome theshock and start to internalise the thing and to reflecton it. Any earlier than that is probably too soon;experience tells us that 72 hours is a good time. It isdone in a structured way over a period of time withall of the people involved.The key purpose of that is, first, to get them talkingabout it and their reaction among themselves, so thatthey feel that is okay, and secondly, to identify in thatsecond phase—talking about the incident itself—where someone may be at risk of having an acutedegree of stress. At that stage, all we do is identifythat and allow them, if necessary, to go to someonelike the padre or the medics to talk about it, and toallow them almost, as it were, to overcome that stressthemselves by getting back into the operationalroutine and so on.If we have identified them with that problem, we willdo another intervention within a month to see wherethey are and whether that stress is being coped withas we all cope with stress over time, or whether it hasnot in fact been coped with and has become moreacute. At that stage, we would look to involve somemental health professionals to start to help them toreduce that stress.

Q362 Mr Hancock: Is there a risk associated withthat, General? Somebody who has shown emotionaldistress over what has gone on will, for one month,be in the same environment doing exactly the samejob with that going on inside their head. Is there norisk attached to that?



Major General Berragan: It is important to know thatthe chain of command is aware of what that individualor that patrol has been through and will understandthe pressures that they are under and watching for anysigns of stress. But this is on top of what we wouldnormally expect the chain of command of thosepeople to do.It is also worth knowing that we got to this pointhaving been through the process of immediatecounselling, which became fashionable about eight ornine years ago and which I think has proven to becounter-productive. If you introduce people intoformal counselling—psychiatric counselling—tooearly, you can make the problem worse because youget them to go over it in a way that almost makes thething worse rather than better.We return to TRiM on the basis that the medics say itdoes no harm; our experience from talking to peoplewho have been through it is that it does an enormousamount of good. It is very popular. The other thingthat it does is de-stigmatise mental stress. In the past,both in the Army and across society, that has been areal problem. Now those who they see as key rolemodels in their lives—people they look up to—talkthrough these issues with them. That is a hugelypositive step.

Q363 Mr Hancock: How often is someone taken outof theatre because of mental health problems? Is thata rare occurrence?Surgeon Commodore McArthur: Yes, it is a rareoccurrence. For reasons that the General has describedincluding the, deployed mental health teams in theatre.People are robust—they are doing a job; they arefocused and surviving. People, by and large, are notbeing evacuated from theatre with acute mentalhealth issues.

Q364 Mr Hancock: When they are back here—andthis is the point of the question about the treatmentsand the pathway for somebody with mental health—asoldier with a physical disability could be two yearsin the pathways, but they are still in the Forces and soon. What would the same programme be for someonecoming back with acute mental health problems? Howdo you deal with that? Do you maintain them in theService for a prolonged period of time, or do youmake a quick assessment about their suitability toremain?Surgeon Commodore McArthur: It is difficult togeneralise. If somebody comes back and is diagnosedas having a mental health issue, clearly, as every manand woman is an individual, they need to be assessedand treated. That will be done through the variousdepartments of community mental health that we haveon a tri-Service basis across the UK. Once that personis treated and they respond to treatment, hopefullythey can carry on.

Q365 Mr Hancock: Where would they go? If youhave a physical disability, you will end up at HeadleyCourt at some time and you start off at Birmingham.Where does someone coming back with a mentalhealth problem go in the system? Where do they get

the ongoing military support? What happens to thoseindividuals? You don’t have that sort of unit.Surgeon Commodore McArthur: No, we have theDepartment of Community Mental Health.

Q366 Mr Hancock: Where is that?Surgeon Commodore McArthur: There are regionalbases. For example there will be ones in Catterickgarrison, Aldershot and Portsmouth.

Q367 Mr Hancock: There are a lot of Servicepersonnel living in my and Penny Mordaunt’sconstituencies, in and around the south of Hampshire.Where is the mental health facility there? I am curiousto know where it is.Surgeon Commodore McArthur: We have one inAldershot and one in Portsmouth.

Q368 Mr Hancock: In Portsmouth?Surgeon Commodore McArthur: Yes, in the navalbase.

Q369 Mr Hancock: In the naval base itself? Aresidential unit?Surgeon Commodore McArthur: It is not residential.This is a community-based approach. Most Servicepersonnel do not require in-patient psychiatric care. Ifthey do, it is provided through a hosting contract withStaffordshire and Shropshire NHS Trust.Mr Hancock: That is what I wanted to know.Surgeon Commodore McArthur: That is a rarity.

Q370 Mrs Moon: I just want to follow up on MrHancock’s questions. I have a group in myconstituency that has been funded by the BritishLegion. It is a post-traumatic stress disorder group.These are people who left the Services some yearsago. When I met them, the common theme was aroundtheir distress over the discharge process. One of themhad acute mental health problems as a result of hisexperiences in the Balkans. He was discharged with amental health condition and felt that he was cut loose.That was some years ago, and I am sure there aredifferent processes in place now. Can you say a bitabout what the discharge processes are when someonehas an identified mental health condition, and how youensure that they are slotted into the appropriatesupport service once they leave the Services?Surgeon Commodore McArthur: I think it would beunfortunate to treat a mental health issue differentlyfrom any other medical issue. If somebody has amedical problem or a mental health issue that requiresthem being medically downgraded, they would betreated appropriately for the condition. If they werenot getting better, after a period of 12 months theywould go to a medical board to be assessed. Thatmedical board would put them into a medicalcategory. That person would then go to anemployability board to be assessed as to whether theywere suitable for employment in the Army, Navy orAir Force. If they are not, they will be discharged.You were talking about the Balkans—it is a decadeago now—and I think that, as you said, we have learntan awful lot over the last few years. I would hope that



that process would be much more sophisticated andslick now, so that a person, once he is cut loose fromthe Army or Navy, is properly treated and followed onwithin the NHS. That is partly what the new transitionprotocol, which has been developed between the MoDand the Department of Health, is there to do. It is totry and ensure a seamless transfer of care, into theNHS, whether it be mental health or physical.

Q371 Ms Stuart: General Berragan, I was veryinterested in what you said about the kind of shiftfrom immediate counselling to that 72-hour point,which I think is quite critical in terms of channellingwhether you think this is the narrowest escape or mosthorrible thing that ever happened to you. Just for thebenefit of the Committee, is there some follow-upresearch—published literature—that we could look at,or is it too early for that?Major General Berragan: It is too early at themoment. Certainly the King’s College research pickedup on the TRiM process. It made the point that Imade, which is that medically it appears to do you noharm and is popular and well received. Certainly interms of anecdote, soldiers appreciate it and they thinkit is a good thing.The whole approach that we take to operational stressis far more mature now, as the Commodore said, fromdoing the intervention in Cyprus where they areallowed to let off steam and so on right the waythrough to TRiM, and the post-operations stressmanagement system that we have in place is a moremature one now.We still have a hill to climb on stigma. We have acampaign running right now—June to September—totry to de-stigmatise mental health. I have someexamples here of some of the articles and posters thatwe have running in Soldier magazine, Sixth Sense,Garrison radio and in and around units. This is one ofmy guys talking about it in a Soldier magazine article.The campaign is to get people to talk about it. In thepast, the attitude has been that if you had a physicalmedical problem, you went to the doctor. If you hada mental health problem, people have always felt, “I’lldeal with it. If I say anything, it will affect my careerprospects or somehow make me something less thanmy mates”. Our message is no different. Whether it isa physical or mental problem, you have to treat bothif necessary.

Q372 Ms Stuart: At what stage can we start to lookfor some analysis? I think it is quite a big shift. Whendo you think King’s will come up with something thatthe Committee can consider?Major General Berragan: It is continuing with thesame research.

Q373 Ms Stuart: What is the dateline for theresearch?Major General Berragan: It is continuing with thesame cohort. It reported in 2006 and it reported lastyear, so I suspect that we will see some follow-upresearch probably in the next two or three years. It iscertainly very interested in the effect of trauma.

Mr Hancock: Can I ask one final question?[Interruption.]Chair: There is a Division in the House on the ten-minute rule Bill. We shall suspend the sitting until weare quorate again.Sitting suspended for a Division in the House.On resuming—Chair: Order. Although Mike Hancock has a questionthat he wishes to ask you, I think that he can ask itwhen he gets back. So Jeffrey Donaldson will ask thenext question.

Q374 Mr Donaldson: Gentlemen, is alcohol abusethe major mental health problem in the Armed Forcesand, if it is, what are you doing about it?Major General Berragan: Let me start and I willprobably bring some of the others in, if I may.First, what we know, certainly from the King’s Centreresearch, is that alcohol dependence in the ArmedForces is not a major problem. By dependence, I meanalcoholism. Actually, alcohol abuse or misuse is aproblem in the age group under 35. When we compareourselves against broader society, we are probablytwice as likely to misuse alcohol in that age group. Ithink that the figure for females in the Services is evenhigher, as well. But from the age of 35 onwards, webroadly reflect society in terms of use or misuse ofalcohol.So why is that? Here, I am speaking on the basis of32 years’ experience rather than on the basis of hardevidence. But having spent three years running therecruiting and training division, I know who werecruit and what they are like, and having commandedsoldiers for the best part of that 30 years, I know themreasonably well. I think that that research missessomething, in the sense that it compares a broadersocietal trend against a particular group of people whoare, by definition, risk takers. We recruit risk takers,we need people to take risks and often that is whypeople join the Services. And so they perhaps have aslightly different approach to what might be seen ashazardous behaviour than some other elements ofsociety.We take that group of risk takers and we put them instressful situations; we take them away from alcoholfor long periods of time, on operations; and then wereturn them to this country and we give them a lot ofmoney and a lot of time off. So I think that there is adefinite relationship between young risk takers whowould normally expect to drink—certainly in thesociety they come from they would expect to drink,as it is part of the culture they come from—and thefact that we deprive them of alcohol, then put themthrough some stressful situations and then they comeback and what might be termed “self-medicate” interms of alcohol.We also know that that binge drinking tends to comeat a period about two months or so after the operationhas concluded and then starts to tail off again as theyget back into a normal training regime. So, yes, I thinkthat we have a problem compared with broadersociety. It is in a particular part of our structure and itis perhaps related to who we recruit and their access,



or otherwise, to alcohol. We certainly recognise thatit is a problem.Secondly, it has got a lot better. I have served in theArmy for 32 years. We were talking about this before.When I joined the Army, lunchtime drinking wasroutine and alcohol consumption was greater acrossthe full spectrum than it is now. That may reflectbroader society—I don’t know—but it was myexperience. Talking to my colleagues, their experiencewas similar. That is almost unheard of in the Servicesnow. Nobody drinks at lunchtime. We used to give outprizes of cases of beer and things like that for winningsporting competitions. We do not do that anymore. Wehave picked up on this problem and we are takingaction.On what we are doing about it, it is another pillar inour whole strategy. The first pillar of any strategy isawareness. On a cyclical basis, we go through aprocess of posters, awareness and briefings on thedangers of alcohol misuse. The first point aboutsolving any problem is giving people the facts. Thatis what we try to do.Beyond that, the second stage is informal warningsand counselling. Beyond that, there is administrativeaction and counselling. If you like, there is a clinicalintervention and a disciplinary intervention. If theproblem does not go away and they fail to control it,they can ultimately be discharged from the Army. Ifthe problem affects their operational effectiveness andtheir ability to do the job, the ultimate sanction isdischarge.There is a four-stage treatment process involving boththe chain of command and the clinical chain. I willget Commodore McArthur to talk a little more aboutwhat we do clinically for those with alcohol problems.We also have pricing policies, where any alcohol soldin camp has to reflect local market prices, so we donot encourage people to drink by cutting prices. Thepay-as-you-dine contractors have to provide non-alcoholic facilities in camp, like internet cafes orCosta Coffees, so that there is an alternative to thebar. I have talked about the inter-unit activities andalcohol prizes, but awareness is the other issue. I willhand over to Commodore McArthur to discuss what isavailable in the medical chain for those with a seriousalcohol problem.Surgeon Commodore McArthur: I think the Generalhas covered most of the stuff. I would say, however,that it is about trying to prevent the situation reachingthe stage where you have to put the soldier or sailorinto a formal treatment programme. Education isterribly important. That is a routine thing through allunits in the Army, Navy and Air Force. There is anongoing education programme. It is about mentoring,through the chain of command on a division basis, asquadron basis or a flight basis, trying to nip it in thebud if a guy is drinking too much.Ultimately, treatment, can be provided if required,through the Department of Community MentalHealth, which I mentioned before. Not everyDepartment of Community Mental Health can put onan alcohol treatment programme, but some do. By andlarge that it is a week-long programme, with group-based activities and a good success rate. I will say

from my perception as a medical officer who hasserved for many years, that the level of alcohol abuseand misuse, as the General said, has markedly gonedown.

Q375 Mr Havard: It is not just about alcohol; it isabout risky behaviour. I know a chap who came backwho had been in an urban environment. He would notdrive a car, because of how he had driven withdefensive driving and the rest of it. He knew that hehad a problem and that if he got into a car hisbehaviour would not be conducive to his health oranyone else’s. He understood that, but a lot of otherpeople will engage in all sorts of risky behaviour.Unless they pop up in the courts, with the police orsomewhere else, how do you deal with that riskybehaviour?Major General Berragan: Part of theirdecompression covers that. They are shown videos onthis subject, particularly on driving, where, as you say,on operations they are encouraged to, and often haveto, drive without seatbelts in a particularly riskyway.1

Mr Havard: He said he learned that from me, butthat is not true.Major General Berragan: We are very conscious ofit so they do get briefed on it and they are made awareof it. I think it still happens. The other aspect is thatthey have been living on an adrenalin rush for the bestpart of six months. Coming off adrenalin is likecoming off any other form of substance; you have todo it in a measured way. That perhaps explains whypeople do risky things after operations, because theyare still seeking part of that adrenalin rush that theyhave become accustomed to on operations.

Q376 Chair: You say it is part of decompression.How long does decompression last?Major General Berragan: They are about 36 to 48hours in Cyprus.

Q377 Chair: That is not enough to instil a change inbehaviour, is it?Major General Berragan: It is not. Going back towhat I said before, the first problem is awareness—understand it is going to happen, understand what thesymptoms are, understand what the dangers are. Thatis really what we concentrate on, making them aware.They will also not go on leave immediately when theycome back. As you know, they spend up to two weeksin camp, normally doing some routine activity to getthem off the high tempo of routine that they have hadin operations and get them back into a sense ofnormality before they go on post-operational tourleave, to help them wind down for that reason.1 Note by witness: Since the HCDC evidence session, we have

established that this is not the case. The wearing of therestraint system/seat belt is mandatory for everyonetravelling in a vehicle. The restraint system must be fittedand worn correctly in order to maximise safety in the eventof an accident or IED strike. The only exception is when thevehicle gunner is required to man the weapon system due tothe perceived threat or whilst undergoing training.Additionally, driving in a hazardous manner is notencouraged.



Chair: That is fine for the regulars.Major General Berragan: And the TA too now,because we mobilise them for longer, and part of thatmobilisation period includes POTL, they will gothrough the same decompression and wind-down asthe regulars do. It is not always popular, of course,because the first thing they want to do is go back andsee their family, but we try to keep them together asa unit. Often they will have some form of memorialservice for the people they have lost. We try to keepthem as a formed unit, a battle group that they formedup in, and as close together as possible until they goon post-operational tour leave. The other point is thatthey go back through RTMC, as they come back andcome off their contract. There is a mechanism as theygo through RTMC to raise concerns and issues,whether their mental health, stress, or drinking. All ofthose things are warning symptoms.The other ally that we have got in this sense is thefamilies, because when they do disperse back tofamilies, whether Reserves or regulars, it is thefamilies who see what the impact has been. We havedone a lot of work recently in terms of providinginformation to families. There are two separate guides,one is for the families of deployed regular personnel,and the other is purely aimed at Reservist personnel,because the families are in different circumstances,they have different support mechanisms available andoften face different challenges, so they are specificallywritten for the two kinds of families. Both of theseare available on the front page of Army web.We do a lot of family briefings. 16 Brigade just gotback in April. Something like 1,500 family memberswere briefed before they went, with a further 1,500family events across the Brigade during the tour. Theythen conducted post-briefings for families, which arenot as well attended, and about 150 attended those.We recognise the family has a role to play here,because they clearly see the soldier or Servicemanonce they come back on leave and they will see thoserisk factors and how their stresses materialise. Helpingthem to understand them is a key part of it.Chair: Thank you very much. It would be helpful ifyou could leave those behind.Major General Berragan: Absolutely.

Q378 Mrs Moon: The development of those booksis absolutely excellent and I commend you for doingthat. In terms of Reservists, are you doing any workwith employers? If you have got this desire for theadrenalin rush, and you are going back into a moresedentary job, how can we make sure that theytransfer back into that quieter, calmer job pace? Areyou working with employers, so that they understandsome of the difficulties on return?Major General Berragan: We are through the RFCAand the NEAB, both of whom are our interface withemployers at a regional and local level. Some of thebig employers who are used to having TA orReservists, are very good and engage with us. Someof the smaller employers have less interest in doingso, so it depends on the size of the employer and howconnected they are to Reserve Service. Some of themare excellent and really good, and understand it.

Others, probably because they only have maybe oneTA or Reservist member in the whole company, areless so and harder to reach.

Q379 Mrs Moon: Is anyone doing any workchecking the figures on people who, once they havebeen in theatre and come back, lose their jobs? Is thatbeing followed at all or monitored?Major General Berragan: I don’t have those figures,but we can come back to you with them. I am surewe do have them, but I have not got them availableto me at the moment.

Q380 Ms Stuart: When we went up to the QueenElizabeth Hospital, it became clear that some—particularly the Territorials—who are injured whenthey come back, may be part of a big company supplychain, for example, and think of themselves asworking for large company X—but while the smallunit they work for recognises them, the companyitself doesn’t.I had a conversation this morning on one case, andthe guy on the small supply chain said, “Well, I didn’teven think it was appropriate for me to tellheadquarters that this was the situation, and wethought we’d do it when he comes back to work.” Iwas just wondering whether there is more work wecan do to show people that it is appropriate that youtell employers.Major General Berragan: I am sure there is.

Q381 Ms Stuart: Is there more you could do?Major General Berragan: I am sure there is. And Ithink it’s something we should look at. As I say, weare connected with SaBRE, with NEAB and theRFCAs, with employers, but I am sure we can domore in terms of formalising that brief.Ms Stuart: Could I flag this up, in relation to thosewho are part of a supply chain of a much largercompany? The Reservists clearly thought they werepart of this large company’s family, but it didn’t makeits way up and therefore wasn’t sufficientlyrecognised.

Q382 John Glen: Can I just follow up on whathappens with individuals who deploy to do preciseroles, who perhaps aren’t accustomed to the sort ofcamaraderie that you would get as part of a unit? Whatprovision is there for how they are looked after whenthey come back, perhaps on their own, with a uniqueexperience? This is different to a group of people, whocan obviously be treated as such.Major General Berragan: Individual augmentees,you’re talking about. As you say, we do mobilise anumber of those. In the first instance, they will goback for RTMC, as a bare minimum, and there is acatch-all there, as they demobilise, for briefings andconnectivity. They will go back into a unit, and thatunit will receive them back. That unit CO is stillresponsible for them, having mobilised them in thefirst place. So we do have a safety net still there, andI think that is based on the RTMC and the TA unitthey belong to. Even if it is a CHQ, they still have a



unit they belong to, who can be, if you like, thesupport network that they turn to.Almost every single TA unit in the Army has nowmobilised people and sent them on operations, so Ithink there is that experience now, of what that means,what impact that can have on people as they comeback. There is a breadth and depth of experience nowamong the TA that enables that. At least someone inthat unit knows what they’ve been through, knowswhat the problems might be, and so can be ofassistance.Then there is the reach-back. There is a mental healthprogramme at RTMC for Reservists. There are about180 of them on there at the moment, who havesubsequently developed problems and have gone backthrough the RTMC mental health programme and arebeing clinically treated. So there is that reach-back.The RTMC is a gateway both ways, for Reservistscoming in and going back out, which gives us anassurance that they should not get lost in the system.

Q383 Chair: I will come to you in a moment,Commodore Mansergh. On the issue that Gisela Stuartraised, about the relationship between woundedpersonnel and employers: we are likely to includesomething on that issue in our report arising out ofthis inquiry, so anything you can provide us with inwriting before we do—about the work that is donewith employers to get them to acknowledge theincredible benefit they get, and what people have donefor their country when they come back wounded—would be extremely helpful. Commodore Mansergh?Commodore Mansergh: I just wanted to add to whatthe General said. Individual augmentees are notnecessarily Reservists; they may be from the NavalService or Air Force. There are a lot of bespokecapabilities that individuals provide, and they go outoutside a formed unit. I think we have recognised—certainly in recent years, the last two years—theimportance of including them in the decompressionprogramme. A number of them were coming back andescaping that process, so we have now tightened thatup considerably.All will come back through Cyprus. They will dodecompression as part of a group. They are not put onto another formed unit, because that was seen as beingactually more of a challenge for them. So they are puttogether as a group, they decompress in Cyprus, andthen come back. The Naval Service has a mountingand dismounting centre, so they will go through aprocess in which we check whether they are gettingthe operational stress management ticks. That willthen be followed up.Further to that, on the point about employers, thecommanding officers of our Reserve units knowwhere their people have been and, where an individualis employed, they will ensure that, where possible, theinformation is shared with the employer through theindividual.On the individual augmentee point, we are muchbetter than we were two years ago at ensuring that weare tracking to ensure that the commanding officer ofa returning individual understands what thatindividual has been through and has documented

proof that the individual has been properly lookedafter.

Q384 Mr Havard: If we could return to the recoverypathway. We understand rehabilitation and recovery,and we understand the transition that people makewithin it. The RAF is not represented today, but wehave already taken some evidence from it on theparticulars of its approach to some of these issues.May I first ask about the Army process? We canperhaps then deal with the Navy, which hopefullyincludes the Marines. How many people are currentlyon the pathway, and what proportion of them arecasualties coming out of theatre?Major General Berragan: I’ll ask Colonel Mason topick up that question. He is well connected to theRAF, so he can probably talk about that, too.Colonel Mason: On the overall pathway at themoment, so far as the Army is concerned, there are600, although the number ebbs and flows a little bit.That figure of 600 represents the current capacity ofthe Army Recovery Capability, which is not bigenough. We have done an enormous amount of work,as directed by General Berragan, the director generalpersonnel, to define the requirement exactly and tolook at the additional resources needed to deliveragainst that requirement. I anticipate the capacityrising to about 1,000 by the end of the year. That, ifyou like, is the need.Of those who are war wounded, and those who areinjured or sick through other incidents and are equallydeserving of being in the recovery process, becausethere is a filter to ensure that the process is availableto the most deserving and the neediest—Mr Havard: You’re anticipating some of my otherquestions—it saves me asking.Colonel Mason: A third of those are operational, andtwo thirds are through normal training—not thatanything we do is particularly normal—or aredamaged in ways other than being on duty onoperations. Of the flow through of the Army RecoveryCapability, about which I can speak in detail, twothirds transition out—our main effort is to ensure thatthose who come in can transition through to a civilianlife—and a third go back to duty.

Q385 Mr Havard: That is interesting. Are you nowcapturing everyone in the process? Are you confidentthat everyone who needs to be in the process is in it?Colonel Mason: The answer is that we are capturingthem procedurally. We have them on the radar, but wedo not yet have the capacity to take them into theprocess. Particularly in the current austereenvironment, when everything is reducing,downsizing and generally getting smaller, trying tobuild anything from scratch is like swimming againstthe tide. To do that, quite rightly, we need empiricalevidence, otherwise asking for more, like Oliver, isnot very helpful.We now have evidence from the assignment boards,which bring people into the Army RecoveryCapability. Just like being promoted, there are manymajors and few lieutenant-colonels, so how do youget to that point? There needs to be a proper



promotion board that can stand scrutiny. Theassignment board for the Army Recovery Capabilityhas to be formal and properly recorded. Because wehave done the work, we now have a clear picture ofthose who are out there waiting to come in. Thatevidence is driving the enhancement that will see usgo from 600 to 1,000.

Q386 Mr Havard: Is there particular support forthose who return to Service, as opposed totransitioning out, that comes through the recoveryprocess? Or is that dealt with in some other way?Colonel Mason: The key to this is command. One ofthe reasons the Army Recovery Capability wasestablished was that those who were wounded, injuredand sick fell away from command, naturally, becauseunits were focused on the next fight and, with all thecomplexity of dealing with those from the previousone, they tended to fall away. That is exactly what theARC is designed to prevent. Personnel are either in aparent unit and being looked after because they aredeployable or they are in the ARC because they’renot. We’re either getting them better in order to deployagain—and when they go back to units they will beat a medical grading that will see them deploy again—or, because they will never achieve that medicalgrading, they are to transition out. The ARC isdesigned to ensure that we deliver either trajectory.

Q387 Mr Havard: What is the situation as far asthe Navy is concerned? Could you explain where it isslightly different and where it is similar?Commodore Mansergh: In broad terms we have avery similar system. The Naval Service—excuse mefor using that term, but it means the Royal Navy andRoyal Marines because we are one organisation—have had a recovery pathway for some time. Itincludes everybody who is medically downgraded. Inother words, if they are not able to do their jobmedically, or for compassionate or even disciplinaryreasons, we keep all those people in what we call therecovery pathway. The Navy currently has 749 in thatpathway, which is quite a large number if youcompare it with the Army.Mr Havard: You have more.Commodore Mansergh: We do, but discipline makesup a reasonable part of that, for example people whoare not employed because they are awaiting courtmartial. That is the difference; our recovery pathwayis an umbrella over everybody in the Naval Service.It is not just medical, but also compassionate“downgrading”, which we call it, though it is probablynot the right term. We put people in a position wherethey are not able to work because they are there forcompassionate reasons.

Q388 Mr Havard: What proportion is made up ofthose who have recently been involved in theatre, asopposed to the rest? Is it two thirds?Commodore Mansergh: Answering the question ofhow many are involved through battle or operationalinjuries is difficult, because we have an awful lot ofpeople who are deployed on operations who might fall

down a ladder, but we’re perhaps not putting them inthe same position as the focus on Afghanistan.Mr Havard: When I go to Afghanistan, I trip overthe Navy all the time. Most of the people there seemto be in the Navy, and they’re not all in the Marineseither.Commodore Mansergh: No, absolutely. At themoment we have 45 long-term battle injuries in HaslerCompany—people who have complex injuries fromwar fighting. As you said, we have just had two navalmedical assistants who were wounded in Afghanistanand have come back. One has actually returned totheatre. It is not easy to give a percentage of howmany are in a wounded category. I would say thatprobably 10% of that 749 will have been woundedin operations.I want to make a point about the way that the NavalService Recovery Pathway operates. We haverecovery cells, recovery troops and then HaslerCompany all under the same umbrella, so we arelooking at the totality of everybody who is not fit towork, for whatever reason. It is quite dangerous tomake a comparison with the Army figures, which arebased on slightly different criteria.Mr Havard: Okay.Commodore Mansergh: We have found that ensuringwe have centralised control, particularly of those withcomplex injuries, has been of huge value in therecovery pathway. Hasler Company demonstrates howwe have centralised the support to individuals. At themoment, we have 63 assigned to Hasler Company. Wedon’t have 63 actually at Hasler Company, but theyare still being looked after. Their needs might be bestaddressed somewhere else in the country, or even athome, but they are being administered through HaslerCompany. The important point that I want to make isthat the recovery pathway is an umbrella overeverybody who needs support to maximise theirrecovery potential so that they can come back inwhatever capacity, whether it’s back to work or atransition to civilian life. That is all done under onepolicy and one organisation.

Q389 Chair: On getting back to civilian life, are youall using the transition protocol? How is it going?Major General Berragan: The transition protocol thatyou mention is the transition of medical care fromthe military medical services to the NHS. We viewtransition much more broadly, and I will get Andrewto talk a bit about how we view transition, which, interms of expanding the capacity and the capability ofthe ARC, is our main effort. I have a complicateddiagram here, which is our recognised recoverypicture. It shows all the components on a single pieceof paper. On the left hand side, from your perspective,are those people in the pool who will potentially comeinto the ARC. At any one time, that could be 2,000people. Of those, 1,000 will be short-termdowngraded—a twisted ankle or something likethat—who will probably never come into the ARC.The remaining 1,000 could potentially come into theARC. Hence, as Andrew said, there is the need toestablish a capacity of 1,000 for the ARC. That is theassessment process that he describes, and this figure



shows how people are going through it. This describesall the personnel recovery units across the country,including Hasler Company down here. Here, on thenext line—

Q390 Chair: May I stop you? There is a bit of aproblem with using a visual aid in that it is a bit trickyto get into Hansard.Major General Berragan: Sorry. I will describe it inmore general terms. The next line portrays theresidential capacity of the residential centres, andthese are sort of things that you will have heard about.Tedworth House opened in an interim capability onMonday. The centre in Edinburgh is already up andrunning. We are building one in Catterick, one inColchester and so on. Hasler, again, already has aresidential capacity.Finally, the arrows on the other side of the diagramshow the flow or transition out. That—I will handover to Andrew in a second—is where we are reallystarting to build capacity in terms of enabling peopleto transition back to civilian life, in particular, in anabsolutely swept-up way.Colonel Mason: It is fair to say that the transitionprotocol covering the clinical and social care aspectsis not the entire solution, because we need to ensurethat we have a holistic and multifaceted approach, asindeed we have adopted all the way through. The aimright from the very beginning in setting up the ARCwas to try to take the clinical excellence that we weredelivering out of places such as Headley Court andBirmingham and to ensure that the whole pipeline ofrecovery, from point of entry to a minimum of 18months post-discharge in supported employment, wascoherent. We have had to bring a raft of other expertsthis side of the fence—for want of a better term—towhom we would have traditionally handed theindividual in transition. We would have got thembetter and then handed them to the Service charitiesand said, “Over to you.” That is not the way that it isdone now.Part of the enhancement of the ARC since the lasttime we were before the Committee is that we havevery much looked at the defence employment andopportunities team to corral all the opportunities foremployment together. The Army Benevolent Fund hasfunded 10 expert employment advisers down at unitlevel, so we now have an operational and tactical levelpiece for employment. A transitional support team isbeing set up with seven in my branch to oversee it atan operational level, but, equally and importantly, atthe tactical level, we have a mentoring trial starting inSeptember out of our personnel recovery andassessment centres north and south—the PRACs inCatterick and Tidworth. We are starting that withthose transitioning out to thicken up the support net asthey go, so we are increasingly looking at supportedemployment as the cornerstone of well-being for thefuture for these individuals. That is a complex anddifficult thing to do. It is creating impetus at the backend of the recovery pipe, which will hopefully drawpeople through in a more effective way, as opposed tobringing them to the gate and waving them goodbye.

That is not the best way of delivering effectiverecovery.We are increasingly seeing that success in transitionequals success in recovery for those who willtransition, so it is a virtuous spiral of activity that weneed to get right on the other side of the fence. Wehave put together the means to do that.

Q391 Chair: Commodore Mansergh, is thereanything that you want to add?Commodore Mansergh: Just a few examples. Out ofHasler Company, eight have transitioned; they havegone into employment, for example, as a BT networkengineer, a student on a physio course, or maritimesecurity managers, site managers, mentors andmotivational speakers. They have transitioned throughthe process and are now finding employment, wherethey get satisfaction outside the Service.

Q392 Chair: Is there anything that needs to be saidabout any differences between the transition indifferent parts of England, or in relation to theDevolved Administrations?Colonel Mason: One of the tasks of the transitionsupport team is to conduct a transitional assurancepackage before the guys go, really building towardsthat. Return from whence they came—a third-generation unemployed council house in Darlington,potentially, which is the sort of area that we recruit alot of people from—is not necessarily conducive totheir future.Therefore, relocation is a part of our hard facts that welook at—housing, health, accommodation, relocation,and all the other bits and pieces form a checklist ontransition. Relocation is quite important, because theymay not return from whence they came, which meansthey are leaving one family but not returning to theirold one. They going to support themselves in the kindof jobs that were being described earlier, so relocationas part of the transitional piece is important.

Q393 Chair: Have there been more enthusiasticresponses to this transition issue from, say, Scotland,Wales or northern England?Colonel Mason: Scotland is a case in point; it is easierto deal with a single Administration and a single NHS.It is a good microcosm and testing ground, which iswhy we have had so much benefit from the first centreopening there. We have learnt a lot of lessons fromthat, but we are trying to read those across. We arenot seeing a huge number transition yet. The Navy isa tactical bound ahead of us—we don’t like sayingthat, because it is Royal Marines and that would upsetme—and we have learnt a lot of lessons from itsexperience. A very good pace is being set that weintend to match—and indeed, beat, I hope.Chair: You look very pleased, CommodoreMansergh.Commodore Mansergh: I have nothing to add really,other than to say that we are sharing, working veryclosely together and getting the best practice out ofboth Services, so it is not a competition.



Q394 Mr Havard: I spent some time with anOPFOR training group of Marines, and they didn’twin. That is a different matter. They don’t always win.The argument about the Devolved Administrationspoint is clearly important, because the structures thatyou are dealing with are different.My concern—this relates to a number of things withthe Covenant—is that if there are declarations fromthe centre about a commitment to an individual forparticular services, how do you ensure that that isdelivered against a differentiated architecture ofprovision, commissioning, and so on, which will bedifferent across the UK? It seems a big problem tome. We are just asking whether the transition protocolcould be consistently applied—even though it cannotbe uniformly applied—if you had the adequatearrangements. Is that where we are going, or do weneed to do something else?Major General Berragan: Let me answer the first bitof that question, if I may. In terms of liaison withthe Devolved Administrations, that is the role of ourregional chain of command, as you know. In the caseof Wales, it is the 160 Brigade; for Scotland, it is theGOC Scotland; and in Northern Ireland, it is the 38Brigade. So, each of those brigade commanders—orGOCs, in the case of Scotland—is responsible forliaison with the Devolved Administration.It is also the fact that the Army Recovery Capability,or the personnel recovery units, are under thecommand of the regional chain, so they deliver thatservice in their area. The interface between, forexample, the personnel recovery unit in Wales and theDevolved Administration is the person of Commander160 Brigade. He is responsible for that and he does itacross the board, whether it is about education for theServicemen in Wales, or whatever the issue. He is theinterface between the Army and the DevolvedAdministration.The other Services have similar arrangements orstructures—for instance, the Navy do so in Scotland,with FOSNNI. However, I don’t sense that the MoDnecessarily is connected in a direct way with thoseAdministrations in the way that you might describe.2

We find, certainly from a practitioners’ perspective,that the liaison and interface with the DevolvedAdministration and the regional command structureworks well.

Q395 Mr Havard: Our concern is where iscompliance and who is responsible should there be,for whatever reason, a difficulty at the end of the day?Major General Berragan: That would come up backthrough us and into the MoD for resolution at thepolicy level. It is not something that we would try todo ourselves. If it cannot be resolved locally it wouldend up coming back into MoD main building for it tobe resolved, I guess, with the appropriateDepartment here.2 Note by witness: The MoD is connected in a direct way with

the Devolved Administrations. The Transition Protocol, forexample, has been agreed with all three DevolvedAdministrations and there is regular contact between MoDHead Office officials and their counterparts in the DevolvedAdministrations.

Colonel Mason: Our experience to date, I would haveto say, is that there is not an issue. We are seeingreal positivity across the piece. It is easier in Scotlandbecause you are dealing with one organisation. Butacross the piece elsewhere our regional brigadeswould be reporting if they were experiencing push-back locally. They are not. They are experiencing alot of help. They are getting out and engaging. Thereis very positive feeling out there that people genuinelywant to help in this transitional phase.Mr Havard: We have not heard any evidence to thecontrary. But clearly there is more strategic capacityin some of the Devolved areas to do it and it is moredifferentiated and becoming so in England. We areconcerned that a consistency can be applied.

Q396 John Glen: I want to focus on three aspects todo with those people who are medically discharged.First, could someone tell us about the housingarrangements? Where there is a need for housing howdoes that work?Secondly, a lot of concern has been expressed in thevarious evidence sessions about the lack of orinadequacy of financial advice to those who have beenseverely injured and are in receipt of a large payment.What sort of financial advice is available? Thirdly,what support is there for bereaved families? Also,what support is there for the families of those whohave been severely injured? Often, with all theuncertainty around their needs, some support isprobably required. I do not know who is best placedto answer those questions.Major General Berragan: I’ll lead, and I’ll bring inthe Navy in support. Let me start on housing. In termsof entitlements to families accommodation, becausethat is what we are talking about, our policy says thatthose being medically discharged are entitled to 93days’ continued use and occupancy at the sameentitled rates as they were when they were serving,and that can be extendable on compassionate groundsby the local commander. So it is not a policy decisionin London. It can be extendable for further periods of93 days at a time on non-entitled rates. In other words,they would go up to a more market rent if they had togo beyond that period. Essentially there is threemonths almost as a given. It is extendable by anotherthree months at local request, and beyond that ifnecessary.So the first point is we don’t throw people who arebeing medically discharged out of their houses.Bereaved families can stay for up to two years andlonger. Again, generally speaking, on a case-by-casebasis, we would never move a bereaved family outunless they had arrangements in place. We take a lotof care to make sure that they move where they wantto move, their arrangements are sound before suchtime as their entitlement runs out. We are certainly notin the business of booting people out.That is the first point. The second is that we spend alot of money on adapting Service accommodation forpeople when they are injured and making sure that itis disability compliant, in other words making surethat they can live in their house, whether it iswidening doors, fitting special showers or whatever.



Something like 13,000 Service familyaccommodations have been specifically adapted forthat purpose for those people who require it. Thatwill continue.I will let Andy Mason come in in a minute on whatwe are providing for those transitioning through theARC. But we have a lot of help from the third sector,particularly in the case of Haig Homes, who providea number of houses that are specially adapted fordisabled people to go and live in as they leave.Another charity, more localised in the south-west, isAlabaré, which also provides accommodation for us.We are starting to get involved with the third sectorin housing. As Andy said, one of the key criteria inthe transition assessment is housing; they need to havesomewhere to live and support themselves. Andy, Idon’t know if you want to add anything on housing atthis stage.Colonel Mason: It is not one-dimensional. It is notmoving out of the Army and going home and that’sit. The house is an aspect, the family is an aspect andemployment is clearly the aspect. Making sure thatpeople are properly plugged into the NHS is anotheraspect, as well as what welfare support and mentoringis in place. Once you start to lay all of this out, it is afairly big piece.But you are not going to have success in transitionunless you have addressed it properly as part of theplan. This is where an individual recovery plan comesin, checked at the end by a transitional assurancepackage to ensure that all of that is coherent and stillrelevant, and that the guy is completely comfortablewith where he is going, allowing him to step off onthe right foot.Housing forms part of the plan, but it is no more orless important than a whole raft of other things. Inmany ways, home is where the work will be. Definingwhat a person is going to do when he leaves is prettyimportant. Even those with fundamental injuries, suchas triple amputees, still have a lot to offer. But findingspecific jobs that suit them for the future may meanthat relocating is an aspect of all that. The timing ofthe adaptation of their house is a fairly key issue. It isspecialist stuff, and we are not very good at it yet.Chair: Commodore Mansergh, is there anything youwould like to add?Commodore Mansergh: I don’t think so, other thanthat it is very similar to the way the Naval Service issupported, both by the third sector and by the processwe have through Hasler Company. In the phased timethat people spend in recovery, they are looking atwhere they are going to be housed and how that isgoing to be taken forward.Chair: We will come back to financial advice.

Q397 Mr Havard: Colonel Mason, you saidsomething about supported employment, which I aminterested in. My constituency offices are in a unit thathas supported employment as part of it, so I havesome experience of how that works. Could you say alittle more about how you are going to be engaged ingiving people supported employment? You havesupported housing, how are you going to dosupported employment?

Colonel Mason: It is very important to suggest thatwe are not, dressed like this; we are going to involveregional experts and those who do it for a living.Remploy is a good example. There is a Remploymember on our defence employment opportunitiesteam. Others are engaged as experts in employmentopportunity, whom we use right from the beginning,from the assessment. We are trying to join up thatassessment piece with where people are going at theend. It is ensuring that as many opportunities aspossible are available and that we link ability withthat opportunity, ensuring that the guy is there. It issupporting employers so that they do not have to payfor employing a disabled person. It is ensuring that allof the work is done, and that placements take placeand that both parties are comfortable with thearrangement. All of that is part of the plan thatdelivers the outcome.

Q398 Mr Havard: Are you commissioning fromsomewhere like Merthyr Tydfil Institute for the Blind,who also put people into employment and do whatyou have just said as training providers? That is justone example, and there are lots of others. Are yougoing to commission individual groups like that todo it?Colonel Mason: This is where the regional placementof our personnel recovery units is key. If a guy isgoing to be involved in that transitional piece, there isan awful lot of work that happens at the regional level,informed by the process that will identify what theguy can do, rather than what he cannot do. That allowsus to see what availability there is and, equally, tohave a national view at the operational level for majorproviders, who have providers of their own, to ensurethat we are spreading the net as widely as possible, onthe understanding that a guy has to work in transition.

Q399 Chair: Financial advice?Major General Berragan: Let me pick up on this one.First, we cannot give financial advice to our soldiers.We are not qualified to do that. It is also a trickysubject in a sense, because if we give them financialadvice that subsequently turns out to be incorrect, weare potentially liable.

Q400 Chair: But you can give employment, housingand medical advice.Major General Berragan: Financial advice isdifferent.

Q401 John Glen: You can facilitate access to an IFA.Major General Berragan: That is exactly my point.We recognise that, and we seek to bring in qualifiedfinancial advice. That is where the Government’s freemoney advice service comes in. It was set up by theGovernment and is run by a consumer financialeducation body. We give those people access andenable them to give financial advice to patients at theDMRC. That is now working well.As well as that, and as part of the recovery process,one of the key components of the assessment courseis a day and a bit of financial briefings. We useBarclays staff who are part of its Armed Forces



Community Investment Programme, which is part ofits CSR. They come in on a voluntary basis to thecourses and provide advice on financial planning, howto invest and all the information that someone whomight be leaving with a sum of money in their handsreally needs. So the answer to your question is: wecannot do it, but we bring in people who can, at theright time.I know that in the past there have been examples ofsoldiers who have had big pay-outs from some sort ofcompensation scheme or insurance, which has gonestraight into an adapted Porsche or something likethat, which has probably not been the best use of thatmoney. We are now getting ahead, so that, ideally, thefinancial advice is available before the money hitstheir pay packets.

Q402 John Glen: May I briefly come back on that? Iunderstand the constraints and your response indicatesthat. One of my concerns is that if you join one of theServices, in essence, many things are done for you—housing and so on. I had an Adjournment debate acouple of weeks ago on getting facilitated access tofinancial advice for members of the serving ArmedForces much earlier on. They need advice on accessto mortgages and need to be able to make betterdecisions earlier on, so that the crisis points—at anypoint of exit and not necessarily associated withinjuries—are likely to be less difficult.Another aspect is that people are going out to serve intheatres of war and are making wills. I have comeacross several cases where that has not been doneproperly and it has created no end of problems indealing with compensation payments and in theimpact on benefits for those who have received them.I observe that there is a joined-up piece here that givesus some lessons about what you do earlier on. Hasanyone got any comments on that? Has that createdany thoughts around how you might adapt that?Major General Berragan: Across the board, we haveapproved Army agents who are given access toprovide financial briefings to soldiers and officers, andthey do so on a regular basis. I remember that when Iwas commanding a regiment, we had them visit. Theydo briefings in all three messes—in the officers’ mess,the sergeants’ mess, and in the NAAFI and the juniorranks club. They focus their information around whatthe interests and advice needs of those three messeswould be. So we do have those services, but wecannot force people to go to them.John Glen: No, unfortunately.Major General Berragan: Unfortunately. And wecertainly cannot force them to act on that advice, butthose briefings are available. I absolutely concede thatour all-encompassing welfare wrapper does notprepare people necessarily well for when they cometo leave. That has improved markedly for those whoare serving beyond six years and are able to use theresettlement process. The financial briefings as part ofthe resettlement process through the Career TransitionPartnership are excellent and professional. Whathappens to those who leave before the six-year pointand have not had that financial advice is a good point.It is something that we have to keep working at.

Commodore Mansergh: The White EnsignAssociation, from a Naval Service point of view, isan organisation that helps to show individuals wherefinancial advice can be sought and found. I also takethe point that we do not do it early enough. We do notstart an individual’s career with advice; this is whenpeople should begin to think about resettlement, andright at the moment, of course, with redundancy beingon a lot of people’s minds, suddenly there is a rush toget this support from such organisations as the WhiteEnsign Association.Major General Berragan: Was the third thingfamilies?

Q403 John Glen: Yes, and then I have anotherquestion about a slightly different subject. I amparticularly concerned about the families of those whoare severely wounded. Your answer was around theentitlements for housing for those who are bereaved,but sometimes people are on a very uncertain path.They might want to stay in; that is unrealistic, but howdo you look after those people who are in sometrauma?Major General Berragan: The first point is that partof the responsibility of the personnel recovery units—the command unit and the personnel recovery officer,who has a caseload of up to 15 and who will beregularly visiting those people under his command—is to look after the needs of the family and to ensurethat the family are dealing with it. It is a reallysensitive area, and funnily enough I was talking aboutthis very subject with one of our seriously woundedonly yesterday. We talked about how the impact of hisinjury on his family, particularly on his children, tookhim by surprise. His wife was with him in terms ofdealing with it, but they had not realised the impacton the children.It is an area where we continue to learn lessons, butin our case the first point of contact is the PRO, whois our interface with the family. What we need to dois to bring in the other agencies—SSAFA and perhapssome qualified social workers—where necessary tosupport where the family are not dealing with it verywell. That is an area where we probably need toimprove.

Q404 John Glen: I have another question about thecharitable sector. We have seen a wonderful explosionof voluntary giving, which I imagine imposes on yousome difficult decisions about how to work with thecharitable sector to configure a service that you cansustain from public funding but also make use of thatextra money. Could you set out how you see thatrelationship with the charitable sector, and what stepsyou have taken to ensure that it is sustainable so thatwhen perhaps the sympathy and concern recedes in afew years—because there is not the need for it—youare not left with a situation that you cannot sustain?Major General Berragan: You are right. The firstpoint I would make is that we have a very long historyof the involvement of the third sector in supportingserving soldiers. I think there is a myth out there thatin the past we looked after serving and the third sectorlooked after veterans. That is not the case, and one



only has to look at organisations such as SSAFA andthe Royal British Legion, which have been engagedin helping serving soldiers for many years—90-oddyears, in the case of the RBL.Regimental charities also often fund a lot of activitiesfor serving soldiers, such as welfare-type activities,support to expeditions, support to sport and support tosome of the social occasions to do with the regiment.We have always had third sector engagement. We areused to it, we are comfortable with it and I think it isvery much part of the norm.What is not part of the norm, as you have said, is thistidal wave of public support and sympathy, expressedin particular by quite how well Help for Heroes hascaptured that mood. It has had a spin-off on othercharities as well, because it has improved theirfundraising too, to such an extent that we are nowalmost faced with an embarrassment of riches.How do we deal with it? You probably know alreadyfrom when Air Vice-Marshal Murray was here thatwe have set up something called a defence recoverysteering group, on which I and my contemporaries inthe other two Services sit. He chairs it in MoD, andBryn Parry and Chris Simpkins sit on it, as does TonyStables from COBSEO representing the smallercharities. We have, if you like, the top level, wherewe discuss what our priorities might be across defencefor third sector assistance and charitable donationwhere we really need it.At the next level down, we have very good embeddedsupport within the personal recovery capability, andAndy has permanent representation from the RoyalBritish Legion, the Soldiers, Sailors, Airmen andFamilies Association, the Army Benevolent Fund andothers, which at operational level are making sure thatthe funding that they are providing to us is being putto good use and, if necessary, more funding will beavailable if we find a new requirement for it. At theworking level, that really is very practical. If someoneturns up and says, “We’ve got some money for you.How can you use it?”, it will be integrated into arecovery plan for an individual, to make sure that thatindividual’s recovery is optimised. We deal with thatat an operational level.At the tactical level, again each of the personnelrecovery units has interfaces with the local charities—be they regimental charities or local military charities.At all the three levels of strategic, operational andtactical, we are connected and get together. As well asthat and, in terms of capturing what is now a vastnumber of defence Service-related charities—3,000 orso, if we count them all up—I hold a welfare forumtwice a year. They are all invited and go into a bigtheatre.We lay out what we are doing, and where we areseeking help. We get them to come back with ideason how they might be able to help. The other knock-on, spin-off effect of that meeting is that we give themlunch and they talk to each other, which is really goodas well. We facilitate their working together in someareas. We have a system in place for engaging withthe charities at both the top and CO level with theoperational level through the ARC and at the tacticallevel with the PRUs, and that is working okay.

Sustainability was the other part of the question. Whathappens when someone throws a lot of money at us?We build something, and how do we sustain it? Wehave learnt lessons from our experience of swimmingpools. In every case as we go through the process, wehave to satisfy both the Department and the Treasurythat anything we build is sustainable in terms ofsupport; that a component of military funding isinvolved, whether that is staffing it or whatever, andthat that funding is secure within the Department’sresources.Our bit of the plan is absolutely included in theDepartment’s financial planning and the robustness ofthe position of the charities must be such that we haveconfidence of, let us say, a 10-year-period where weknow that they can provide the funding for it. At theend of that 10-year-period, if we do not need thatcapability any more, we have an arrangement incontract with the charities whereby we walk awayfrom each other. That is how we do it. We have learntlessons in making sure that any donations that aremade are done on a basis that is sustainable, certainlyfor the mid-term.

Q405 Chair: I have one final question for each ofyou. I will start with General Berragan. What is yourgreatest challenge? It will be the same question foreach of the others. It does not have to be a longanswer.Major General Berragan: Andy put his finger on it.Our greatest challenge is successful transition.Something that keeps me awake at night more thananything else—and quite a lot of things do that—isensuring that we make a successful transition for thosewho need it, particularly the more complex, seriouslywounded casualties. That is my greatest challenge.

Q406 Chair: Colonel Mason, do you agree with that?You do not have to, not in this forum.Colonel Mason: For those who are staying in theService, their life has not changed. Their recoverytrajectory will see them return to duty, which is whatthey want. Their mum doesn’t want them home; theyhave a job, and they have a future. For those intransition, we have to do much better. It is new.We are putting in an awful lot of effort, time andthought and we are drawing an awful lot of expertisefrom elsewhere to get it right. We have not seen theflow start yet to prove the case. Once we do—Ianticipate that if we get the resources to allow thecapacity and the flow to increase to 1,000 and allowit to flow from there, we will have a very capablerecovery capability by this time next year because wewill have proved it by then.Surgeon Commodore McArthur: The main challengeor the main effort is always making sure that theServiceman in that Role 4 pathway is getting the bestclinical, welfare and administrative support that he orshe can get. But my other challenge, of course, is tomake sure that the person delivering that care isgetting the support that he or she needs.If you think about it, the folk up in Birmingham or atHeadley Court have been full on now for five or sixyears. They are not burned out; they are all committed



and they are all doing a great job. There is a greatchallenge to make sure that they are getting thesupport that they need to do that.Chair: Thank you. We talked about that a bit at QueenElizabeth, but it is very good that you have mentionedit again.Commodore Mansergh: Apart from agreeing with allthose other challenges, I think it is the longer term—what happens to our people when they have left theService is, to my mind, probably the most difficultchallenge to address. We have a role in that right now,in the way we are identifying exactly what our peoplehave been through and how we can springboard them,with the support they need, to make the transition andto be able to continue for many years in a life in which

they do not go off the rails and have challenges in thefuture—because of the way we have invested in thattransition and made sure that they have got the supportwhile they are in Service.Chair: I am very glad you have raised that becausewhen we were at Queen Elizabeth, and previouslywhen we were at Headley Court, precisely that issuewas raised with us by Servicemen. I am glad that youhave it on board.Thank you all very much for giving evidence. Thankyou also for your hospitality on various visits toHasler Company, Queen Elizabeth and Headley Court.Your presence there and your work today have beenvery gratefully received by the Committee.



Members present:


Mr Julian BrazierThomas DochertyMr Jeffrey M. DonaldsonJohn GlenMr Dai Havard

________________


Witnesses: Sue Freeth, Director of Health and Welfare, Royal British Legion, Kevin Shinkwin, Head of PublicAffairs, Royal British Legion, Bryn Parry, Chief Executive and co-founder, Help for Heroes, and JeromeChurch, General Secretary, British Limbless Ex-Service Men’s Association, gave evidence.

Q407 Chair: Welcome to the Committee. As youknow, our inquiry is called “The Military Covenant inaction? Part 1: military casualties”. We apologise forkeeping you waiting; I am afraid that we weredisrupted by a Division, but these demands ofdemocracy happen from time to time. They may evenhappen during the course of the evidence session, butwe hope not. May I invite you all to introduceyourselves and to say what you do?Sue Freeth: My name is Sue Freeth, and I am thedirector of health and welfare at the Royal BritishLegion.Kevin Shinkwin: I am Kevin Shinkwin, and I am headof public affairs at the Royal British Legion.Bryn Parry: I am Bryn Parry, and I am the co-founderand chief executive of Help for Heroes.Jerome Church: I am Jerome Church, and I am amember and general secretary of BLESMA, theBritish Limbless Ex-Service Men’s Association.

Q408 Chair: Could you set out very briefly, in acouple of sentences or so, what each of yourorganisations does, perhaps contrasting it with whatother organisations do?Sue Freeth: The Royal British Legion is well knownin a number of areas. It represents and campaigns onbehalf of the Armed Forces community. It is thecustodian of remembrance and is the organisationresponsible for the Cenotaph and remembranceservices around the country and, more recently, evenvirtually. We also have very large health and welfareprogrammes, so we run a large number of welfareservices. We support serving personnel, their familiesand, of course, veterans and their dependants. We arethe largest organisation and provide a wide range ofservices, but those are also complemented by anumber of organisations that we fund in the ex-Service sector. We provide grants, homes, and breaks,and case management for liaising between individualsand the services that we and other charities have. Wenow work quite closely with a number of other largecharitable organisations to tap into their services, sowe have a strategic partnership with the benefits andmoney advice service to enable people to have theirmoney, benefits and debt sorted out. A very widerange of services are provided by the Legion.

Mrs Madeleine MoonPenny MordauntSandra OsborneBob StewartMs Gisela Stuart

Q409 Chair: What proportion would you say goesto serving personnel, as opposed to no-longer-servingpersonnel or to families?Sue Freeth: It has increased over the last five years.I would say approximately 20% of our casework isaround supporting either serving personnel or,particularly, their families. Surprisingly, over 50% ofour work is actually now supporting people who areof working age. That is a significant shift that hasreally occurred over the last 10 years, and particularlythe last five years.

Q410 Chair: Is there anything that you wish to addto that, Kevin Shinkwin?Kevin Shinkwin: I would only add that, regarding theCovenant, as the nation’s guardian of the MilitaryCovenant, we are just incredibly grateful to Membersof the Committee and, indeed, Members of Parliamentand Members of the House of Lords for their supportfor getting the principles of the Covenant enshrined inlaw. I would really like to take this opportunity to puton record our sincere gratitude for that.

Q411 Chair: Thank you. Bryn Parry, you appearedbefore the Armed Forces Bill Committee, but I do notthink that you have appeared before this Committee.Bryn Parry: No, I have not.Chair: Welcome to this one.Bryn Parry: Thank you.

Q412 Chair: Tell us about Help for Heroes.Bryn Parry: It was founded in 2007 as a directresponse to hearing about the casualties in bothAfghanistan and Iraq. We have wide objectives, butwe currently choose to focus on what we call thecurrent wounded, injured and sick, so there is nodifference there—the people who are affected by theirService. Typically, that is post-9/11. The vast majorityof what we do is for the serving, but, obviously, aspeople are now transiting into civilian life, we arestarting to pick up more cases of young veterans.

Q413 Chair: So you do not actually have a dividingline that says that you do not deal with one or theother.Bryn Parry: No. We promote and protect the healthof those who have been wounded or injured whileserving in the Armed Forces by the provision of


7 September 2011 Sue Freeth, Kevin Shinkwin, Bryn Parry and Jerome Church

facilities, equipment and services. Then we can alsolook after people and their families, and anyone,actually, who is under the command of the ArmedForces, so it would work for people who have beeninjured while being a journalist, for example.So far, we have raised about £108 million, and wehave given out in grants—either spent or allocated—about £100 million, all for direct and practicalsupport. The first task was to provide a rehabilitationcomplex at Headley Court—the swimming poolcomplex. That was £8.5 million. We have then goneon and given grants to various different charities,including SSAFA, BLESMA and St Dunstan’s, andwe have a number of capital projects with them. Weare now working with our partners in the RoyalBritish Legion on the recovery process; we arecreating recovery centres around the country.Chair: We will come on to that later.Bryn Parry: We also have a fund called the QuickReaction Fund, and another called the IndividualRecovery Fund, where we are looking afterindividuals and working in partnership with thebenevolent funds of the respective services. We aredoing both capital projects and individual support.

Q414 Chair: Thank you. Jerome Church.Jerome Church: We are one of the specialist charitiesformed after the First World War, and we are veryfocused on prosthetic issues, among other things. Weare a membership organisation, a sort of fellowship ofshared experience—I have to say, a group ofindividuals with a certain perverse pride as well.Despite our name, we are men and women, in Serviceand ex-Service, and always have been, but we cannottell our membership to change the name, because theylike it. We provide, through, I suppose, a socialnetwork and a more professional approach, a well-being service for our people—a very good welfareservice that focuses on every aspect of welfare.Rehabilitation has become increasingly important—rehabilitation through life. We work with othercharities and with Help for Heroes on that area. Wehave always focused on prosthetics issues. I think thecountry’s prosthetic service has basically grown upwith BLESMA after two world wars, and I hope weare in the business of helping it to grow substantiallyagain, in technique and expertise, over the next yearor so. We also respond to issues as and when theyarise. For example, we have been very closelyinvolved—pretty effectively, I think—with the reviewof the Armed Forces Compensation Scheme. I sat onLord Boyce’s committee. We are still very involvedwith that on an individual basis, which leads me tothe last point, which is that we represent our membersindividually, whatever their needs are, dealing withauthorities in whichever area—national or local. Werepresent them collectively wearing our campaigninghat, as we did on the Armed Forces CompensationScheme and as we are presently doing, with the helpof Help for Heroes and my COBSEO colleagues, onDr Murrison’s report into prosthetics, which we areawaiting.Chair: We will come on to that as well. We have agroup of questions about the relationship between the

Ministry of Defence and charities. We will start withJeffrey Donaldson.

Q415 Mr Donaldson: Thank you. In itsmemorandum to the Committee, the MoD recognisedthat there has been a step change in the charitablefunding offered to the Armed Forces. It had initiallynot co-ordinated the facilitation of such offers well.How would you assess the performance of the MoDin working with each of your charities?Sue Freeth: Would you like me to start?Collaboration between the charitable sector and theMoD has a long history. Headley Court and theorganisations here have a long-standing relationshipwith the MoD. Over the past five years, andparticularly in the past couple of years, there has beenmuch greater encouragement and involvement. I thinkit is only just beginning to bear some fruit; we needto give it some time to see how well that develops. Attimes, there is a reluctance to engage with the charitiesin a co-ordinated way, as you say, and perhaps toengage with them early enough in identifyingproblems and looking at potential solutions. Idefinitely think that at the moment there is awillingness—we are and I know colleagues in the ex-Service sector are willing—to look at how we cancomplement some areas of operation that are reallyoutside the core business of the MoD, and use theskills, experience and expertise of the charitable sectorbetter—better than we are doing now. I feel positiveabout it.We want the MoD to be encouraged to see us asprofessionals, and as able to provide some of thethings that perhaps traditionally it saw itself asneeding to provide, while not diminishing theresponsibility for services to be there. I feel positivethat the Legion can make a contribution. We wouldlike to see more openness, more transparency andmore engagement earlier.Bryn Parry: I came to this from a small businessbackground; I didn’t have a charitable background atall. When my wife and I started the charity, we foundit extremely difficult to work with the MoD, and tounderstand it and with whom we had to deal. The firstthree years were complicated, and I felt that we weretreated with a certain amount of suspicion, perhaps.Perhaps we were almost looked upon as an irritant,or as outsiders trying to interfere, when in fact ourmotivation was simply to help. However, it was verydifficult to find a simple conduit—a way of helping—for our desire to help. Initially, we met the Chief ofthe General Staff, General Sir Richard Dannatt, and Iunderstood that we were given a task, which was tofund the swimming pool and rehab centre at HeadleyCourt. We then went through a long process to try toget that in place.I found the first couple of years quite complicated anddifficult. This year, we finally have a single point ofcontact up at defence level, and we sit on the DefenceRecovery Steering Group every two months. I can talkdirectly to a two-star at defence level, who isnominated to be my point of contact, which isextremely helpful. Whenever I have an issue or I hearsomething, I can ring him up, and it is working verywell. I would ask for that role to be expanded within



the MoD to make my life even simpler, but certainly,since Christmas 2010, things have improveddramatically by having that point of contact.

Q416 Mr Donaldson: Do you think that the MoD issufficiently well equipped to manage the additionalfunding that has been generated by charities’activities? You referred to expanding the interfacewith the MoD; have you any particular thoughts onthat?Bryn Parry: I think it is not the MoD’s fault that it isused to looking after its own, and likewise,regimentally, everyone looks after their own. Anawful lot of people believe that they are doing theright thing, and that it is their responsibility to do it. Ican completely see where it comes from. When youhave an extraordinary amount of public support,which, in turn, provides an extraordinary amount ofextra funding, it is very important that that is properlytargeted and directed. That targeting should not bedecided by people like me, who are ill informed. Itshould be the decision of experts, whom I would taketo be the MoD. In an ideal world, I would be workingon a series of targets or projects. That is what I alwayswanted. I ended up finding that I was second-guessing, because there appeared to be a vacuum ofideas, so instead of working down a list, I wascreating one.Now, we have the beginnings of the three Services,and their principal personnel officers, looking at listsof what they want to do, then bringing that up to thedefence recovery steering group. They sift throughand decide what they think could, or should, takethird-sector support. Ideally, that is then passed out tothe third sector. I do not believe that we should beworking in parallel; we should be working inpartnership and support. I would be very interested tosee that area developed.

Q417 John Glen: Bryn, can I focus on your evolvingrelationship with the MoD? You said that, initially, itwas complicated and difficult, but that the single pointof contact has made it much easier. Over three or fouryears, no doubt you have had considerable interactionwith many aspects of the MoD. Can you identify forus, in a bit more depth and with a bit more colour,perhaps, what you think some of the barriers were?There is the cultural barrier, in terms of its inherentcapacity to do what it does, and there is a shift inmindset, but what are some of the practical issues thatexisted and have been overcome? Secondly, whatremains that still grates? You may now have a pointof contact, but, no doubt, the whole of the MoD hasto respond to whatever you push in through your pointof contact. There must still be some barriersremaining.Bryn Parry: Yes. The point of contact gives me oneentry point, as opposed to trying to work out who totalk to. So, if I—or we—have an issue to do withhousing or prosthetics, instead of having to try to findout who to talk to, you simply go to that one, and theyput you in contact, or they chair the right person. Thatis a great step forward.Our difficulties were that, possibly, we were seen ashighlighting that there were gaps in what the MoD

was providing, or was seen to be providing. There isa sensitivity that we were doing Government work,or were being seen to do Government work—or thatGovernment could be held up to be accused of usdoing Government work. Rather than us being seen asan emotional response to a feeling of helplessness—to meeting the young men and women who had beengrievously injured, wanting to do something to help,and raising money and expecting to work inpartnership—our offer of help was seen as criticism,or prospective criticism. It took an awful lot of timefor me to explain to people that we were notcriticising: we simply wanted to help. We wanted tohelp to best effect. It is very wearing to spend yourtime arguing that what you are doing is simply tryingto help, as opposed to being seen as an irritant. Beingcalled the grit in the oyster was one of the more politethings, but I have heard less polite things as well, ifyou wanted some colour.John Glen: It always helps.Bryn Parry: Inevitably, it was upsetting the status quoto some extent. There has been a realisation that first,we are here to stay and secondly, we need to work inpartnership. Genuinely, I do not think the provision ofsupport to members of the Armed Forces for lifeshould be the total preserve of the MoD. Members ofthe Armed Forces, or people who choose to serve ourArmed Forces, are the responsibility of all the citizensand all the taxpayers of this country. As a taxpayer, Iam happy to do my bit towards supporting thosepeople in the MoD. It makes me feel better, when myson or his friends are fighting, that I feel I can dosomething. I cannot prevent these young men frombeing hurt, but I can help them get better. That makesme feel better, and therefore I think we must allowthat to be able to be there.If we raise funds and raise support, that must beproperly channelled to something worth while. Weshould not be given little tasks. Likewise, we shouldnot be providing body armour or ammunition ormedical support. We should be doing what they callthe extras, the nice-to-haves. I feel very strongly, andI have not changed my tune in four years, that menand women who are prepared to serve our countrydeserve the very best, and I am prepared to do my bitto ensure that that happens.

Q418 Chair: Now, Jerome Church, do you want toadd anything to what has already been answered onthis question?Jerome Church: No great detail, Chairman; I agreewith everything that has been said. I have watchedthis change over 11 years; before then, most of thecare for veterans belonged to different GovernmentMinistries, and then I saw it come into the Ministryof Defence—the transfer of the War Pensions Agencyand all that aspect. At the same time, we have alwaysbeen closely involved with the medical services, forobvious reasons. I have to say, I have had terrific co-operation over these last few years with all thoseparticular areas—the SPVA, the medical services and,of course, Headley Court. We had quite a lot to dowith the provision of advice about prosthetics, whichnever used to be done by the Ministry of Defence. Inmy day, we just went along to the local limb centre



and hoped for the best. Most of the time that workedquite well. All I am trying to say is that there has beenterrific evolutionary change. The co-operation withofficials—not just with senior officers, but also atofficial level—has been an extremely positiveexperience of late.Bob Stewart: Doesn’t grit become a pearlsometimes?Jerome Church: That’s the hope.

Q419 Bob Stewart: When the Ministry of Defencefrees up all this space, in your collective opinion,would it be a good idea to put some of the charitiesinto the space in the Ministry of Defence—COBSEO,possibly, and other people like that, such as yourcharity, BLESMA?Chair: In the main building.Jerome Church: We step into a slightly difficult anddangerous area when you start suggesting thatcharities should take a certain course. There might bea logic in it, but there are some compelling reasons, Isuspect, why we would like to keep our independence,even among ourselves, all for the good. Don’t thinkwe do not co-operate, but to have a sort of forcinghouse might be detrimental in the end.

Q420 Bob Stewart: Bryn mentioned a point ofcontact. You could have a COBSEO room.Bryn Parry: Are you thinking that they would all haveoffices in there?

Q421 Bob Stewart: A sort of liaison office, at least.Bryn Parry: There is value in liaison. We all value it,and there is great good in being independent and fleetof foot, and being able to manoeuvre quickly withouthaving to go through process. That is one of thereasons why we have been successful in being able todeliver a lot of things very quickly: we are nothidebound by process. That, in many ways, has beenone of the things that we have found difficult, becausethe MoD has not been able to react as fast as we can.Liaison is good, but to imagine floors and floors ofcharity workers all wearing grey suits and ties—I amvery happy wearing my hoodie, sitting in myindustrial unit in Downton.

Q422 Bob Stewart: I am thinking of the RoyalBritish Legion as well. What is your view, as you havemoved from Pall Mall?Sue Freeth: On the ground, at base level, the idea ofus being present to support and being close to peopleis very important. I would support my colleague’sresponse; there is a benefit in our separateness in onesense, but I think we would welcome making moreroutine our involvement and our engagement at anumber of senior levels, so that we can help the MoDto look forward and plan responses together. At times,we have felt like the afterthought. When we have beenable to identify issues, the Ministry of Defence hasnot felt ready yet to admit that there were gaps; norhas it been able to specify what the requirement was.That is one of the challenges that Bryn and the BritishLegion particularly have had, in terms of shaping anddeveloping the defence recovery service.

Bryn Parry: If we can all—in the MoD as well—understand what the MoD needs from us, and if we,the charities, can work very closely to ensure that theright people do the right bit of that, there can beproper co-ordination so that we do not get overlap. Inmany ways, if you can funnel it up through the MoDand have the DRSG or whatever you have at the top,and talk across to the third sector—and we can all putour hands up and say, “That is the bit I think I amgood at”—that is great. We have collectively found itvery frustrating being picked off by various peoplewithin the MoD. If we think we are doing somethingand, say, the Legion thinks it is doing another, but infact we are both doing the same, there has beenconflict. We are now hand in hand together, and weare now sitting down in partnership with those peoplein the MoD. That is working well.Jerome Church: In the end, we need to achieve abalance between the need to co-operate to make itgood for the beneficiary, and the need also to representand campaign for that beneficiary. That is a neatbalance for charities in this sort of business.

Q423 Bob Stewart: So the collective wisdom andanswer is: thumbs down.Chair: It sounds more lukewarm than thumbs down.Jerome Church: Yes, lukewarm.

Q424 Mr Brazier: Mr Parry, what did you say thisnew co-ordinating body was called that acts as yourpoint of contact?Bryn Parry: It is the Defence Recovery SteeringGroup. Primarily, it is the three principal personnelofficers, or their representatives; it is the Surgeon-General’s representatives; and it is thecommunications side of the MoD. At the moment, itworks with a representative from COBSEO, whorepresents the various different charities, such asBLESMA. Because we are largely focused at themoment on the development of the defence recoverycapability, the Legion and Help for Heroes are the twoprincipals, so I sit there with its director general.

Q425 Mr Brazier: Right. Just a small follow-throughon that: I think we have something like 200Regimental Associations in this country, some ofwhich have really quite significant assets. I think theyare all nominally members of COBSEO. Do you feelthat they are in any way being brought into thepicture, or do you think that more could be done tomake use of them?Bryn Parry: I understand that there are over 450Service charities.Mr Brazier: Four hundred and fifty?Bryn Parry: That is what I understand, if you countall the Regimental Associations and all the charitiesset up to provide flags for every ship in the BritishEmpire and so on. I believe that collectively they areworth £1.9 billion. When I was trying to raise my firstmillion, I found that staggering, so we have all beentrying to work out how that is well co-ordinated.Regimental Associations are extremely important,certainly as part of the recovery process, where theAssociation between the Regiment and the individualdoes not cut across his membership of BLESMA or



his membership of the Legion, or whatever it is. It ishis family, but then he has to go to various differentplaces. There is also a community of the wounded.Where it is falling down is that in the old days youhad Regimental depots, and your serving woundedwent back to the depot when they had a few monthsin which they were not able to serve in the battalion.That does not happen anymore, so we are no longerable to send our injured, probably with their families,for a period of recuperation. We have to find somealternative to that.Certainly, there are the links with the regiment.Organisations such as the Rifles and the Grenadiershave their own Regimental casualties officers, whoback up the Regimental association and deal with theirserving wounded. Some regiments, such as the Rifles,have several hundred—250 or 270—wounded on theirbooks, and have their own Regimental casualtiesofficer.Mr Brazier: I have met him.Bryn Parry: Mike and I work hand in glove—we haveto—and he will be working with Jerome, too.Mr Brazier: If I may, I will send you a paper fromsomeone from the Life Guards Association who hassome ideas for putting it all together.Sue Freeth: The Legion and the ABF work closelytogether, and we have close working relations with theRegimental Associations. Can we do more to bring ustogether? Yes, we can. We need to, not only to makebest use of the available funds over the coming years,but to streamline the administrative costs, so that wehave as much money as possible to supportindividuals. We would all welcome a greater focus onencouraging people to do that. There is a great senseof family in the Service community, but there is alsoa great sense of individual organisations and their ownseparate identities too. It is how you strike thatbalance while achieving efficiencies, so that, as Brynsays, individuals can benefit from the very largeamount of money that resides in those differentsmaller organisations, which can feel as if it is difficultto get out. There is a lot of willingness, butencouragement is needed.Bryn Parry: We have a lot of overlap and a lack ofco-ordination. There is an awful lot of money, but atthe moment there is an awful lot of need. I heard onewonderful comment: somebody said that a RegimentalAssociation was asked how much money the regimenthad. When he was told, he asked, “What is it therefor?” and he was told, “It is there for a rainy day.”His comment, which came from the back of the hall,was, “As far as I can see, it is raining very hard”—except he did not use that expression—“so who isputting up the umbrellas?” The umbrellas need to goup. This is when the money should be spent—at themoment. The idea of sitting on vast sums, with areducing community who will ultimately need it,should be looked at.Chair: We will come on to that.

Q426 Mrs Moon: One of the pieces of evidence wereceived suggested that, because of the plethora oforganisations and the financial power of the maincharities, people have become silo-orientated and theopportunities for innovation have been reduced.

People are almost saying, “Oh, that’s my field, andI’m not going to share anything, because I do that.”Would you concur with that? Has there been abuilding of walls around people’s identified areas ofexpertise, rather than there being opportunities forinnovation? What about the smaller charities that aretrying to establish themselves? Are they finding itharder to break through with their new ideas andconcepts?Sue Freeth: COBSEO, particularly under theleadership of Tony Stables, has tried to lead the wayforward on that. There have been a number ofinitiatives over the past couple of years. One of them,which is now being implemented, means that all ofthe organisations are able to use one internet systemso they can pass cases to each other very quickly. Thathas started to break down the ownership, “I do thisbit, and you do that bit.” The British Legion has beenvery conscious of that, and we have been lookingclosely at our own services. What are the things thatwe can do, should do and are equipped to do well andbetter in the future? What things that we have done inthe past should we leave to other organisations whichthey are capable of taking forward? We have startedto take responsibility between us for providing acompletely joined-up service.One challenge that individuals definitely face is thatthere is a lot of help out there, but finding it isextremely difficult. We are starting to engage anumber of the other charities around us, small andlarge, as well as some of the agencies—the ServicePersonnel and Veterans Agency and others in theMoD—and we propose to focus our expertise onproviding very good, joined-up information onlineand on the ground and helping people through thatpathway, we can leave the other specialist areas tothose charities that already have a great deal ofexpertise and perhaps develop and provide some ofour own funding to enable them to do that. We aretrying and will be leading the way on that, and it feelsas though there is an appetite around us to think muchmore innovatively. I feel very hopeful about that.We have certainly been working with smaller localorganisations in the last three or four years andproviding more funding for them, and we are actuallygetting much better results for people when we investin the community. That is a model that we are startingto share with other charities. The time has come tobreak down some of the walls between us. It is notalways easy to do, and it is very difficult sometimesto step away from something that either your trusteeboard or your members—in our case—or beneficiariesreally like you doing, but the reality is that you haveto stand back and allow organisations to do thingsthey are closer to individuals and better at doing. Weare definitely up for leading the way and genuinelydemonstrating that we are willing to do lead. I believethat there are organisations around us that are startingto think like that. It is only very early days, but thepotential is there.Bryn Parry: I would agree with that. Following onfrom Julian Brazier’s comments, I think that, from mypoint of view—that of the wounded—a man may bea rifleman, a commando or a Para, but he has still losthis leg or still has a spinal injury. The regiments have



to let go, because they cannot look after a person.They have to go to specialists. Likewise, charitiessuch as BLESMA, while 99% of all the wounded atthe moment are BLESMA members, would not wantto think that they can solve all their problems.Jerome Church: Most of them.Bryn Parry: Certainly, part of the job of Help forHeroes is making sure that we fund the right peoplewho do the right bits. We see life, from the momentof impact to the rest of their lives, as a road torecovery, and we want to ensure that there are bothcapital projects and facilities and individual fundingalong that road. Paving stones—if you like—are putin place and some, which are to do with prosthetics,will be provided by organisations such as BLESMA,some to do with welfare and other things will bethrough the Legion, and there is also St Dunstan’s, thecharities for the blind and so on. Likewise, we needto find people for employment and housing and so on.COBSEO has been working towards that by selectingcharities to lead in what are called clusters, so youhave a cluster of charities that all specialise in onearea with one driving it forward. That is a very usefulbeginning, but I do not think that we have got thereyet. In the last three, four, five or six years, there hasbeen a tremendous change under COBSEO’sleadership, but it is the beginning. The right thing iscertainly not in place at the moment, but we are onthe way.

Q427 Mr Havard: Following that, the MoD talkedto us about the embryonic contracting process that isdeveloping in this area. You almost described a sortof contracting process yourself there with whatCOBSEO is undertaking, which leads to collaborationrather than competition. Could you say somethingabout what your discussion about that contractingprocess will be and whether it is going to lead to morecollaboration? Is there a danger that it will actuallyjust cement competition between the organisationsover securing some of those contracts?Bryn Parry: The word “contract” sounds likeprocurement.

Q428 Mr Havard: Exactly, it is also like primes andsubs and the sort of language that comes out of theMoD.Bryn Parry: Don’t get me started on that, otherwisewe will have to go out to European tender for toiletrolls.Mr Havard: Exactly.Bryn Parry: No. This is sitting down and saying,“What is the need? What should be funded byGovernment? What is available to be funded byothers? Where do we need your help?” Then a teamof like-minded people sit in a room and see who isbest equipped to do it. It is not for the MoD to sitthere and tell us who they wish to do it or for us totender for it. In my opinion, that would not be a goodidea. There are charities with skills; the trick is toensure that we all know what our skills are and inwhat we want to specialise. We can’t all be multi-skilled, so we specialise in our area.We all know what we are doing, so if somebody walksinto the room and says, “My legs don’t fit, my wife

doesn’t like me, I’ve lost my job and I’m havingnightmares”, I would like to see BLESMA stick itshand up and say, “Prosthetics—we’ll take that”;Combat Stress stick its hand up and say, “We’ll takethe nightmares”; Remploy take the job issues; andHaig Housing Trust or whoever take the housingissues. We have specialist teams who take theproblems.All these boys carry what I call a “portfolio” ofproblems. The fact that you’ve lost your leg is not theonly problem, because all sorts of things cascade outof that, not only to do with the individual but to dowith his family. All those things need be addressed.Some of them need to be addressed by the rightMinistry—it doesn’t have to be the MoD, but couldbe the DWP. I am very keen to see some organisationor person adjusting and ensuring that that person ischampioned to the right people who can provide himwith the right support.Jerome Church: Charities like ours that have beenaround for a long time intuitively do that. That’s whatwe do. If one of my members has a housing problem,we have a terrific relationship with Haig Homes, soit’s no problem. It’s sorted and the boy or young girlis sorted out. We do it.Sue Freeth: None of us, round this table at least, hasa contract for service as such, other than the currentrelationship with the Defence Recovery Unit. To adegree, we probably welcome the freedom. We do nothave a contractual relationship with the MoD. Fromthe Legion’s point of view, I do not think wenecessarily would not want to have one, but that doesnot mean that we do not believe that there are servicesthat we could provide well for which we would notbe prepared to have an agreement. However, if thereis no money—if there is not a contractual or fundingreason—a formal contract is not really necessary. Ithink it is more about agreements to operate and worktogether that could focus stronger workingrelationships in certain areas. However, moving intocontracting is not necessarily the solution, by anymeans. Unless it was on the right terms, most wouldprobably rather not have them than be tied intohaving them.

Q429 Ms Stuart: You have implicitly answered quitea lot of the questions we wanted to ask, so can I justpin down a few things for clarity? Bryn Parry, wewere wondering when you decided to work with theMoD rather than work on your own. From youranswers, I gather that in Christmas 2010 you got a co-ordinating person. You were quite happy to work offa list and I note that you said, “We were asked to raisemoney for the swimming pool in Headley Court”. Canyou take me through that? You were asked to raisemoney for Headley Court. Who decided that theywanted a swimming pool?Bryn Parry: Would it be helpful if I went through abrief history?

Q430 Ms Stuart: I am keen on knowing about thatmoment when you decided to work with the MoDrather than on your own. What was that link?Bryn Parry: My motivation was to help. I thoughtthat I could raise a reasonable amount of money.



Originally, I thought I could raise £500,000 in thesummer of 2007. I then met a general and I said, “Ithink I can raise £500,000”. Five days later, heintroduced me to the Chief of the General Staff,General Sir Richard Dannatt, and I said, “I want tohelp and I think I can raise £500,000, so what wouldyou suggest I raise it for?” I did not want to raise itjust to put into a big pot. He had been to visit HeadleyCourt and said, “I think we need a swimming pool atHeadley Court”. I thought that I was getting my taskfrom the Chief of the General Staff, which, as a failedcaptain, was good enough for me. I then realised thatit was not that easy.It was not that I chose not to work with the MoD, butin order to fulfil my task, as I saw it, I had to workwith the MoD. We had to go through all theprocurement, the other testing things and challenges todeliver a building—a facility—at a reasonable price,within a reasonable time. That put lots of grey hair onmy head. I have always worked with the MoD but Ihave never had any direction from the MoD. As aresult of a continued amount of frustration, I went tosee the Chief of the Defence Staff on 15 March thisyear and that is when I said I think there needs to bea single point of contact at a senior defence level,rather than single Service level, who can be my pointof contact. They are not tasking me. They are sittingdown with me and saying, “This is what we wouldlike to do. Would you like to help?” There is nocontract, as we have already discovered, this has beena partnership. Again we are very sensitive that whatwe are providing is the extras and not the core. Weare not providing the medical treatment. We areproviding the slightly softer things to do withtransition and so on. In my mind there has never beenany difference. I wanted to help. I wanted someone totell me how to help.

Q431 Ms Stuart: Before I open up to widerquestions, there is one other thing. You startedsomething new, as I understand it; it is a tradingcompany that works with Help for Heroes. Has therebeen a change in the way you report to the CharityCommission?Bryn Parry: Every major charity can have a tradingcompany in order to do trading activities. If you wantto sell tea towels you have to have a trading company.Charities are not allowed to make profits, so you havea trading company. That is how all charities work.This is not to do with how we work with the MoD;this is simply how we choose to offset our operatingcosts. We have a trading company which sells about450 different product lines, some of which I amdisplaying here, if anyone would like to buy some.The income from that is then granted across to thecharity and that is used to offset our costs.

Q432 Ms Stuart: But in terms of the charity’srunning costs and the way you reported to the CharityCommission last year, will it be the same next year?There have not been any changes or things you spellout more clearly?Bryn Parry: I am not sure I understand. We haveaudited accounts, exactly the same as everybody else.So what we do is have a trading company. Most

people’s trading companies do not make much money.We have a trading company. It is within our group. Itis an individual thing. It makes money. It then donatesa grant or donation and that helps us cover ouroperating costs. It is as simple as that. The RoyalBritish Legion does the same thing. When you sellyour wristbands, buttons or whatever, the profits fromthat are gifted across to the charities. It is the samething. Ours has just become a core, if you like, of howwe operate.

Q433 Ms Stuart: All of you have started to addressthis question of the things we have a right to expectgovernments to do and the MoD needs to do and thethings where we think it appropriate that people makeindividual donations and the voluntary sector comesin. Do you think we have got that balance right or isthere a danger that you become subcontractors of theMoD and provide services which the MoD should beproviding?Bryn Parry: This is the question. This is why we mustretain our independence. We will always decidewhether we want to get involved.

Q434 Ms Stuart: With respect, there is a differencebetween who the “we” is who decides. If you are amembership organisation then the we is themembership organisation. If it is a fundraising charity,the “we” is quite different.Bryn Parry: It is my trustees, but taking good advice.

Q435 Ms Stuart: And you think that is sufficient?Bryn Parry: My board of trustees—Jerome Church: And your donors—Bryn Parry: And the donors. I say, “This is our wishlist”. We are currently trying to raise a lot of moneyfor recovery centres. We have put photographs up ofthem. We explained to the public what we are doingand when they are going to be ready. Frankly, if thepublic do not agree they would not have given usmoney. We have a board of trustees and we have goodgovernance and we have everything properly auditedso that you know exactly how much money we havegot in and what we are proposing to spend and howwe are spending it. So there is complete transparency.

Q436 Ms Stuart: What is the British Legion’s viewon that?Sue Freeth: For the British Legion’s trustees, that is,as you say, a thorny issue: how do you make sure thatyou protect the entitlements that you believe the Stateshould and can provide for individuals and how far dothe voluntary organisations use their resources to fillthose gaps as they emerge? I think the Legion hasdone that so far. The partnership, for example, onDefence Recovery is a very conscious decision and awish to make sure that people who are being injurednow in much larger numbers really get the quality ofsupport they need, given that they are so young andsome people have been particularly seriously injured.To do that at the right point and quickly is absolutelycritical.Our trustees take every step when they look atwhether we are doing something that was previouslydone by the State. They take those steps very carefully



and decide on an evidence basis. We have startedworking over the past five years or so very much onresearch. We do our research on what the greatestneeds are from a very large constituency of people,and we take decisions about what services we provideon that basis. Our trustees will continue to think verycarefully about things that they want to do and thatthey believe the charity should be doing, and aboutthe things that we should be asking Government tofind the resources to do.

Q437 Ms Stuart: Jerome Church, can you addwhether, in your experience, the MoD is actuallyusing the money you give it properly?Jerome Church: I do not actually give the MoD anymoney.

Q438 Ms Stuart: Or the resources or the goodwill—Jerome Church: I have always been interested in thatboundary between the statutory requirement andworking with charities or charitable funds—thebalance between what should happen and what needsto happen. My motto is—I am afraid that we all knowthis, going back to dealing with local government andwith all sorts of areas—that sometimes we just needto meet need with speed, and we cannot wait for thebath lift or whatever to come from the official sources;we just have to get on and do it. Otherwise, my oldermembers would be dead before it arrives, and wewon’t have that. There is always that sort of conflictthat a charity has to reconcile and justify.Bryn Parry: Can I go back to our first example, whichwas the swimming pool at Headley Court? There wasno swimming pool at Headley Court, but the argumentwas that patients at Headley Court had access toswimming. They were taken to a swimming pool atLeatherhead, where they were able to swim in onelane of a public swimming pool. Government, or theMoD, were able to say that the need had beenprovided—if there is a requirement for the guy toswim a couple of hours a week, he is getting that—but we came along and said, “We would prefer thatindividual to be able to swim in his own swimmingpool within the confines of his own building,surrounded by people who will not object to his beingin that pool.” The need was being fulfilled. Was itbeing provided to the very best level? I did not thinkso, therefore I said to the public, “Please could youhelp me to raise some money if you feel the same asI do?” And they did. That is how it is.Jerome Church: We are moving into the same area.Bryn and I have talked a lot about this, and we went toSimon Burns in December last year about prosthetics,because we are very worried. BLESMA has alwaysbeen very concerned about funding prosthetics,because it is a bottomless pit, if you are not careful.It is a very expensive business.

Q439 Ms Stuart: Just to finish the block ofquestions, the past few years have seen a considerableincrease in donations from the public, not leastbecause of new concepts and new approaches. In 10or 15 years’ time, however, a man in a wheelchairwho probably did not control his weight quite as wellas he should have done will no longer strike a chord

as being a hero who requires help, and there will bea whole generation of children who say, “Where isAfghanistan? I don’t know where it is.” I wonder whatthought you have given to this, and this may besomething that Kevin wants to think about a bit more.How do we continue that involvement of raisingmoney? What is the thinking, post-Afghanistan, toraise the money that we need?Kevin Shinkwin: I think one of the main ways ofencouraging people to give their support is byshowing that we are delivering and that we are makinga difference to people’s lives. Each of ourorganisations is doing that very visibly. The currentvisibility of Afghanistan and the conflict there isimportant as an incentive, but there will continue tobe issues such as the ongoing support for people whowill have long-term conditions even though they arevery young now. So, it is important to show peoplethat we are making a difference by providing services,by ensuring that we give voice to people’s concerns,and by campaigning, because campaigning is a verycost-effective way of raising and maintaining profile.We should ensure that we continue to do that to makesure that we are relevant, so, regardless of whetherthere is a current conflict, people understand that alifelong duty of care remains—not just a lifelong dutyof care to those who are injured, but to bereavedArmed Forces families, whose debt, as a society, wecan never repay.

Q440 Chair: My concern echoes what Gisela Stuarthas said. While what you suggested should happenclearly should—that we should maintain this level ofinterest, even when Afghanistan has become an itemof history—the worry that such interest might not bemaintained is real. I wonder whether anything mightbe said, for example, for setting up a ring-fenced fundto come into effect, say, 20 years from now, in orderto deal with the perhaps significantly greater problemsof our Armed Service veterans. This is, in a sense, therainy-day issue. It is a defined issue, however, to copewith a problem that may well arise, which needs to beaddressed now.Bryn Parry: There is £1.9 billion stuck away in bankaccounts. The way most Service charities work is thatthey have invested the money, they do somefundraising, and they then spend the income on thatmoney. The capital money is not being used. Apercentage of that could be used at the moment,because, frankly, I think it is raining outside. If youcould use some money now to put in place asignificant project that would provide support, all youhave to do in the long term is keep that going. Wehave an opportunity with the public support at themoment. It is a once-in-a-lifetime chance to get thisright. I have seen the last four years as a race to tryand put in place recovery centres and get the recoverycapability in place, as the thousands of young menand women who will now go through their lives as acollective cohort will need special help.I do not get the argument that when a Servicemanmoves into civilian life he should not bedisadvantaged. I am afraid that I am an advocate ofsaying that a Serviceman who joins, risks his life, andthen sustains a life-changing injury must be positively



advantaged. They need to be treated specially, and thatmeans it needs to be made easy for him or her, so thatwhen they have a problem in later life which is relatedto their Service, they immediately get the very best.At the moment, we have money available. It is comingin, and this is what we have been trying to do, but weneed an awful lot of it to be released, where possible.We need help to see where that can be done, and weneed co-ordination. It is all very well having a bunchof good people trying to do their best, but right at themoment, it is not as focused as perhaps it could be.This is our opportunity to get it right. If we do not—I was with a boy last night who lost his legs very high,and he has got all sorts of other problems. That chapis 22 years old now and he is living an undignifiedlife, because he trod on an IED at Christmas time. Ido not want to see that boy living an undignified lifewhen he is an old man.Sue Freeth: The creation of a fund has been areaction, over time, on a repeated basis. The Legionnow administers a number of those funds. One wasset up for Northern Ireland and one for the Falklands.There have been a whole series of them. In a way, Iagree with Bryn, who is saying that actually, it ismuch easier to show the public that you are spendingthe money as close to the time that it is actually beingraised. Clearly, the large number of people whom weare still supporting are veterans from previouscampaigns, right back to Korea, the Falkland Islands,and all the campaigns between then and now. Thecreation of a fund is tempting, but I am sure that ifthe coffers now available to us were emptied and wewere able to show and tell the stories that we heardpeople telling earlier, people in the future would stillfeel an affinity with this group of people, particularlyif we still manage to evolve remembrance.Remembrance is not only about those who have giventheir lives, but about those who have been injured andare casualties of previous conflicts. We have ourmoment’s silence—the first half is for those who havelost their lives and the other half is for those who arestill with us. I think it is that combination of things.We already know that we are probably coming veryclose to the end of the public’s willingness tocontribute as generously as they have to this campaigngroup. I think that in five years’ time, it will be muchmore difficult for us to engage the public. Thechallenge will be with organisations, such as ourselvesand the new ones that spring up, to keep that spiritalive. It will be difficult, and it has been difficult. Inhistory, there have been moments when it has beeneasier and moments when it is very difficult. We donot know what the needs of the current cohort, whohave been injured very young, will be or what theirlives will be like. We need to be ready to support themthrough a very long life ahead—which they expectto have.Jerome Church: I echo what has been said. Myorganisation tries to fundraise by always telling thedonors that we are a long-term business. ManyService charities are. That is easy to illustrate inBLESMA’s case, because every year between ’19 and’99 is represented. It is indicative that we still havemore Second World War members than currentconflict members. It shows how long they live. I know

what they have had to go through. I know their storiesand I hope that the new generation will not have togo through quite what some of our older memberswent through.Bryn Parry: The sad thing now is that people aresurviving injuries that they never would have.Jerome Church: That is the added component to theissue. We are all very concerned about care rightthrough life, not just in old age when the old injuriescome back to haunt them, which tends to be the casewith today’s old veterans. It is right the way throughwith these youngsters.

Q441 John Glen: I want to get to the bottom of theassessment made of the costs that will accrue. I thinkthat Help for Heroes spends 92% or 93% of its moneyon capital projects, which, in essence, set up liabilitiesfor the future—the running costs. If every charity ormore charities put a higher proportion of their capitalinto projects today, which sets up running costs forthe future, and we see a reduction in the income flowto charities due to less public awareness or whatever,you will create increased liability for ongoing runningcosts and reduced income. There is a difficulty there.When you go to the MoD and agree a project, whichyou are given discretion to deliver, what is yourimpression of the assessment made to take account ofthe ongoing costs for those better facilities, which inthe past have not been provided for by the MoD?Bryn Parry: At the moment, there are four majorcentres for recovery. There are five—the Legion andErskine are working together. We did the initialfunding on conversion and the Legion took therunning costs over for Erskine. However, if we takethe four that we are on at the moment, they have bigcapital costs to provide the buildings. The best ofthose will take 60—the one for the Royal Marines inPlymouth. It is 50 in Catterick and Tidworth, and 30in Colchester. The building cost for Catterick is, say,£13, million and the running costs look like they willbe somewhere between £1 million and £1.3 million.That is all worked out by people who are rathercleverer than I am. We are meeting the capital costand working with the Legion, which will contributetowards the running costs. We will be going to theprivate sector, looking for sponsorship and everythingelse. With the bits that it does not manage to do, wewill do our very best to top up to whatever it costs.Sue Freeth: Our trustees have given a commitment to£50 million over 10 years for those running costs.That is the contribution to the Defence RecoveryCapability that we have made.Bryn Parry: If you take a building, the expensive bitfor the big fundraising effort is the capital, becauseyou have to raise £13 million in a lump to build it.Then, if you have to do £1.3 million a year for a longtime, that is a very large amount of money, but it iseasier to raise £1.5 million a year than it is to raise£13 million. So I would argue that if we can releasethat much money and focus on the putting together ofa very well co-ordinated plan that is future-proofed, itis then rather like, back in King Charles II’s time, theChelsea Hospital being built. I do not know whetherthat was created with a foundation—ideally it is.Wellington College, to which Julian Brazier and I



went, was set up in 1859 and endowed with afoundation for people like me, who werefoundationers. The cost of the building must havebeen huge, but funding 10 people like me every yearto go through a free education is probably not huge.We will have less to raise every year if we can get itright now.

Q442 Sandra Osborne: We want to explore the issueof the recovery of injured personnel and their families.Sue, could you tell me to what extent the RoyalBritish Legion works with people who have beeninjured?Sue Freeth: We work in complement with bothBLESMA and the Army Recovery Capability thatBryn has created. Our focus is particularly on helpingpeople to find their way to the things that they areentitled to from the different organisations around us,and on filling in the gaps left by the otherorganisations where there is not funding available tohelp them. One of the biggest challenges that we seefor people is housing during their recovery period.There are still problems, particularly while people arerecovering and still inside the Ministry of Defence andits responsibility. It is difficult for people to get theirtemporary adaptation sorted out, because some ofthem will be living on base, some will be living athome and some of them living in social housing. Thatis a problem area that we see on a regular basis. Ithink colleagues here will probably support that.We are seeing people who, in particular, are lookingfor ways into further training and work. A lot ofpeople who have been injured have not completedtheir full training—they are not work ready. They aregoing to need an awful lot of support. While peoplewho are medically discharged and seriously injuredare entitled to the full career transition partnershippackage, that actually needs to be much more of acomprehensive package for someone who is leavingthe Armed Forces well before they expected to. Theyare incredibly young, and need not just help intraining but help with finding further training,accessing benefits that they may well have to dependon to complement the package of support that theyleft with, and finding a home to live in that is not justgoing home to mum and dad. They have a whole ofplethora of needs, and I think the role that we areplaying in particular, because we know the statutoryand charitable organisations so well, is helping toaccompany that individual through that pathway. Thatis certainly a role that we can do more of—makingthe best use of all the other Service charities’ services.

Q443 Sandra Osborne: What do you feel about thequality of the input from the Ministry of Defence? Doyou think it is adequate? What else could be done?Sue Freeth: Certainly, the new policy—the newAGAI 99—is in place now. It is very early days. Ithink all the ingredients are there to get it right. Thereare some tension areas that we have some concernsabout. For example, on the manning levels of DefenceMedical Capability, we are slightly concerned thatthere may not be enough qualified people available tosupport that process. I think that we are not the onlyones who would raise that as a concern. I think that

the BMA has also raised this as being a worrying area.That is something that we have shared with theMinistry of Defence, and I am sure that it will be keento make sure that it addresses that.The potential changes in the National Health Servicecould disrupt some of the protocols that are being putin place to support people who have continuing careneeds, who are going to be living with, serious injuriesfor a lifetime. Again, we share those concerns. Thereis quite a bit of piloting going on at the moment, interms of trying to make this a seamless journey. It isvery early, and we need to work very hard to try tomake sure that this journey gets joined up. We needto pre-empt as the environment changes around us.We need to watch out, so that once people leave, bothat local government level and in the NHS, the goodwill and good intentions do not get unravelled. Thosewould be our primary areas of concern.

Q444 Sandra Osborne: Is there any difference in thesupport that is going to Reservists?Sue Freeth: I do not think that the initiatives, ofwhich there are now a large number, are findingReservists judging by the Reservists cases we havecome across. We know that the Ministry of Defencehas got Reservists at the top of its priority list, butfinding ways of capturing Reservists is something Ido not think the initiatives we have at the moment aredoing well enough. More work is needed, frankly. Ihaven’t got solutions, but we are all tasked withthinking about how to make that better and promotingit to reservists and employers who have reservists ontheir staff.Chair: Bob Stewart, you do not have to say yes tothis question, but were you catching my eye?Bob Stewart: I was trying to.Chair: Then you have done so.

Q445 Bob Stewart: We have a Veterans Minister. Ithink that the Service Personnel and Veterans Agencyis a pretty useless organisation; I have said that for along time. I really think that, as Bryn and all of youhave said, we have a direct and urgent responsibilityto look after people who have been hurt in the Serviceof our country until the grave. I personally think it israther sad that a bit of the SDSR did not look at howwe deal with the long-term wounded, particularly asthe ratio has gone up from one in three in our day,Jerome, to one in 10. You know, one dead, 10—Bryn Parry: One in five.Bob Stewart: One in five, you think; okay. But it hasgone up substantially, hasn’t it? The responsibility thatis very much on your shoulders at the moment shouldbe taken in by Government in a much more seriousway, because every time I have challenged the ServicePersonnel and Veterans Agency in one way or another,I have been told, “Go to Blackpool”, or wherever it isand so on.We require the Ministry of Defence to be very muchmore serious and professional in looking after thosepeople once they have taken their uniforms off andare cast on to the NHS and social services. I just donot believe it when it says, “We have a tag oneveryone who is wounded, and we’ll keep a tag on



them for the rest of their lives.” I just have not seenthat. I ask for your comments on that.Jerome Church: Of course, it comes from the old WarPensions Agency, which did not belong to theMinistry of Defence. There is quite a history there,and it was a good history. It was a good organisation.A lot of the people were the same people. I am a bigof a supporter of the Service Personnel and VeteransAgency. It has worked very hard to sort out itsunderstanding of the way the Armed ForcesCompensation Scheme worked. We have helped italong. That is just one aspect of the Government. Yes,we have a Veterans Minister and quite a smallveterans department, which seems to be gettingsmaller all the time, because the MoD is gettingsmaller. Clearly, there is not going to be the capacityin the MoD to look after them in the way that onemight wish. The capacity actually belongs to thecountry. We have got to work very hard. For instance,if we go back to the prosthetics business, we havebeen working very hard on NHS responsibilities there.We will see if that works—and it had jolly well better.There will be other, parallel, concerns about the careof the wounded that relate to the NHS and to all thoseagencies that do care. We have people now who aregoing to leave very soon who will need care all thetime for the rest of their lives. It is not the MoD thathas identified that, but somebody has.Bob Stewart: It could be under MoD auspicesthough.Jerome Church: I don’t think it has the capacity.

Q446 Bob Stewart: No, no. It’s got to have thecapacity. I think the feeling of the Committee is thatwe are extremely concerned about the long-termlooking after of our wounded. It is better now than ithas been in the past, but, my goodness—Jerome Church: The in-service is very good.

Q447 Bob Stewart: In-service is fantastic. It is notthe in-service that I am concerned about.Sue Freeth: We have seen from the current Covenantinitiatives and the creation of the Covenant ExecutiveGroup, which is bringing all the GovernmentDepartments together. This is a new commitment fromGovernment Departments to share that responsibilitywith the Ministry of Defence. Again, it is very earlydays, but there certainly are signs, for instance in whatwe are doing with the Department of Health, that theyare committing resources. They are seeing, in thinkingabout this community, how doing so is benefitingother people whom they have responsibility for, whomthey could approach slightly differently. Coming fromthose Government Departments are very smallamounts of money that are available to dedicate tothis community. The Ministry of Defence at themoment has very little to offer in terms of cash, andmost of the initiatives are being funded and resourcedby other Government Departments, charities and, inone or two areas, commercial organisations anddonors. Whether that is going to be sufficient—Bob Stewart: The answer is no. It is not going to besufficient. The suggestion is—Chair: Order.Bob Stewart: I must shut up. All right.

Chair: Order. We need to pick up a bit of speed, so Iwould like crisp questions and crisp answers.Bryn Parry: I consider that the long-term care of thewounded, the injured and the sick cannot be withinthe boundaries of purely the MoD. We need, therefore,to have some other way of picking up thoseindividuals while they are serving, ensuring that theytransition successfully into civilian life, andoverseeing and linking in to all the various differentDepartments—whether housing, welfare orpensions—that they need. Somebody needs to bechampioning that particular, unique and very specialgroup through their lives. That should not, and cannot,be left to a junior Minister in the MoD, and nor shouldwe be kicking him, because it is way beyond the areathat he should be covering.The point is that while people are in Service, they aregetting superb treatment. If you go to Headley Courtand look at, say, the prosthetics provision there, it iswonderful. The problem is that the guy comes outwith his C-Leg and takes it home to Bournemouth,and in two years’ time he goes to his NHS prosthetist,who says, “I haven’t got the experience or the fundingto give you a new one.” That is the problem.

Q448 Bob Stewart: Of course, the boys and girls aretalking about that; they are worried about that whenthey leave the Services.Jerome Church: We are all waiting, to be fair—Chair: We are just about to come on to the Murrisonreport.Bryn Parry: But the point is that young men andwomen are staying in the Army at the moment, orwanting to stay in the Army, because they are worriedthat care in civilian life is not going to be as good asthey are getting. We want to congratulate the Servicesand the MoD for what those people get while they arein, but we need to be concerned about what they aregoing to get if they leave. That is holding people backfrom thinking about having fulfilling futures. We nowneed to inspire, enable and support them as they gothrough the rest of their lives. Until we have got thatright, the thought of losing your legs will seem like adeath sentence, because you will prefer to be the biffin the stores rather than make a success as a chiefexecutive of some multinational with no legs later on.Chair: I have no doubt that this will feature heavilyin the Report that comes out of this inquiry.

Q449 Mr Brazier: In America, from the momentyou cease to be in uniform, you are under the auspicesof an organisation that is wholly at arm’s length fromthe Pentagon. Having had a strong disagreement withthe British Legion many years ago on this, could I askyou whether you think it right that the VeteransAgency is in the MoD?Bryn Parry: No, I don’t.Sue Freeth: I agree.

Q450 Ms Stuart: This is a very specific questionaimed at Jerome Church, and I declare an interestbecause the Queen Elizabeth Hospital is in myconstituency. Could you tell us a little more about howHeadley Court, the QE and you worked together onthe provision? Also, to make the question brief, tell



us a bit more how you contributed towards theMurrison report.Chair: The Murrison report, for the interests of therecord, being into the provision of prosthetics.Jerome Church: Murrison mark 2, as it were. Verybriefly, as an organisation we have always beenallowed by the MoD into Selly Oak and now the QE.That was originally because we were the guys whocould talk about the life ahead a bit, particularly to thefamilies who might be by the bedside. We still try todo that as much as possible. We then follow veryclosely our people at Headley Court and we have asurgery there every couple of weeks, mainly to dowith making sure their compensation scheme thing isworking all right, and we have had some greatsuccesses there, and alerting them to the other thingswe can do. That is building a relationship with peoplewhom I hope we can help for the rest of their lives.That is our job.On Headley Court we were delightfully surprised fiveyears ago when we saw the quality of what was beingprovided. We campaigned to have it put there and wedid not expect it to be quite so good. I then had toscratch my head and say, “Crikey, this is going to bea problem in a few years’ time”. We knew what wouldhappen out there in the real world of the NHS with itsvery limited budgets and very local decision-making.As was always said, they don’t lose their legs forAnywhereshire; they lose them for the whole country,as it were. It is the country’s responsibility, not localdecision-making, postcode lottery and all that sort ofstuff.We campaigned for a long time to get that right. Helpfor Heroes also gave us some support, particularly asit got more and more urgent. We were given thepromise, “Oh yes, it will be done.” But we know howthe system works and we knew that there was nomethod of doing that. There was no funding chain,and that is the key thing. So we then have been veryinvolved with Dr Murrison. We were delighted he wasappointed to do it and he was extremely interested andreceptive and consultative with us and others. I knowa good deal about what his thinking is and I think andlet us hope—I know it has gone to No. 10 and I knowit is now back at the Department of Health—it is beingimproved even more. I am sure they are doing a verygood job.

Q451 Mr Havard: This sustainability argument,particularly in this narrow area, but the generalquestion of the sustainability of services over time isclearly crucial to the whole of the thing we arediscussing. Yes, there are fears among individualsabout whether they will be able to have these state ofthe art things in future. I want to come back later andask you a question about how this applies across thewhole of the UK, but how do you think this will playwithin the English health authorities who are going tohave a very varied commissioning process? What arethe potentials for a consistency of application acrossthe areas of England, rather than a uniformity ofallocation in terms of providing these services overtime?Jerome Church: My contacts within thatcommunity—the prosthetic world, as it were—are

very hopeful that they will be given structures thatthey can prove their worth with. That is my reading.There are skills there. They can be a bit dissipated.The prosthetic community itself—the number ofprosthetists—is fragile. We have to be very careful.We have to look after it for the good of the wholecountry.

Q452 Mr Havard: It is not just populated bydoctors?Jerome Church: No, no. Doctors don’t knowanything about prosthetics. It is the prosthetists andthe technicians who really know their business and,may I say, those of us who use it. That is the reallyimportant part. If they can be focused in the rightplace, and I think there is every desire to do that, inthe right centres with the right resources—the fundingchain is absolutely crucial to this—so the prosthetistdoes not have to look over his shoulder and say, “Oh,that’s beyond my budget.” He can go to the veteransbudget—or whatever they are going to call it; thecommissioning process—and that money will beguaranteed.

Q453 Mr Havard: So, you think there should besomething specific in that commissioning process—no matter how it might be differentiated for otherarrangements—particularly dealing with somebodybeing able to tap the right money at the right time.Jerome Church: Absolutely. Who said it? Followthe money.Bryn Parry: Money and expertise.Chair: We will not press you about what is in theMurrison report. I want to move on from these veryphysical injuries to the linked, but wholly different,psychological injuries.

Q454 Mrs Moon: I wonder if you can tell us howeffective the MoD is in identifying personnel who areexperiencing mental health problems, whether as aresult of combat or not? Is the MoD effective, andwhat could it do to improve the service it provides?Sue Freeth: I think Dr Murrison’s mental healthreport and the recommendations from it are to belaunched next week. We have certainly been involvedin the development of those, and we are very satisfiedwith the involvement we have had—I know thatCombat Stress is, too. We need to see how well theyreach out to people and encourage people to comeforward. They will, and should, make a significantdifference. They have been trialled and tested, if onlywith small numbers at the moment. Again, there is achance for these new measures to be more effectiveand to address concerns that a large number of ushave had.There will always be a challenge for people who haveserved in the Armed Forces to come forward withmental health problems. It is almost an added barrier,on top of those faced by the general population, whoalso do not find it easy to come forward. One areawhere we have had, and still have, concerns, whichwe have shared, is that at the moment, people havea vulnerability test when they return from tours, atdecompression. We wonder, as others do, whether thatis too early to capture people’s vulnerability and that



actually, it should be done later, when people havesettled, gone home, and had more time for reflection.That is when things tend to occur, rather thanimmediately after a tour of operations, when you areon your way home and your mind may be distractedor on other things. We would certainly like to see thataddressed, and for it to be properly evaluated, toensure that as many people as possible are beingcaptured.However, we have every confidence that the initiativesthat are now being launched have a real opportunity toreach out to people. Particularly, the Big White Wallinitiative, which will allow people to come forwardanonymously. We have great hopes for it, but we willonly know when we actually see it go live. Like theprosthetics side, in our experience, we are seeing andfinding people who are looking for help and havedepression and anxiety just as much, if not more, thanPTSD. These people are coming forward now fromthe Falklands and subsequent campaigns. It takespeople varying amounts of time before they arewilling to come forward, and I do not think that thatwill necessarily change in future.

Q455 Mrs Moon: Mr Parry, did you want to comein? You looked as though you wanted to saysomething.Bryn Parry: I always want to come in on this subject,but I am not crossing—have you finished?If I am allowed to say, I think that one has to assumethat anyone who has had their life changed by injuryin the Service has associated mental issues. The waythat the Armed Forces look at mental issues is thatthere is a screening process during decompression andthe idea of TRiM. Again, that happens very early, andit tends to be that you march into a room, the sergeant-major asks how you are feeling, and you say that youare feeling fine. He then asks whether you are sleepingall right, and you say fine. He asks whether you aretroubled by the tour, and you say no, not at all, andmarch out. That is it. Actually, if anyone has beeninjured, they have problems and it ought to beassumed that they have, unless proved otherwise.Therefore, I think that psychological support shouldbe integral to the recovery process and not a door thatyou can knock on if you are having a bad time. Thatis what I have been pushing within the Surgeon-General’s department, to see the psychologicalsupport in Service to be absolutely integrated. Downat Plymouth, with the Royal Marines, they have twopsychiatric nurses who work with the guys all thetime, so when they are on the treadmill in themorning, they can have a chat to the guy on the nexttreadmill who is a CPN. It shouldn’t be the stigmaof knocking on a door. That’s the problem. You getServicemen who have spent an awful lot of timetrying to be Servicemen, especially people in theinfantry, special forces or anything like that. They arecertainly not going to say, “I think I am a nutter” toanybody. Someone said to me, “When I am in abattalion, I am a mong, but when I am together withmy mates, we are all mongs together.” That is thepoint—there is no stigma. Once you have beeninjured, you know that you have some sort of issuesthat you need to chat to people about. It is not a big

thing. Psychological support should be part of it,without stigma, in the same way as bandages,prosthetics or anything else.Jerome Church: We don’t really understandpsychological in BLESMA. I have often been askedthis question, “Do you have big problems?” We arenot entirely sure, but we think what happens is thefellowship business—I mentioned one companyearlier that had shared experience. That has helped.We were very much branch-orientated in the old days;we have very few now. Once loneliness comes in,coupled with physical injury, and once you are pastthe adrenaline of recovery in three or four years’ time,there is a danger. That’s why we are keeping peopleentwined in some way. Bryn is doing the same withBand of Brothers, and we do it in BLESMA all thetime. I believe that it has a huge effect on thepsychological injury abatement.

Q456 Mrs Moon: Is there a difference in theeffectiveness of treatments available to those whohave a general mental health problem from theeffectiveness of treatments available to those whosuffer trauma as a result of Service and theirexperience in combat? Is there a difference in thetreatments offered? How effective are they?Sue Freeth: The Kings College Centre for MilitaryHealth has been following a cohort that it started backin 2003. It is teasing out those differences so that wecan get the Department of Health and the Ministry ofDefence to respond. As we have said, one of the areasthat has already been identified is an unwillingness ora reluctance to look for help, and the way that peoplefind help accessible is through comradeshipexperience.There are a number of initiatives that I think will help.Now, people are to be encouraged to register with aGP before they leave the Armed Forces, so that theirgeneral practitioner’s name and details can go on totheir medical records and go out with them. Thatinitiative is only just starting. That provides a potentialfor people, gradually, to start to recognise that askingfor help and asking for a particular type of help thatyou need is available. The Armed Forces network thatthe Department of Health has set up will bringtogether people to look at health issues and find waysto resource them, for example now, with communitymental health practitioners, who are being recruited.These practitioners where possible, are being recruitedfrom people who have a Service background. Thatwill start to bring together a lot more communitiesto support people and lots more support groups. Thatshould start to address the problem.But we are at an early stage. We are less than a yearinto the creation of that Armed Forces network set upby the Department of Health, and the resources thatwere identified in the Murrison report are literallyonly just now being turned into community mentalhealth nurses. There are only a few on the ground atthe moment. In a year’s time, we hope to see manymore. It is very early days.Jerome Church: But very encouraging.Sue Freeth: But very encouraging. It is somethingthat we have wanted for a long time, and which wehope we will be able to retain with the changing



nature of the NHS ahead. The biggest anxiety is thatthose resources will be dissipated and that thestructures, such as the Strategic Health Authoritybodies which are being tasked to oversee this work,will not be there to protect and to foster thatrelationship—and to foster it with the Service charitiesand the comradeship groups.

Q457 Mrs Moon: There is a huge hill to climb ingetting GPs to understand mental health generally. Butto get them to understand combat stress-related mentalhealth problems is going to be even bigger.Bryn Parry: To take that one point, it is veryencouraging, but we have been at war for 10 years—and I do not find that very encouraging; I find itenormously disappointing. We have been at war for10 years and these issues have been going along for along time. We had experience in Northern Ireland andin the Falklands before that, yet we seem to be wakingup to something for the first time. It has been goingon for a very long time and now we need to solve it.

Q458 Mrs Moon: Mental health is an area that wehave long needed to sort out, and GPs play a criticalrole in that. Do you see yourselves playing a role inopening up GPs’ awareness of mental health andcombat-related mental health strategy? I notice thatCombat Stress said that only 5% of those who arereferred to it, as a charity, have come through GPs.That demonstrates a general lack of awareness amongGPs of combat stress-related illness, and a lack ofchecking, even, to see whether patients in front ofthem have a Service background. How do we get themto appreciate the services that they could direct peopleto? Do you see yourselves playing a role in that?Sue Freeth: Last year, we started developing arelationship with the Royal College of GeneralPractitioners. We did a survey last year to benchmarkhow much understanding and knowledge there wasacross the GP community of veterans’ needs and theservices available to them. You will not be surprisedto hear that the level of understanding and knowledgewas very low. What little they were aware of hadapparently been learned from the press, not from theirown colleges and the Department of Health, so we arestarting from a very low base.More online training is being designed this year, butwe see ourselves—and the networks see themselves—having a role to play in getting GPs to understandwhat is available locally to connect the people whomthey are seeing to services and to ask them whetherthey have served their country, which is important. Wewould very much like GPs to have that on the list ofthings that they are obliged to ask their patients whenthey register. We have not been successful inmanaging to achieve this yet, but we will not stopcontinuing to press for it, because we think that it isa very important factor in connecting people to theright kind of health services.There is a big job to do and we see ourselves havinga role in shaping it. It must be done through nationalorganisations as well as at a local level. We mustconnect people to charities that can provide peoplewith not only awareness, but the ability to do

something and the resource to plug into, because I donot think that they will ask the question otherwise.

Q459 Mrs Moon: Is the alcohol culture in the ArmedForces exacerbating the mental health problem? Is itmasking it? Is it increasing it? What role is alcoholplaying?Jerome Church: It depends what you mean byculture. Responsible behaviour is something that theArmed Forces try to inculcate, as far as I remember.But it is not something that you are likely to preventcompletely.Bryn Parry: If someone is not getting the properpsychological support, they are facing demons andthey need to drink to sleep—Mrs Moon: To self-medicate.Bryn Parry:—the chain of command will often pickthat up. That is a typical combat stress matter that yousee with someone later on in their life—a person hasbecome an alcoholic and is then getting help for post-traumatic stress disorder, or whatever it is.I do not know whether that is part of the problem; theproblem is that the guy is going to fight a war and iscoming back with all sorts of problems because youhave asked a civilian to become a soldier and go andkill people, or take incoming fire, and so on. Then youask him to come back and readjust to society. One ofthe ways in which he will do that is by using alcohol,but you cannot blame the alcohol culture for theproblem. It is much wider than that, as we are askingpeople to go to war. We train them to go to war andthen we have to train them to become civilians.

Q460 Mr Havard: Along with alcohol, there is aseries of other risk behaviours that often are indicatorsof a problem rather than the cause of the problem.Bryn Parry: Your happy person has a drink when heis with his mates and enjoys it. Your unhappy persondrinks alone to try to mask a problem.Mr Havard: Or engages in other risky behaviour.

Q461 Chair: Can I put to you some evidence thathas been given to us by Resolution? There has beenconsiderable mention of Combat Stress today on themental health issues. However, it is not the onlyorganisation that deals with mental health issues. Twopoints come out from what Resolution says. The firstthat, “At present funding is channelled to certain well-established third sector organisations (Combat Stress,RBL, SSAFA, etc)…From experience, they aredisinclined even to consider…new operationalapproaches which they might be able to adopt in orderto increase efficiency and effectiveness withinthemselves.” Therefore, Resolution is saying,essentially, “All the money is going to people otherthan us”, which may be true and something that needsto be addressed.However, Resolution also says, “the arrival ofpersonalised medicine is an opportunity for thegovernment to accept that individuals vary widely intheir response to different treatments and that whatworks for one person may well not work for another.Rather than see this variance as an irritant, we suggestthat the DoH and MoD should respond by inviting allproviders with an interest in this area, to collaborate



in a new, open practice and research network…whereevidence from outcomes in individual practice andcases, is used to guide treatment.” Do you think thereis something to be said for that approach, basingfunding perhaps on the evidence achieved fromoutcomes?Sue Freeth: I would certainly identify that Resolutionand other small organisations that have alternativetreatment practices do face difficulties when theycome to organisations, and indeed when they come tothe Ministry of Defence, in terms of looking forfunding. What you describe is the policy of theLegion. We consult with the organisations that webelieve are the experts. We are not experts in mentalhealth, so we do take a lead and look for guidancefrom the Department of Health particularly on whichtreatments are safe for us to fund and support.Where someone is looking for funding for adevelopmental area we feel much more nervous andreluctant to support it if we cannot determine whethera treatment is safe or otherwise. We use NICEguidelines, we fund only practitioners who followNICE guidelines, and treatments when they are notalready being funded and are not already a statutoryfunded service.I think it would be very helpful if the development ofthis practice and variety was led by DoH. At themoment it is very difficult for those of us on theperiphery: I recognise that. I think the Department ofHealth and the Ministry of Defence and some of thecharities are trying to bring together some policystatements to enable us better to develop relationshipswith those organisations.Jerome Church: We all instinctively go towardsevidence-based treatment. That is the way we tend tothink. If the evidence is there, I suspect that supportwould follow in most instances. It is a very difficultarea.

Q462 Chair: It is a different area from whatBLESMA deals with?Jerome Church: It is not something we have muchexperience in, I have to say. But in COBSEO—I ama member of the executive there—I do see thesearguments from time to time.

Q463 Mrs Moon: I wonder how you are seeingdifferent mental health provision being generated,operated, and whether there is innovation, perhaps, insome of the Devolved Administrations. You talked agreat deal about the Department of Health, but thatdoes not operate in three areas of the UK. TheMinistry of Defence does not necessarily have an easycommunication system with the devolvedAdministrations in the rest of the UK. Is there workbeing undertaken outside England that is innovativeor is there actually less flexibility and innovation?How do you see the availability elsewhere?Sue Freeth: Wales and Scotland are contributing tothe discussions and planning of the variety of differenttreatments that are working effectively there, so theyare beginning to share some work that they have led.Wales, in particular, invested slightly earlier thanEngland in developing better mental health services—or started to think about that—for the veteran

community. It has developed some ways of workingand it is beginning to share those practices.From what I can glean, the area which there is mostconversation about and which there is mostinvestment going into, at a local level, is talkingtherapies. Talking therapies sound as though they willbe particularly beneficial to the veteran community,particularly those who have depression and anxietyproblems. I was in Devon and Cornwall last week andI met the two Department of Health-funded—butlocal—community mental health staff, and those typesof treatments are what they were doing most of. Theywere meeting individuals and linking them togetherinto talking therapy programmes. They reported goodengagement and real progress for those people whowere doing it. Cornwall and Devon Armed ForcesNetworks are at the forefront: they were the first onesto start up. That is as much information that is comingthrough at the moment.A mixture of alternative therapies are being tried outand are being reported to be successful, but they havenot been thoroughly examined. If you bring a groupof people together who have had no support and givethem support, almost anything is better than nothing.The extent to which it actually has a long-term benefitfor the individual is something you are going to findout over time.We are not qualified organisations to be able tocomment much further.Chair: Not too many more questions now. We willmove on to support for families.

Q464 Mr Donaldson: Sue, may I ask you how wellthe MoD supports the families of injured or killedpersonnel from the Armed Forces? What is yourexperience of that?Sue Freeth: I will talk about the injured, and Kevinwill comment on the work we have been doing aroundthe families of those who have lost their lives. On theinjured side, families are now becoming moreinvolved and more engaged. Bryn was telling a shortstory just outside, before we came in, about howfamilies can often very much affect whether or notsomeone engages with what is available.Interestingly, the Ministry of Defence had a welfareconference last week and it is the first time in theseven years that I have been in this sector that familieshave been present at an MoD welfare conference. Infact, the first half of the conference was a presentationby a variety of different family members describingtheir experiences. That was a demonstration that theMinistry of Defence is trying to recognise thatengaging early with the families of people who areinjured is very important in their pathway. That doesnot mean that it isn’t without its challenges. Thefamilies who were present had some good newsstories and each of them also had some areas wherethey felt that had been left down. More effort will beneeded, but the MoD has started to take that seriously.Family members are now incorporated in the woundedsick and injured protocol, both once people have losttheir life and their family is informed, and for thosewho are injured. It is not perfect, but they are workinghard at it



Q465 Mr Donaldson: It is improving, you think?Sue Freeth: It is improving.Kevin Shinkwin: For bereaved families, the mainpoint I would make is that Parliament did a wonderfulthing in 2009 in passing the Coroners and Justice Actwith very broad cross-party support. The reason whyit was such a wonderful thing was because the chiefcoroner that the Act created was identified as aposition that would spearhead essential reform of thecoroners service. Sadly, we know first hand that manyfamilies have mixed experience of, for example,military inquests and the inquest system itself. Briefly,the point that I would make is that Parliament has afantastic opportunity right now, in the passage of thePublic Bodies Bill, to reinforce the good that it did in2009 by ensuring that the chief coroner is taken outcompletely from the Public Bodies Bill.Just one additional point that I would make is that Iam bemused, dismayed, to see that figures that I donot recognise in terms of the cost of the chief coronerare being bandied about when honestly we ascharities—a number of charities—are arguing that thechief coroner is cost-effective and far less expensivethan the figures that seem to be emanating fromvarious parts of Government. We have made a verypragmatic, principled and constructive offer toGovernment, to say that we would like a chiefcoroner—we want it taken out of the Public BodiesBill—but we recognise that because costs are suchan important issue that there should be an elongatedtimetable for the implementation of the Coroners andJustice Act 2009, which governs how the chiefcoroner is set up and the activities that that post holderwill undertake.

Q466 Mr Havard: Individuals will have differentviews about this. In my personal experience, from2003 on this Committee, we were dealing withDeepcut and suicides and so on—right the waythrough the whole process—and then the involvementof the coroner service in repatriations and all sorts ofdifferent things. That reform of the coroner services,and their ability to provide appropriately, at the righttime, throughout all of these things with the ArmedServices, has been a problem right the way through,and it is starting to resolve itself. If, however, that isnot done and they do not take it out of the PublicBodies Bill, you said that the establishment of thechief coroner was helping to consolidate and developthe very reform that was required, which I agree with,so how do you see it going forward, if it remains inthe Bill?Kevin Shinkwin: The option that the Governmentseem to be in favour of at the moment is effectivelyto put the post on ice. They are calling it Schedule5—that is the part of the Bill that they are saying theywill reinsert the chief coroner into.The point that I would make very quickly is that, inDecember, the Government suffered their biggestdefeat since the election, when the Lords took thechief coroner out of the Bill. So the status quo at themoment is that the chief coroner is safe. It will onlynot be safe if the Government proceed with their planto reinsert it.

Now, in terms of schedule 5 and putting the chiefcoroner on ice, the consensus from, for example theBMA, Inquest and others is that actually the need fora chief coroner would continue. I mentioned that I wasdismayed by how the arguments have been presentedby Government. My dismay is rooted in the fact thatthe Government seem to be focusing not on the humancost of Deepcut and other issues that you raised buton the financial cost. I made the point earlier abouthow we can never repay our debt to bereaved ArmedForces families. If the Government, by putting thechief coroner in Schedule 5—on ice, rather thanabolishing it outright—tacitly accept that there mightwell be a need for a chief coroner, why not proceedwith a chief coroner who is actually significantlycheaper than what they are suggesting would be thecase? Surely, bereaved Armed Forces families havesuffered enough and deserve the chief coroner as amark of respect.In answer to your question, I would rather notentertain the possibility of there not being a chiefcoroner because I think that the Government aretacitly accepting, by presenting the schedule 5 option,that they may need to revisit the situation in the future.My argument would be, “Let’s not actually go there.Let’s really consider how we are to make it work nowwithin existing financial constraints and within thecontext of an elongated implementation timetable forthe Coroners and Justice Act 2009.”

Q467 Mr Havard: I agree that the costs of not doingit go far greater than the obvious, and they are notjust simply financial. What is the difference betweenputting it on ice—as you described it—in Schedule 5,and an elongated process of implementation? Are theynot the same thing in a sense?Kevin Shinkwin: They are not for one particularreason. Fundamental and integral—Bryn made thepoint about the importance of something beingintegral—to the Coroners and Justice Act was theconcept and application of independent leadership byan independent judicial figure. I am not aware of anyproposal being made by the Government now thatwould replicate that concept to any extent, yet it isan absolutely essential and integral part of the reformequation. For example, with the ministerial board thathas been proposed by the Government, and whichwould be chaired by a Minister, if you had coroners—as we have now—who are resistant to reform, whywould they not say, in obstructing reform, “Ah, I amsimply standing up for the judicial integrity of thecoroner’s service,” and actually reveal that theMinister does not have sufficient authority to pushthrough reform in a way that the chief coroner could?In addition, the chief coroner could do so more cost-effectively than now because there would not need tobe a reliance on judicial review, which is incrediblyexpensive and very upsetting for families.

Q468 Mr Havard: Well, you have got my vote. Iwanted to finish off the questioning about Devolvedauthority and the different architecture. We have alittle difficulty here because we tried to break up ourdiscussion about the Covenant into manageablechunks. At the moment we are doing the injuries part



of it, but we are clearly aware that when peopletransition out of the Service with difficulties, it is notonly the health service that is involved.It seems you suggest that in order to square the circleof a different architecture of provision andcommissioning arrangements in the four countries thatmake up the United Kingdom and the differentiatedprocess in England, on limbs for example, and so on,there may be the need for a specialist fund that iscentrally deployed. We are struggling with thequestion of how a declaration of intention that ismeant to cover the whole of the United Kingdom, andcitizens in the United Kingdom who may later movearound within it over the long period of life that theywill have, will get a consistent application of a centraldeclaration in that differentiated architecture ofcommissioning provision. Understanding that is ourdifficulty and, particularly in relation to the healthservice delivery, I wanted to ask what observationsyou may have about delivery as it now is. Thesituation is already radically different in Wales,Northern Ireland, Scotland and England, and anyobservations you might have would help us—just asmall question.Jerome Church: The words “pious hope” come tomind.Mr Havard: Not me.Jerome Church: Certainly, looking at the limbservice, we know where it works well. In all ouradministrations there are good and working artificiallimb centres. We believe that they intend to follow thespirit of what comes out of the Murrison report andthe structures that it suggests, which should be, in myview, reasonably easily implemented, if that was theway that the devolved Administrations felt they couldfollow it. They should do that. I go back to what I saidbefore: time will tell on this one. It is a nagging worry.Sue Freeth: Certainly the evidence that we gave tothe prosthesis review was that we felt that sharedagreements between the Administrations and apooling of funding, not only from the Department ofHealth but perhaps from the MoD as well, particularlyduring the recovery period when the person is stillofficially serving, are necessary to ensure that there isa real commitment to co-ordinate this pathway. It cantake quite a long time. An individual might be in therecovery phase for six or seven years, or three or fouryears. If there is a pooled funding structure and a jointfunding structure, people have to talk to each other. Ifthere is not, they do not have to work together.It is not just about the money itself; it is the leveragethe money gives you which we want to see beingapplied. We want joint commitments and agreementsbetween Government Departments and pooled fundsto support this group. That could be applied to notonly prosthetics, but to other areas, perhaps to on-the-ground continuing care, where individuals, who mighthave their entitlement dismantled or disjointed orsimilarly not enacted in one part of the country, mightget that entitlement in full if they lived somewhereelse.

Q469 Chair: Final question. You have theopportunity to make one recommendation to the

Ministry of Defence. No cheating: not two. What isyour recommendation?Jerome Church: Can I think about that? I have arather long list.Bryn Parry: To create a particular department atdefence level to champion the wounded, injured andsick. I would ask that we create an extra, outside ofthe MoD, role for an independent commissioner or atsar—whatever you want to call it—who heads up ateam that talks to all the various different Ministries,agencies and charities, so that we have one co-ordinated approach. If the recommendation is for justthe MoD, it has to be at defence level, but if I amallowed to widen it, then that is what I would like. Weneed to treat these men and women as they becomeolder as a special group who need special support.That needs to be co-ordinated.

Q470 Mr Havard: A bit like the veterans agenciesin America.Bryn Parry: Yes. Going back to the architecture, inlong-term life, when you get ill and get flu orwhatever, you go to your GP. If you have a medical,psychological or housing need that is pertinent orspecial because of your service, you need to be ableto tap into special support. I would therefore suggestthat we have regional centres so that you know that ifyou have a problem with your prosthetic or problemspsychologically, you can talk to someone whounderstands the nature of warfare. You do not want togo to a mental health group where you are asked notto talk about your military experience, which hashappened on several occasions, because it might upsetothers in the group, and you do not want to end uptalking to some so-called psychologist who does notunderstand what you have been through. When youfeel that your needs are to do with your militaryService, you need to go to someone who understands.I would centre them around the country, obviously inWales, obviously in Scotland and elsewhere as wellso that there are special centres within an hour and ahalf or two hours of anywhere in this country.Kevin Shinkwin: I would very respectfully urge theMoD to urge the Ministry of Justice to reflect on thedebt that we as a nation owe to those who have fallenand those whom they leave behind, the Armed Forcesfamilies, and not to reinsert the chief coroner into thePublic Bodies Bill.

Q471 Chair: Sue? It’s unfair for the Royal BritishLegion to have two goes at this, but there we are.Sue Freeth: You very generously allowed us to havetwo voices, so thank you for that. The issue that Iwant to mention is early engagement. I’m talkingabout engaging the organisations that are already ableto contribute in order to fill some of the gaps thatwe’ve been talking about today. In that way, we makethe best use of what we have already.

Q472 Chair: Jerome, you have your second bite atthis.Jerome Church: And I agree very much with whatBryn said, but I would like a guarantee from theMinistry of Defence, down at the level where thingsreally happen, that in a recovery process, the handover



of the injured person will be properly effective, notjust in relation to prosthetics—although I really hopethat is effective—but in relation to all aspects of theirhealth. At the moment, there is a lot of, “Yes, that’swhat we’re going to do,” but I would like to see itproperly formulated. As we said in relation toprosthetics, we need it done properly. We have hadlots of promises. We want to see how you are goingto do it.

Q473 Mr Havard: Do you mean that it would beright for the individual in some way to be representedin a process of compliance? Is that what you aresaying?

Jerome Church: At some stage, he ceases to be asoldier. At that stage, all the right avenues and all theright contacts need to have been made in terms of hishealth and his condition then, and in terms of alertingpeople to the future deterioration that may well come.Every aspect of his health and social care should beproperly handed over. That is the MoD’s job. If I amallowed to go wider, going back to the word “cross-cutting” and everything else, the various Governmentbodies that take on that responsibility should besomehow held to account.Chair: Thank you all very much. This has been a veryrich evidence session, with a lot of interesting ideasand threads coming out of it. We are most grateful.



Members present:


Mr Julian BrazierThomas DochertyMr Jeffrey M. DonaldsonJohn GlenMr Mike Hancock

________________


Witnesses: The Rt Hon. Mr Andrew Robathan MP, Minister for Defence Personnel, Welfare and Veterans,Ministry of Defence and the Rt Hon. Mr Simon Burns MP, Minister of State for Health, Department ofHealth, gave evidence.

Q474 Chair: Welcome both of you, for the first time,to the Defence Committee. Military casualties are thesubject today, as part of our series of inquiries into theMilitary Covenant in action. I would normally refer toyou as Minister, but we cannot do that with two ofyou, so we shall say Andrew Robathan and SimonBurns.I want to begin, Andrew Robathan, by asking youabout the advances in treating and rehabilitatingtroops who have been wounded on operations. Themain issue we wish to cover this afternoon is whetherpeople who have been injured on operations on behalfof their country will be able to have an appropriatelyhigh level of care and sustained care for the rest oftheir lives, both under the Ministry of Defence and theNational Health Service. We shall be coming to thatissue time and again this afternoon but, starting withthe Defence Medical Services, will they continue tohave an appropriate level of resources to look afterpeople who have been injured on operations?Mr Robathan: If I can start with almost an openingstatement, it will set the scene. Some of us in the roomare old enough to think back 40 years when there wasan entirely different set-up in the Defence MedicalServices. You might remember the CambridgeMilitary Hospital, Haslar and others, which for anumber of reasons have closed. By the way, we thinkthat is the right way forward; nobody is suggestingthat we should go back to individual militaryhospitals.Pace the Falkland Islands, we were in the Cold Warand medical services were changing. They had beenset up during the Second World War, and they werechanging. Falklands war people might remember thatSurgeon Commander Rick Holly had a field hospitalat San Carlos and gained great credit for the work hedid there. But that was a one-off, and it was not untilthe invasion of Iraq in 2003 and subsequently the warin Afghanistan that we have been in a position wherewe had casualties and injuries such as we sustain now.I shall not do it again, you will be pleased to know,but I wish to pay tribute to the last Government inthat eight years ago it was certainly the case that theDefence Medical Services were not in the sameposition as they are now; we may discuss the ArmyRecovery Capability later. Although there wasprovision for field hospitals and so on, the casualtieswho have come back from Iraq and Afghanistan have

Mr Dai HavardMrs Madeleine MoonSandra OsborneBob StewartMs Gisela Stuart

completely changed the nature of what we have todeal with in the Defence Medical Services. That rathersets the scene.Do we have the resources? I am tempted to say thatwe would always like more, but actually we do havethe manpower to sustain the treatment that we aregiving. We have the same work force needs, if I canput it that way, as the NHS, particularly in what isquite a new speciality—emergency medicine. I am nota clinician. I do not know if anybody here is, butemergency medicine is a new speciality and we wouldlike more of it. But we are able to manage it. Wecertainly are managing, but we would like to increaseit in one or two areas.One way that we do manage the DMS and itsresources is by the use of Reservists. Some of youmay have seen the Reserve deployment in theemergency field hospital at Bastion, which is veryoften staffed by Reservists. I have seen it, and it isincredibly impressive.

Q475 Chair: We have the resources now, but in afew years’ time we will withdraw from combatoperations from Afghanistan. Will we have theresources then?Mr Robathan: I can only speak for myself, but yes Ithink that we most certainly will. The tragicexperience of Afghanistan and Iraq has taught uswhere our needs may be, and we are concentrating onthose. There is certainly no intention to reduce theDMS; indeed, a project entitled DMS 2020 willdetermine the future size and shape of the DefenceMedical Services post operations in Afghanistan. Ithink you have been given information about thatalready.

Q476 Chair: Yes, we have. Thank you.One of our deepest concerns as a Committee is thatwhen the conflict in Afghanistan is out of people’sminds because it has moved into history, we will stillhave a large number of people with serious physicaland mental injuries who may no longer be at theforefront of people’s sympathy in this country. That isone of the things that we want to ensure is properlydealt with so that they are treated as they fully deserveto be treated and money is laid aside now to cope withthat. Simon Burns, do you have anything to add to


14 September 2011 Rt Hon. Mr Andrew Robathan MP and Rt Hon. Mr Simon Burns MP

what Andrew Robathan has said in relation to theDepartment of Health?Mr Burns: On that narrow point, Chairman, I wouldadd that both the Ministry of Defence and theDepartment of Health have recognised that, sadly,because of the nature of the injuries that have beensustained, they are something that will last individualmembers of the Armed Forces for the rest of theirlives. That is why, given the commitments that wecame into Government with, the Prime Ministercommissioned our colleague Dr Andrew Murrison tocarry out two stand-alone reports. One, which waspublished late last year, dealt with the mental healthaspects of Servicemen’s needs. The second one wason prosthetics, which is a crucial issue.We have seen from the decisions that flowed from theGovernment—from DH and MoD—after therecommendations of the report on mental health thatwe accepted all the recommendations that DrMurrison put forward. They are being implementedand will continue thereafter. Part of that will be achange in the attitude towards dealing with mentalhealth problems in the Armed Forces. Similarly, theDepartment of Health is doing a considerable amountof work to change attitudes and the treatment ofmental health in the wider community.In addition, Dr Murrison has completed an inquiry,with recommendations, into prosthetics, dealingspecifically with the concerns that you have raisedwith us, and that report has been presented to thePrime Minister. It is being looked at and in due coursedecisions will be taken and announced as to the bestway forward.Chair: No doubt we will be coming back to thatreport during the course of this evidence session.Mr Robathan: May I add one thing? It is probably anappropriate time to say this because you asked whatwe were looking forward to after Afghanistan. I knowthat the Committee has been to Headley Courtrecently. I don’t think anybody here was on it but theArmed Forces Bill Committee also went. More thanthree quarters of the new cases in Headley Court lastyear were not related to operations at all. They werelargely related to skeletal problems caused throughtraining or through sport, which is an important part oftraining. Although you are concentrating on militarycasualties, the military sick are not just fromoperations.

Q477 Chair: One final question. We will be comingback to all these things during the course of thisafternoon. How is the Department of Health workingwith the Ministry of Defence to translate some of theadvances that have been made into learning in theNHS?Mr Burns: It would be fair to say that we accept thatthere is a considerable amount that the NHS can learnfrom the skills and techniques that have beendeveloped following the military conflicts both in Iraqand Afghanistan. Let me give you an anecdotal pieceof evidence. Someone from the NHS serving at CampBastion for three months will sadly, due to thecircumstances, have more experience in trauma carethan he or she would working in the NHS in Englandover a five to 10-year period. That is the scale of the

challenge facing medical personnel, but it also showsthe amount we can learn and how we can developskills and techniques through unfortunatecircumstances.We are working extremely closely with the MoD toensure that the NHS can capitalise fully on thelearning and research that is coming out of bothconflicts. What we have done to ensure that we donot lose out is create the National Institute of HealthResearch, which is a partnership that has been put inplace to realise this. It is a partnership between theDepartment of Health and the Ministry of Defence incollaboration with University Hospitals BirminghamNHS Foundation Trust, which runs the QueenElizabeth Hospital in Birmingham. All partners aremaking a significant investment in ensuring that wecan capitalise on what we are learning, to improve andenhance patient care.Mr Robathan: It is a two-way thing, and when we arenot in operations MoD doctors will be enhancing theirtrauma skills by working in NHS hospitals, as theyalready do. It is important to realise that. There istremendous learning and cross-fertilisation that theNIHR in Birmingham is drawing on.

Q478 Chair: That was the fundamental reason forclosing the military hospitals, at Frimley Park forexample, and I think that that was accepted by allparties.Mr Robathan: Absolutely.

Q479 Thomas Docherty: On the issue of learningand cross-fertilisation, the Committee went to theUnited States in April and went to the Walter Reedhospital. Can I ask the two Ministers what experiencesharing you are doing with your US counterparts?Clearly, they have a greater volume of cases.Mr Robathan: We work very closely together inAfghanistan, for a start, and indeed you will knowthat some Americans come into Bastion, depending onhow things work. I am not entirely clear what cross-fertilisation we have had with the Americans, butthere is a lot of clinical co-ordination. If you like, Iwill let you know exactly what we are doing when Ihave the illustrious Surgeon General who can tell mein rather more detail what exactly we are doing. Wecertainly co-operate. They are our closest allies andwe work with them.Mr Burns: What the Department of Health has doneis to create a US-UK Task Force to help to share thelearning, and they are meeting with me shortly.1

That is part of a range of things, of course, becausewhat we are doing generally within the NHS to raisestandards and make sure that we are world-class, is tolook at all experiences of best practice, whether it bemedical treatments or the way in which we organisethe running of parts of the Health Service. That willhave an international flavour, because we are lookingat best practice elsewhere to see if we can pull thingsfrom it that would be applicable to enhancing and1 Note by witness: This initiative was launched jointly by US

President Barack Obama and the Prime Minister, on theoccasion of his visit to this country back in May this year.The MoD and the Department of Health are both keymembers of this Task Force.



improving the quality and provision of care in theNHS. As I said in my earlier answer—I won’t repeatthe whole background—the NIHR has beenestablished as a body to capture and build uponresearch from the experiences in Afghanistan andIraq, and it will also be a body that can look elsewhereto see if we can learn any lessons.Mr Robathan: I have just been prompted, so ratherthan write to you let me just tell you that besides theUS-UK Task Force we have exchange medicalofficers, who go to the US Institution of SurgicalResearch in San Antonio. We regularly exchangepapers. The co-ordination is pretty good between thetwo countries.

Q480 Sandra Osborne: I have some questions forAndrew Robathan in relation to mental healthproblems as a result of operations. The King’sresearch has shown that there is an increased risk ofPTSD, psychological distress and alcohol abuse if theharmony guidelines are exceeded. What account haveyou taken of those findings?Mr Robathan: First, we are keen that the harmonyguidelines are not exceeded, and I have the figureshere. In fact, we are working very hard to ensure thatthey are not exceeded. In the Royal Navy, which ofcourse includes the Royal Marines who are currentlyout there in 3 Commando Brigade, only 0.8% arebreaching harmony guidelines at the moment. In theArmy, 5% breach harmony guidelines, and in the RAFit is 2.6%. First, we want to stop that as far as we can,but sometimes it is difficult for all sorts of people whoare moving units or whatever it may be. Furthermore,people sometimes volunteer to go out again with adifferent unit, for whatever reason.I tread very carefully around the issue of mentalhealth, because I am not a clinician and do not wishto pretend that I know more about mental health thanI do. PTSD is a very complex situation. Apparently,approximately 4% of the general population arereckoned to have some form of PTSD and that isactually mirrored in the troops coming back fromcombat areas and indeed in the veterans who have leftthe Armed Forces. Actually, for those who have notbeen in combat, and indeed overall, the overall figurefor the Armed Forces in the last three months is thatonly 0.3 people per thousand, which is 0.03%, are newreferrals at DCMHs with PTSD. It is a very seriousissue—very serious—and we must do all we can tohelp, but we should not make too much of it. As I say,I am not a clinician but I can see that those who havebeen in pretty traumatic situations do come back fromoperations, but PTSD is treatable and many of thosewith it are treated, and treated quite well.

Q481 Sandra Osborne: Research has shown thatthose who have been in combat roles are more likelyto suffer from mental heath problems. What accountdo you take of that in considering furtherdeployments?Mr Robathan: Somebody who is suffering from amental health condition and is being treated willalmost invariably not be deployed while they areundertaking treatment. I am pretty sure that is correct.

Q482 Sandra Osborne: One of the major issues thatwe have heard about so far is that abuse of alcohol isquite a problem in the Armed Forces. What can bedone to tackle that?Mr Robathan: Alcohol dependence–alcoholism, inlayman’s terms—is not actually common. The reasonsfor that are manifold. Of course, one is that if youspend six months in Afghanistan, you are dry for allbut the two weeks of your R and R, so it is difficultto be dependent upon alcohol. We have not found anyeffect on operational effectiveness, partly becauseoperational theatres are dry.It is true that young men and—particularlyinterestingly—women in the Armed Forces drinkquite considerably more than their civiliancounterparts in the under-35s cohort. We hear a lotabout binge drinking. It is partly because you putpeople together in a close-knit community. Certainlyin the past, perhaps indeed when I was in the Armysome 20 years ago, alcohol was more of a sort ofbonding element of Armed Forces life. I understandthat it is very much less so now and although peoplewho serve now tell me that there is an issue, it is aproblem that we do not underestimate. For instance,now you are never given a prize of alcohol for asporting event. I must confess that in my larder athome there is a magnum of champagne that waspresented to me for winning a competition betweenthe House of Commons and the House of Lords. Sowe still do it here, if I can put it that way, but we donot do it in the Armed Forces, for the reasons that youhave identified.

Q483 Sandra Osborne: Reservists suffer more onreturn from deployment. What can be done toprevent that?Mr Robathan: I think that you came to Chilwell withthe Armed Forces Bill Committee. First, the mentalhealth of all those who serve really is a top priority. AsI said, it is very difficult; you will know the MurrisonFighting Fit report, which I think has gone some wayto addressing the problem. I do not think that I needto recap what was said about it.Of course, there is an issue with demobilisedreservists, because they are out of the community inwhich they have served and that in itself presentsproblems. Furthermore, they do not have immediatereference to an Armed Forces doctor—a militarydoctor.It is very important that people’s GPs—civilian GPs—understand the impact that service might have had onan individual. For that reason, we are working withthe Department of Health and the NHS to make GPsmore aware of that issue. I should stress that themedical records of an individual Reservist that arebuilt up while he is serving are then transferred backto his home GP, so people should understand theissues, but there is slightly an education issue.

Q484 Mrs Moon: When this Committee was inWashington, I took the opportunity to visit the newpost-traumatic stress disorder and mental health unitopened by the Veterans agency. One of the issues theyraised with me was the high incidence that they werefinding of post-traumatic stress disorder in those who



worked in the health services that were provided intheatre. Constant dealing with serious and traumaticinjuries was causing an impact. Has any work beendone within the Ministry of Defence and thoseservices deployed by ourselves to provide medicalservices in theatre?Mr Robathan: We have done a couple of smallstudies, but we certainly have not found any increasein PTSD among medical personnel. Have you seenthe hospital in Camp Bastion?Mrs Moon: I haven’t.Mr Robathan: When you come out of the swirlingwind, dust-storm area of the camp around Bastion andgo into the camp base hospital, which is very busy, itis like entering a haven of quiet. I am not sure if thatis why it is the case, but we have not found anyevidence.

Q485 Mrs Moon: I doubt the operating theatre is ahaven of quiet. It is the actual experience of dealingwith constant traumatic injuries that the Americansfound was causing particular problems, and also forthose in the Medevac units.Mr Robathan: That is a very good point. I have tosay we have had no experience of that—no evidenceof it—but we will certainly look at that.

Q486 Chair: If there is further information youdiscover on getting further inspiration, it will behelpful if you can write to us.Mr Robathan: We will.

Q487 Mr Hancock: Andrew, do you believe theArmy is equipped to seek out and find people who aresuffering from mental disorders, if such people havenot referred the possibility of their having a mentalhealth problem to their superiors or if they have notsought medical treatment? We were told in previousevidence sessions that to a certain extent theindividual was reluctant to admit to having a mentalhealth problem, so the onus is on the unit at variouslevels to recognise that there is a problem.Mr Robathan: I think we have realised that there isthe potential for big problems. You are absolutelyright. Historically, there has been an attitude that onewould not wish to confess to being stressed out orwhatever it might be, because it would somehowundermine one’s credibility. But I think that haschanged quite dramatically. There is something calledTRiM—Trauma Risk Management—within the chainof command and the unit, and people are actuallychecking up on their fellows.The decompression that people undergo in Cyprus ispretty important. I can remember friends of mine whocame back from Vietnam; they said they were in a firefight one minute and six hours later walking aroundCalifornia. It was not a good way to be. I think thatis important.

Q488 Chair: How long is it?

Mr Robathan: It varies. I think it is normally threedays. It is 36 hours minimum.2 I am afraid quite alot of alcohol may be consumed, but it is an importantcalming-down business. Normalisation takes placeand people understand that life is returning to normal.On the Reservists mentioned earlier, every Reservistwill be interviewed twice by the command structureand asked whether they have problems after being onoperations. Those interviews, although they will notspecifically be about mental health, will give peoplethe opportunity to ask about and indeed volunteer anymental health problems.

Q489 Mr Hancock: How effective would you saythe military medical services are at dealing withmental health problems for Service personnel?Mr Robathan: I think they are pretty effective. It isan improving picture, if I could put it that way. I goback to my point that once upon a time it was in someway a stigma to be thought to suffer PTSD orwhatever. I do not think that is the case any more. Ithink they are good and we are learning on that. I goback to Dr Murrison’s Fighting Fit report. That isputting emphasis on mental health, which both in theArmed Forces and for veterans, is very important.

Q490 Mr Hancock: Simon, is there any evidence ofthe military not being able to cope with mental healthproblems; that Service personnel are being treated incivilian facilities for mental health problems whilestill being in the military? Has there been an increasein that?Mr Burns: The narrow answer to your question, MrHancock, is that I have seen no evidence of figures.The guiding principle has got to be that militarypersonnel, like anyone else, must have access to themost appropriate care. That may well be in a militarysetting; it may be in an NHS hospital or unit. Itdepends on the individual circumstances.

Q491 Mr Hancock: Back to you then, Andrew. Whatare the obstacles that might be in the way of Servicepersonnel getting the right treatment for mentalhealth problems?Mr Robathan: They are not dissimilar issues fromacross the country or the general population. First, onehas to understand that one has a problem and accepta diagnosis. This is where I tread very carefully.Secondly, military personnel often move around a hellof a lot, which is difficult. However, the chain ofcommand is well aware of mental health issues thesedays and, dare I say, is much better than 20 years agoat making sure that people are not moved around. Wewould not wish to deploy people back on operationsif they are being treated for a mental health problem,as I said earlier.The obstacles? Treatment exists. As a result ofAndrew Murrison’s report there are 30 communitymental health nurses being deployed around thecountry, specifically for veterans. That is progress. I2 Note by witness: The period of Decompression generally

lasts for between 24–36 hours as this has been determinedas the optimum period for ensuring that personnel returningfrom operations are given sufficient time to undergo themandatory briefings and activities without delaying theirhomecoming any longer than is necessary.



do not think the difficulties—apart from the style oflife that people lead—are that much different fromthose of other people who suffer some trauma andPTSD, or whatever it might be.

Q492 Mr Hancock: Simon, can you tell us about thearrangements with Staffordshire and Shropshire NHS,and how that is working?Mr Burns: Yes. I do not know if you have been there.Generally, and rightly to my mind, Queen ElizabethHospital is regarded as world-class. The new hospitalthat opened last summer has a dedicated military wardwithin the hospital, and the MoD works extremelyclosely with the Chief Executive and her staff, toensure that those seriously injured continue to get thebest possible care.

Q493 Chair: This is about the Staffordshire andShropshire trust.Mr Burns: Sorry, Staffordshire, not Queen Elizabeth,I misheard.Mr Hancock: These are the arrangements you set upwith those two trusts.Chair: Instead of with the Priory. This is the follow-on mental health.Mr Hancock: From doing it privately.Mr Robathan: Staffordshire and Shropshire is thelead trust for eight trusts. It carries on from what Iwas saying. We are working with the best NHS trustsfor mental health. I think it has been going on for fouryears, which is significant of the change over the pastdecade. We are very happy with the way the contracthas operated, and the level of care provided.

Q494 Mr Hancock: But are you aware that peoplehave to wait to get treatment there?Mr Robathan: I am not aware of that.

Q495 Mr Hancock: Could you write to theCommittee to give some information about theamount of time people have to wait to get referredand treated?Mr Robathan: I can give you the details on that, MrHancock, of course.

Q496 Bob Stewart: Andrew Robathan, the ArmyRecovery Capability, which is excellent, is currentlyincreasing in capacity, is it not? Is it going to make acapacity of 1,000 by the end of the year?Mr Robathan: By April next year we are building itup to 1,000. We hope that will be a sufficient number.We believe that it will meet projected demand over anumber of years, especially since, God willing,casualties will reduce in Afghanistan and because ofour planned withdrawal from Afghanistan.

Q497 Bob Stewart: At unit level, there is a naturaldichotomy between wanting to look after your ownonce they are wounded and the requirement of thecommander to have fully fit soldiers. What are yourpersonal views on trying to manage the balance ofhaving operational capability and soldiers wanting tostay with their units, and commanders wanting themto stay but having the problem of keeping his or herunit up to strength?

Mr Robathan: Are you talking about people beingdischarged?Bob Stewart: Yes, I am.Mr Robathan: The Army Recovery Capability, as youknow, was put in motion by the last Administration,and that was a good step forward; it is going in theright direction entirely. It is designed to allow peoplewho are at home or still in the unit, but probably attheir home address, to be assessed and given everypossible assistance, either to go back to their unit—even if they are disabled in some way or medicallydowngraded—or to move on to civilian life. I am keenthat no one who is injured on operations, particularlythose who are badly injured, leaves the Armed Forces,until when and if it is decided by both the individualconcerned and the Armed Forces that that is the bestway forward for them.We all have to be realistic about the fact thateverybody—two of them are having a conversation atthe moment—leaves the Armed Forces in the end. Beit at the age of 25, 35 or 45, everyone will leave. ButI am very keen that those who have suffered in theService of their country are not compelled to leaveuntil they are prepared and ready so to do.3 Doesthat answer the question?

Q498 Bob Stewart: Yes, it does. What about asoldier who is badly wounded with fewer than fiveyears’ service? There are some thoughts that such asoldier gets less resettlement or is not automaticallyredirected to the Armed Forces CompensationScheme. Does a soldier who is wounded with underfive years’ Service get exactly the same conditions asone who has gone beyond five years?Mr Robathan: I have not heard anyone suggest thatthey do not; I would be very surprised if they did not.If someone is badly injured, they are badly injured.

Q499 Bob Stewart: I think that the Royal BritishLegion is suggesting that. It might be worth checking.Mr Robathan: What is true is that people who areleaving the Armed Forces with fewer than four years’Service get a less full resettlement package, but thatwould not apply in the case of someone who goesdown the Army Recovery Capability road, whichinvolves treatment, advice, and medical and otherassistance.

Q500 Bob Stewart: Would you mind if your officialschecked that, because the Royal British Legion hassuggested that that might not be the case?Mr Robathan: I have some notes here that relate tothat; it is regardless of how long people have beenin Service. [Interruption.] That would be a waste ofpeople’s time. If someone can come up with someevidence, I would be delighted to hear it, but I ampretty certain that all medical discharges get the fullresettlement package. Certainly, I would be veryunhappy, as a Minister, if I discovered that people who3 Note by witness: Policy allows for all seriously wounded,

injured and sick personnel to be retained where a useful rolecan be found for them or it is in the interests both of theArmed Forces and the individual. All cases are assessedindividually and no-one will leave the Armed Forces untilthey have reached a point in their recovery where it is rightfor them to leave.



were badly injured in Afghanistan were not receivingproper treatment and resettlement on discharge.Bob Stewart: I thought that would be your attitude.That is helpful.

Q501 John Glen: Andrew Robathan, when someoneis killed in operations, I believe that the PrimeMinister writes to the bereaved family. Is theresufficient recognition for those who are seriouslyinjured while on operations?Mr Robathan: Yes. Are you suggesting that the PrimeMinister should write to them as well?

Q502 John Glen: It is a matter I would like you tocomment on.Mr Robathan: I have seen some of the letters, and Ithought that the last Prime Minister, Gordon Brown,the right hon. Member for Kirkcaldy andCowdenbeath, was unreasonably criticised in some ofthe media for trying to do his best. When a bereavedfamily get a handwritten letter from the PrimeMinister, they are in a very difficult time, but theymust realise that actually—you and I write a hell of alot of letters, if I can put it that way—to write ahandwritten letter to an individual takes quite a lot ofeffort, and they are very decent letters. I have seenthem. I think that writing to all individuals who areinjured would be a superhuman task, and that does notreflect a lack of care, but just the fact that it is notreally possible.We see no reason to change the current approach.What I would say is that we recognise, both throughthe Armed Forces Compensation Scheme and throughpublic recognition in the country as a whole, thesacrifice that many people have made in terms oflimbs and health.Chair: Simon Burns, you commented before on theworking between the Queen Elizabeth Hospital andthe Ministry of Defence. We did not ask you questionsabout that because we visited the Queen ElizabethHospital a couple of months ago, and we also wentthere in the previous Parliament. As before, we wereextraordinarily impressed by the arrangements thatexist and the quality of the care that is given to peoplewho go through there. We felt we had a pretty goodworking knowledge of how that operates, which waswhy we did not ask you questions.We are moving on to the topic that I said we wouldspend a lot of time on, which is the return to civilianlife and what happens in the future.

Q503 Mrs Moon: These questions are for both ofyou. We have had evidence from the Royal Collegeof Physicians expressing grave concern about theavailability of support for those who have life-changing injuries, and I will work through some issuesthat have been raised.I am aware that we are waiting for the Murrison reporton prostheses, but in terms of costs for a below-the-knee prosthesis, the replacement cost for one issuedby Headley Court is £6,500, while one availablethrough the NHS costs £350. Maintenance costs foran above-the-knee prosthesis are £2,000, on thepurchase cost of £9,000, while the NHS cost is£1,000, with very little maintenance. What assurance

can you give that those replacement, qualityprostheses will be at that high level across the life ofthe individual who has suffered limb loss?Mr Burns: You raise an extremely important issuethat I know is also of grave concern to members ofthe Armed Forces who have sustained injuries. WhatI can say at this point is that we certainly recognisethe problem. I understand, as many others do, thefigures that you have just given, which illustrate thescale of the situation and what needs to be addressed.I hope you will bear with me, because as was referredto earlier, Dr Murrison was commissioned by thePrime Minister, as his second inquiry and report, tolook into this matter and all the issues flowing fromit. He has completed a very detailed report, which isbeing considered. I am afraid that until decisions havebeen taken arising from his recommendations, there isnot much I can say to help the Committee, in so faras I am not in a position at this stage to pre-announceor prejudge what decisions may flow from it. What Ican give by way of assurance is that we fullyrecognise the situation and the challenges and we aregiving extremely careful consideration to the reportand its recommendations. As soon as it is appropriateand possible we will make announcements.

Q504 Mrs Moon: Have you any idea of the timeframe for those announcements?Mr Burns: The only time frame I can give you at themoment that is realistic and not misleading is that weare anxious to do it as soon as possible without cuttingany corners and rushing decisions.

Q505 Mrs Moon: So are we talking six weeks orsix months?Mr Burns: Now you are trying to press me.Mrs Moon: That’s my job.Mr Burns: Indeed it is, but it is my job to avoidpitfalls or misleading anyone.Mr Robathan: This is one of the biggest issues—youtouched on it earlier, Chairman—long-term care.These very brave young men in their 20s who aregoing off to the north pole, sailing round the world orwhatever—that is one thing, but how will they belooked after in their 40s and their 50s? There arevarious levels to it, but I think this Government, likethe last Government, and any future government willwish to look after those people properly. I think theMilitary Covenant will be one way in which peoplewill say, “Hold on. These people deserve more, ordeserve what you are giving them. So make sure youdo give it to them.” That is how we are looking at it.It is not just the report that is coming out. This is workin progress and we will need to make sure that welook after these people, which will be a long-termproblem. I would stress that the numbers, fortunately,are not huge. For each individual it is a tragedy, but itis not a huge number of people, thank goodness.

Q506 Mrs Moon: There are examples that the RoyalCollege of Physicians has raised of concerns relatingto tensions—Mr Burns: Sorry?



Q507 Mrs Moon: Concerns relating to tension havebeen raised by the Royal College of Physicians aboutinjured military personnel in the prosthesis clinicsbeing seen to be given a different level of service.How do you intend to deal with that? In particular, forexample, they cite the situation where you might havesomeone from the police force or the fire brigade whohas also been injured in Service. How are youbuilding into the NHS recognition that there will bedifferent tensions and difficulties when people aremoving into NHS clinics and are going to be treatedand seen alongside other civilians, if I can put it thatway?Mr Robathan: That is a huge question that we allneed to be aware of, because in our desire, quiterightly, to recognise the sacrifice the Armed Forcesare going through—the Service they have given to thiscountry—there is likely to be an element of, dare Isay it, discrimination or some form of jealousy. Peoplesay, “Why is this person getting better treatment thanI am?” The police and fire services are doing it in theservice of the community as well but I would say thatthose who put their lives on the line for their countryare in a special place.Mr Burns: I have certainly heard the same commentsas you have about this. The challenge is that amodernised NHS has to be responsive to the needs ofpatients and it has to strive to be world-class andamong the best in the world. So the challenge to theNHS is to make sure that we minimise the potentialfor jealousies by making sure that NHS patients getimproved quality of service, quality of care and in thiscase we seek to improve the quality and standards ofthe prosthetics.

Q508 Mr Brazier: That last answer leads me directlyinto what I wanted to ask. The understanding for sometime now has been that war veterans were to takepriority over other NHS patients for a variety ofprocedures. That was certainly the policy towards theend of the previous government. Is that the policy ofthe current Government? If it is, in an increasinglyfragmented structure—Mr Burns: There is no fragmented structure.

Q509 Mr Brazier: All right, in a devolvedstructure—a structure that I support—or in a structurewhere key decisions have rightly been devolved to alower level, how are we ensuring that theunderstanding of that priority is promulgated?Mr Burns: As an introductory remark, there is noquestion of fragmenting the NHS under itsmodernisation. We want local decisions at a locallevel, within a far more collaborative and integratedservice, rather than a fragmented one. Having saidthat, there is no change. We recognise the debt thatwe owe as a society to those who are selflesslyprepared to defend freedom and our country indifficult circumstances that can lead to horrendousinjuries and, sadly, death. We believe, as the previousgovernment did, that former members of the ArmedServices, if their medical condition is directly relatedto their service in the Armed Forces, should haveaccess to treatment—not in a crude way ofautomatically queue-jumping—that is clinically

decided, because no one would want someone whowas an absolute emergency to be pushed aside by aformer member of the Armed Forces, least of all theindividual concerned. We believe that, as long as it issubject to clinical necessity, where appropriate,veterans will be seen more quickly.

Q510 Mr Brazier: Forgive me, but you have notanswered my question. How are you ensuring thatindividual hospital trusts are doing that?Mr Burns: Most of it is through the GPs, because itis the GPs who will make the referrals when a veterangoes to see them with whatever the medical complaintis. What we have been doing since we came to officeis ensuring that GPs are aware of this requirement andare familiar with what it actually is, because in thepast there has been some misunderstanding around itsimply being for anyone who has been a soldier,regardless of the nature of their medical condition andhow they got it. It applies only to a medical conditionthat is a result of them having served in the ArmedForces. They believed that they were automaticallyallowed to, to put it crudely, queue jump. That is notthe system; it is more refined than that. Doctors havebeen contacted by the NHS to make them more awareand more understanding of the requirement. Veteranorganisations have also been more active in explainingto former members of the Armed Services what theyare entitled to, so that they can make use of it. Thereis a degree of ignorance of what it is on both sides,and we are seeking to address that.

Q511 Mr Havard: The Royal College of Physicianstalks—rightly so, because they are clinicians—aboutthe potential of the individuals who come through thedoor, even though they are of a certain category. Itsays that there are “10 NHS patients of similar fitnessand potential to each veteran.” The size of theproblem is significant. The provision for veterans interms of these limbs and so on is at the smaller endof the scale. It is about the rest of the NHS populationthat are of a similar potential. There is a questionabout policemen, firemen, first responders and whereyou provide these definitions. Is some of this inMurrison’s report or is he restricting himself toService people? If so, is there a start point for theobligation? There are still veterans from the SecondWorld War, the Falklands and other conflicts who arecasualties not just because they have been in wartheatre but because they have been damaged while inService. There is a legacy problem as well as a currentproblem, and a potential forward planning problem.Mr Burns: I do not want to be evasive. I will ask—Mr Havard: Are they in the report or aren’t they?Mr Burns: Can I just finish? I do not want to beevasive. I ask you to be patient. What you are tryingto do, in an equally subtle way, is what your colleaguewas trying to do, which is to get me to answer aquestion that I am not in a position at this point to beable to answer.

Q512 Mr Havard: I think you are able to answer it.It is either catered for in his terms of reference or it isnot. If it is not, are you in the NHS in England,



Scotland, Wales and Northern Ireland catering for it?Who is catering for it?Mr Burns: The purpose of Dr Murrison’s report wasto look into the whole issue of prosthetics andmembers and former members of the Armed Forces.His report, as I said, has been completed with anumber of recommendations. It is being considered atthe moment. As soon as it is appropriately possible topublish it and our decisions on the recommendations,we will do so, but it would be extremely unwise ofme to be tempted by you to answer questions at thisstage, when it is premature to provide answers.

Q513 Mr Havard: Let me ask you the question theother way around, then. What are you in the NHSdoing to address that problem? Never mind whatMurrison is doing. What are you doing?Mr Burns: Well, I will turn my answer around andsay that what we are seeking to do in the NHS is toimprove and enhance quality and standards of care sothat we have a world-class National Health Servicefor all our citizens, free at the point of use for thoseeligible to use it.Chair: We look forward with considerableanticipation to receiving Dr Murrison’s report.

Q514 Mrs Moon: Can I take you to an area thatperhaps you can talk about, brain injury? You havesaid that the priority treatment pathway is available tothose injured during their Service life. If traumaticbrain injury results from operations in theatre orduring Service life, it will, on the whole, beidentifiable while they are still within the Services, buttraumatic brain injury can also not be identified forsome years, and can become a serious issue affectingthe person’s life and their capacity to cope. How areyou going to ensure that brain injury whose causerelates back to Service is also given priority treatment,when it may well appear some considerable timeforward and may manifest itself through difficult andbizarre behaviour, mental health behaviour andcriminal behaviour?Mr Burns: The commitment applies not only whensomeone is serving in the Armed Forces but for therest of their life, for any medical condition that arisesas a result of when they were serving in the ArmedForces. The single-word answer to your question isyes. They will receive priority, with the provisos Igave in my earlier answer.

Q515 Mrs Moon: I talked about difficult behaviour.It could appear as bizarre behaviour, often self-medicated through drugs and alcohol, that could leadsomeone into the mental health services or into thecriminal justice system. How do you intend to trackthose manifestations of brain injury and ensure thatthey receive the appropriate medical services and aregiven the priority pathways? Are you going to trackpeople through their post-service life so that they areflagged and receive the appropriate pathways of care?Mr Robathan: If I might say briefly—of course, thiswill go to the NHS; I just need to say something. Weare not going to track people as they leave the ArmedForces in general because about 20,000 people a yearleave the Armed Forces, and not everybody would

wish to get a telephone call saying, “How are yougetting on?” What is important is that if an injury—abrain injury or whatever—is related to Service in theArmed forces, it is identified.

Q516 Mrs Moon: And will be identified in thefuture.Mr Robathan: Yes, and that is partly a question ofeducation for GPs, although not everybody wishes tobe known as an ex-Serviceman.Mrs Moon: I appreciate that.Mr Robathan: We get into issues of individualpreference in life, but if a brain injury were to beidentified as due to Service, that person would getpreferential treatment—ought to get preferentialtreatment. I cannot swear blind that they all would,but they ought to.

Q517 Chair: The impression that I have in relationto the question and in relation to the question askedby Julian Brazier is that the entire priority systemreally rests on the education of GPs issue. Is thatright?Mr Robathan: Not entirely, but to a large extent.

Q518 Chair: Nevertheless, the priority issue isGovernment policy, and if the education of GPs matterappears not to be achieving the priority system thatyou clearly both wish to achieve, further steps will betaken to ensure that it is.Mr Burns: Yes, quite clearly, because there is thecommitment. We expect it to be honoured and ifevidence emerges that it is not being honoured or toomany GPs are unaware of it or not implementing it inthe way that we believe it should be, we will have tolook again to ensure that more is done to educate,familiarise and ensure that GPs are keeping to thecommitments that we have given and the lastGovernment gave for this.

Q519 Chair: That is helpful. You wanted to addsomething—Mr Burns: If that answer was helpful to that question,can I just say that the NHS, for the first year thatsomeone leaves the Armed Forces, offers to follow upwith individuals for the first year that they come outof the Armed Forces on a voluntary basis if theindividuals want it because, as Andrew Robathan saidin his answer, some people do not want—howeverbeneficial or well meant—to be followed up.Can I add just one other thing on the general issue ofmental health and helping veterans who may havemental health problems at the time that they leave theArmed Forces or develop them later? A considerableamount of initiatives have been taken—a number fromthe recommendations of Andrew Murrison’s firstreport—to help to assist. For example, today the BigWhite Wall initiative is being launched. What iscrucial there—we have not mentioned it in the courseof the questions and answers so far—is that we mustnot simply think of members of the Armed Forces,vital and important as that is. There are also theirfamilies and relations who also need to be helped andgiven assistance, counselling, advice or whateverwhere appropriate. So I do not think that we should



look at it in isolation, but remember the needs offamily, partners etc.Chair: We are going to come on to that in just amoment.Mrs Moon: Can I go on to the social care costs?Chair: Please do.

Q520 Mrs Moon: It is easy to look at the NHS costs,and the NHS is free at the point of delivery. But socialcare is not free at the point of delivery. The cheapestcost of social care, if you needed, say, four calls a daywould be around £20,000 a year. There is also thequestion of means-testing for aids and adaptation of aperson’s home through local authorities. Again, abasic cost for the provision of walk-in wetroomfacilities is £20,000. Those are high-level costs. Howwill we ensure that local authorities have the capacityto meet that level of care and support and, in particularwith aids and adaptation, to do them promptly? Canwe have an assurance that, while the person remainsin the military, the aids and adaptations will beundertaken in the military accommodation in whichthe person lives?Mr Robathan: On your latter question, certainly theywould be adapted, and indeed many homes are wherenecessary. Regarding the cost to local authorities, thetruth is, as I have said before, that luckily there arenot thousands of people—thank God—who are in thisposition, and the numbers are therefore relativelysmall. I don’t think it should throw over or destroyany local authority’s budget.

Q521 Mrs Moon: Is there an expectation that peoplewill pay for their social care costs out of their pensionand compensation?Mr Burns: Perhaps I could give you an answer aboutthe whole social care issue, once someone leaves theArmed Forces. As you will know, there is going to bea social care White Paper next year, which will dealwith the whole sensitive subject. It is not possible atthe moment to anticipate what may or may not flowfrom that process, once there has been a White Paper,consultation and debate on the whole future of howsocial care is going to move forward.

Q522 Mrs Moon: Can you tell us in relation to thepresent situation? Because if there is a White Papernext year, we are talking at least five years hence,possibly, before there is any change. Within thecurrent legislation and scenario, are social care costsgoing to be met by the individual out of theircompensation and pension commitments? That willdisappear very rapidly.Mr Robathan: That is an important issue that is beinglooked at. There have been incidences where peoplehave been asked to contribute, I understand. I don’thave the details to back it up. Actually, what weadvise is that the lump sum payment from an ArmedForces Compensation Scheme—compensation for theinjuries they received in the Service of their country,not to provide a walk-in shower or whatever—is putin a trust that is exempt from social care costcontributions, so that it is not taken into account. Thatis the current situation: it is in a trust. It is a problemthat is arising, and there is work in progress and we

hope things are getting better rather than worse on allthese issues.Mr Burns: I think Andrew has dealt with that now.

Q523 Mr Brazier: I wanted to ask a tiny questionon that. Surely the solution is similar to the specialarrangements we made over disregard for widow’spensions with housing benefit. In this case we aretalking about very small numbers of people nationally.Most local authorities will be dealing only with singlefigures, if any. So the solution would be simply to putthrough an exemption. It saves people having to putmoney into trusts and the rest of it.Mr Robathan: That is work in progress. Discussionsare going on, and that is a very good point.Mr Burns: That is precisely what we are proposingto do.Chair: Madeleine, do you have anything to add, orshall we move on?

Q524 Mrs Moon: Only in relation to vocationalrehabilitation services. Again, the Royal College ofPhysicians has said that the vocational rehabilitationservices, particularly for those with long-termneurological problems, are patchy, to put it politely,though appalling is probably closer to the reality. Thatis an area I worked in prior to coming into Parliament.They are struggling now to cope with neurologicalinjuries as a result of sports and car injuries and soon, within the ordinary population. With the increasednumbers coming through as a result of those injureddue to their Service in the Armed Forces, can we havesome sort of commitment to an increased prioritybeing given to those vocational rehabilitation services,so that they are available to increase whatever qualityof life can be offered and built on for those who havebeen injured in theatre?Mr Burns: I certainly cannot give a firm commitmenttoday in response to that, but we will consider thatwhole area of care post-Murrison. You can have thatcommitment from me. I would also like to say, on thequestion of integrated care and continuity of care,which is crucial, sadly you are right. There iscurrently, and there has been for some time—thisproblem isn’t the responsibility of one government—too much disjointed provision of care, rather than aseamless pathway.One of the important pillars of NHS modernisation isthat we seek to provide—through the commissioningprocess, through the public health responsibilities oflocal authorities, where relevant, and through thehealth and wellbeing boards, which ensure that theneeds and requirements of the local health economyare met—a far more integrated, seamless provision ofcare for the benefit of the patient. That is one of thepillars that has to be achieved in a modernised NHS.

Q525 Ms Stuart: That leads me very nicely to thenext question, which is on the Transitional Protocolthat the Surgeon General and the excellent AndrewCash are working on. I will bundle it up so that youknow the package of the question. Do you think it isworking, and what early evidence do you have thatit is?



Much more precisely, Andrew Robathan keepscoming back, saying that there are very smallnumbers involved.Mr Robathan: I was talking about seriously injured.

Q526 Ms Stuart: Simon Burns, you referred to thenew structures of the NHS. Unless I have seriouslymisunderstood those new structures, Primary CareTrusts will cease to exist and Strategic HealthAuthorities are on the way out, other than the threeplus London, which are so big as to be—and they aregoing. Political accountability is through the healthand wellbeing boards, which are very much localauthority led, and the national commissioning bodies.I have a real sense that veterans’ needs are too smallto register in each of those areas, unless you are nowtelling me that veterans’ needs will have a specialpocket in the National Commissioning Board.Mr Burns: No, what I am telling you is that, as youare aware, the National Commissioning Board willoperate through a mandate from the Secretary of State.In that mandate, as well as in the NHS operatingframework, there will be special reference to meetingthe needs and requirements of veterans.

Q527 Ms Stuart: And who is policing that? At themoment it is the health and wellbeing boards.Mr Burns: It depends what you call policing.

Q528 Ms Stuart: Let’s talk about Birmingham,where the QE has all these people. In Birmingham, itwill be the health and wellbeing board, and you willnot have sufficient numbers to track those people who,in all our previous questions, we said should be apriority. They will fall by the wayside.Mr Burns: I am not as pessimistic on that as you are.Ms Stuart: I like to trust, but I also like to verify.Mr Burns: And I like to reassure and convince. Let’ssee if we succeed.As you know, veterans’ Armed Forces health care willbe a national commissioning responsibility of theNational Commissioning Board. The mandate that theSecretary of State gives to the NationalCommissioning Board will contain, among otherthings, specific reference to meeting the healthrequirements of veterans. The operating framework,which already has specific reference to meetingveterans’ health needs in different ways, will, onepresumes, continue.Where is the accountability? The health and wellbeingboards will certainly have an important role to play,because, for the first time ever, I think, we will havebodies with democratic accountability. Electedcouncillors will be on the boards, but there will alsobe others from a range of other health care provisions,plus nurses, doctors, etc. I am not convinced that theboards will be, as you said, local governmentdominated.

Q529 Ms Stuart: No, you shouldn’t just be “notconvinced”. Let’s be realistic. Birmingham—population of 1 million. There will be localcouncillors, who will all want to be re-elected. Willthe needs of the veterans be of significant weight thatthey will not be overlooked? You can only assure us

of that if you make it part of the NationalCommissioning requirement that every single healthand wellbeing board in its terms of reference will alsohave to refer to the needs of the Armed Forces. Is thatwhat you are going to do?Mr Burns: The mandate will.Ms Stuart: Each one of them will be charged to—Mr Burns: No, there is one mandate from theSecretary of State to the Commissioning Board,telling it what the Secretary of State expects it todeliver for the money given to it to distribute andkeep.May I just pick up on and correct one small point? Isaid that the National Commissioning would be donefor both the Armed Forces and veterans. It is just forthe Armed Forces. Veterans’ commissioning will bedone at the clinical commissioning group level, wherethe health and wellbeing boards will have a role.However, I’d like to remind you that there is otheraccountability—that is accountability throughMembers of Parliament. There will still be, or therecould still be in this House and another place, debateson veterans’ health or Adjournment Debates onindividual cases, as there are now. There is QuestionTime, there are written questions and so on. There aremore areas of accountability.The bottom line is that because the CommissioningBoard will be distributing the money for the clinicalcommissioning groups to commission care, it will bekeeping an eye on the CCGs to see that they deliverwhat is expected of them for the money it gives them.There will be health and wellbeing boards, which arethere, among other things, to ensure that the needs ofthe local health economy are being met. There willalso be Local HealthWatch, which is a neworganisation.

Q530 Ms Stuart: But Local HealthWatches are justabout general patients. The handful of Armed Serviceveterans will be flooded—they will be such a smallgroup.Mr Burns: But veterans are also patients.Chair: We cannot have both of you talking at once.

Q531 Ms Stuart: My whole point is that in all thestructures, the veterans and the Armed Forces will besuch a small group that they will always be swampedby the other structures unless they are specificallyteased out and given a special place.Mr Burns: I do not altogether share that view, becauseI think that having a specific reference in the mandateand the operating framework gives them a degree ofprotection, and also, of course, there will be theJSNAs.

Q532 Ms Stuart: Could you tell us what that is?Mr Burns: The Joint Strategic Needs Assessment,which is a local assessment of the needs in thelocalities, which will also have a bearing on the needsof veterans in each area where there is a JSNA.

Q533 Ms Stuart: Can you let us have a note on whatthat means? It is the first time I have heard of it.Mr Burns: Yes, absolutely.



Mr Robathan: May I add something very briefly?There is a very real problem, although if I may say soit ties in with what Mrs Moon was saying aboutwanting to be slightly careful not to give unduepreference, because it may lead to unhappiness amongthe general population—if I can put it that way. Wehave the Armed Forces Covenant report and,notwithstanding much discussion about it, I am certainthat if there were much evidence—anecdotal or hardevidence—that veterans were not getting properlytreated, this Committee, among others, would haveraised the point. Furthermore, we also have thevoluntary sector. You would be surprised how wellorganised the voluntary sector is—sorry, that soundswrong. The voluntary sector is very well organisedand if ex-Service personnel go to it, as they do a lot,it knows very well how to signpost people to the rightforms of treatment, to their MPs and to my office.Chair: We will come on to that in a moment.

Q534 Ms Stuart: Very quickly on the TransitionalProtocol—Mr Burns: Can I come back on that? Can I comeback on your earlier point to try to give you somemore reassurance? Armed forces networks acrossEngland have been set up in recent months and thatwill continue. There are 10, which will broadly reflectthe old SHAs plus London. One of their key jobs isto ensure that, where there are difficulties or wherethings plainly go wrong, whether on a collective orindividual level, there are people who are namedcontacts who can work quickly to put things right, andaccess the relevant authorities or service providers todo so. I think there is a whole package of safeguardsalong the lines we have discussed, so if it is anindividual problem for an individual person to try andcut through all the fog and actually put somethingright that may have gone wrong, there are thesenetworks, which are single focus. Have I convincedyou?Ms Stuart: Not yet, but you are much further on theway than you were.Chair: John Glen.John Glen: My question has been answered.Mr Havard: Are you going to ask about the rest ofthe United Kingdom?

Q535 Ms Stuart: Yes. I still want to come back tothem about the transition networks and whether theythink the Transitional Protocol actually works.Mr Robathan: Yes, we do, and we are pilotingschemes.Mr Burns: Just to reinforce what Andrew Robathanis saying, we are working very closely with the MoD,because, as you know, the schemes are very new—intheir infancy—and being piloted. We want to ensurethat they will actually be in such a place that theyachieve the aims designed for them, and that the careof an individual is prepared in advance of discharge.It is a little premature to get a proper view, but I ampleased at the way it is going so far.

Q536 Mr Havard: Well, that was a jolly interestinginterchange about how you are going to do things in

England, because you appear to have some problems;but there we are.Compliance, however, is a very important issue as faras the whole of the UK is concerned, but moreimportant is some sort of consistent application of theobligations that are in the covenant for this to happen,because people may currently live in England, thenmove to Wales, go to Scotland or whatever. So it isnot just about the English Health Service, and thingsare done differently. The Transitional Protocol, forexample, is done partly through this concordatbetween Wales and the MoD for health servicedelivery. The veterans’ services will be done in aslightly different fashion, and so on. So there is avariable geometry, as it were, around the UnitedKingdom. How are the obligations within theCovenant going to be properly and consistentlymonitored and applied in these areas, across all thedifferent health services that now make up theUnited Kingdom?Mr Robathan: If I might briefly say, before going onto health service issues, that I have recently receivedletters from both the Welsh Government, or the WelshAssembly or whatever they call it—Ms Stuart: Welsh Assembly Government.Mr Robathan: Thank you. I have received lettersfrom them and from the Scottish Government, whohave both welcomed the Covenant and welcomed theCommunity Covenants—

Q537 Mr Havard: Northern Ireland is in this as well.Mr Robathan: I don’t think I’ve received anythingfrom Northern Ireland.

Q538 Mr Havard: Well, we know you haven’t, andwe are asking questions ourselves about why youhaven’t.Mr Robathan: You know that we haven’t, and so doI. In Scotland and Wales, they are certainly of thesame intention as us, but of course devolutioninvolves different decisions sometimes being taken indifferent parts of the Devolved Administrations. Weare keen, however, that everybody should get the samegood standard of treatment. On the NHS side, I willhand over to Simon.Mr Havard: Before you do, Simon—Mr Robathan: I have just been told that theTransitional Protocol has been agreed with all threeDevolved Governments, including Northern Ireland.

Q539 Chair: The answer that you have just givenimplies that the priority for veterans is a matter ofdiscretion in the Devolved Administrations.Mr Robathan: No, I think the manner ofimplementation, depending on what is devolved, is toa certain extent—I will let the Health Service answeron this—and they may do things in a slightly differentway, because that is the nature of devolvedgovernment.

Q540 Chair: So the priority remains a nationalpriority even though its implementation in DevolvedAdministrations may be differently handled. Is thatcorrect?



Mr Burns: If you are talking about health, when Icome to answer, I would like to answer in my ownway to get the wording right for the Department ofHealth and our focus on health care throughout theUK.Chair: Would you like to do that now?

Q541 Mr Havard: Before you do, you talked abouta Cabinet board—is that what you said?Mr Robathan: I don’t think I mentioned a Cabinetboard. Perhaps it is my bad pronunciation.

Q542 Mr Havard: Let me ask the question then.Who in the Ministry of Defence is going to measureand ensure that what you believe is a consistentapplication is in fact a consistent application?Mr Robathan: Some matters will obviously come tous. The Ministry of Defence will be able to lookacross the board—I must not use the word “board”.The MoD will look across the country and theCovenant report will of course cover other parts of thecountry. My point is, Mr Havard, that we haveDevolved Governments. Whether we are particularlykeen on them or not, we have Devolved Governments,so that is the situation that we are in, and we thereforeneed to work in co-operation with those Governments.They may be of varying political hues, but we areworking in co-operation with them and they agree onthe way forward. We have received agreement on theTransitional Protocol and we have received letters inthe last month or so from both the Scottish and WelshGovernments about the Community Covenants, whichwere part of the Strachan report late last year.

Q543 Mr Havard: In the MoD, are you the personresponsible—Chair: Order. We need to pick up a bit of speed.Mr Havard: Are you the person responsible forensuring that that happens? Who in the MoD looksacross the piece to ensure that the obligations of thecovenant are being properly applied with all theseother organisations?Mr Robathan: The Secretary of State will producean annual report to Parliament, which I am sure thisCommittee will examine. It will therefore be hisoverall responsibility, but in the day-to-dayadministration it is delegated to me.

Q544 Chair: Now, Simon Burns, you were going toanswer in your own words.Mr Burns: From our experience of dealing with theDevolved Governments—we have dealings across thewhole health spectrum with health Ministers in Wales,Northern Ireland and Scotland—we have found that itis an effective relationship. To meet the needs of theArmed Forces in specific as opposed to other healthissues, we have got an MoD-UK Departments ofHealth Partnership Board, the purpose of which is toshare information.If we decide to implement a policy such as the BigWhite Wall that was announced in England today, wewill share with the other UK governments what it is,how it works and how it has been put together—allthe nitty-gritty of it. It will be up to them whether theywant to implement the same sort of service for that

target group. Obviously, because of devolution, wecannot force them; it is up to them. The partnershipboard will provide them with all the information—theanalysis of what we think can be achieved and how itcan benefit those it is targeted at—and they will takea decision. Delivery may be different between the fourparts of the UK, but there is a single united focus toprovide the best possible quality care.

Q545 Mrs Moon: One area we need to look at is inrelation to—again—mental health problems. In yourexchange with Gisela, there was a suggestion that thenumbers coming through were going to be small. TheMurrison report points out that 24,000 people leavethe military every year; at least 10,000 have been onoperations; and the 58 English mental health trustswould expect to see at least 413 patients a year, whichis a not inconsiderable additional number. Two issueshave been raised. I may have misunderstood this, butI think there was a suggestion that there is an offerthat people can be followed up for one year afterleaving.Mr Burns: Through the NHS, the Department ofHealth offers a service for the first year that someonehas left the Armed Forces. They can be followed upif they wish to be, just to check if they are all right,how they are feeling and whether they feel they needhelp or access to treatment. That is totally voluntarybecause, as Andrew Robathan said in an earlieranswer, a number of people leaving the Armed Forcesdo not want to be followed up or to have any contactwith what they consider to be “the authorities”.

Q546 Mrs Moon: I understand that. I would like togo very quickly into two issues. First, I have a post-traumatic stress disorder group in my constituencythat is funded by the British Legion. One of the majorcomplaints of those who left the military with mentalhealth problems is that they felt abandoned when theyleft. How will you ensure that they no longer feel thatabandonment, given that they may also have someresentment to being followed up?Secondly, how do you ensure that those who leavetheir Services, and are perhaps a little worried as timegoes on about how they are coping and whether theirmental health is beginning to deteriorate, have accessto the equivalent of something like the Big WhiteWall, which is an incredible move forward? If itoperates and works successfully in mental healthterms, it will be a dramatic change in mental healthservice provision. How will you ensure that those whogo into the devolved Administrations also have theopportunity to come back and to utilise that service,which, as I understand from what you said, is goingto be only English-based?Mr Burns: On the general issue of the provision ofmental health care for veterans and how veterans canaccess it, there is a problem in this country across therange on mental health issues.

Q547 Mrs Moon: That is why I am particularlyconcerned, because of the rising numbers that thiswould produce.Mr Burns: We have suffered for far too long withmental health in general being a Cinderella service of



the NHS. It has been the service that no one wantsto talk about, including sufferers and their families,because of the stigma that is unacceptably attached toit. If you suffer from mental health, you are not treatedin the same way as if you have appendicitis—there isnot the sympathy, and even the patients and familymembers often do not want to discuss it, because theyare either ashamed of their or their family member’scondition or they are frightened of the reaction theywill get from other people.Frankly, what we saw from the Major Governmentand, to their credit, the Blair Government and theBrown Government, was not only a significantincrease in the funding of mental health services anda deliberate policy to increase and play catch-up—although one can argue that there should be evenmore—but also deliberate attempts to break down thestigma attached to mental health. Sadly, particularlyon the latter, there is still a long way to go, but therehave been great strides in the 14 years of the LabourGovernment and under the Major Government, andthat is continuing under this coalition Government.In that context, there have been a number of initiativesso that veterans and their families can access help.One of the ways that will happen, as for anyone else,will be through their GP making referrals on theirbehalf to the most appropriate place to go to for help,depending on their medical condition or problems,and through the mental health community partnership.We have targeted veterans in particular, because nextyear we are going to implement a Veterans’Information Service,4 which is for Service leavers.It will give them help, advice and information abouttheir health and wellbeing. The Big White Wall, whichI keep mentioning today, is a service for them—andtheir family members, who are equally important.There are also services like the 24-hour helpline,which is delivered, and up and running. It has hadabout 3,000 calls to date on its freephone number.There are non-specific helplines and access, such asNHS Direct and NHS 111, which is being piloted atthe moment. A Royal College of General Practitionerse-learning tool is being launched today, which coversmany of the concerns that are raised by familymembers and veterans about mental health.So a package of help is provided in different ways.Help is targeted on a voluntary basis, so veterans andtheir family members can access the service if theywant to. There is also the traditional and moreconventional way of going to see your GP if youbelieve that there is a problem, and then accessing therelevant NHS help. Mental health care is provided inother ways at the more extreme end when people getinto significant problems in public, at which point themental health Acts come into force.Chair: We move on to services that supportfamilies—those who are bereaved or those whosefamily member has been injured.

4 Note by witness: The plans are at a well-advanced stage andthe Service is still being finalised. Veterans will be contacted12 months after leaving the Armed Forces to assess whetherfurther help is needed. We anticipate that the VIS will launchin its entirety early next year.

Q548 Sandra Osborne: Does the MoD recognise thelong-term needs of families who have been bereavedor whose relative has been seriously injured?Mr Robathan: Yes, we do. Each individual case isdifferent, but each one is tragic. One of the aspects ofmy job is seeing, occasionally, bereaved families whohave an issue to raise, and, frankly, it is pretty heart-rending. We can never do enough, and in each casepeople will move in different ways.We have talked about long-term care of those who areseriously injured, but there are various issues for thebereaved. As I said, we have been getting better andbetter for a number of years. We have family activitybreaks, which, I think, are open to bereaved familiesand families of the injured. We have access tocounselling, and an organisation called Cruse will alsocounsel families. As you know, the Prime Minister hasannounced that there will be university scholarshipsto pay the fees—which, as we know, will be quite alot—of the orphaned children of Servicemen. Thosewho are bereaved can retain their living quarters fortwo years or more while further arrangements arebeing made. In conjunction with the RBL, we providethe Independent Inquest Advice service for bereavedfamilies.You can never do enough. These are awful cases—many of them are tragic. But we are getting better andit is important that we continue to do so—and learn.Yesterday, I was talking to someone who wassuggesting how we could improve the making of willsby Servicemen. One problem is that when people arekilled in action, although they will have had all thenecessary advice—Bob Stewart will know this—theywill not necessarily have made a will. We cannotcompel them to do so, but we can encourage themeven further.

Q549 Sandra Osborne: In relation to the particularneeds of children, any problems often manifestthemselves in the classroom. Have there been anyattempts to educate teachers and the education systemin general about bereaved children’s needs?Mr Robathan: You may have come across anorganisation called the Directorate Children andYoung People, which is down in Andover. It isresponsible, among other things, for Serviceeducation, and it used to be part of what was called“Service Children’s Education”, or something similar,but is now the Directorate Children and Young People.That organisation is closely involved with supportingchildren and young people, particularly when theirparent has been killed in action. That is one of itsfocuses, besides the broader education system—indeed, it also deals with situations where a parent ismedically discharged after an operational injury.In a broader sense, there is a £3 million fund thatschools and local education authorities can apply tofor schools with a large number of Service children.Of course, there is also the Pupil Premium for Servicechildren. For bereaved children, I have mentionedscholarships, and we also work closely with thecharitable sector—SSAFA, in particular, and the ChildBereavement Charity, to ensure that Service children,of both the injured and killed, are given as much helpas possible.



Q550 Sandra Osborne: I ask the Health Minister thesame question, in relation to GPs and other healthprofessionals. Are they conscious of the problems ofbereaved families in the longer term? Can they pointthem in the right direction so they can get adequatesupport?Mr Burns: I certainly believe that most GPs knowhow to point a family in the right direction forappropriate help and counselling. Because GPs alsoprovide that service for people who have nothing todo with the Armed Forces, many of them will befamiliar with the right way to go. That does not meanto say, however, that one can relax and take it forgranted that everything is fine. One has to ensure thatGPs are cognisant of the best way to look after theirpatients, and that they can point them in the rightdirection.

Q551 Chair: Moving on to the relationship with thecharitable sector, the Ministry of Defence, in itsmemorandum, said that there has been a step changein the amount of funding from the charitable sector.Andrew Robathan, do you think that the Ministry ofDefence is spending that money well, and is there anysuggestion that money provided by the charitablesector is now going on things that would previouslyhave been considered the responsibility ofGovernment?Mr Robathan: On your second point, it is importantto realise that it is not new for the charitable sectoror the voluntary sector to be involved in providingassistance with, for example, casualties from wartime.There is a fantastic house—I think it was called theErskine estate, but Sandra Osborne might know—onthe banks of the Clyde. It is now the Mar Hotel, but Ithink the estate was gifted as a charitable institutionfor injured Service personnel after the first world war.Headley Court itself is a charitable trust that wasgiven to the Nation.The voluntary sector’s involvement should beapplauded. What it really does is provide assistance,and such things would not necessarily be done so wellor so thoroughly otherwise. It is almost about luxurieson top—not luxuries; it is the additional bonus on top.I do not always believe, and this is because I comefrom the party that I do, that the dead hand of theState is the best way to run all such provision. Thevoluntary sector should be applauded, but that doesnot exempt the State from its responsibilities at all.There is a balance to be struck, if I can put it that way.On spending, I think what you mean is running thingsthat are provided by capital grants.

Q552 Chair: For instance. That would be onequestion.Mr Robathan: Well, a particular example recentlywas the £11 million that was spent on the swimmingpool at Headley Court.5 I think you have all seen it.It is a fantastic facility, with a floor going up anddown, and gymnasium facilities, too. It is very good,and was provided by Help for Heroes. Before we weregiven that—it was under the previous government—5 Note by witness: Help for Heroes provided £8 million with

£3 million provided from public funds for the Infrastructurecost of swimming pool.

there was a proper discussion to ensure that we couldafford it, and that we would have the funds to run it.We do. We will only take on a project if the runningcosts are affordable and sustainable. That is aparticularly good example, which I think you haveseen.

Q553 Chair: If smaller charities want to offerinnovative services to the Ministry of Defence, howwould the MoD evaluate them and allow them afoothold in working with Service or ex-Servicepersonnel? I can give you an example, which you nodoubt know, which would be Resolution.Mr Robathan: Sorry?Chair: Resolution is an organisation which, I think,feels slightly squeezed out of the Ministry ofDefence’s attention. It provides help in the mentalhealth arena and it feels that the Government, like thelarger charities, only consider the rather moreconventional approaches to dealing with mentalhealth issues.Mr Robathan: This is PTSD Resolution?Chair: That sort of thing, yes.Mr Robathan: First, those working in the charitableor voluntary sector are doing a fantastic job. Theyshould be given all credit. Not every organisation isas good as others. We must accept that. But I take theview that we should not be prescriptive. If peoplewish to set up a charity to do something, they almostinvariably have our blessing. But we will onlysupport, especially in the medical field, which you areinvestigating, NICE-accredited clinical interventions.Quite a lot of people come forward suggesting thatthey can do this, that and the other. Our advice,especially in the mental health field, is that it is notnecessarily the case. Much of this intervention is wellintentioned, but we have a responsibility only tosupport those that are NICE-accredited. I think youwould accept that.We welcome the charitable sector. There is aproliferation of small charities. Sometimes small localcharities make good local links, but you will know thework of COBSEO to try to bring together charities,which is excellent. I see them quite often. As I said,it is not for us to be prescriptive. The outstandingexample in the charitable sector is Help for Heroes,which four years ago did not exist. In four years it hasraised £100 million and more. I pay great credit toBryn Parry and his wife Emma for doing that. Whenthey came on the scene I understand they were notparticularly welcomed by some others who said, “Youjust fit in with whatever we are doing in the biggercharity world.” He said, “No, we want to do this” andthey have achieved remarkable things.

Q554 John Glen: The other thing that Bryn Parrymentioned last week was the lack of a speedyresponse from the MoD. One of the issues we werelooking at was the whole issue of masses of capitalinvestment setting up ongoing running costs and aclear delineation of what the MoD should provide andwhat liabilities would be taken on by ad hocinvestments in the short term. There was concernabout whether, when the income flows perhapsdiminish in a few years’ time, the running costs that



have been set up with these capital investments willbe properly accounted for in the planning.Mr Robathan: That is a very good point because weare not talking about just this year; we are talkingabout decades, and perhaps further. I used theillustration, and I will stick with it if I may, of theHeadley Court swimming pool. There is an agreementthat we will run it for as long as Headley Court isthere and open.

Q555 John Glen: Is that more broadly enshrined inpolicies and processes?Mr Robathan: Yes, for instance there are the ArmyPersonnel Recovery Centres, which you will knowabout; Tedworth House down in your neck of thewoods, Chairman, is being set up by Help for Heroes.Its running costs are going to be paid jointly by theMoD and the RBL. The British Legion is paying mostof the running costs but we will be very heavilyinvolved. It comes down to protocols and agreements,which are quite formalised for good reason.Sometimes, with very good intentions, charities fail.They try hard and they fail. We are not prepared totake on the responsibility for all charities. I was askedto take on responsibility for a charity that we advisedwe would not support financially. It came to us forfinancial support and we said that we could not do itand you will understand why not.Chair: Finally, future challenges. Gisela Stuart.

Q556 Ms Stuart: May I start with health? SimonBurns, when we went to Walter Reed and we askedthem what their biggest worry was for the future, theysaid that it was mental health. As far as you areconcerned, what is your biggest worry for the future,in the context of the military covenant and theDepartment of Health?Mr Burns: The biggest challenge, rather than worry,is that we have to ensure that the Department ofHealth and the NHS focus and improve on outcomes,because outcomes are the most important thing to theindividual when they need treatment. For those whoare injured, we have to ensure that the outcome is thatthey can return to as normal a life as possible asquickly as possible, having had the finest careavailable. If, as a result of their injuries or theircondition, it becomes a long-term condition, we haveto ensure that they have integrated and seamlessprovision of care. That is the challenge. I phrase itmore positively than calling it a worry, which wouldbe more negative.I believe—I suspect, with all due respect, that you willdisagree—that the modernisation of the NHS will helpthat, because the NHS is by definition an evolutionarybody. It is also a crucial challenge that we ensurecontinuity of care. That is essential and uppermost inthe needs of patients. It is crucial that they are able tomake the transition from Service to civilian life, whichis challenging in itself, let alone if you have a medical

condition or a disability or whatever. We have to worktogether to ensure that the needs of each individualare met to the highest possible standard. That is wherethe Armed Forces networks have an important andcrucial role to play, because if something goes wrong,they provide a point where someone can go tosomeone who can make the necessary phone call tosort it out as quickly as possible, rather than themgetting into a backlog where it will be dealt with indue course. At the point where someone accesses anetwork, for them it has become a crisis or it isuppermost and urgent in their mind. They will wantaction, and they will probably want it now. That iswhy the networks are so important.

Q557 Ms Stuart: And the Armed Forces networkwill also encompass social care?Mr Burns: Yes, it is a complete package, fromdifferent facets of input, whether the health service,the military, the PCTs now but CCGs next and othersin respect of social care.Finally, so I can shut up, it is important that the hardwork being done at the moment will put in placeprocesses for the transition of seriously injuredpersonnel. The urgency of awareness-raising and theidentification of the needs of veterans that is takingplace for good and obvious reasons has beenhighlighted over the past few years because of whathas been going on in Afghanistan and Iraq. We haveto make sure that that continues afterwards and thateverything that is being done at the moment does notcome to a jolting halt as soon as we discover that weare not in conflict somewhere around the world. It hasto be sustainable long term because from a healthpoint of view, sadly, the injuries, needs andrequirements of too many people will not end the daythat we cease having a presence overseas in a warzone.

Q558 Chair: I am very pleased that you made thatlast point. Andrew Robathan?Mr Robathan: He has really made my point for me. Iwould only add that, as the Minister in charge of ex-Service personnel and veterans, this is a long-termchallenge. It will continue to be work in progress asmedical technology improves, because the care forthese brave, young men will go on for 30, 40, 50 or 60years and we need to be clear that our responsibilitiestowards them remain. That is why we have prettygood co-ordination between the Department of Healthand the MoD, and across the Government. Thiscontinues to be work in progress, but it is veryimportant that we get the co-ordination right. Peoplewill inevitably fall through the floorboards from timeto time, but we need to make sure that we are there tohelp them—with, indeed, the voluntary sector.Chair: We are done. Thank you both very muchindeed for coming to give evidence and thanks to yoursupporting teams behind you.


Written evidence

Written evidence from the Ministry of Defence

Question 1—The current Policy for the support of injured personnel and their families while personnel arestill serving and after their discharge including the long term vision for the support will be sustained forthose still in service and those leaving?

1.1 The care and welfare of injured personnel who are still serving and their families remain the responsibilityof the Service chain of command. Each Service has its own system for ensuring the best possible care for thosein need; these are called the Army Recovery Capability, the Naval Service Recovery Pathway for the RoyalNavy and Royal Marines and the Personnel Holding Flight for the Royal Air Force. These capabilities aredescribed in detail in answer to Question 5.

1.2 For those who are due to transition out of Service with an ongoing medical and/or social care need, thesingle Services will use the Transition Protocol.

Transition Protocol

1.3 The Transition Protocol process has been developed under the auspices of the MoD/Departments ofHealth Partnership Board which is co-chaired by the Surgeon General and Sir Andrew Cash, Chief Executiveof the Sheffield Teaching Hospital NHS Foundation Trust. Alongside extant arrangements governing thecoordination of medical and welfare support to those leaving the Services, the MoD has negotiated a TransitionProtocol with the Department of Health (DH) and the Association of Directors of Adult Social Services(ADASS) to ensure a seamless transition for ill and injured Service personnel from military to civilian life.The Protocol was agreed by departments in September 2010 and the initial trial period concluded in March2011, at which point it became policy for the three Services, DH and the Devolved Administrations.

1.4 The Protocol sets out the responsibilities and procedures for planning the transition of health and socialcare for injured Service leavers to local public providers. The Protocol ensures that a bespoke Transition Planis agreed by the receiving care providers at an early stage. A Multi-Disciplinary Team consisting of MoD, pluslocal service providers and Veterans Welfare Service (VWS) representatives are brought together by an MoDCase Co-ordinator at least three months in advance of the discharge date to assess the medical and social needsof the leaver. The Protocol provides a mechanism for the development of an appropriate care package whichwill be drawn together by the MoD Case Coordinator in liaison with the relevant health and social care expertswithin the Primary Care Trust and Local Authority. This should ensure that a care package provided by localservice deliverers is in place from the moment an injured Service leaver is discharged.

1.5 A number of the Voluntary and Community Sector organisations have considerable expertise in deliveringsupport to injured and ill Service personnel which is complementary to that provided by the public sector. TheVWS is responsible for coordinating the Voluntary and Community Sector participation in the Multi-Disciplinary Team assessment to ensure that the appropriate elements of the sector are present.

1.6 The protocol does not absolve the Department of a moral responsibility to remain engaged with medicalleavers for as long as the requirement endures. The VWS retains an important role as the prime point of contactto whom Veterans can turn for assistance. Routine VWS engagement is reduced at around the two year pointbut the VWS never close a medical discharge case file. It continues to provide support for as long as it isrequired. VWS has established arrangements to call every medically discharged veteran each year for the nexttwo years. This process will be tracked to provide management information which will inform a review of theeffectiveness of these extended contact arrangements.

1.7 The NHS will be undergoing a major re-structuring process over the next few years but this should notaffect the Protocol principles. The DH has confirmed its commitment to provide Armed Forces champions inthe new structure. Close liaison will be maintained with the DH to ensure that appropriate points of contactfor the Armed Forces Network remain in place.

Mental Health

1.8 The Murrison report “Fighting Fit” looks into mental health issues relating to Serving and ex-Servicepersonnel. His report makes recommendations on improving mental health assessment at routine medicals,extending entitlement of access to community mental health services to personnel for six months beyonddischarge, conducting research into post operational mental health screening (see Question 12) and a trial ofweb-based mental health support. For veterans his recommendations include a veteran information service thatwill actively offer support 12 months after discharge, provision of mental health professionals to operate aveteran outreach service, a 24 hour help-line, a trial of web-based mental health support, and an aim to improveco-operation between MoD, DH and the voluntary and Community Sector.


Question 2—Description of the Systems for dealing with personnel (military including Reservists andcivilian) who are medically unfit with particular regard to those who have been injured physically orpsychologically as a result of operations

Tri-Service Medical Policy

2.1 The MoD policy is that Armed Forces personnel should have the best possible care and we work withthe UK Departments of Health and the NHS to provide this. The majority of routine day-to-day healthcare forall Service personnel, wherever they are based, is provided through military primary care health centres situatedin or near their individual unit. The range of medical care that is provided will depend on the size of the localmilitary population that a centre is required to serve, but it will generally provide high standard primary medicaland dental care. In addition, most major military primary care centres will have Primary Care RehabilitationFacilities either on site or nearby. These will provide out-patient rehabilitation and musculo-skeletal treatmentsfor the simpler kind of sports and training injuries commonly suffered by Armed Forces personnel. Manyprimary care medical staff are also able to offer treatment for the less serious mental health disorders.

2.2 For personnel who require physical rehabilitation that cannot be provided at primary care centres, MoDmaintains a range of more specialist facilities. There are 15 Regional Rehabilitation Units (RRUs) located inareas of major military population around the UK and overseas which offer more specialist physiotherapy tothose requiring it. For those needing more specialist treatment, such as amputees, the dedicated DefenceMedical Rehabilitation Centre (DMRC) at Headley Court in Surrey provides a first-rate facility on an in-patient basis to all Service personnel. (More information on the treatment of injured Service personnel iscontained below.)

2.3 Likewise, more specialist mental healthcare for serving Service personnel is provided through MoD's 15military-run Departments of Community Mental Health in the UK (with additional centres in Germany, Cyprusand Gibraltar). They are located to be convenient for major centres of military population, and support theprovision of healthcare that is available through Service primary care facilities. For those Service personnelrequiring in-patient mental healthcare, the MoD has a contract with a consortium of eight NHS Trusts, led bySouth Staffordshire and Shropshire Healthcare NHS Foundation Trust, which delivers in-patient care in a rangeof facilities around the country.

2.4 In addition to the healthcare provided to Reservist personnel when mobilised, the Reserves Mental HealthProgramme was launched in 2006 and offers support to any Reservist deployed after 2003 who has mentalhealth issues. To access the assessment programme Reservists can self refer or can be referred by their GP. Anindependent clinical review in 2010 indicated that the programme is well received and offers an effective andacceptable intervention service to recently de-mobilised Reservists. The MoD continually reviews thisprogramme and future direction will take into consideration any findings from research by King’s CollegeMental Health Research, the Medical Assessment Programme and the NHS Mental Health Pilots.

2.5 Service personnel who need in-patient hospital care will obtain this at any NHS hospital in the UK. Thespecific hospital to which they are referred may depend upon the need for a particular clinical specialty, butthe majority will be treated at the nearest suitable facility, as close as possible to their family, friends and allthe local welfare support provided by their home unit. The exception to this is the treatment of operationalcasualties, where the primary facility is the Queen Elizabeth Hospital in Birmingham.

2.6 Defence Medical Services continue to improve their deployed medical capabilities on operations. Theexcellence of care extends from the point of wounding, through casualty extraction using the exemplary skillsof the helicopter borne Medical Emergency Response Team and on to the state-of-the-art facilities at CampBastion which have been designed specifically to deal with trauma casualties and ensures that seriously injuredpersonnel receive the medical care that they need. A key element of the medical care is the world wideaeromedical evacuation of personnel from operational theatres by the RAF to repatriate personnel to the UK.This includes the movement of seriously wounded or critically ill personnel using Critical Care Air SupportTeams. These teams are able to provide necessary in flight care which allows personnel to reach NHS provideddefinitive care in a timely manner.

2.7 Back in the UK, the quality of care for our seriously injured personnel provided at the new QueenElizabeth Hospital in Birmingham is acknowledged to be first-class. The new military ward within QEH,building upon the military-managed ward at Selly Oak, was opened in June 2010. The move brought togetherall the key clinical services which had been used by Service personnel to one site. Military patients are treatedin single rooms or four bed wards and the ward is managed in a way that ensures that military and civilianpatients are treated separately. Not all seriously injured personnel are treated on the military ward; specialistclinical needs (eg burns and eye injuries) can dictate that military patients be treated in specialist hospitals orwards rather than the military ward. In this way, our operational casualties benefit from groundbreaking caredelivered by one of Europe’s leading trauma care providers in one of its most modern facilities.

Joint Medical Employment Standard

2.8 Service personnel are awarded a Joint Medical Employment Standard (JMES) which provides guidanceto line managers on any functional or employment restrictions required due to their health. This serves both toprotect the individual from being required to undertake tasks which would be detrimental to existing medical


conditions (the effect of work on health) and also to ensure that individuals are medically fit to undertake theirrequired duties (the effect of health on work).

2.9 An individual’s JMES will be altered on a temporary basis as appropriate during active treatment, toreflect current functional limitations, and the need to ensure they are available for ongoing care. At the end oftheir care, or if they are not recovered within the permitted timeframe, they will be reassessed to determineand assign an appropriate permanent JMES. This assessment may include input from primary care, secondarycare, rehabilitation and specialist military occupational medical services as is required by the particular case,the final grading being undertaken by a medical board. Each service has their own arrangements for medicalboarding, suited to single Service requirements, but all are broadly similar and involve a medical assessment,the results of which are sent to an executive board for consideration of their continued employability. Bothphysical and psychological injuries are managed in the same manner.

2.10 Where the medical board determines an individual is unfit for further military service, they will bemedically discharged. In some cases, individuals may be medically fit for limited duties, but their Service maynot be able to usefully employ them within the required limitations. In these situations the executive board willoffer an administrative discharge for medical reasons, which attracts the same benefits.

2.11 Military reservists do not come under the military medical system until mobilised. At this point, theyhave a medical review to ensure they have an appropriate JMES. Once mobilised, they receive the same careas regular service personnel, including medical boarding. Care for injuries sustained on operations will beprovided via Service sources, although in such cases it may be more appropriate to hand an individual’s careover to the NHS in the area where they normally live. Reservists are not demobilised until their initial medicalcare is complete, or they are medically boarded and a decision made to retain or discharge them from theReserves.

2.12 Whilst MoD is not responsible for providing mental healthcare to Service leavers, it does make theDMHS available (through the Reservists Mental Health Programme based at RTMC Chilwell) to reservepersonnel who have suffered an operationally related mental health problem as a result of their military Servicesince 2003. Furthermore whilst mobilised Reservists are entitled to the full range of military medical careoptions available to regulars including access to DCMHs, MoD also funds the Medical Assessment Programme(MAP) at St Thomas’ Hospital in London which whilst not a provider of treatment will provide acomprehensive mental health assessment for personnel (including veterans) who have served on operationssince 1982. MoD also works closely with other government departments and with the Voluntary andCommunity Sector to maximize the opportunities for veterans to access high quality mental healthcare shouldthey need it. As previously mentioned, the recently published Murrison study, “Fighting Fit”, includes a numberof initiatives which aim to support the mental health of Service personnel and veterans; the implementation ofthe various initiatives has just begun and it is too early to determine what their impact will be. Action pointsinclude improving the mental health assessment element of routine and discharge medicals, providing an onlinemental health support package for serving personnel and veterans and the establishment of a telephone followup for all veterans after they have left service in order to ascertain if they have had mental health problemssince they were discharged. The recommendations are being monitored within the Armed Forces CovenantProgramme of Measures.

Civilians

2.13 Civilians deploying on operations receive a thorough health and fitness assessment (Civilian OperationalDeployment Assessment—CODA). This is a full medical examination and fitness test and is normallyperformed at RTMC Chilwell as part of pre-deployment training. While on deployment, civilians are entitledto use the same medical facilities and receive the same treatment as Service personnel, including medicalevacuation back to UK. Once they have returned to the UK, treatment is handed back to the NHS.

2.14 From the psychological point of view, civilians complete a “wellness questionnaire” before deployment,immediately on returning from deployment and 12 weeks after return from deployment. The currentquestionnaire used is more specific for stress and Post Traumatic Stress Disorder than its predecessor. Thosewith high scores are referred for assessment by the Community Psychiatric Nurse at Chilwell. If they have acondition treatable as an outpatient by military psychiatric services, they will be referred to their nearest DCMHfor treatment. If the condition is not suitable for such care, they will be referred to the NHS via their GP underthe provisions of Civilian Operational Deployment Assessment Post-Operational Psychological Support(CODAPOPS).

2.15 In normal circumstances in the UK, Civil Servants do not receive primary care from military medicalservices, usually being cared for by the NHS. Occupational medical care is provided by MoD either directlyor via contract with an occupational health provider. The model of care is equivalent to that within any largeorganisation with an occupational health provision. Routine clinical care is provided by the NHS, withappropriate advice on employability provided to line management by occupational health services with theindividual's consent. Where applicable under the Equality Act, reasonable adjustments may be required for anindividual’s employment. If an individual he is unable to work, or requires excessive time off, they mayultimately be discharged from employment.


Royal Navy

2.16 Whether injured on operations or not and irrespective of the cause of their serious injury or illness, allNaval Service personnel are treated in the same manner through the Naval Service Recovery Pathway (NSRP).There may be occasions when NS personnel require the specialist support established through Hasler Company.In such circumstances personnel are managed through the Recovery Pathway for seriously injured personnel.The Recovery Pathway for seriously injured personnel applies to all those with long term complex or servicelimiting injuries. The pathway involves the command, management and care of injured and seriously ill NSpersonnel. Care commences at point of injury and treats every case according to the clinical, welfare andexecutive needs of the individual, enabling personnel to recover from their injuries to a point where theircontinued service can be effectively assessed. The Naval Service’s main gauge for continued service is whetherindividuals are able to undertake meaningful and fulfilling employment with a realistic possibility of furtheradvancement and promotion for the remainder of their engagement. This facet is fundamental to any decisionon continued service. The comprehensive consideration of all aspects of the Service requirement andindividual’s abilities versus their constraints is very much the purpose of the extant NS medical processes ofNaval Service Medical Board of Survey (NSMBOS) and the Naval Service Medical Employability Board(NSMEB). The pathway manages the transition to civilian life for those who are unfit for military service inaccordance with the tri Service policy for transition, the Seriously Injured Leavers Protocol (SILP).

2.17 Within the Royal Navy and indeed within the rest of Defence, mental healthcare is delivered in bothprimary care and specialist settings. The Departments of Community Mental Health (DCMHs) which arelocated in Plymouth, Portsmouth and Faslane work in close collaboration with the other 12 DCMHs in the UK.Across the whole Defence Mental Health Services (DMHS) there are more than 150 mental health professionalsincluding psychiatrists, mental health nurses, social workers and psychologists. All DCMHs are operationallymanaged by the Army Primary Health Care Services (APHCS) and provide care to personnel from all threeServices that are either based or live in the DCMH catchment area. The primary aims of the DCMHs are toprovide high quality, timely and occupationally focused mental healthcare. Personnel are also supported by avariety of non healthcare initiatives including widespread access to chaplaincy services and access to a networkof peer supporters called TRiM practitioners (Trauma Risk Management) which is an evidence based systemof providing support and monitoring to those who have been exposed to traumatic events.

2.18 The DCMHs carry out a considerable amount of liaison and educational work in order to ensure thatpersonnel, including the chain of command, are able to spot signs and symptoms which may indicate thatsomeone needs extra support or medical help for mental health reasons. The initial access point to the DMHSis through primary care professionals. Routine referrals to DCMHs are seen within 20 working days; urgentcases can be seen the next working day. In the rare case where someone requires inpatient care, this is availablethrough a consortium of NHS Trusts led by South Staffordshire and Shropshire NHS trust which operates anumber of bespoke inpatient facilities across the UK which treats Service personnel who require inpatient care.The majority of those referred to the DMHS are, however, managed within a DCMH setting. DCMH cliniciansoffer a wide range of evidence based therapies which are in accordance with the various guidance documentsissued by the National Institute for Health and Clinical Excellence (NICE). A recent publication whichexamined the occupational outcomes of a substantial number of patients referred to a RN DCMH showed thatabout 2/3 were able to return to full duties after treatment.

2.19 Personnel who suffer significant physical injuries and as a result are evacuated from an operationaltheatre to a UK hospital are subject to a monitoring process which aims to regularly check on their mentalhealth in order to identify whether the individual might benefit from professional support. However, the UKmilitary does not make use of routine post deployment screening as there is a lack of evidence to support theeffectiveness of such a process. A high quality scientific trial to determine if post deployment mental healthscreening could be made to work is underway and is one of a large number of scientific investigations beingcarried out by the Academic Centre for Defence Mental Health (ACDMH). ACDMH is funded by the Ministryof Defence and provides the Armed Forces with a high quality mental health research facility; it is based atthe Institute of Psychiatry in London and co-directed by the Defence Professor of Mental Health who is auniformed Royal Navy consultant psychiatrist.

Army

2.20 There is no difference in the treatment of wounded, injured or sick personnel who have been injuredon operations and that of those whose conditions have otherwise occurred.

2.21 Army policies and administrative instructions describe the systems for dealing with wounded, injuredand sick military personnel, and the tri-Service medical employment policy has been developed to allow someindividuals who might otherwise have been subject to a medical discharge to continue their employment withintheir respective Service, as long as that is appropriate for the individual and the Service.

2.22 Those Army personnel who fall permanently below the minimum medical retention standard aremanaged in accordance with the relevant Administrative Pamphlet. Where individuals are able to be employedeither in their current trade or in another for which they are suitable, qualified or can reasonably be trained,then retention can be considered. However, this may only occur where the individual’s condition will not be


made worse by retention and that neither the individual, nor those working alongside them, are placed inany danger.

2.23 Those for whom alternative employment cannot be found will be considered for a discharge on medicalgrounds, with access to the invaliding package of support including pension and Armed Forces CompensationScheme as appropriate.

2.24 The Administrative Pamphlet covers all elements of functionality and therefore encompassespsychological as well as physical wounding, injuries and sickness.

2.25 The medical employment policy for Reservists is the same as for Regular personnel and an individual’sability to undertake their military employment is assessed from a medical perspective and then an informeddecision is made. This is particularly important for mobilised Reservists.

A copy of the Administrative Pamphlet (PAP10) will be provided to the Committee, if they would find it usefulto have further detail.

Royal Air Force

2.26 There are several areas within Air Command that provide support in managing medically unfitpersonnel; Air Medical Casework, the Manning Directorate (military career management), Air PersonnelCasework (administrative process management) and the Personnel Holding Flight (PHF) (please see Q5 fordescription of duties). Service Personnel injured on Operations are reviewed in exactly the same way as anyother individual who is presented to the RAF Medical Board. The Board ultimately provides a true reflectionof an individual’s employability and deployability, regardless of the cause of their illness or injury. This isreflected in the permanent Joint Medical Employment Standard (JMES) awarded. The processes below broadlyoutline the subsequent staffing routes dependent upon the RAF Medical Board direction:

2.27 RAF Medical Board Decision—Permanently Reduced “Working” Joint Medical Employment Standard.A decision of this nature invokes an Employability Review Board procedure using Manning Directorate StaffInstruction (MSI) Vol 1, Part 2, Chapter 8. The staffing route is broadly summarised as follows:

2.28 Air Medical Casework review the medical process thus far to provide guidance to Manning staffs on theimpact of any medical limitations, likelihood of utility and, if discharge is subsequently considered, guidance onwhether an individual should leave on invaliding or non-invaliding terms.

2.29 Manning staffs consider the medical limitations and decide on the continued utility of an individualwithin their current trade/branch with those limitations. If the limitations are deemed to be too inhibitive withintheir current trade/branch, consideration is given to trade reselection.

2.30 Should medical limitations dictate that an individual is unsuitable for continued employment in theircurrent trade and that reselection cannot be achieved, then a discharge case is forwarded to Air PersonnelCasework staff to determine the MoDe of Exit (ie in accordance with invaliding or non-invaliding clauses inQueen’s Regulations). The key deciding factor on invaliding is whether an individual’s condition is likely tohave “a genuine lasting and discernable effect impacting upon quality of life and civilian employmentprospects”. All cases are subsequently forwarded to the Service Personnel and Veterans Agency(SPVA) todecide upon Service attributability and entitlement to an invaliding pension.

2.31 RAF Medical Board Decision—Unfit Further Service. The key difference with this decision is thatManning staffs are no longer engaged in the decision process as the Medical Board has not attributed apermanent ‘working’ JMES. The staffing route is as follows:

2.32 Air Medical Casework confirms the RAF Medical Board’s findings and then provides guidance onwhether an individual should leave the Service on invaliding or non-invaliding terms.

2.33 The case is forwarded to Air Personnel Casework to determine the mode of Exit, applying the rationaledescribed above and taking account of the likely impact an individual’s condition will have in their civilianlife. Again the case is forwarded to the SPVA to decide upon Service attributability and entitlement to aninvaliding pension.

2.34 Air Med casework has the authority to delay an individual’s Medical discharge date by up to fourmonths if their discharge has such a profound psychological effect such that their chances of recovery and ofbecoming a useful member of the community would be prejudiced, or if their leaving the service mightmaterially hasten their death if their life expectancy is 4 months or less. It is also possible to extend anindividual’s discharge date if they are going to be an inpatient on the date of exit.

2.35 The processes outlined above are very similar for Reservists, with the exception that if they are assessedas being medically unfit by the RAF Med Board, the Employment Review Board outcome is forwarded to HQReserves Manning Cell (instead of Air Personnel Casework), for review and appropriate action. Currently, aninjured Reservist is not demobilised until they either become fit again and are subsequently discharged uponcompletion of their reserve commitment or they are discharged on medical grounds.


2.36 In summary, the key decision on retention in Service initially rests with the RAF Medical Board andsubsequent staffing is dictated by whether a working JMES is awarded or the individual is declared unfit forfurther Service.

Question 3—The Committee would also like to know if, when determining the current policy on support forinjured personnel, the MoD drew on any formal lessons from past operations such as Falklands, the Balkansand Northern Ireland?

3.1 Welfare and care procedures have developed over time based on experiences gained from previousconflicts. However, the nature and number of serious injuries sustained in Iraq and Afghanistan, combined withthe advancements in battlefield first aid and military medical care have made the care requirements for ourinjured personnel quite different now than for previous conflicts. This change in need has driven thedevelopment of the new care and recovery systems which are being implemented and are described inQuestion 5.

Question 4—The costs and funding of support to injured personnel and their families per annum for the past10 years

4.1 This question as posed is extremely broad in scope and could potentially focus on a variety of supportelements ranging from, for example, treatment in the Queen Elizabeth Hospital, to rehabilitation at DMRC, towelfare support for families and alterations to living accommodation. Accurate information on PrimaryHealthcare costs is not readily available. Moreover, the Department’s accounting structure does not contain thenecessary granularity to provide this information. Finally, it may not be possible to distinguish costs arisingdue to injury in conflict from other (non-conflict) injuries and illness.

4.2 What we are able to provided is the total additional costs that the Surgeon General has incurred as aconsequence of operations and which is recovered separately through NACMO (Net Additional Cost of MilitaryOperations). Although by no means a comprehensive response to the question, this provides a proxy todemonstrate the increase in numbers of injured personnel currently requiring support for their injuries.

The NACMO costs in recent years have been:

2010–11 £25.0m (estimated, year end not yet finalised)2009–10 £20.1m2008–09 £18.1m2007–08 £14.6m2006–07 £11.1m2005–06 £5.6m

The figures for earlier years are, regrettably, not available.

Question 5—In particular, the Committee would like to understand the Army Recovery Capability and whatsimilar systems are in place in the Royal Navy and the Royal Air Force?

5.1 Each Service is responsible for the management of their respective personnel including provision of thenecessary support for those seriously injured and ill. All 3 Services have recently reviewed the delivery of thisresponsibility, in part due to the recent changes in operational need, and have modified or enhanced theirexisting structures to deliver a more coherent recovery pathway for all injured and ill Service personnel.

Royal Navy

5.2 The Naval Service Recovery Pathway (NSRP) Policy was published in May 2010 with Hasler Companyhaving been established in September 2009 for the management of seriously injured and ill personnel.

— the assignment board process or similar including selection criteria

5.3 Personnel will be assigned from their parent unit into the Recovery Pathway following confirmation ofrequirement through a formal Case Conference, co-ordinated by the parent unit Executive, involving allinterested parties to establish the best recovery route for the individual.

— the nature and type of service offered, including any provided by charities

5.4 Once injured personnel have been evacuated from the battlefield, like the other Services the RN utilisesthe centrally delivered rehabilitation capabilities provided by the Defence Medical services, specifically theRoyal Centre for Defence Medicine in Birmingham, the Defence Medical Rehabilitation Centre at HeadleyCourt, the Devonport Casualty Receiving Facility; the South West Regional Rehabilitation Unit; the DevonportDepartment of Community Mental Health and the Ministry of Defence Hospital Unit in Derriford (PlymouthHospitals NHS Trust). It should be noted that the Defence Medical Services are responsible for all rehabilitationthroughout an individual’s recovery, whilst they remain in the Service.

5.5 The Naval Service has a sophisticated and well established process to command, manage and care forinjured and seriously ill personnel. This is called the Naval Service Recovery Pathway (NSRP) of which a


bespoke element for those with complex injuries is Hasler Company located at HMS Drake within DevonportNaval Base.

5.6 The NSRP is articulated in the Naval Service Recovery Pathway Policy, detailed in BR3, Part 5 Ch 33which was published in May 2010.

The scope of the policy includes:

(a) The Recovery Pathway for seriously injured and wounded Naval Service personnel, who aremanaged in transition back to active service or to discharge, through Hasler Company; and

(b) The Recovery Pathway for members of the Naval Service who require long term sickness, injury,pregnancy management, disciplinary, divisional or welfare care, who are managed throughRecovery Cells or Royal Marine Base organisations.

5.7 The Recovery Pathway joins together Welfare, Pastoral, Medical and Executive elements, under theoverall co-ordination of the Recovery Cell or Hasler Company and draws on divisional, regimental, careermanagement, resettlement and third sector support to ensure the necessary Pathway is identified and maintainedfor the individual. Personnel are assigned from their parent unit into the Recovery Pathway following theconfirmation of a requirement through a formal Case Conference, which is co-ordinated by the parent unitExecutive. The aim of the conference, involving all interested parties, is to establish the best recovery routefor the individual.

— locations of services provided and whether owned or rented by the MoD

5.8 The Naval Service Recovery Cells are located in Her Majesty’s Naval Bases (HMNBs) of Portsmouth,Plymouth and Faslane and Naval Air Stations at Culdrose and Yeovilton. These cells follow the NSRP process.This location was carefully selected as it has a large concentration of Royal Marine families and thus providesa large support network.

— funding of the services provided including any funds provided by charities (which charity and howmuch)

5.9 The NSRP, Hasler Company and the required infrastructure have been delivered entirely by the RN.Specifically, the Navy re-prioritised its manpower resources to realise the required enhancements in commandand management support personnel and annual operating costs of the capability, which represents £19 millionover the 4 year purview of the MoD financial planning process.

5.10 A number of Voluntary and Community Sector organisations have contributed significantly to the NSRPand individuals’ progress. Voluntary and Community Sector organisations have resourced: elements of therequired rehabilitation equipment; funded novel resettlement and education courses; assisted with personalaccommodation requirements; delivered employment placements, employment opportunities and ultimatelyjobs; and delivered extensive sporting and adventurous training activities. A large number of charities havecontributed to all of these activities and they include: the Royal Navy and Royal Marines Charity; the RoyalMarines Charitable Trust Fund; the Royal Marines Association; the C Group; and Help for Heroes who haveprovided ready access to financial support through their provision of a Quick Response Fund to support theentire Royal Navy.

5.11 The funding demarcation between charitable and voted funds is in place and felt to be operatingsatisfactorily.

— numbers going through each system by year, split by those with physical or psychological injury orboth for each Service with reservists separately identified for last 10 years

5.12 At present, there is no routine data collected which can identify personnel who consult primary careprofessionals about mental health problems. However, DASA routinely publish the statistics relating to mentalhealthcare delivery by the Defence Mental Health Services (DMHS). These data have not shown any substantialrise in numbers seen by the DMHS over recent years although the rates of PTSD diagnoses have increased byonly a very small amount. The numbers of personnel diagnosed with some other mental health disorders hashowever decreased. It is not possible to identify from the DASA data how many patients are seen at DCMHsbut the DASA stats do split the referrals by service. Additionally no specific data is currently collected aboutmobilised reservist mental healthcare. The numbers of reservists seen by the reservists mental healthprogramme at Chilwell, established in Nov 2006, is small; just over 100 personnel were seen by the RMHPduring the first three years of operation.

— policy on redundancy while in the “pathway”

5.13 For personnel that are in scope for redundancy (the first tranche of redundancy was published on 4April 2011 for RN personnel) should an applicant or non-applicant who has been selected for redundancy, buthas not yet left the Service, be referred to the Naval Service Medical Employability Board (NSMEB) anddischarged on the grounds of employability they may elect to be discharged through either the medical orredundancy process but not both. The scheme elected by an individual will normally be the most financiallybeneficial to them. Personnel made redundant are not prevented from applying for compensation under theArmed Forces Compensation Scheme.


— links with the ordinary resettlement services

5.14 A key feature of NSRP is to use temporary employment while personnel are in the Recovery Pathway.This enables the Executive and the individual involved to form a view of what jobs and roles are feasible andviable. All temporary employment options must be sanctioned by the appropriate medical staff before they areundertaken. Commanding Officers have responsibility to ensure that personnel involved are fully aware thatthis activity is not necessarily an indicator that they will be retained. Temporary employment has two facets:

Temporary Employment within the Service. In this instance, injured personnel are placed in positionswhere they might be employed if retained.

Temporary Employment in Civilian Roles. Utilising the civilian companies that are participating inthe Defence Career Partnership (DCP) Return to Work Initiative (RTWI) or Recovery Placementindividuals may be placed in an array of civilian roles to ascertain what is viable for their specificcircumstances.

In addition to the temporary employment process personnel assigned to Recovery Cells or Hasler Companyhave access to the Resettlement Services delivered to the Naval Service in accordance with DirectorResettlement (DRes) tri-service policy.

Army

5.15 Several new processes and procedures were introduced under AGAI 99, including the ARC AssignmentBoard (ARCAB), which is the mechanism by which wounded, injured and sick personnel from across theArmy are assigned to the ARC. AGAI 99 describes the assignment process and how eligibility is assessed.The key criteria that are considered for the assessment of eligibility are:

— Complex Needs—wounded, injured and sick individuals with complex medical and welfareneeds are to be assigned to a Personnel Recovery Unit (PRU).

— Royal Centre for Defence Medicine (RCDM) at Queen Elizabeth Hospital—those in RCDMwith an expected stay of over seven days must be considered for assignment to a PRU; thisis based on the understanding that if they are admitted for more than seven days, they arelikely to have complex injuries that will result in absence from duty of more than 56 days.

— Length of Recovery—Individuals who are long term sick or whose recovery is likely to takea long time should be assigned to a PRU with access to specialist expertise as units do nothave the resources to be able to fully manage these individuals over extended periods ofabsence from their duty station.

— Ability to Manage—Some soldiers may require extensive psychological support and othersmay need specialist advice and guidance in dealing with their issues.

— Welfare—personal circumstances and domestic situations can affect recovery. Complexwelfare requirements can be exacerbated when combined with extensive medical treatment.

— Operational requirements—someone with an essential operational skill-set or is a pinch-pointtrade is likely to return to duty.

— Age—the younger the individual, the greater their need is likely to be for direction andguidance during recovery. There may also be issues with domestic arrangements that precluderecovery periods at home.

5.16 The chain of command submit regular and prioritised proposals to the ARCAB, against these eligibilitycriteria, for individual cases to be considered, and if successful, based on the overall need of the individual,they are transferred to a PRU. This allows those individuals access to the service and resources of the ARC.The ARCAB is held monthly so that it can remain responsive to the pan-Army demand and respond to outflowas well as allowing each of the eleven PRUs to incrementally increase their capacity.

— Nature and type of service offered, including any provided by charities

5.17 The ARC is made up of four key components. The update below describes these four components andthe progress that has been made in delivering them over the past year.

Personnel Recovery Branch

5.18 The Personnel Recovery Branch is located in the Headquarters of Personnel and Support Command ofHeadquarters Land Forces and has been operational since August 09. The Personnel Recovery Branch is staffedby military and civilian personnel with medical, welfare, education, administration, resettlement and legalexperience and is responsible for coordinating the recovery process and providing functional control of recoverypolicy and procedures.

5.19 The Branch also includes permanent and representatives from the charity and commercial sector:Service Personnel Veterans’ Agency, The Royal British Legion, Help for Heroes, REMPLOY, the ArmyWelfare Service, ABF ‘The Soldier’s Charity’, Erskine, Regular Forces Employment Agency and the Soldiers,Sailors, Airmen and Families Association. The Branch works with the RCDM, Birmingham, DMRC Headley


Court and all other elements of Defence medical and welfare services as well as external healthcare providers,to ensure a joined-up approach to recovery.

Personnel Recovery Units

5.20 Eleven Personnel Recovery Units have been established throughout the UK (including Northern Ireland)and Germany. The role of the Personnel Recovery Units is to command soldiers in the Army RecoveryCapability and to deliver an Individual Recovery Plan to the point when an individual is able to return to dutyor transition to civilian life. The Personnel Recovery Unit will identify occasions when it would benefit thesoldier to spend time in a Personnel Recovery Centre or at the Joint Battle Back Centre (described more fullybelow) in order to accelerate recovery. Allocation to a Personnel Recovery Unit is controlled by PersonnelRecovery Branch and will be determined by an initial assessment and against the eligibility criteria.

Personnel Recovery Centres

5.21 Experience shows that injured personnel find a military environment conducive to recovery and part ofthe Army Recovery Capability provision is purpose-built Personnel Recovery Centres and Personnel Recoveryand Assessment Centres around the UK. These Centres have largely been planned and will be developed ingarrison areas where the Army has its greatest concentration of military units. This will ensure that the Centrescan take advantage of the full range of Army facilities required for effective recovery, including administrative,welfare, medical rehabilitation and education. There are also plans for a bespoke Personnel Recovery Facilityin Germany.

5.22 Personnel Recovery Centres and Personnel Recovery and Assessment Centres are considered a‘conducive military environment’ that supports a soldier’s recovery. The Centres are not medical facilities butprovide supported residential accommodation for soldiers undergoing recovery who do not have suitablealternative accommodation at home or in their unit. Soldiers who do not need residential accommodation areable to attend as day visitors ensuring access to the facilities provided at the Centres.

The Joint Battle Back Challenge Centre

5.23 Undertaking and overcoming challenge is proven to enhance recovery. Battle Back activities aredesigned to deliver programmes to promote confidence and independence. They focus on what individuals cando rather than what they cannot in order to promote a positive mental attitude throughout an individual’sIndividual Recovery Plan. The in-house programs run and external activities coordinated by the Joint BattleBack Centre will be open to all recovering personnel from all three Services. Funded and established by TheRoyal British Legion, the Joint Battle Back Centre will provide regular participation in inclusive sport andoutdoor activities. The Joint Battle Back Centre will be established in the Midlands by late Summer 2011.

— Locations of services provided and whether owned or rented by the MoD

5.24 The Army has established Personnel Recovery Units within its nine regional Brigades in the UK, aswell as one in London District and another in Germany.

5.25 The Personnel Recovery Centres and Personnel Recovery and Assessment Centres are located asfollows, there are also plans for a bespoke Personnel Recovery Facility in Germany:

Edinburgh

The Erskine Edinburgh Home, established as the Army’s ‘pathfinder’ Personnel Recovery Centre inAugust 2009 in partnership with the Scottish Government, the veterans’ charity Erskine and Help forHeroes. It has been critical to the development of the Army Recovery Capability. It providesresidential accommodation for 12 soldiers and has the capacity for a further 12 day attendees. Thearrangement at the Erskine Edinburgh Home was extended, in partnership with The Royal BritishLegion, on 1 January 2011 when the facility officially became the Personnel Recovery CentreEdinburgh.

Colchester

Colchester Garrison, is one of the largest garrisons in the country, with more than 3,300 troops,and will be home to the first purpose-built Personnel Recovery Centre. It will provide residentialaccommodation for 29 soldiers and will also have the capacity for a further 31 day attendees. Thebuilding has been funded by Help for Heroes with The Royal British Legion assuming responsibilityfor its running costs.

Tidworth

Tedworth House has been selected as a location to combine a Personnel Recovery Centre with anAssessment Facility. The Personnel Recovery and Assessment Centre, as it will be known, willprovide residential accommodation for 30 soldiers undergoing recovery and for a further 20 soldierscompleting the ARC Assessment Course. It will also provide sufficient capacity for 30 day attendees.

Tedworth House, a listed building and former officers’ mess, was leased to Help for Heroes inFebruary 2011. In partnership with the Army, they will conduct a £17m capital works programme todeliver a Personnel Recovery and Assessment Centre by April 2012. The Royal British Legion will


also assume part responsibility for its running costs. In the meantime, an interim capability will beestablished in Tidworth by Summer 2011.

Help for Heroes intend to introduce two extended services at the centre. A pathfinder ‘One StopWelfare Shop’ will be created in partnership with the appropriate charities to provide an ongoingwelfare and specialist support centre for wounded, injured or sick soldiers as they return to duty ortransition into civilian life. In addition, ‘The Band of Brothers Club’ will be established to providesoldiers with a focal point to stay in touch with the Armed Forces and provide access to the centre’sfacilities eg gym, IT suite and opportunities to attend various events during the year.

Catterick

Catterick is the largest British Army Garrison in the world with 12,000 troops. Catterick has beenselected as a location for a purpose-built Personnel Recovery and Assessment Centre which willcomplement the capacity and output of its counterpart at Tedworth House, and will be built by late2012. The Personnel Recovery and Assessment Centre will provide residential accommodation for30 soldiers and a further 20 soldiers completing their Assessment Course. It will also providesufficient capacity for 30 day attendees. In the meantime, an interim capability will be providedwithin the Garrison by Summer 2011.

The Personnel Recovery and Assessment Centre will be funded by Help for Heroes with The RoyalBritish Legion assuming responsibility for its running costs once in operation.

As soon as is practicable, those assigned to the ARC will undergo a formal Assessment Course. Theseare holistic assessment courses designed to identify an individual’s needs, abilities and aspirations andtranslate them into a focused and resourced Individual Recovery Plan designed to deliver the mostappropriate outcome for the individual and for the Army. Seven pilot assessment courses have beenconducted since September 2010 at a number of external locations where the MoD has rented trainingfacilities, including the veteran charity Erskine’s Bishopton Home in Glasgow, Enham Alamein sitein Andover and the Royal British Legion Industries site in Aylesford, Kent. Assessment courses willbe conducted from interim Personnel Assessment Recovery Centre capabilities in Catterick Garrisonand Tedworth House, Tidworth from Summer 2011.

— Funding of the services provided including any funds provided by charities (which charity and howmuch)

5.25 The MoD is investing around £35M over four years to fund the ARC. This includes the provision ofmilitary and civilian service personnel to coordinate, manage and deliver the ARC, including the PRCs. Thiswill provide an increased capacity to conduct home visits, a contribution towards the cost of re-skilling andadditional rehabilitation capacity in order to speed recovery pathways, as well as other associated ancillarycosts.

5.26 Help for Heroes has committed a total of £70M in support of the ARC. This includes: the capitalinvestment to fund the initial building of the PRC in Colchester and the PRAC in Catterick; the redevelopmentof Tedworth House; £15M over four years in support of Individual Recovery Plans and a further £6M QuickReaction Fund, managed by ABF The Soldiers’ Charity, to provide individual benevolence across the Army tothose injured in training or wounded in action since 9/11.

5.27 The Royal British Legion has committed £50M over ten yeas to the ARC which will be used to fundthe Joint Battle Back Centre with the remainder in support of running costs of the PRCs in Edinburgh andColchester and the PRAC in Catterick. They are also making a significant contribution to the sustainment ofthe PRAC at Tedworth House, which will be run by Help for Heroes. The Royal British Legion will fund thefull capital costs of £500K of the Personnel Recovery Facility in Germany.

5.28 ABF The Soldiers’ Charity has recently committed £1M per year for three years in support of IndividualRecovery Plans.

5.29 While the ARC has been operational since 1 November 2010, it will not run at full capacity until Spring2012 when it achieves Full Operating Capability. The ARC will always have a finite capacity, determined bythe number of Personnel Recovery Officers within each of the PRUs and the complexity of the individual casesassigned to them. It is predicted that the number of those under command will rise to around 750 over the next12 months. The ARCAB will remain the primary method of balancing pan-Army demand with PRU capacity.

— Policy on redundancy while in the “pathway”

5.30 Every case of wounded, injured or sick personnel will be assessed individually. Individuals who arepermanently below the minimum medical retention standard (including those injured on operations) are notexempt from the compulsory redundancy programme, but if selected for redundancy, either as an applicant ornon-applicant, will be given the opportunity to gain the best outcome for them financially (which may bethrough the medical discharge process). Those personnel temporarily medically downgraded going through theArmy Recovery Centre process will not leave the Army through redundancy or otherwise until they havereached a point in their recovery where leaving the Army is the right decision, however long it takes.


— Links with the ordinary resettlement services

5.31 All personnel who are medically discharged from the Service are entitled to the full resettlementprovision. This includes Graduated Resettlement Time, access to the Career Transition Partnership services andan Individual Resettlement and Training Costs grant, in accordance with the Tri-Service Resettlement Manual.

Royal Air Force

RAF Personnel Recovery Pathway

5.32 For Royal Air Force personnel deemed non-effective on medical grounds or long-term sick, thePersonnel Holding Flight (PHF), located at RAF High Wycombe, is responsible for establishing the optimalsupport package for each individual. Working in conjunction with the individual’s station or unit, the OfficerCommanding PHF (OC PHF) determines who is best placed to provide appropriate support. Factors taken intoconsideration include: an individual’s home and family location, availability of appropriate housing, theprovision of ongoing medical treatment and the length of time an individual is made non-effective. For thoseindividuals who are looked after by PHF, the Officer in Command provides the full command, welfare, re-skilling, education, enhanced resettlement and personnel support up to the point where an individual eitherreturns to duty or is discharged through the Medical and Employment Review Board process. OC PHF alsoacts as the Personal Recovery Officer for those personnel who, following attendance at an Assessment SkillsCourse, complete an Individual Recovery Plan. Although Individual Recovery Plans will be funded by theRAF Benevolent Fund, the RAF currently accesses this resource through the Army Recovery Capability.

5.33 The majority of wounded injured and sick (WIS) personnel in the RAF remain the responsibility of thestation or unit at which they are serving. However, OC PHF works in partnership with RAF Medical Boardsand the station or unit staffs keeping PHF appraised on complex individual cases. If the need for enhancedsupport is identified, the station or unit will discuss whether an individual should be referred to PHF for long-term support.

5.34 Air Member for Personnel has recently announced a full review of RAF PHF capability to ensure thatit continues to meet the required recovery capability for RAF personnel both now and in the future.

Question 6—The Committee also wishes to know how the MoD liaises with health and local authorities inEngland and with those in the devolved administrations. It would also be useful if the MoD could set out anyproblems with these relationships and plans?

6.1 The principal way in which the Department liaises with the Departments of Health is through the MoD/Departments of Health Partnership Board. As mentioned earlier the Board is co-chaired by the Surgeon Generaland Sir Andrew Cash, Chief Executive of the Sheffield Teaching Hospital NHS Foundation Trust. It includesas members key officials from the UK’s Departments of Health and other senior NHS executives. Relationshipsbetween the MoD, DH in England and the Devolved Administrations are working effectively and have beendeveloped through the introduction and piloting of the Transition Protocol (See Question 1) and establishmentof the 10 Armed Forces Networks. Each Strategic Health Authority now has an Armed Forces Champion tofacilitate appropriate links between the MoD and Primary Care Trusts and Local Authorities. Early engagementwith multi disciplinary teams, mutual education and constant communication are the key elements that ensurea smooth transition from in-Service to post-Service care. The Armed Forces Network is essential to convertthe inter departmental agreements into delivery at a local level. As the NHS transition moves forward thestructure will change, but the principle of maintaining an Armed Forces Network will endure.

Question 7—The Committee would also like to understand relationships between the MoD and the manycharities in this field and how they are co-ordinated and funded?

7.1 There are a significant number of Service related charities that support bereaved families and Servicepersonnel who have suffered injury, illness or are suffering from mental health issues. In the main these Servicerelated charities are members of the Confederation of British Service and Ex Service Organisations (COBSEO)which provides a single voice into MoD if a common issue needs to be raised. In addition to existing regularmeetings with MoD for specific interest groups such as the Defence Bereaved Families Group (See Question14). The Deputy Chief of Defence Staff for Personnel and Training (DCDS(Pers and Trg) has recentlyestablished a Defence Recovery Steering Group (DRSG) to coordinate and prioritise charitable funding andsupport for recovery related issues. This group includes key stakeholders such as Help for Heroes and TheRoyal British Legion, but could include any other organisations who wish to offer their support. The MoD iscurrently investigating how to better coordinate, prioritise and facilitate all elements of voluntary or charitablesupport across defence. Over recent years there has been an increase in the level of partnership both internallybetween charities, and between charities and the MoD to deliver the complex current projects such as the ArmyRecovery Capability.

MoD’s relationship with Service and ex-Service Organisations

7.2 The MoD, largely through DCDS(Pers) Pensions Compensation and Veterans (PCV), has regular contactwith COBSEO and the ex-Service organisations to ensure that there is mutual commitment to take new


initiatives forward. Examples of collaborative working include the Welfare Pathway and the supported housingin Aldershot (Mike Jackson House) and Catterick (The Beacon).

7.3 COBSEO acts as an umbrella organisation for Service and ex-Service organisations and associationswho work to represent, promote and further the interests, especially welfare, of Serving and ex-Service menand women and their dependants by all practical and proper means. COBSEO has a membership of some 181organisations including 65 Regimental Associations.

7.4 COBSEO attend various MoD forums including the Welfare Conference, Executive Steering Group,Service Personnel and Veterans Agency (SPVA) Owners Advisory Board and SPVA Central AdvisoryCommittee. COBSEO is also a member of the Cabinet Office External Reference Group that drives the crossGovernment approach to the Armed Forces Community.

MoD funding of charities

7.5 The MoD does not directly fund charities—any funding that MoD provides would be in the form of aGrant in Aid to fund part or all of the administration costs of the recipient body, in the form of a Grant for aspecific service or through the provision of services by a charity or voluntary organisation under a normalcommercial contract. In future, Government intends that the contracting opportunities for the voluntary andcommunity sector will be significantly increased and details of new procurement opportunities, tenderdocuments and contracts for central government in excess of £10 000 are available on line atwww.contractsfinder.busineslink.gov.uk

7.6 Charitable organisations are required to raise their own funds through public and corporate donationsand from grant-making trusts. This is in keeping with the long standing practice that central Government doesnot ordinarily provide funds, raised through taxation, to assist individual charities' core activities. The CharityCommissioners advise that there are over 200,000 individual charities and it would be impossible for theGovernment to assist directly in a way that is fair to all. All charities receive indirect support from theGovernment by way of certain tax reliefs, including Gift Aid on donations made by the tax-paying public.

7.7 It is important that MoD is seen to be even-handed when dealing with charities and voluntaryorganisations. No preferential treatment can be given to Service charities or charities with a Service interest;all charities and voluntary organisations should be treated equally and on the same terms.

Charitable funding of core defence activities and resources

7.8 In January 2011 the Defence Internal Audit (DIA) reported on the governance of charity donations thatare used to support core defence activity and resources. The report recognised that the use of charitable fundingto support core-Defence activity and resources provides an opportunity for the public to recognise, support anddemonstrate gratitude for the work of the Armed Forces, especially during the current high-intensity operationsof Afghanistan and previously in Iraq.

7.9 It also recognised that there has been a step-change in the charitable funding being offered. TraditionallyService charities have assisted in the welfare and veterans arenas through the provision of advice andcounselling services and through welcome but relatively low-value gifts. Donations are now being specificallytargeted, such as at the provision of rehabilitation facilities for serving personnel injured in the course of duty,and involve millions of pounds of expenditure on complex and long-term projects. The report’s conclusion wasthat the process set out in Defence Instruction Notice (DIN 01–061) (March 2008) for the identification,coordination and prioritisation of charitable offers had not been effective and the DIN was not being compliedwith. Its focus on small scale projects had been superseded by the need for a process which identifies andprioritises significant Departmental projects which may attract substantial financial offers from the charitysector.

7.10 It was agreed with DIA that, with agreement of the three single Service Personnel Policy Officers(PPOs), and following discussion with stakeholders, PCV would issue a DIN detailing a new process to identifyand staff projects (over a financial threshold) to the PPOs and thereafter the Service Personnel Board forprioritisation in attracting charitable assistance. It is intended that the DIN will encourage project managers toconsider the various aspects of sustainability, longevity and applicability across the whole of Defence andencourage early engagement of the relevant SFO. Work to finalise the DIN is ongoing.

7.11 There are also several charities who work hand in hand with the MoD to support the Armed Forcesdeployed on operations. The main aim of these charities is to provide support to deployed personnel eitherthrough sending carefully designed welfare parcels or by raising funds to support the Operational WelfareFund. SSAFA, UK4U Thanks!, Support Our Soldiers, Thank the Forces and Afghan Heroes are the leadendorsed charities in this field.

7.12 The Operational Welfare Fund is administered by SSAFA and was set up to purchase desirable itemsabove and beyond the essential items supplied through the Deployed Welfare Package. MoD maintains a closeliaison with charities to help co-ordinate activity and reduce, where possible, duplication of effort. In the caseof welfare parcels, MoD facilitates their delivery without causing disruption to the BFPO system.


7.13 In addition to individual and thematic relationships with relevant charities, the MoD has held a WelfareConference every year since 2007. The aim of the Conference is to provide a forum at which both MoDWelfare providers and external Charities / Federations can share their views, receive up-to-date briefings andvoice any concerns. The Conference is led by DCDS (Pers &Trg) and is attended by Ministers.

Question 8—The policy guidelines that MoD follows for inquests and the Coroners Courts including anyanticipated changes to the guidelines, in general but also covering any attempts to reduce delays in theprocess

Policy Guidelines

Joint Service Publication 751—Joint Casualty and Compassionate Policy and Procedures (Chapter 5—Coroners Inquests)

2008DIN05–052—The Defence Inquests Unit

JSP 832—Guide to Service Inquiries

The Coroners and Justice Act 2009

8.1 Anticipated Changes

The Coroners and Justice Act 2009 created the post of Chief Coroner in order to reform the coronialsystem. The creation of the post was welcomed by bereaved military families and those organisations thatsupport them: notable issues were a new appeals process, coroner training, overview of inquests takingmore than twelve months, formalisation of the transfer of inquests to home coroners, and establishmentof a mechanism to transfer inquests to Fatal Accident Inquiries in Scotland. At the end of last year theMinistry of Justice (MOJ) decided that due to the current economic climate they could not afford theChief Coroner’s position and sought to abolish it through the Public Bodies Bill and to transfer theresponsibilities to other judicial appointments, such as the Lord Chief Justice, and to MOJ Ministers. AtCommittee stage of the Bill on 14 December 2010, Baroness Finlay tabled an amendment removing theoffice of Chief Coroner from the list of those bodies to be abolished in the Bill: her amendment waspassed by 277 votes to 165, removing the post from the Bill. The MOJ are currently considering how totake this matter forward. Once agreed the relevant amendments will be incorporated into policy.

8.2 Reduction of delays

The Defence Inquests Unit (DIU) was established on 5 May 2008 at the direction of Ministers and PUSto coordinate and manage all Defence related inquests into the deaths of Service and MoD personnel, whodie on, or as a result of injuries sustained while on operations; and those who die as a result of trainingactivity. The DIU is also the Departmental focal point for any other inquests involving MoD personnel,although the more routine are delegated to the single Services to manage. The Unit’s key role is to assistCoroners so that they complete relevant inquests fully, thoroughly and as quickly as possible.

The establishment of the DIU has allowed the MoD to present a single coherent approach to inquests.The coordinated support and guidance now available to Coroners has meant that any issues or questionsthey have prior to the inquest (which may in the past have delayed the scheduling the inquest) are dealtwith as quickly as possible. Another role the DIU has undertaken has been to highlight the role the unitplays in the Coronial process, intending to increase overall awareness and support within the MoD, withthe aim of personnel being available to attend inquests at the right time and information to be producedto the required standard and in a timely manner for the Coroner’s investigations. Finally a Joint WrittenMinisterial Statement is submitted which reports on the progress made with regard to Military inquestson a quarterly basis by MoD (through the DIU) and the MOJ.

Question 9—Any systems adopted for the identification of mental health difficulties resulting fromoperations?

9.1 The Armed Forces have comprehensive policies and guidelines for addressing issues surrounding theprevention and management of traumatic stress related disorders in deployed Armed Forces personnel. Thereexists overarching direction for medical personnel, both regular and reserve in an effort to raise awareness ofpsychological injury and care pathways following exposure to potentially traumatic events. Equally,responsibilities are placed on the Chain of Command who frequently provide pre deployment training in orderto give information to commanders and deploying personnel on how to manage operational stress andpsychological injury. Post deployment, a further presentation is delivered which recaps on some of the issuesprovided pre-deployment. Appropriate briefings on the same topic are also available to Service families.Guidance is provided on referral arrangements both during and after deployment and on MoD’s responsibilitiesto ex Service personnel.

Trauma Risk Management (TRiM)

9.2 Operational stress and exposure to traumatic events is an unavoidable part of military operations and canbe considered an occupational hazard for all UK Armed Forces personnel. In order to identify, manage andminimise the effect that these events have on Service personnel, a process called Trauma Risk Management(TRiM) has been developed.


9.3 TRiM is a tri-Service endorsed methodology for providing support to personnel involved in a traumaticevent. A traumatic incident is any event that can be considered to be outside of an individual’s usual experiencewhich has the potential to cause physical, emotional or psychological harm. These incidents could include;sudden death, serious injury, disablement or disfigurement, multiple traumas, a near miss, encounteringoverwhelming distress (eg disaster relief and body handling duties) and engagement with child enemycombatants.

9.4 A key feature of traumatic incidents is that there is no universal response to them; individuals respondto them in different ways. TRiM is a procedure for managing the non-physical impact on individuals oftraumatic incidents.

9.5 TRiM is a chain of command function that formalises good leadership and human resource managementpractice. It is conducted by fellow personnel, as a peer group initiative, rather than by medical specialists. Theintention is to help individuals use their own coping mechanisms in order to remain operationally effective. Itis not a substitute for effective stress management during the normalisation phase of recovery from operationsnor for medical intervention. Those identified as psychologically injured are referred for professionalassessment through the medical chain.

9.6 TRiM is judged to contribute to operational effectiveness because it ensures a timely and demonstrablefront line response to the welfare needs of Service personnel exposed to traumatic events. TRiM aims to reducethe stigma associated with mental health issues and meets the needs of affected individuals. It is a tool to assistCommanders in discharging their responsibilities for managing stress in traumatic circumstances. It fulfils theMoD’s obligations to ensure that, where possible, psychological risks on operations are mitigated. Commandersat all levels must be able to:

(a) Identify a potentially traumatic incident.

(b) Determine the consequent level of stress experienced by those under their command.

(c) Identify traumatised personnel and make support and treatment available to them as appropriate.

9.7 TRiM affords commanders a number of options when dealing with a traumatic event. In the immediateaftermath, those exposed to the event will usually benefit from practical support (assurance of physical safety,acknowledgement of the stressful event, group discussion etc) and the provision of information and adviceabout stress reactions, rather than detailed psychological interventions. For minor incidents commanders mayemploy TRiM practitioners to facilitate internal discussion to provide appropriate education to unit members.Having peers within a unit who have some skills in risk assessment potentially allows for an initial unit-ledapproach without fear of the stigma of medical/psychiatric referral. This discreet approach is still classified asa TRiM intervention and details are recorded.

9.8 For major incidents, particularly if they involve death, the unit TRiM team may be deployed in additionto medical, pastoral and welfare services. TRiM helps to assess the initial impact of traumatic stress andreassures the Command that vulnerable people are being identified promptly and signposted to receive specialistsupport at the earliest opportunity as required. Of key importance to the TRiM process is that as soon aspractical and within three days of the incident a planning meeting should be convened to determine theappropriate strategy for the management of the incident and the affected individuals.

There are three strands to TRiM strategy which are:

(a) Education—Pre-incident awareness training is particularly relevant to operations, when theprobability of traumatic incident occurrence is greater.

(b) Individual/Group Risk Assessment—Following an incident, assessments are conducted after threedays, one month and, when considered necessary, at three months. Such assessments enable thelevel of risk posed to an individual, or group, to be assessed and to facilitate early referral fortreatment when judged necessary.

(c) Mentoring—The mentoring process gives access to a TRiM Practitioner to discuss any issuesarising from a traumatic incident.

Decompression

9.9 By their very nature, military operations are stressful for all those involved. The levels of stress felt byindividuals can vary greatly and no two people will deal with their experiences in the same way. On returnfrom operations, some will have no residual effects while others will take much longer to adjust to routinemilitary and family life. In order to ensure that Service personnel returning from operational theatres are giventime to re-adjust in a graduated and controlled manner, a period of decompression is provided immediatelyfollowing their withdrawal from the operational theatre and prior to their return to their UK home base. Theaim of a period of decompression is to reduce the potential for maladaptive psychological adjustment.

9.10 Decompression is one element of a complete Post Operational Stress Management cycle which fulfils3 functions designed to improve the quality of homecoming. This is achieved by giving personnel theopportunity to rationalise, contextualise and talk through operational experiences. During this period ofdecompression Service personnel will receive mandatory health, safety and welfare briefings. They are giventhe opportunity to unwind together wherever possible, all of which combine to facilitate adjustment to a


non-operational routine and the management of expectation concerning return to the home unit. Importantly,decompression also provides an opportunity for mental health readjustment for those who need it. It is PJHQpolicy that all personnel returning from operations pass through decompression, and waivers are only grantedexceptionally at the request of an individual’s commanding officer.

Question 10—The Committee wishes to know the number of deaths and injuries for each of the majoroperations involving UK Armed Forces since 2000 (see annex for suggested format). It would like that set inthe context of the number of deaths in each theatre which were not conflict related and the overall numbersof deaths, injuries and mental health problems. It would also like to know the extent of civilian deaths orinjuries whilst serving in theatre. If the information is readily available the Committee would also beinterested in the extent of deaths and injuries including mental health problems from Northern Ireland andthe Balkans. The Committee is interested in determining the scale of any long term commitment by the MoDto physically and psychologically injured personnel

UK Armed Forces Deaths, Casualties and Mental Health Statistics 1 January 2000 to 21 March2011

The Department is able to supply:

— Deaths Information for Iraq (1 January 2003 to 3 April 2011), Afghanistan (7 October 2001to 3 April 2011), Balkans (1 January 2000 to 30 April 2007), Sierra Leone (5 May 2000 to31 July 2002) and Northern Ireland (14 August 1969 to 31 July 2007).

— Casualty information for serious injuries whilst on the following Operations: Iraq (1 January2003 to 28 February 2010), Afghanistan (7 October 2001 to 28 February 2011), Balkans(1 January 2000 to 30 April 2007) and Non Operational incidents (1 January 2006 to 28February 2011).

— Department of Community Mental Health (DCMH) information for Iraq (1 January 2007 to31 December 2010), and Afghanistan (1 January 2007 to 31 December 2010).

Information on UK Service personnel injured in Northern Ireland is not compiled centrally by the MoD.Information on injuries can be obtained from UKDS (Chapter 7, Table 7.4 UKDS 2008) data for this sectionwas supplied by the Police Service of Northern Ireland.

The Department can not supply information on mental health problems for Service personnel who havedeployed on Operations other than Iraq and Afghanistan.

The Department only collates casualty information on entitled civilians on Operations to Iraq andAfghanistan.

UK Armed Forces Deaths

1. Table 1 presents the number of UK Armed Forces deaths by Operation and year between 1 January 2001and 3 April 2011 (latest date for which data is available) for regulars and reservists.


T

ab

le 1

. U

K A

rme

d F

orc

es

de

ath

s1 b

y O

pe

rati

on

, M

ilit

ary

ch

ara

cte

risti

cs

, ca

us

e a

nd

yea

r, 1

Ja

nu

ary

20

00 t

o 0

3 A

pri

l 20

11

, n

um

bers

.

Ho

sti

le

acti

on

2O

the

r3H

os

tile

acti

on

2O

ther3

Ho

sti

le

ac

tio

n2

Oth

er3

Ho

sti

le

acti

on

2O

ther3

Ho

sti

le

ac

tion

2O

the

r3H

os

tile

a

cti

on

2O

ther3

Ho

sti

le

ac

tion

2O

ther3

Ho

stile

a

cti

on

2O

ther3

Iraq

41

35

43

13

14

04

31

82

00

96

34

33

17

41

02003

40

12

38

10

22

14

10

02

27

22

22

00

2004

10

12

10

12

00

00

00

10

11

00

01

00

2005

20

32

02

01

00

00

11

20

19

00

02006

27

22

62

10

40

00

20

21

02

00

02007

36

11

35

11

10

01

00

32

90

03

11

02008

22

22

00

00

00

12

00

10

00

2009

01

01

00

00

00

01

00

00

00

Afg

han

ista

n5

323

39

30

63

717

24

62

10

25

62

115

24

14

10

2002

03

03

00

00

00

03

00

00

00

2003

00

00

00

00

00

00

00

00

00

2004

10

00

10

00

00

00

10

00

00

2005

10

10

00

00

00

10

00

00

00

2006

21

18

21

18

00

41

00

17

50

00

12

00

2007

37

53

64

11

51

00

30

31

11

00

02008

50

14

41

60

16

00

02

71

50

10

10

2009

107

110

31

40

70

00

95

14

01

00

02010

95

89

17

41

14

01

07

65

31

12

00

2011

11

31

03

10

00

00

10

31

00

00

0B

alk

an

s6

212

21

20

00

00

02

10

00

02

00

2000

05

05

00

00

00

05

00

00

00

2001

25

25

00

00

00

24

00

01

00

2002

00

00

00

00

00

00

00

00

00

2003

00

00

00

00

00

00

00

00

00

2004

01

01

00

00

00

01

00

00

00

2005

00

00

00

00

00

00

00

00

00

2006

01

01

00

00

00

00

00

01

00

Sie

rra L

eo

ne

71

41

40

00

00

01

40

00

00

02000

10

10

00

00

00

10

00

00

00

2001

01

01

00

00

00

01

00

00

00

2002

03

03

00

00

00

03

00

00

00

No

rth

ern

Ire

lan

d8

045

02

60

19

01

00

02

30

19

02

00

2000

09

03

06

00

00

02

06

01

00

2001

07

05

02

00

00

05

02

00

00

2002

06

02

04

01

00

01

04

00

00

2003

09

06

03

00

00

06

03

00

00

2004

05

04

01

00

00

03

01

01

00

2005

03

02

01

00

00

02

01

00

00

2006

04

03

01

00

00

03

01

00

00

2007

02

01

01

00

00

01

01

00

00

1. F

igure

s a

re fo

r all

tri-S

erv

ice r

eg

ula

r a

nd r

eserv

ist pers

onne

l2. In

cludes b

oth

dea

ths c

lassifi

ed a

s K

illed

in A

ctio

n (K

IA)

and D

ied o

f W

ou

nds (

DoW

) w

he

re;

- K

IA is

a b

attle

casualty

who is k

illed o

utr

igh

t or

who d

ies a

s a

re

sult

of w

oun

ds

or

oth

er in

juries b

efo

re r

eachin

g a

me

dic

al tr

eatm

ent fa

cili

ty.

- D

oW

is a

batt

le c

asua

lty w

ho d

ies o

f w

ounds o

r oth

er

inju

ries re

ceiv

ed in a

ctio

n, aft

er

havin

g r

eached a

me

dic

al tr

eatm

ent

facili

ty.

Data

on K

IA a

nd D

OW

split

s is

on

ly a

vaila

ble

for

Iraq a

nd A

fgha

nis

tan

.3. In

cludes d

eath

s d

ue

to A

ccid

ents

, N

atu

ral c

au

ses,

Assa

ults

an

d c

oro

ner

confirm

ed S

uic

ide

or

Open v

erd

icts

4. F

rom

1 J

anu

ary

200

3 to 0

3 A

pril 2

011

5. F

rom

7 O

cto

ber

2001 t

o 0

3 A

pril 201

16. F

rom

1 J

anu

ary

200

0 to 0

3 A

pril 2

011

7. F

rom

5 M

ay

20

00 to

31 J

uly

200

28. F

rom

1 J

anu

ary

200

0 to 3

1 J

uly

2007

. In

clu

des o

nly

tho

se p

ers

onne

l who

die

d in

Nort

hern

Ire

lan

d a

nd

me

t th

e c

rite

ria to

be inscr

ibed o

n the

Arm

ed F

orc

es M

em

oria

l at

the A

rbore

tum

in S

tafford

shir

e.

In a

dditi

on t

here

were

6 r

egula

r and

7 r

eserv

ist

pers

onnel w

ho d

ied in

Nort

hern

Ire

lan

d w

ho d

id n

ot m

eet th

e c

rite

ria a

nd

there

fore

are

not in

cluded

in t

he a

bove fig

ure

s.

Ope

rati

on

All

Reg

ula

rR

eserv

ist

All

Hos

tile

acti

on

2O

ther3

Nav

al S

erv

ice

Reg

ula

rR

eserv

ist

Arm

yR

eg

ula

rR

eserv

ist

RA

FR

eg

ula

rR

eserv

ist

Defence Analytical Services and Advice (DASA) compiles the Department’s authoritative deaths database,based on information from several internal and external sources, from which a number of internal analyses and


external National Statistics Notices are released. Information on deaths among members of the voluntaryreserve and regular reserve is only available if they have been called up for active duty. Information onpersonnel discharged from the Services is not generally available.

Please note that the data for Service personnel who died as a result of Operations in Northern Ireland (OpBANNER) only includes those personnel who met the criteria for inclusion on the Armed Forces memorial atthe Arboretum in Staffordshire. In addition there were 13 Personnel (6 Regulars and 7 Reservists) who died inNorthern Ireland and have not been included on the memorial and thus are excluded from this answer.

UK Entitled Civilian Deaths

10.3 In 2003 one UK Entitled civilian died (as a result of natural causes) whilst on Operations in Iraq. Wedo not collate statistics on civilian deaths.

Casualties

Table 2 presents the number of UK Armed Forces casualties by Operation and year between 1 January 2003and 28 February 2011 (latest date for which data is available) for regulars and reservists.

Between 1 January 2006 and 28 February 2011 no entitled civilians have been classified as very seriouslyinjured or seriously injured as a result of injuries sustained on Operations in Iraq and Afghanistan.

Between 1 January 2006 and 28 February 2011 38 entitled civilians have been aeromedically evacuated fromIraq and 43 aeromedically evacuated from Afghanistan.

Notification of Casualty (or “NOTICAS”) is the name for the formalised system of reporting casualtieswithin the UK Armed Forces. The NOTICAS reports raised for casualties contain information on how seriouslymedical staff in theatre judge their condition to be. They are not strictly medical categories but are designedto give an indication of the severity of the injury or illness to inform what the individual’s next of kin are told.

As defined in JSP 751 the NOTICAS medically categorises casualties with the following severities:

Very Seriously Injured (VSI)—A patient is termed “very seriously injured” when his/her injury isof such a severity that life is imminently endangered.

Seriously Injured (SI)—A patient is termed “seriously injured” when his/her injury is of suchseverity that there is cause for immediate concern but there is no imminent danger to life.

2. Data presented includes all injuries, including wounded in action (WIA) and Operational accidents.

Information on casualties sustained on Operations in Northern Ireland has not been compiled centrally. Toinclude this information would require a manual trawl of paper records by the single Services.


Ta

ble

2. U

K A

rmed

For

ces

casu

alti

es b

y O

per

atio

n, M

ilita

ry c

hara

cter

istic

s, s

ever

ity

and

yea

r, 1

Jan

uar

y 20

00 to

28

Febr

uary

201

1, n

umbe

rs

VS

IS

IV

SI

SI

VS

IS

IV

SI

SI

VS

IS

IV

SI

SI

VS

IS

IV

SI

SI

VS

IS

I

Iraq

222

23

10

00

6112

26

100

02

101

20

220

031

460

20

00

011

222

50

01

20

00

120

0445

00

00

00

1026

42

00

02

00

01

2005

200

00

00

05

120

20

00

10

00

020

0632

11

10

00

919

00

00

01

00

00

2007

691

00

00

021

380

10

01

41

20

020

089

00

00

00

54

00

00

00

00

00

2009

10

00

00

00

10

00

00

00

00

020

100

00

00

00

00

00

00

00

00

00

2011

20

00

00

00

00

00

00

00

00

00

Afg

han

ista

n50

027

361

00

020

720

38

80

01

90

00

020

013

00

00

00

00

00

00

00

00

00

020

021

10

00

00

00

00

00

00

00

00

2003

10

00

00

00

00

10

00

00

00

020

046

00

00

00

11

22

00

00

00

00

2005

20

00

00

02

00

00

00

00

00

020

0631

34

00

00

159

00

00

00

00

00

2007

634

91

00

017

271

20

00

20

00

020

0865

96

00

00

1729

10

00

03

00

00

2009

157

610

00

00

7563

00

00

12

00

00

2010

154

47

00

00

7263

43

00

01

00

00

2011

220

00

00

00

811

00

00

01

00

00

Bal

kans

170

10

00

03

91

20

00

10

00

020

014

60

00

00

02

40

00

00

00

00

020

022

00

00

00

10

10

00

00

00

00

2003

30

00

00

00

20

10

00

00

00

020

042

00

00

00

02

00

00

00

00

00

2005

00

00

00

00

00

00

00

00

00

020

062

00

00

00

01

01

00

00

00

00

2007

52

01

00

00

00

00

00

01

00

00

Non

-Ope

rati

onal

663

2556

01

02

175

309

517

02

2642

02

00

2006

611

71

80

00

036

520

30

26

90

00

020

0716

69

140

00

250

682

30

010

80

00

020

0812

72

130

00

030

631

60

15

60

00

020

0913

74

130

10

032

720

30

03

80

10

020

1097

87

00

00

2247

11

00

28

01

00

2011

218

11

00

00

57

11

00

02

00

00

So

urce

: N

OT

ICA

S1.

Dat

a st

arts

1 J

anua

ry 2

003

2. D

ata

is u

p to

28

Feb

ruar

y 20

113.

Dat

a st

arts

7 O

ctob

er 2

001

4. D

ata

star

ts 1

Jan

uary

200

15.

Dat

a is

up

to 3

0 A

pril

2007

6. D

ata

star

ts 1

Jan

uary

200

67.

The

VS

I and

SI

inju

ry d

ata

incl

udes

rec

ords

cla

ssifi

ed a

s 'O

ther

Cau

ses'

. Thi

s cl

assi

ficat

ion

is u

sed

whe

n th

ere

is in

suffi

cien

t inf

orm

atio

n to

attr

ibut

e a

casu

alty

to in

jury

or n

atur

al c

ause

.

All

Yea

rR

eser

vist

Unk

no

wn

RA

FR

egul

arR

eser

vist

Reg

ular

Reg

ular

Res

ervi

stU

nkn

ow

nN

aval

Ser

vice

Unk

no

wn

Arm

y


Mental Health

10.4 Deployment information on Northern Ireland, Sierra Leone and the Balkans is not held centrally andthus we are not able to asses the impact of these Operations on referrals to a DCMH. Deployment markerswere assigned using the criteria that an individual was recorded as being deployed to the Iraq and/orAfghanistan theatres of operation if they had deployed to these theatres prior to their appointment date.

10.5 DCMH staff record the initial mental health assessment during a patient’s first appointment, based onpresenting complaints. The information is provisional and final diagnoses may differ as some patients do notpresent the full range of symptoms, signs or clinical history during their first appointment. The mental healthassessment of condition data were categorised into three standard groupings of common mental disordersused by the World Health Organisation’s International Statistical Classification of Diseases and Health-RelatedDisorders 10th edition (ICD-10).

Table 3 presents the number of UK Armed Forces mental health episodes of care at a DCMH by Operation,year and Service between 1 January 2007 and 31 December 2010 (latest date for which data is available) forregulars and reservists.

Table 3. UK Armed Forces new episodes of care at the MoD’s DCMHs for mental disorders, by Operation,Military characteristics and year, 1 January 2007—31 December 2010, numbers.

All Services

Regulars (n) Reservists (n) Regulars (n) Reservists (n) Regulars (n) Reservists (n)Unknown Reg/Res

statusIraq

2007 162 0 1,175 35 330 ~ 212008 143 ~ 965 14 325 ~ 122009 173 ~ 1,045 22 385 ~ 192010 127 ~ 1,086 20 438 ~ 9

Afghanistan2007 57 0 219 6 85 ~ 72008 54 0 455 10 137 ~ ~2009 131 ~ 683 20 190 0 23

2010 78 ~ 1,167 28 287 ~ 20

Neither2007 394 ~ 928 27 479 6 31

2008 301 ~ 661 20 326 ~ 59

2009 254 ~ 729 31 329 ~ 33

2010 246 0 738 36 407 ~ 16

Operation and Year

Naval Service Army RAF

1. Data presented as "~" has been suppressed in accordance with DASA's rounding policy (see paragraph 33).

2. Data for Jan 2007 covers new attendances. Data from July 2009 data covers new episodes of care.

10.6 For the period 1 January 2007 to 31 December 2007, the rate of mental disorders for all personnel whohad previously deployed to Iraq was 18.8 per 1,000 personnel (95% CI: 17.9–19.7, n=1,725) and the rate ofmental disorders for personnel who had previously deployed to Afghanistan was 12.5 per 1,000 personnel,(95% CI: 11.2–13.8, n= 375). For Service personnel who had not deployed to Iraq or Afghanistan, the overallrate was 19.6 per 1,000 personnel (95% CI: 18.7–20.5, n=1,867).

10.7 For the period 1 January 2008 to 31 December 2008, the rate of mental disorders for all personnel whohad previously deployed to Iraq was 15.8 per 1,000 personnel (95% CI: 15.0–16.6, n=1,463) and the rate ofmental disorders for personnel who had previously deployed to Afghanistan was 15.0 per 1,000 personnel,(95% CI: 13.9–16.2, n= 661). For Service personnel who had not deployed to Iraq or Afghanistan the overallrate was 16.1 per 1,000 personnel (95% CI: 15.3–17.0, n=1,370).

10.8 For the period 1 January 2009 to 31 December 2009, the rate of mental disorders for all personnel whohad previously deployed to Iraq was 18.0 per 1,000 personnel (95% CI: 17.1–18.8, n=1,648) and the rate ofmental disorders for personnel who had previously deployed to Afghanistan was 18.2 per 1,000 personnel,(95% CI: 17.1–19.3, n= 1,049). For Service personnel who had not deployed to Iraq or Afghanistan the overallrate was 16.9 per 1,000 personnel (95% CI: 16.0–17.7, n=1,382).

10.9 For the period 1 January 2010 to 31 December 2010, the rate of mental disorders for all personnel whohad previously deployed to Iraq was 19.0 per 1,000 personnel (95% CI: 18.1–19.9, n=1,682) and the rate ofmental disorders for personnel who had previously deployed to Afghanistan was 21.7 per 1,000 personnel,(95% CI: 20.6–22.7, n= 1,582). For Service personnel who had not deployed to Iraq or Afghanistan the overallrate was 18.3 per 1,000 personnel (95% CI: 17.4–19.3, n=1,447).

10.10 The methodology for only capturing an individuals first attendance at a DCMH was revised in July2009, figures from this date onwards now include repeat attendances if they are classified by the DCMH as anew episode of care. This has resulted in an increase in recorded numbers from July 2009 onwards. Proportionsacross the quarters, however, have remained broadly the same, suggesting that the revised methodology hasnot altered the pattern of findings.


10.11 However caution should be taken when comparing numbers under the old and revised methodology.

10.12 The deployment data presented in the mental health data in Table 3 represent deployments to thetheatre of operation and not deployment to a specific country ie Deployment to the Iraq theatre of operationincludes deployment to other countries in the Gulf region such as Kuwait and Oman. Therefore, this datacannot be compared to data on personnel deployed to a specific country such as Iraq.

10.13 Person level deployment data for Afghanistan was not available between 1 January 2003 and 14October 2005. Therefore, it is possible that some UK Armed Forces personnel who were deployed toAfghanistan during this period and subsequently attended a DCMH have not been identified as having deployedto Afghanistan in this report. Please note: the mental health tables compares those who had been deployedbefore their episode of care with those who have not been identified as having deployed before their episodeof care.

10.14 Some mental health problems will be resolved through peer support and individual resources; patientspresenting to the UK Armed Forces’ mental health services will have undergone a process that begins with theindividual’s identification of a problem and initial presentation to primary care or other agencies such as thepadres or Service social workers. A proportion of mental health issues will have been resolved at these levelswithout the need for further referral. The diagnostic breakdown in this report is based upon initial assessmentsat DCMHs, which may be subject to later amendment.

10.15 In line with DASA’s rounding policy (May 2009) all numbers fewer than five have been suppressed.Where there is only one cell in a row or column that is fewer than five, the next smallest number has also beensuppressed so that numbers cannot be derived from totals. Where there are equal values, both numbers havebeen suppressed. This policy applies to Table 3 only.

Question 11—The Committee is very interested in the support given to families from notification of death orinjury to support with personnel return, in particular, bereavement support for families

11.1 Joint Service Publication (JSP) 751—Casualty & Compassionate Policy & Procedures—provides theframework, guidance and direction on casualty management and bereavement. There is therefore a commonlevel of support provided to families. However, each Service delivers that support based on their own ethos,organisational structures and experiences. For example the Army trains a cadre of serving personnel as CasualtyNotification Officers (CNO) and Visiting Officers (VO) and tries where possible to match the cap badge of thecasualty. The RN/RM, however, primarily uses its specialist welfare personnel. JSP 751 is reviewed twice ayear in consultation with the Services, the Joint Casualty and Compassionate Cell, Deputy Chief of DefenceStaff Personnel Operational Welfare, Royal Centre of Defence Medicine (Birmingham) and representativesfrom the Service Personnel and Veterans Agency in Blackpool and Glasgow.

11.2 The Services place great importance on the care of the Next of Kin (NOK), Emergency Contact (EC)or Civil Partners (CP) following injury or death of Service personnel. A CNO is a trained individual to informthe family of the incident while a VO is a specially selected and trained individual who is appointed thereafterto provide a single point of contact for the family. The VO develops a supporting relationship to ensure thateverything possible is done to help the family to deal with the circumstances they face and prepare for thefuture. VOs are appointed by the Service Notifying Authority (NA) and thus are the responsibility of thesingle Services.

11.3 The policy and responsibilities of the VO are clearly laid down in Joint Service Publication (JSP) 751(Casualty and Compassionate Policy and Procedures). However, each Service is responsible for the training,selection and support of their respective VOs. The casualty’s Commanding Officer (CO) remains activelyinvolved with the NOK/EC/CP until a good working relationship is fully established between the VO and thefamily. The CO remains in contact with any deployed VO and must satisfy themselves that the NOK/EC/CPare receiving the help and advice they need. The CO is also responsible for ensuring that the VO has thenecessary support they require to enable them to carry out their duties. A VO will remain engaged with afamily until there is no longer a need, which can be months or years depending on the circumstances.

11.4 All families show different reactions to loss and bereavement, and our training teaches the VO tounderstand these differences and react accordingly. The level of support will therefore be responsive toindividual needs, but it has to be enduring so that families do not feel abandoned. The SPVA Veterans WelfareService (VWS) provides the tri service long term point of contact for all military issues. Each Service maintainsits own lead organisation which are Army Inquiries and Aftercare Support Cell (AIASC), Naval Personnel andFamilies Service (NPFS) and the RAF via SSAFA case workers. Often the deceased’s regiment, unit, stationor base will continue to keep in touch on a more social level for as long as the family wishes.

11.5 In parallel to the support described above, and that provided by a unit to its own families, there are aseries of Service related bereavement charities. They meet regularly with the MoD to exchange views andprovide feedback which helps to inform MoD’s policies and delivery (See Defence Bereaved Families GroupQuestion 14). Families are made aware of these external support networks throughout the bereavement processby the VO and other support providers.


11.6 In addition to the emotional and practical support provided by the VO and others, bereaved familiesare also entitled to the following, paid for by public funds:

(1) Travel and hotel accommodation (bed, breakfast and evening meal) for seven persons the nightbefore the repatriation.

(2) Private funeral grant of up to £2,945 or military funeral at public expense, plus incidental expensesallowance of £500.

(3) Military Headstone and maintenance of grave, or military urn marker.

(4) Travel and hotel accommodation (bed, breakfast and evening meal) for three persons to attendthe inquest.

(5) Travel and hotel accommodation (bed, breakfast and evening meal) for two persons to attend aService Inquiry.

(6) Transfer of the deceased Service Person’s resettlement entitlement for up to five years.

(7) Retention of Continuity of Education Allowance until the end of a stage of education.

(8) Families living overseas are entitled to the same allowances.

11.7 If Service personnel (SP) are unexpectedly hospitalised and there is a medical recommendation for thefamily to be present, three family members of the injured individual are authorised to travel at public expenseto be at their bedside. All casualties are notified by a CNO; all CNOs receive training prior to undertaking therole. In all cases the parent unit of the SP remain responsible for arranging the reception, briefing, transportand the coordination of Welfare support for the visitors.

Comment on the Quality of Support to Bereaved Families

11.8 Over the past eight years (since the start of OP TELIC), the support provided to bereaved families hassteadily improved. Far from being complacent at the reduction of adverse criticism by families, the Servicescontinue to seek further improvements in the quality of their support. They remain acutely aware of the sacrificemade by families, as well as the Service person, and the need to include the wider family in that support. Thekey factors which have driven this continuous improvement are as follows:

(1) Creation of Joint Casualty Clearing Cell in 2005 and the consequent creation of the Army Inquiriesand aftercare Support Cell (AIASC) for the Army.

(2) Creation of the Defence Inquest Unit in 2008.

(3) The centralised training package devised and maintained by AIASC.

(4) Feed back from VOs and families.

(5) Greater awareness by regiments, bases, units and stations, of the need to be proactive.

(6) Greater support from the chain of command in managing the process.

Navy

11.9 The Naval Service (NS) policy is that the support to bereaved families and injured personnel is providedby NS second level specialist welfare organisations, specifically the Naval Personal and Family Service (NPFS)and Royal Marines Welfare (RMW) who undertake the Visiting Officer (VO) function. This approach ensuresa high quality service, but also minimises the need to change VOs because of deployment and assigningpatterns, and facilitates consistent delivery. NS policy, principles and practices are common to both the RNand RM but the differences in size and structure of the two elements are reflected in their processes. Howeverthe common policy, principles and practice enable VOs from NPFS to work with RM families (and vice versa)at times of high demand/ surge or if it is more appropriate/practical to do so. The NS embraces the policy thatthe VO is the principle point of contact with the family to co-ordinate input rather than attempt to be expert inevery area of business.

Royal Navy

11.10 There are three RN Notifying Authorities (NA). The NA is the Captain of the Base, On receipt of theKinforming instruction from JCCC the NA appoints: a suitable Casualty Notification Officer (CNO), who isusually a uniformed commissioned Officer; the Funeral Officer (FO); and liaises with the NPFS managementover the appointment of the VO. The NA responsibility is defined by the geographical area in which theNOK resides.

Royal Marines

11.11 The RM NA is Department of the Commandant General Royal Marines (DCGRM), who delegates theduty to Corps Casualty Officer (CCO) based at Navy Command HQ. On receipt of the JCCC Kinforminginstruction CCO will direct the appointment of a CNO and appoint a FO. CCO will also contact the RMWmanagement who will allocate a VO, or CVO—see paragraph below.


NS Selection, Training, Briefing and Support to VOs

11.12 NPFS/RMW are a mixed service and civilian workforce, with all welfare workers available toundertake VO functions. The majority of staff are qualified and registered Social Workers. The result is adedicated number of professionals with increasing depth of experience and knowledge in the role.

11.13 As a response to recent deployment patterns it was decided to train a cadre of Casualty Visiting Officers(CVO) (currently standing at 85), to provide a strategic reserve/surge capability. CVOs are predominantly (butnot exclusively) Royal Marines SNCOs, Warrant Officers and Officers, and form a significant proportion ofthe Base Company. They are generally used in conjunction with lower level casualties or in other circumstanceswhich make the appointment of a VO inappropriate, thereby maintaining VO capability for Death and veryseriously ill cases.

11.14 All CNOs, FOs, VO’s and CVOs attend tailored training courses which include functionalresponsibilities of each role, processes (including undertakers and a visit to a crematorium) and, wherenecessary, a bereavement and loss package.

11.15 NPFS/RMW uses an established model of Social Work Supervision for all welfare workers includingVOs. The model is based on monthly (or more frequent if appropriate) supervision which is designed to:support the VO; quality assure delivery; and develop/identify best practice. The supervision model alsogenerates feedback on policy and practice as well as being central to cascading new developments. CVOs areclosely supported by allocated NPFS/RMW staff using a similar model.

Army

11.16 Although the regimental system provides the basis of Army support for bereaved families, managementand co-ordination of individual cases is effected through the Regional Force (RF) HQs, normally until theinquest has taken place or the Visiting Officer (VO) has been stood down. In addition the Army Inquiries andAftercare Support Cell maintains a focus for all bereaved families, often leading in the more sensitive andcomplex cases. The AIASC is also responsible for the training of VOs, and consistency in delivery acrossregional forces.

11.17 The JCCC is responsible for co-ordinating notification through the relevant RF HQs—the NotifyingAuthorities (NAs), which are in turn responsible for appointing the Casualty Notifying Officer (CNO) and VO.These are always different people so that the bringer of bad news is not involved or associated with theprovision of subsequent support. Either the CNO or VO will quickly establish the dynamics of the family, andif necessary the NA will appoint a second VO. Even if the Emergency Contact is not the Next of Kin, bothbiological parents will be formally contacted and notified in cases of death and missing.

11.18 The VO remains the primary point of contact for the family for six to none months, and will guide,support and assist them through the repatriation ceremony, the funeral arrangements, any media issues, and thereturn of the deceased’s personal effects. The VO is supported, as required, by a Padre, the Army WelfareService, which can organise counselling, an SPVA Veterans Welfare Manager, who will advise on all financialmatters (benefits, pensions, Armed Forces Compensation Scheme etc.) and of course the soldier’s parent unit.It is, however, the VO who will co-ordinate all aspects of the family’s needs and requirements and submitregular reports to the NA and the AIASC. The VO should consciously decrease the amount of contact andnumber of visits to the family after 3 or 4 months, so that they do not become too dependent on him/her.

RAF

11.19 In the event of a notification of death or injury by the JCCC, the RAF Notifying Authority willimmediately appoint a Casualty Notifying Officer (CNO) and a Visiting Officer (VO). The RAF deploys anetwork of personnel to support and assist the family in what ever capacity is needed, taking appropriateaccount of unique family dynamics regarding the Next of Kin (NoK). In line with the other Services, we traina number of personnel as CNO’S and VO’s to support the family unit. These individuals are selected for theirinnate inter-personal skills and experience, they must also demonstrate sufficient maturity to enable them toassist a family with the practicalities of dealing with a bereavement or an injury to a service person. As partof their training, CNO/VOs will have a working knowledge of the wider welfare support services available toassist them with this important and demanding task; but, they are not expected to be subject matter expertsand will refer to specialists for assistance.

11.20 Once appointed as the Station Commander’s representative, the VO remains the primary point ofcontact for the family for between six to 18 months, and will guide, support and assist them through therepatriation ceremony, the funeral arrangements, inquest hearings, any media issues, and the return of thedeceased’s personal effects. VOs are proactively monitored and supported by the Station Welfare CaseworkCommittee (SWCC) as well as their Chain of Command. The SWCC consists of a team of experienced welfarepractitioners, under the chairmanship of Officer Commanding Personnel Management Squadron (OC PMS).Membership of the SWCC also includes the Station Medical Officer, the Chaplain and the Station SSAFA-FHSocial Worker. The SWCC monitors the individual welfare of the CNO, VO and any other personnel assistingthe family.


11.21 In cases of injury, where RAF personnel are classified as Very Seriously Ill (VSI) or Seriously Ill (SI)and have been admitted to hospital (RCDM or elsewhere), VOs are assigned and provide the same level ofsupport to a family as articulated above and this may include, in the early stages, escorting family members tothe relevant hospital, organising travel and accommodation.

Question 12—The Committee would like to know of any research into outcomes for those injured onoperations, in particular the research commissioned from King’s College London on the health of ArmedForces personnel returning from operations. What other internal or external research has the MoDcommissioned?

Mental Health

12.1 The Academic Centre for Defence Mental Health (ACDMH) was formed as a result of recommendationscontained in the Medical Quinquennial Review (MQR) of 2000, the Northern Centre Report of 2001 and inthe judgement of His Honour Judge Owen in the PTSD Class Action of 2003. The mission of ACDMH is tobe a resource of research excellence and expertise within Defence Medical Services (DMS) Mental HealthServices (MHS) and to act as a catalyst for the promotion of a strong research-based culture within DMSMHS.

12.2 ACDMH is funded by the MoD and is led by Professor Simon Wessely. The King’s Centre for MilitaryHealth Research 15 year Report encapsulates Mental Health Research into outcomes resulting from operations.

Trauma Research

12.3 There are currently 11 ongoing research activities concentrating on operational theatres engaged withthe provision of emergency and trauma care. They include work on blood clotting in trauma, battlefield painmanagement and the treatment of blast lung injuries. The Surgeon General’s Medical Director is responsiblefor maintaining a database of defence medical research work and taking steps to ensure that research isexploited and developed into approved clinical interventions and treatments.

12.4 This research builds on a programme of work already completed, and is part of a continual process ofimprovement in the service we provide. Completed research has included strategies for the control of fatalhaemorrhage, battlefield resuscitation and testing and delivery of blood transfusion products. This has had ademonstrable and positive impact on patient care, morbidity and mortality rates.

12.5 In addition the recently opened National Institute for Health Research Centre (NIHR) for SurgicalReconstruction and Microbiology at University Hospitals Birmingham brings military and civilian traumasurgeons and scientists together to share innovation in medical research and advanced clinical practice in thebattlefield to benefit both Military and NHS trauma patients at an early stage of injury. The centre will buildupon existing research into complex trauma injuries focusing initially on today’s most urgent challenges intrauma including the effects of blast wounding, stemming blood loss, resuscitation, surgical care followingsevere injury and fighting wound-infection. The Department of Health, the MoD, University HospitalsBirmingham NHS Foundation Trust and the University of Birmingham have collectively invested £20m inthe centre.

12.6 Surgeon General’s Medical Director pursues close collaboration between the US and UK in many areasof research and audit which lead to improved patient care for casualties from both nations. In addition to theengagement between the NIHR and US Medical Research facilities which continues to develop, furtherinteraction with American military medical research includes:

Academic Department of Military Surgery and Trauma (ADMST), RCDM

12.7 The ADMST has had two research fellows (military surgical trainees) in San Antonio Texas at the USArmy Institute of Surgical Research (ISR) and USAF Wilford Hall since 2008. They are now collocated as aUS Army–USAF facility adjoined to the San Antonio Military Medical Centre (SAMMC) at Fort Sam Houston.Although experimental costs are provided through DoD budget the UK has considerable input into the USprogramme and data sharing, investigating methods to prevent fracture infection using novel techniques and aspart of the vascular injury initiative. These positions are operationally very relevant to collaborative researchand translational development from laboratory to clinical application in the management of combat casualties.UK has complimentary rather than equivalent programmes, deliberately collaborating to avoid nugatoryduplicative effort. Such relationships have already had beneficial effect and will likely to be of enduringimportance to secure military surgical knowledge and future developments. Defence Professor of Surgery hasbeen invited as visiting Professor for 04–08 April 2011 at SAMMC.

12.8 ADMST are regular contributors to the annual ATACCC (Advanced Technology Applications forCombat Casualty Care) meeting in Florida and Society of Military Vascular Surgery in Washington, DC.

Academic Department of Mental Health (ADMH)

12.9 ADMH has liaised with the US who have provided information on the US Battlemind post deploymentpsycho-education programme which the UK has now tested via a high quality scientific trial with UK troops.


The UK has also provided US with information about decompression and facilitated a visit of US forces to theUK decompression facility.

12.10 ADMH intends to formally share some epidemiological data with US in the coming months in orderto investigate the substantial differences in post deployment mental health in both nations (US forces tendingto report higher rates of mental ill health post deployment).

12.11 As referred to earlier in the answer to Question 1, the UK is also working towards a post deploymentscreening randomised controlled trial, as recommended by Dr Murrison’s Fighting Fit report, utilising with USfunding, as US pan-force screening policy would not allow them to do so themselves. We are ensuring that thetrial is capable of generating data that will be of benefit in a UK context.

Question 13—The Committee would like copies of any “lessons learned” reports on support from NorthernIreland, the Falklands, the Balkans, First Gulf War and recent operations in Iraq and Afghanistan

13.1 The DMS Lessons Identified (LI) process is the mechanism by which lessons from operations andexercises are identified, collated, analysed, actioned and monitored. The DMS utilises Defence LessonsIdentified Management Systems (DLIMS) to ensure coherence and compliance is achieved in capturing lessonsand assigning management responsibility. However there are multiple HQ DLIMS systems rather than oneconsolidated DMS DLIMS. In addition any clinical lessons fed back from Theatre to PJHQ are also sent tothe Joint Medical Command Medical Director and appropriate Defence Consultant Advisors (DCAs).

13.2 PJHQ gathers LIs from: In-theatre Commander Medical (Comd Med) monthly reports, Comd Med PostOperational Tour reports (POTRs), DCA reports, Significant Event Reports (SERs) and other theatre returns,LIs are then allocated a Lead Action Manager within PJHQ and placed on the PJHQ DLIMs database.Operational level LIs are then identified from the database for regular review by medical personnel. Onceallocated, the Lead Action Manager is responsible for staffing the follow on action required to resolve theissues generated by the lesson. Lessons Identified are continually monitored and reviewed and are also the linkwith the LAND LIs Group and LAND DLIMs.

13.3 The Army Medical department additionally gather Tactical/Operational LIs from medical units and thePre Deployment Training (PDT) process. However, there is always cross discussion between AMD and PJHQto determine appropriate LAMs and to ensure there is no duplication of work. There is a LAND LIs Gp whichhas representation from PJHQ.

13.4 The Strategic Lessons Identified Management Group meets every 6 months. This group is chaired bythe Surgeon General’s Head of Medical Operations and Plans and brings together the most recent CommandersMedical, PJHQ, Front Line Commands, Defence Equipment and Support and Joint Medical Command toreport/review Strategic LIs. Once an LI has been assimilated into practice or a mitigation action put in place,it is archived according to local policy as part of the organisation’s LI process.

13.5 Clinical Guidelines for Operations (CGOs) guide clinicians on deployed operations in the managementof clinical conditions. The guidance has been developed, is based on best practice and is updated as a result ofLIs to ensure that clinicians are current and training is appropriate.

Question 14—What systems are in place for injured personnel and their families and bereaved families tofeed back their experiences of their processes?

14.1 The MoD casualty reporting and notification process is coordinated through the Joint Casualty andCompassionate Centre (JCCC) based at Innsworth. The JCCC was launched in April 2005. It was formed toprovide a single focal point for all three Services for all Casualty and Compassionate Casework. It replacedthe three single-Services Cells and was introduced because of the increasingly joint nature of operations toensure that one system existed for the management of casualties and compassionate cases on a worldwidebasis. The introduction of the Joint Personnel Administration (JPA) system further harmonised reportingprocedures. Policy and procedures for JCCC are laid down in JSP 751 (Casualty and Compassionate Policyand Procedures).

14.2 JSP 751 is reviewed twice a year in consultation with the Services, the JCCC, DCDS Pers OperationalWelfare, Royal College of Defence Medicine (Birmingham) and representatives from the Service Personneland Veterans Agency in Blackpool and Glasgow. The meetings provide the forum for feedback from serviceusers and families to be discussed and reflected in policy.

14.3 The VO is the main conduit for communication between families and the Services. The Services debrieftheir individual VOs on a regular basis in order to obtain feedback from the families. Where appropriate,policies and procedures are adapted accordingly.

The Soldiers, Sailors and Airmen’s Family Association (SSAFA) facilitate 3 self help groups:

(i) Bereaved Families Support Group.

(ii) Families of the Seriously Injured.

(iii) Bereaved Siblings Group.


14.4 Although facilitated by SSAFA a strong link is maintained by DCDS Pers Operational Welfare tocapture feedback and allay fears and concerns.

14.5 During the last three years the Royal British Legion(RBL) has hosted two, two day workshops attendedby bereaved families. These workshops were designed to look at the families’ experiences and examine waysin which they felt that things could be improved. Representatives from MoD have attended both conferencesat the feedback stage, resulting in the production of action plans that were worked on by RBL and MoD toimprove policy and procedures.

Defence Bereaved Families Group (DBFG)

14.6 The role of the DBFG is to provide a forum at which issues relating to the policy for care of bereavedfamilies can be raised by representatives of those families. The meeting is attended by delivery and policyorganisations and where appropriate, policy and processes are adapted. Latterly the DGFB have considered suchissues as bereavement support, Military Inquest assistance, pensions and support for children amongst others.

18 April 2011

Further written evidence from the Ministry of Defence

STATISTICAL CONTEXT

Introduction

1. This note provides statistical data on Service casualties, focusing on those injured on operations,aeromedically evacuated from Theatre and treated by the Defence Medical Services and who subsequentlyleave the Service, in order to provide an estimate of likely numbers requiring follow-on care in the NHS onleaving the Services. The analysis shows that in the order of 300 Service personnel with an operational injuryhave been discharged since 2007; although most personnel who have been injured on operations remain inservice. It is assessed that over the next few years’ there will be an increase in the number of such casualtieswho will require assessment through the Transition Protocol prior to discharge.

Key Conclusions

2. The following are the key conclusions:

(a) In 2010, there were 404 new cases treated at the Defence Medical Rehabilitation Centre (DMRC)Headley Court, 23% of which were operational casualties. However, when considering all casesseen at the unit (including revisits) operational casualties accounted for approximately one thirdof patients.

(b) In 2010, of the 1,214 individuals discharged from the Services, only 8% (102) were as aconsequence of injuries/illnesses sustained on current operations.

(c) In 2010, of 1,214 individuals discharged, a pilot group of 10 underwent assessment using theTransition Protocol of whom 6 were related to operations.

(d) The care pathway for serious operational injuries may be prolonged, as a result of the complexityof these cases. Of those injured on operations from 2007 only 21.5% have left specialist medicalcare and only 8.7% have left the Service. The average length of the care pathway will vary withthe needs of the individual, but in the case of those leaving the Service will not normally be lessthan 12 months (the time allowable routinely prior to medical discharge for those unable to workin the Armed Forces) and may be two years or longer in some cases. Extrapolating the currentdata, and in view of increasing maturity of processes, there will be an increase in the steady stateoutflow in the order of 100 to 200 personnel per year who have been injured on operations andmay require assessment under the Transition Protocol (TP). There is limited data to estimate howmany of these will require the highest level of medical care (as defined through the ContinuingHealthcare Checklist), but our assessment is that the numbers will be in the order of 10–20 perannum.

Data

3. The Defence Analytical Services and Advice (DASA) data presented herein is consistent across all threeServices. It sets out the number of patients that have been treated at Defence Medical Services’ (DMS) facilitiesover the last four calendar years. Each of the Services has provided data over the same four year period settingout the number of personnel who attended medical boards and those who were subsequently discharged fromthe Service. The number of personnel who have been injured as a direct result of current operations has beenseparately identified although it has not always been possible to determine this with complete accuracy due todifferences in the way that the single Services capture such data. Injured Service personnel will have theirMedical Employment Status (MES) assessed by a Medical Board. Initially they will be assigned a temporarygrade, with a permanent grade being assigned following recovery or when a “steady state” has been reached.Of these, the majority will be retained in Service in a category that may limit their employment and subsequent


deployability on operations. It is those who are discharged (as a result of their MES being assessed aspermanently medically unfit for continued service, or whose condition is such that no suitable employmentmay be found) who might place an additional burden on the NHS. It should be noted that Service personnelreturning from operations are all treated within the NHS; rehabilitation is the main service that is provided bythe DMS. Therefore it is only those who are medically ‘boarded’ and who are subsequently discharged thatare included in the figures.

Military Rehabilitation Pathway

4. Each individual’s rehabilitation pathway is unique and is determined by an assessment of their needs.This assessment takes into account the type, severity of injury or illness, nature of treatment and time requiredto achieve an optimum medical outcome. The acute phase of this care is provided within the main receivinghospital at University Hospitals Birmingham Foundation Trust (UHBFT) in combination with the Royal Centrefor Defence Medicine (RCDM). Subsequent rehabilitation is provided according to clinical need with majorityof the complex cases going to the Defence Medical Rehabilitation Centre (DMRC). RCDM and DMRC arecollectively known as the UK Role 4 Medical Group. Elective and acute force generation patients1 are alsoadmitted to and treated in both locations. The key nodes in a typical rehabilitation pathway starting from thepoint of wounding are:

(a) Point of wounding where immediate life saving techniques applied appropriately and early willhave a material effect on long term survival and rehabilitation outcome.

(b) Medical Emergency Response Team (MERT) retrieval where minimisation of the consequences ofthe immediate traumatic episode and robust stabilisation of the casualty’s condition will have amaterial effect on long term survival and rehabilitation outcome.

(c) Role 3 (eg Camp Bastion Field Hospital in Afghanistan).

(d) RCDM and the Queen Elizabeth Hospital Birmingham—Role 4.

(e) Defence Medical Rehabilitation Programme which provides Role 4 support and comprises:

(1) DMRC Headley Court—clinical rehabilitation.

(2) Regional Rehabilitation Units (RRU).

(f) Personnel Recovery Unit—implementation of individual recovery plan.

(g) Medical Board—to assess optimum medical recovery potential and medical category.

(h) Employment Board—to assess individual’s employment opportunities within the Services (thisbeing a Personnel function, on the advice of the Medical Board).

(i) Return to Duty or Discharge from Service—depending on outcome of Medical and Employmentboards.

(j) Transition Protocol (TP)—to ensure the seamless transfer of care for wounded injured sick (WIS)Service personnel from MoD to post-Service care providers.

5. Each of the Service recovery organisations2 takes command of the WIS personnel at an appropriatepoint during the rehabilitation process. These organisations coordinate and manage the individual’s recoveryplan and engage with other government departments if managed transition is required. A flow diagramsummarising the WIS Management Pathway is shown at Annex A.

Statistical Context

6. The following analysis is taken primarily from the 2010 data contained in the tables at Annex B. 2010was selected because it is the year with the largest representative sample and is the only year where all theappropriate data was available. Data from previous years is included for information. Numbers in previousyears were generally smaller in magnitude but consistent in proportions to those for 2010.

Camp Bastion and RCDM

7. In 2010, 303 personnel were injured or became severely ill in Afghanistan (of sufficient severity to bemedically listed) and required treatment at Camp Bastion in the Role 3 Hospital.3 In the same period a totalof 297 personnel were treated at RCDM in the Role 4 Queen Elizabeth Hospital in Birmingham,4 of which260 were for injuries related to current operations.5 In sum, 88% of all RCDM patients are from currentoperations; however, the Committee should be aware that other military patients are also treated at this facility,depending on their clinical needs.1 Those patients who are about to deploy on operations and who develop an acute medical problem. Prompt and intensive treatment

of such individuals may enable recovery in time to deploy with their units.2 Naval Service Recovery Pathway (NSRP), Army Recovery Capability (ARC) and Personnel Holding Flight (PHF).3 Data from Table 1, UK Service Personnel with initial NOTICAS of VSI, SI or III treated at Camp Bastion.4 Data from Table 2 and 2a, UK Service Personnel with initial NOTICAS of VSI, SI or III treated at RCDM including operational

casualties.5 Current Operations refers to injuries sustained in either Iraq or Afghanistan during the period 2007–10.


DMRC

8. In 2010 a total of 1,724 new patients were treated at DMRC. 404 of these had injuries attributed to currentoperations.6 The care pathway for serious operational injuries may be prolonged. Of those injured onoperations from 2007 only 21.5% have left specialist medical care and only 8.7% have left the Service.Although the operationally injured comprised less than 25% of all new patients being referred to DMRC in2010 around a third of the unit’s overall clinical caseload are battle casualties. Additionally, these complexcases use a significant proportion of the unit’s accommodation and clinical resources.

Medical Boards and Discharge

9. Single Service data shows that in 2010 the Naval Service held 820 medical boards, the Army 2,610involving permanent downgrading and the RAF 787. The Committee may wish to note that the purpose ofmedical boarding is to assess the medical fitness for employment and deployment on operations of eachindividual Serviceman referred to them, but this process has inter-Service variation in order to meet the needsof each Service as the Employer. Initial medical boards are likely to be temporary, in that the condition of theindividual is most likely to change over time. Such temporary boards are undertaken in different ways in eachService and so there is variation in the figures between each. However, as the conditions leading to dischargeon medical grounds are defined by tri-Service Policy (JSP 346), those given a permanent medical gradingleading to discharge will broadly be similar and so these figures (Tables 4 and 5) are comparable.

10. The medical board’s output is a recommendation to the respective Service on the subject’s medicalfitness for employment and future deployability. It is for the Employer to decide if that individual is to beretained, but a medical grading of P8 (medically unfit for service) should be expected to lead to a medicaldischarge. Service personnel may however be discharged when graded P7 (fit for employment in the firm basebut not for deployed operations) if there is no realistic prospect of employment given this restriction. Thereason for discharge will include the diagnosis; the record of the medical board will invariably note whetherthe injury or illness was sustained on or off duty, but not always whether this was sustained on deployedoperations. Therefore additional data mining has been necessary to identify those who had been deployed. In2010, some 1,214 personnel were discharged from the Services.7 Of those, only 102 (8%) had sustainedinjuries on current operations. This relatively low figure for operational discharges probably does not representthe future steady state outflow. This is a consequence of the time it takes for an individual to achieve theirmaximum recovery potential before being considered for discharge.

Transition Protocol

11. In 2010 a pilot group of 10 candidates of the 1,214 discharged from the Services was identified forassessment in accordance with the TP, of which only 6 were related to operational injuries. Again, The relativelysmall size of the pilot group is again indicative of the time it takes for injured personnel to reach their maximumrecovery potential. Therefore, the experience of MoD cases at the level of both individual Primary Care Trustsand, indeed, Strategic Health Authorities is limited.

The Future

12. In regards to the future, the increase in operational casualties will lead to an increase in the number ofService personnel who are medically discharged. In regard to these casualties, ordinarily they will not bedischarged until the necessary treatment has been given and rehabilitation to civil life has been undertaken.There will nonetheless be some who require ongoing treatment and care; those with severe head injuries wouldbe an example. Based on the increase in operational casualties from 2007 onwards, in two to three years timethere will be an increase in the steady state outflow of such personnel in the order of 100 to 200 per year. Ourassessment is that the majority of these will require an assessment in accordance with the TP. There is limitedevidence available, however, to indicate how many of the up to 300 will require the highest level of medicalcare (as defined through the Continuing Healthcare Checklist); although our assessment is that the numberswill be in the order of 10 to 20 per annum.

30 June 2011

AnnexesA. Wounded, Injured and Sick Management Pathway.

B. DASA Casualty Data 2007–2010.

6 Data from Table 3 and 3a, New Patients treated at DMRC.7 Data from Table 5 and 5a, Discharges.


Ann

ex A

W

OU

ND

ED/IN

JUR

ED/S

ICK

MA

NA

GEM

ENT

PATH

WAY

IN S

ERVI

CE

TR

AN

SITI

ON

PO

ST-S

ERVI

CE

MD

HU

: M

inis

try o

f Def

ence

Hos

pita

l Uni

t D

MR

C:

Def

ence

Med

ical

Reh

abili

tatio

n C

entre

(Hea

dley

Cou

rt)

RR

U:

Reg

iona

l Reh

abili

tatio

n U

nit

PC

RF:

Prim

ary

Car

e R

ehab

ilita

tion

Faci

lity

PR

U:

Per

sonn

el R

ecov

ery

Uni

t

IN-S

ERVI

CE

MA

NA

GEM

ENT

Rol

e 3

Cam

p B

AS

TIO

N

RC

DM

/RO

LE 4

D

MR

C/R

OLE

4

MD

HU

N

HS

R

RU

, PC

RF

MED

ICA

L &

EM

PLO

YMEN

T B

OA

RD

S

FIT

FOR

C

ON

TIN

UED

SE

RVI

CE

UN

FIT

FOR

C

ON

TIN

UED

SE

RVI

CE

ON

GO

ING

CA

RE

REQ

UIR

ED

POST

SER

VIC

E

CA

RE

PRO

VID

ERS

NH

S

3rd S

EC

TOR

O

THE

R

NO

O

NG

OIN

G C

AR

E R

EQU

IRED

TRA

NSI

TIO

N

PRO

TOC

OL

D I S C

H

A

R

G

E D

DIS

CH

AR

GE

PR

OC

ESS

OPE

RA

TIO

NA

L LO

CA

TIO

N

NO

N -

OPE

RA

TIO

NA

L LO

CA

TIO

N

WO

UN

DE

D/IN

JUR

ED

/SIC

K


Table 1

NUMBER OF PATIENTS VSI, SI OR III TREATED AT ROLE 3 AT CAMP BASTION

Total Navy Army RAF

2007 96 22 74 02008 138 16 121 12009 400 27 370 32010 303 27 273 3

937 92 838 7

Table 2

NUMBER OF PATIENTS VSI, SI OR III TREATED AT ROLE 4 SELLY OAK/QEH

Total Navy Army RAF

2007 42 17 23 22008 173 25 137 112009 348 27 308 132010 297 30 255 12

860 99 723 38

Table 2a

NUMBER OF OPS PATIENTS VSI, SI OR III TREATED AT ROLE 4 SELLY OAK/QEH

Total Navy Army RAF

2007 32 14 17 12008 139 19 114 62009 309 17 286 62010 260 20 234 6

740 70 651 19

Table 3

NUMBER OF NEW PATIENTS TREATED AT DMRC

Total Navy Army RAF

2007 DASA unable to provide data by Service2008 6192009 1,6682010 1,724

4,011

Table 3a

NUMBER OF NEW OPS PATIENTS TREATED AT DMRC

Total Navy Army RAF

2007 DASA unable to provide data by Service2008 402009 2622010 404

706

Table 4

NUMBER OF INDIVIDUALS UNDERGOING MEDICAL BOARDS

Total Navy Army* RAF

2007 1,540 678 8622008 1,462 788 6742009 3,619 718 2,065 8362010 4,217 820 2,610 787

10,838 3,004 4,675 3,159* Army data only includes P5-P8 perm downgrading


Table 5

NUMBER OF MEDICALLY BOARDED INDIVIDUALS DISCHARGED FROM SERVICE

Total Navy Army RAF

2007 1,251 274 9772008 1,312 298 842 1722009 1,010 163 681 1662010 1,214 238 829 147

4,787 973 3,329 485

Table 5a

NUMBER DISCHARGED FROM SERVICE AS A RESULT OF OPERATIONS

Total Navy Army RAF

2007 40 402008 92 44 48 02009 87 34 36 172010 102 40 56 6

321 118 180 23

Table 6

NUMBER IDENTIFIED FOR TRANSITION PROTOCOL ASSESSMENT

Total Navy Army RAF

2007200820092010 10 0 8 2

10 0 8 2

Supplementary written evidence from the Ministry of Defence

RESPONSE TO QUESTIONS FROM HEARINGS ON 6 AND 13 JULY 2011

Questions 305 and 347—The joint National Institute for Health Research Centre in Birmingham

Explanation of what it is

1. On 20 January 2011, the National Institute for Health Research, the Ministry of Defence, UniversityHospitals Birmingham and University of Birmingham launched a £20 million NIHR Centre for SurgicalReconstruction and Microbiology to innovate in and share medical research and advanced clinical practice inbattlefield medicine to benefit all trauma patients in the NHS at an early stage of injury.

How it works

2. The NIHR Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC) will carry outworld-leading research to help people recover better and faster from severe injuries helping to make the NHSleaders in the world of trauma care—helping to improve treatment and care in the NHS and around the world.The research is initially focussing on today's most urgent challenges in trauma including identifying effectiveresuscitation techniques, surgical care after multiple injuries or amputation and fighting wound infections.

3. NIHR SRMRC provides the opportunity to build academic knowledge around pioneering clinicalinnovations, often performed for the first time to save lives and limbs. It has the potential to push forwardmedical and surgical practice.

4. NIHR SRMRC Management Executive Board provides strategic oversight. It will ensure the work of theresearch work streams reflects the agreed strategic direction, as well as ensuring management capacity andcapability alongside the monitoring and managing of performance.

When it started

5. The contract between all parties is in final negotiation and due to be signed imminently.

Who staffs it

6. The NIHR SRMRC, for the first time, brings together trauma surgeons, research scientists and manyothers from the military and the NHS.


7. Its clinical director is Professor Sir Keith Porter, who is the UK’s only Professor of Clinical Traumatologyand has been developing world-class treatment for injured military Servicemen and women for the past 10years.

How it is funded

8. At present expenditure to date has been limited to administrative staff costs, but expenditure on researchprogrammes will increase as projects are approved. The £20 million funding is broken down as follows:

— £5 million from the Department of Health over five years;

— £10 million from the Ministry of Defence over 10 years; and

— £5 million from the University Hospitals Birmingham NHS Foundation Trust and Universityof Birmingham over five years.

Annual funding levels since it started and the future budget

9. This is the first time anyone in the world has put together the NHS, the general care system, with themilitary and a first-class university in the interests of improving outcomes for trauma patients.

10. It will be important that the new developments and spin-offs that come out of the understanding ofcomplex trauma are disseminated throughout the NHS and the military. So that the benefits of new techniquesand procedures can be felt by all.

11. Once research streams have been identified, funding sources will be identified and applications made tothe UK Research Councils and other appropriate funding bodies. It is anticipated that the charitable sector willalso be identified.

Questions 313 and 356—Headley Court—the numbers of beds over the last 10 years including the recentincreases and projected increases

By October By July> 2007 2007 2008 2009 2010 2011 Early 2012 2012

Musculoskeletal 110 110 110 110 110 110 110 110rehabilitationbedsIn-patient beds 36 66 66 96 116 122 135 144

(only (only 66 at FOC 96 + 96 established + 13 co- Projected44 at 44 at + 20 beds, +20 opted from requirementFOC) FOC) additional additional additional SLA* 96

30 beds beds +6 co- established(Mallard opted from plus 48

House) SLA* PCAP

* contingency whilst awaiting the completion of the 48 beds of the planned Patient Clinical AccommodationProject

12. The patient population at DMRC has always covered complex rehabilitation and rehabilitation of thosewith training and industrial musculoskeletal injuries. Up until 2005, trauma rehabilitation was related to braininjury and complex injuries with the balance toward brain injury and the NHS regional limb-fitting unit atQueen Mary Hospital Roehampton provided the prosthetic services. At this time, DMRC had 110 hostel bedsfor those with lower level musculoskeletal injuries and 36 in patient beds on the Peter Long Unit.

13. In 2005, patients with more complex physical injuries were being admitted because of combat operations,including some with serious brain injury. In 2007, 30 additional beds were brought on line in the Ward Annex;a modular construction with temporary planning permission for three years. This gave a total of 66 in-patientbeds (of which 44 were at full operating capability.) The hostel accommodation for musculoskeletalrehabilitation remains unchanged at 110.

14. In late summer 2009, Op PANTHERS’ CLAW saw an unprecedented increase in referrals from RCDM.The remaining 22 complex trauma beds were brought to full operating capability and plans were executed toincrease capacity by building an additional 30-bedded ward (Mallard House). This gave a capacity of 96 bedsin-patient beds. Musculoskeletal rehab accommodation remained at 110 beds.

15. In late 2010, the numbers of referrals and readmissions to DMRC began to threaten the capacity.Temporary measures were put in place to deliver an additional 20 beds within the existing structure andplanning was begun to attempt to identify the capacity that would be required to take the unit through to theend of current operations with a three-year clinical tail. In 2010 the temporary planning permission for theWard Annex was also extended to 2013.


16. At present 144 beds is the predicted required capacity to take the unit through to the end of operationsin Afghanistan. This requires the development of an additional 48-bed unit Patient Clinical AccommodationProject (PCAP) on site that will also include the therapy space required to bring those beds to full operatingcapability. Musculoskeletal capacity demand remains at 110 beds.

17. By end of October 2011 a total of 122 in patient beds will be available. In addition to the establishedbeds, further accommodation has been converted from Single Living Accommodation (SLA). By the beginningof 2012 the conversion of the remaining area of SLA into near clinical accommodation will deliver in theregion of 13 more beds bringing the total to near 135. However, the co-option of SLA to near clinicalaccommodation is a temporary measure only to build insurance into the programme whilst we await thecompletion of the 48 beds of the PCAP.

Question 318—Description of the Big White Wall

18. One of the principal recommendations made by Dr Murrison MP in his 2010 “Fighting Fit” report onthe mental health of Service personnel and veterans was for an Armed Forces-specific pilot of an onlinecounselling service. The Department of Health (DH) in partnership with the Ministry of Defence subsequentlycommissioned the Big White Wall to pilot a bespoke service for up to 2,400 veterans, serving personnel andfamily members starting in the autumn 2011. The DH has committed to provide £50k per annum of ongoingfunding to the service for the following three years, depending on the success of the pilot.

19. Working with the Tavistock and Portman NHS Foundation Trust, the Big White Wall(www.bigwhitewall.com) was established in October 2007 as a website that provides support and informationfor people wanting to discuss their problems anonymously. It provides users with access to discussion forumsthat are moderated by counselling staff. This allows individuals to express thoughts and feelings and receivepeer support. Users also have access to online assessments, cases studies and other support material.

Question 330—Description of the 24 hour helpline and of the online learning facility for GPs

24 hour helpline

20. While the concept of a 24-hour helpline was not included as a specific recommendation in Dr Murrisons’s“Fighting Fit” report, the concept behind such a service was strong and so it was packaged in with the Murrisonreport pieces as a key deliverable. The Department of Health commissioned the charities Combat Stress andRethink to provide a 24-hour helpline service that allows veterans, their families, their carers and professionalstreating them to access a source of support at any time of day. It is primarily a signposting service where usersare advised to contact one of an extensive list of relevant services for which Rethink have the latest contactdetails. Since its launch on 11 March 2011 up until the end of July 2011, the helpline has taken 1,686 calls.

Learning facility for GPs

21. The e-learning training programme has been developed in association with the Royal College of GeneralPractitioners to provide education and increased awareness of the needs of veterans and Armed Forces Servicefamilies. Once launched, this course will be available through the Royal College’s website. GeneralPractitioners will gain a recognised qualification upon completion of the course.

22. The content of the package is currently being finalised, but it will contain a section on mental health andseriously injured Service personnel along with information to help GPs refer patients to specific services ifrelevant. The launch will take place in early autumn of 2011.

Question 332—Report on the veteran support pilots mentioned by the Surgeon General

23. Although research on veterans’ health is ongoing, there is little to suggest that veterans generally sufferdifferent mental health disorders from the rest of the community or that these require different treatments inveterans. Mental illness still attracts stigma in society, which can cause sufferers to delay seeking help, whetherthey are ex-Service personnel or not.

24. To tackle this, six NHS community veterans mental health services were set up by the Department ofHealth and Devolved Administrations with support from MoD, at Stafford, Camden & Islington, Cardiff,Bishop Auckland, Cornwall, and Edinburgh to help ensure that ex-Servicemen and women with mental healthproblems had access to a culturally sensitive expert service offering assessment of their needs, followed byappropriate support and treatment. The services had a two-year pilot period and were rolled out progressivelywith the final two-year pilot (Veterans First, Edinburgh) completed in April 2011. All of the former pilot sitescontinue to provide support to veterans.

25. An independent evaluation, funded by the MoD was conducted by the University of Sheffield's Centrefor Psychological Services Research and their report was published on 20 December 2010 by way of a WrittenMinisterial Statement. A copy of the report was placed in the Library of both Houses and is available on theMoD website.


26. Data from clients seen during the pilots, interview findings from lead clinicians and managers from eachsite and data from audits and annual reports revealed it would be beneficial for veterans to be able to self-referthemselves to access a service and that veterans preferred dealing with staff that had training and experienceof working with ex-Service personnel. The pilots also discovered that assessment-only services that lead toveterans being referred to treatment in generic NHS settings proved unsuccessful, as did pathways involvingonward referral with a further waiting list at each stage.

27. The UK Health Departments are taking into account lessons learned from the findings of the evaluationand are using them to inform rollout across the NHS of additional veterans’ mental health services.

Question 338—Why did the MoD decide not to go for a dedicated coroner?

28. It has never been the Ministry of Defence or Ministry of Justice’s belief that the establishment of asingle coroner dedicated to investigating all military deaths would be an improvement on the current system.In fact, it could have a detrimental effect by delaying inquests and forcing families to travel long distances toattend inquests. Coroners must investigate military deaths in the same way that they investigate communitydeaths in order to satisfy themselves that they can answer the four questions required of them (who was killed,when, where and how they were killed). To answer these questions they will require suitable witnesses and onoccasion, subject matter experts. The Defence Inquests Unit works very hard to ensure that Coroners have allthe information regarding a death before them, and that where there are circumstances specific to operations;they are suitably briefed or have experts available to them.

Question 341—The MoD memo page 16 said that the MoD was currently investigating how to bettercoordinate, prioritise and facilitate all elements of voluntary or charitable support across defence. What arethe results of this investigation?

29. The Ministry of Defence is undertaking two main areas of work on how to better coordinate and prioritisevoluntary and charitable support.

30. The work we have undertaken on developing better internal guidance, as outlined on Page 17 of ourprevious memo, continues. This work is at an advanced stage and the draft Defence Instruction Notice (DIN)has been finalised and is now being considered by the Defence Recovery Steering Group.

31. The Department’s other main area of work focuses on ongoing engagement with the Service charities.Both the Service charities and the MoD share the desire to avoid duplication of effort and ensure the mosteffective prioritisation of effort and resources. Identification of priorities and coordination of effort remains oneof the key aims of the MoD/COBSEO Executive Steering Group, as outlined on Page 17 of our previous memo.

32. At a local level the co-ordination and prioritisation of support from both the public funds (for examplethrough local authorities and NHS boards) and the charitable and voluntary sector is one of the aims of boththe Armed Forces Welfare Pathway pilot scheme and the Armed Forces Community Covenant scheme. TheWelfare Pathway initiative is still in its trial period, but initial indications are that the development of relationsbetween local authorities, local Service units and Service charities has improved the ability to support membersof the Armed Forces community.

Question 347—Details on expenditure on research for last five years and budget for the next year splitbetween different types of research.

DEFENCE SCIENCE AND TECHNOLOGY EXPENDITURE ON MEDICAL RESEARCH

Financial Year Spend Details

2007–08 £1,170,000 Includes:Outturn — Combat Casualty Care programme (CCC)

— Tungsten Alloys— Ocular Trauma

The CCC programme focuses on the medical management of battlefieldcasualties from all non-Chemical, Biological, Radiological and Nuclear(CBRN) weapon effects (ie fragments, bullets, blast and burns).Tungsten Alloys supports the Medium Armour and Tracks Team(MATT) in DE&S through the development of a human line cell assayfor assessing tungsten alloy toxicity.

2008–09 £2,264,000 Includes:Outturn — CCC

— Tungsten Alloys— Ocular Trauma




— Tungsten Alloys— Centre for Defence Enterprise (CDE) work


— Clinical Injury Timelines— Ocular Burns— Tungsten Alloys— Ocular Trauma— CDE (Prosthetics and Rehabilitation and Battlefield Medical

Technology)2011–12 £4,034,000 Planned budget for:Planned — CCCBudget — Clinical Injury Timelines

— Ocular Burns— Tungsten Alloys— Ocular Trauma— Longitudinal Health Study (of Operation TELIC and HERRICK— veterans)

National Institute for Health Research (NIHR) Centre for SurgicalReconstruction and Microbiology.

DCDS(PERS) EXPENDITURE ON MEDICAL RESEARCH


2007–08 £1,030,700£878,000 Kings College

Health & Wellbeing Study Contracts£7,100 University of Manchester—Suicides Study -Veterans Challenge Fund

£145,600 University College London—Delayed Onset PTSD Study—VeteransChallenge Fund

2008–09 £394,600£378,600 Kings College

Health & Wellbeing Study Contracts£16,000 University of Sheffield—Evaluation of Veterans Mental Health Pilots—

Veterans Challenge Fund

2009–10 £727,600£563,000 Kings College

Health & Wellbeing Study Contracts£84,600 Cardiff University—Rehabilitation Contract£80,000 University of Sheffield—Evaluation of Veterans Mental Health Pilots—

Veterans Challenge Fund

2010–11 £759,700£571,000 Kings College

Health & Wellbeing Study Contracts£127,000 Cardiff University—Rehabilitation Contract£51,700 Miles and Green Associates Ltd—NTV Health Need Analysis£10,000 University of Sheffield—Evaluation of Veterans Mental Health Pilots—

Veterans Challenge Fund2011–12 £494,200PlannedBudget

£453,600 Kings CollegeHealth & Wellbeing Study Contracts

£40,600 Miles and Green Associates Ltd—NTV Health Need Analysis


DEFENCE MEDICAL SERVICE EXPENDITURE ON MEDICAL RESEARCH (RESEARCHEXPENDITURE)*


2008–09 £137,000

£12,000 Infection Control Surveillance Database£10,000 What are the Primary Health Care Expectations During the out-of-hours

Period for Army Families?£3,000 A Systematic Review on Use of Pre-Hospital Analgesics for Battlefield

Casualties£10,000 PCR: Polymerase Chain Reaction of Microbial Keratitis

£5,000 Lower Limb Injuries from Anti-vehicle Mine Blasts£10,000 PEMF Study£10,000 Prospective Randomised Control Trial of nanocrystalline silver dressing

versus plain gauze as the initial post- debridement management of militarywounds on wound microbiology and healing

£25,000 NIRS as a predictor of completion of resuscitation in hypovolaemic trauma£10,000 Can an OI needle be placed in the normal tibia in the presence of

ipsilateral femoral shaft fractures?£10,000 The application of NIRS in the detection of acute lower limb compartment

syndrome£32,000 Defining the Trauma Population in Selly Oak Hospital: A Retrospective

Review with Emphasis on the incidence of systematic inflammatoryresponses following major trauma

2009–10 £257,600

£30,300 Lower Limb Blast Modelling: The Instrumentation of a Physical TestApparatus to Simulate a Typical Vehicle Mine Explosion

£10,200 Development of a Rigorous Design Paradigm for Energy Transfer toControl Injury Patterning: Application to the Foot-Ankle Complex

£50,000 Evaluation of Combat Boot Design and Limb Orientation(Cadeveric LowerLimb Specimens)

£20,000 Acute Respiratory Disease in Military Recruits£5,400 Medical Officer Training for Role 1—Can Preparation for the Role be

Enhanced to Improve Patient Morbidity and Reduce Mortality£19,200 ICU Inflammation/ARDS

£8,000 Lung Injury Notes Review£11,400 Critical Illness and Gut Hormones£10,000 ROTEM Coagulation Profile (Longitudinal)£35,600 DSTL Pulmonary System

£900 ROTEM Operational Trial£14,000 Leishmaniasis & TB£41,100 Understanding and preventing visual loss in traumatic optic neuropathy

and commotio retinae£1,500 Patient Satisfaction Study

2010–11 £261,000

£9,000 Critical Illness and Gut Hormones£7,000 Acquisition of Novus Spectra Scanning Laser Ophthalmoscope

£23,300 How can the use of Bayesian Networks lead to better decision making inthe management of the mangled extremity?

£10,000 GAS NF and its association with blunt trauma£25,000 BIOSAP: Blast injury outcome study in Armed Forces personnel

£1,900 NI Blast Grant Application£300 A focus group study to explore General Practitioners’ perceptions of

reflective practice£500 FrameWork Software

£4,300 Phil. Trans. B Military Medicine Edition Photographs£7,200 Decompression Study

£81,400 INM—Casualty Nutrition Study£29,000 Laboratory simulation of blast-induced injury to the lower limb—BOOT

£700 STATA Software Package£24,300 Lower Limb Injuries from Under Vehicle Explosions

£800 SPSS Annual Site Licence



£10,000 Understanding and preventing visual loss in traumatic optic neuropathyand commotio retinae

£20,000 The Steroids and immunity from injury through to rehabilitation study(SIR)

£6,300 Rest & Relaxation Study

2011–12 £730,000PlannedBudget

*Pre 2008–09 a different budget structure existed and we could not identify previous funding lines for earlierresearch work without incurring disproportionate costs.

Question 354—Commodore McArthur said that the MoD was studying how to place people in the NHS—canwe see the results of the study

33. There is ongoing work how to improve ways of placing DMS personnel in the NHS in order to preparethem for military operations and to maintain their clinical skills, however there is no specific study or resultsto share with the House of Commons Defence Committee.

34. Work in this area will be taken forward as part of the recontracting of the MDHU capability for whencurrent contracts expire in 2013, which will take into account possible changes in the provision of the NHStrauma centres.

Question 363—Was decompression in Cyprus shortened from one week to 2 days? If so when?

35. In order to allow Service personnel returning from certain operational theatres to re-adjust in a graduatedand controlled manner, a period of Decompression is provided with the aim of reducing the potential formaladaptive psychological adjustment.

36. The period of Decompression generally lasts for between 24–36 hours as this has been determined asthe optimum period for ensuring that personnel returning from operations are given sufficient time to undergothe mandatory briefings and activities without delaying their homecoming any longer than is necessary. Theactual length of time that Service personnel spend at the current Decompression facility at Bloodhound Campin Cyprus is often driven by strategic transport timings or delays, but has never exceeded 48 hours. It thereforefollows that the decompression period has not been shortened from one week to two days.

37. The effectiveness and duration of Decompression is constantly monitored and at this time there are noplans to modify its duration or to significantly alter the content.

Question 371—What services does Staffordshire and Shropshire NHS Trust provide to the MoD?

38. Defence Medical Services mental health services are configured to provide community-based mentalhealth care in line with national best practice and in line with the guidelines and standards set by the NationalInstitute for Health and Clinical Excellence (NICE) and the National Service Frameworks. This is doneprimarily through 15 military Departments of Community Mental Health across the UK and four in Germany(plus mental health personnel in Permanent Joint Operating Bases and on operations), which provide out-patient mental healthcare.

39. In-patient care, when necessary, is provided regionally in specialised psychiatric units under a contractwith a partnership of eight NHS Trusts, led by Staffordshire and Shropshire NHS Foundation Trust. Thiscontract has been in place since 1 March 2009 and has enabled treatment to be offered close to the patient’shome or parent unit, using facilities at each of the Trusts concerned to ensure coverage across the country. AllService personnel requiring urgent in-patient care are admitted immediately to an appropriate facility wherethe aim is to stabilise and return the individual to the community (DCMH care) for onward management.

40. The other seven NHS Trusts involved in the partnership are Cambridge and Peterborough NHSFoundation Trust; NHS Grampian; Southern Health NHS Trust; Lincolnshire Partnership NHS FoundationTrust; Somerset Partnership NHS Foundation Trust; NHS Glasgow and Clyde and Tees, Esk & Wear ValleysNHS Foundation Trust. These Trusts are some of the highest-performing mental health NHS organisations inthe country and the development of a network of hospitals to provide care across the country in this way isunique and a first for the NHS. Close liaison is maintained between local DCMHs and the NHS Trusts toensure that all Service elements relating to inpatient care and management are addressed.

41. Staffordshire and Shropshire NHS Foundation Trust provides a single point of referral as well asadmission advice and guidance to MoD clinicians. As the “network lead” it will also guarantee the quality andgovernance of the services provided. The Foundation Trust status of South Staffordshire and ShropshireHealthcare offers MoD access to services that are subject to unprecedented levels of corporate governance andare monitored by an independent regulator.


Question 376—More detail on how many Departments of Community Mental Health provide alcoholprogrammes and what these contain and how many Armed Forces personnel have been through theprogrammes

42. All of the 15 UK Departments of Community Mental Health (DCMHs) provide assessment and treatmentof personnel presenting with alcohol problems, and treatment consists largely of individual psychotherapeuticapproaches, including Motivational Interviewing, Cognitive Behavioural Therapy for Substance Misuse andrelapse prevention by follow up support. Those that require it, will have access to pharmacological treatmentssuch as anti-craving medication (Acamprosate, Naltrexone) and aversive medication (Disulfiram aka Antabuse).Patients with dependence will have access to community detoxification and a few will be admitted for hospitaldetoxification. Social management is important, especially attention to occupational fitness and manipulationof the person’s environment to suit management of their problem. It should be noted that not all DCMHsprovide alcohol programmes (i.e. specific alcohol treatment groups).

43. There are a number of specific alcohol related education programmes. The three Royal Navy DCMHsrun two alcohol programmes. The “Basic Alcohol Education Course” is a one-day course that individuals canbe referred to by line management. The “Extended Alcohol Education Course” is a five-day alcohol educationintervention for groups of selected attendees of the one-day course. The Army DCMH at Catterick providesan alcohol programme consisting of three group sessions spaced a week apart, and involves follow up in asupport group after this. All these programmes involve a mental health assessment prior to entry to the groupsto help identify any additional mental health problems individuals may be facing.

44. The varied provision of alcohol programmes reflects both legacy provision and the current evidence basefor educational interventions in alcohol misuse treatment. Education programmes are of limited effect, althoughno robust (randomised and controlled) studies have been performed on military populations. The Royal Navyis currently conducting a randomised, controlled study looking at the effectiveness of its one-day alcoholeducation programme.

45. In 2008, 310 individuals presented for an initial assessment at a DCMH for alcohol substance use. In2009, 271 individuals presented. Validated data on how many individuals attend an alcohol treatmentprogramme is not held centrally, but the figure will be very similar to those presenting at initial assessment.

Question 379—General Berragan provided the Committee with hard copies of the guides for deployedpersonnel—regular and reserve, Is it possible to have electronic copies?

46. Electronic Copies were provided on 1 August 2011.

Question 381—General Berragan promised to come back with details of how many reservists lose their jobsafter deployment

47. The Reserve Forces (Safeguard of Employment) Act 1985 (SOE 85) provides protection for Reservistsby making it unlawful for an employer to terminate an individual's employment without their consent, solelyor mainly because they have a liability to be mobilised. The Act gives a mobilised Reservist the right to be re-employed by their former employer after demobilisation. This is however, subject to the Reservist making anapplication for reinstatement in due time, and the continued unchanged existence of their previous employingorganisation. Applications are made under SOE 85 to the Reinstatement Committee, through the TribunalsService.

48. Some Reserve personnel are made redundant in the current climate—normally fairly so—afterdemobilisation and an unknown number of Reservists find a new employment on their return to the civilianworkplace. As we know, people change jobs for a wide spectrum of reasons (pay, status, family, health, jobsatisfaction, work/life balance, diversification, employability, location et al).

However, since 2003 the Reinstatement Committee has dealt with:

33 cases6 successful3 unsuccessful12 withdrawn6 settled before the hearing4 outcome not known2 ongoing

These figures are set against a total of over 24,000 mobilisations since 2003.

Question 384—Could we have details of the mental health programme at RTMC?

49. The Reserves Training and Mobilisation Centre (RTMC) at Chilwell, Nottinghamshire coordinates theReserves Mental Health Programme (RMHP). Although it is a long established policy that Reserve Forces’medical care becomes the responsibility of their own local NHS primary care trust once demobilised, and themajority of Veterans’ physical and mental health needs are met by these provisions, the Department recognisedthat its in-service mental health expertise could help certain individuals in specific circumstances. The RMHP


was established in November 2006 to allow demobilised reservists access to MoD’s Departments of CommunityMental Health.

50. Under the programme, the MoD liaises with the individual’s GP and offers a mental health assessmentat the Reserves Training and Mobilisation Centre. If diagnosed to have a combat-related mental healthcondition, we then offer out-patient treatment via one of the MoD Departments of Community Mental Health.Defence Medical Service will assist those with more acute mental health to access NHS in-patient treatmentwhen necessary.

51. Individuals should approach their GP for a referral. This is the preferred method of contact to ensurethat both the doctor and the RMHP assessors are aware of all the factors affecting the individual’s health.Referrals from civilian psychiatric and veterans’ services (such as Combat Stress) are also accepted but thepatient’s GP is kept informed. In exceptional circumstances, individuals can contact the assessment centredirectly, but no patient will be accepted for treatment without a current GP registration.

52. The RMHP is open to any current or former member of the UK Volunteer and Regular Reserves whohas been demobilised since 1 January 2003 following an overseas operational deployment as a reservist, andwho believes that the deployment may have adversely affected their mental health.

Question 385—The Chair asked for details of the work MoD is doing with employers to get them toacknowledge the incredible benefit they get from employing reservists particularly when they have beendeployed

53. Our commitment to proper training of our Reservists will ensure that we continue to develop personaland professional skills of tangible value to employers and the wider community.

54. The MoD provides support for employers of volunteer reserves through the SaBRE campaign (SupportingBritain’s Reservists and Employers). It communicates the benefits, rights and legal responsibilities associatedwith employing a Reservist through a dedicated website and a freephone help line. In 2010 SaBREcommissioned an assessment of the value of Reserve Forces training to civilian employers and has produced aseries of short guides aimed at informing employers of the benefits to them of Reserve Service training. Thesehave been endorsed by the Chartered Management Institute. SaBRE also encourages discussing skill-sharingexperience when the Reservist is deployed and Reservists receive a performance report at the end of theiroperational deployment that they can share with their employer if they so wish. At the local level Reservists’parent units, the Chain of Command and the regional staff of the Reserve Forces and Cadets Association allwork closely with employers.

55. The National Employer Advisory Board has recommended the piloting of a “Partnership for Talent”between Defence, Education and Industry whereby these three are in a joint venture in seeking talented school-leavers and undergraduates. The aim would be to jointly recruit, train and develop selected high calibregraduates; potentially involving mutually beneficial co-sponsorship. Subsequently Reserve Service could beused by employers as an integral part of their management and leadership training. This is being taken forwardas part of Future Reserves 2020 Study recommendations under the extant Defence Career Partnering initiative.

Question 391—General Berragan used a diagram to illustrate the recognised recovery picture, could we havea copy of it please?

56. Electronic Copies were provided on 1 August 2011

Question 409 and visit to QE Hospital Birmingham—Commodore McArthur talked of the support given tostaff working at the Hospital and Headley Court. Could we have a summary of the approach and supportbeing given

Royal Centre for Defence Medicine (RCDM) at QE Hospital Birmingham

57. A number of measures have been introduced at the RCDM at Queen Elizabeth Hospital Birmingham tofully support staff. There is rigorous enforcement of the operational stress management policy within the Unitand a full time welfare officer has been available since 2010. TRiM training will have been given to over 50personnel by October 2011.

58. The RCDM induction session for new staff includes an introduction to psychological education givenby a psychologist and a mental health nurse, a presentation by a welfare officer and the padre on what supportis available. All professional groups have confidential access to psychological support. A pilot on joint military/civilian group sessions will commence in August 2011.

59. There are a number of initiatives to promote military ethos for those military personnel serving at theRCDM. The RCDM Military Development Systems mandates a number of compulsory days training every sixweeks for most military personnel to enhance Service ethos and military development. Sessions include regularinput to managing stress and coping strategies by mental health professional. There is a strong emphasis onfitness; RCDM has compulsory fitness sessions to ensure personnel maintain their fitness to deploy and thereare opportunities to attend Adventurous Training. There are a number of other entertainment and leisureprogrammes in place to promote military ethos and esprit de corps.


Defence Medical Rehabilitation Centre (DMRC) at Headley Court

60. There are similar support initiatives to support staff at DMRC. This is a mixture of in unit programmes,line management advice and self help networks. Each team devise their own programme of group activities toact as a means of stress relief and team reinforcement for which DMRC provides a level of financial supportfrom non public funds.

61. Staff benefit from significant public recognition which helps them come to terms with the more extremecases they deal with. External organisations offer the opportunity for staff and patients to visit public events,and military units often invite personnel to visit them to express their gratitude for the work that DMRCstaff undertake.

62. For staff that have specific welfare issues such as finance or domestic, Line Managers will do everythingto sign post and advise personnel on what services might be available from within Defence and externalorganisations. Line Managers are also expected to allow personnel sufficient time away from work for them tobe able to resolve their issues without feeling the pressure of work.

63. DMRC management take the mental health of their staff seriously. An assessment process has been putinto place to help monitor the resilience of both individuals and groups to stress. There are also standardprocesses for managing long-term sickness and any associated occupational health issues.

6 September 2011

Supplementary written evidence from the Ministry of Defence

RESPONSE TO QUESTIONS FROM HEARING ON 14 SEPTEMBER 2011

Question 475—Information on DMS 2020

1. The Defence Medical Services 2020 project (DMS 20) was established in January 2011, as a componentof the further work arising from the recent Strategic Defence and Security Review. The Surgeon General setup the DMS 20 project to establish what medical capabilities were required to support Defence in the future,and how they can be best delivered.

2. The project, which is planned to complete its analytical phase by March 2012, is considering therequirement for defence medical capability of the future operational environment, including support tohumanitarian and disaster relief, stabilisation and UK resilience operations. The project will carry out amanpower liability review to identify how many personnel will be needed across all the medical specialism’s.In establishing what the future manpower requirement is, the study will then look at how the requirement couldbe met through utilising regular, reservist and non-uniformed healthcare providers. The training requirementsare also being carefully considered given the long period of training required for some roles.

3. In developing a clearer understanding of Defence’s future healthcare requirements, the project has re-visited the 2006 Policy and Programmes Steering Group baseline and analysed the new strategic guidance. Setagainst the backdrop of endorsed 2015 and 2020 security scenarios, cognisant of lessons identified and medicalevolution in the operational arena, a multi-disciplinary team has completed a cross referencing of future medicalcapability goals with current capabilities and identified capability deltas. The Project Team has also identifiedthe range of medical effects that Defence will require in the 2020 era.

4. The project is just one of the post Strategic Defence and Security Review works strands and projects suchas Whole Force Concept, Total Support Force, New Employment Model and Future Reserves 2020, each witha vision for 2020 and beyond. DMS 20 has links with all these projects where required.

Question 484—PTSD in medical personnel

In Iraq

5. The most informative work on understanding the mental health of Armed Forces medical personnel whohad been deployed to Iraq is a 2008 study undertaken by King’s Centre for Military Mental Health Research.

Jones, M; Fear, N; Greenberg, N; Jones, N; Hull, L; Hotopf, M; Wessely, S; Rona, R (2008) Do medicalservices personnel who deployed to the Iraq war have worse mental health than other deployed personnel?European Journal of Public Health; 18 (4): 422–427.

Abstract:

6. Aim: There is evidence of increased health care utilization by medical personnel (medics) compared toother trades in the UK Armed Forces. The aim of this study was to compare the burden of mental ill health indeployed medics with all other trades during the Iraq war.

7. Methods: Participants’ main duty during deployment was identified from responses to a questionnaire andverified from Service databases. Psychological health outcomes included psychological distress, post-traumaticstress disorder, multiple physical symptoms, fatigue and heavy drinking.


8. Results: A total of 479 out of 5,824 participants had a medical role. Medics were more likely to reportpsychological distress (OR 1.30, 95% CI 1.00–1.70), multiple physical symptoms (OR 1.65, 95% CI 1.20–2.27)and, if men, fatigue (1.38, 95% CI 1.05–1.81) than other personnel. Female medics were less likely to reportfatigue (0.57 95% CI 0.35–0.92). Neither post-traumatic stress disorder nor heavy drinking symptoms wereassociated with a medical role. Traumatic medical experiences, lower group cohesion and preparedness, andpost-deployment experiences explained the positive associations with psychological ill health. Medics madegreater use of medical facilities than other trades.

9. Conclusions: There is a small excess of psychological ill health in medics, which can be explained bypoorer group cohesion, traumatic medical and post-deployment experiences. The association of mental ill healthwith a medical role was not the consequence of a larger proportion of reservists in this group.

In Afghanistan

10. A study of UK military personnel who were deployed to Afghanistan between 23 January and 20February 2010 on Op HERRICK 11 is currently being finalised by the King’s Centre for Military HealthResearch. The aims of the Operational Mental Health Needs Evaluation are to assess the mental health statusof the deployed force and to make appropriate recommendations about potential gaps in support provision andon other topics that were of relevance to the mental health of the deployed force. We will provide the Committeewith the results of the survey in due course.

In UK

11. In order to help the Committee understand the prevalence of mental health issues in medical personnelin the UK, DASA has produced Table 1. It presents the detail of all attendances at Departments of CommunityMental Health (DCMH) in UK, Germany, Cyprus and Gibraltar, with those identified as medical professionals.The data provided below includes all new attendances between January and June 2009 and all new episodesof care between July 2009 to 31 December 2010. It is important to note that table only details the initial mentaldisorders assessment of those reporting to a DCMH rather suggesting an indicative rate for either the wholeService population or the whole Service medical profession.

Table 1

UK ARMED FORCES PERSONNEL DCMH ATTENDANCES,1, 2 MEDICAL CORPS,3, 4, 5

BY INITIAL MENTAL ASSESSMENT, 2009 AND 2010, NUMBERS AND RATESPER 1,000 STRENGTH6

All1, 2 Rate 95% CI

Mental Disorder—All Service personnel 7,478 37.2 (36.4–38.0)Psychoactive substance misuse 637 3.2 (2.9Mood Disorders 1,729 8.6 (8.2–9.0)

of which depressive episodes 1,591 7.9 (7.5–8.3)Neurotic Disorders 4,552 22.6 (22.0–23.3)

of which PTSD 420 2.1 (1.9–2.3)of which Adjustment disorders 2,827 14.1 (13.5–14.6)

Other mental health diagnoses 560 2.8 (2.6–3.0)

Of which medical professionals3, 4, 5 597 64.8 (59.6–70.0)Psychoactive substance misuse 22 2.4 (1.5–3.6)Mood Disorders 159 17.3 (14.6–19.9)

of which depressive episodes 147 16.0 (13.4–18.5)Neurotic Disorders 381 41.4 (37.2–45.5)

of which PTSD 35 3.8 (2.5–5.1)of which Adjustment disorders 229 24.9 (21.6–28.1)

Other mental health diagnoses 35 3.8 (2.5–5.1)

1. Assessed as having a mental disorder at initial assessment.2. New attendances until June 2009, all new episodes of care July 2009 onwards.3. Medical professionals in Naval Service as recorded on JPA as RN Dental (OF), RN Medical (OF), RNMedical (GS), RN Medical SM, RN QARNNS , RN QARNNS (OF) and RN Royal Marines GS.4. Medical Professionals in the Army as recorded on JPA as Royal Army Medical Corps, Royal Army DentalCorps, Royal Army Veterinary Corps and Queen Alexandra’s Royal Army Nursing Corps.5. Medical professionals in the RAF as recorded on JPA as Dental, Dental Officer RAF, Medical, MedicalOfficer RAF, Medical Support and Princess Marys RAF Nursing Service.6. Rates expressed per 1,000 of 2010 UK Armed Forces strength.7. As recorded on Joint Personnel Administration system


Analysis

12. The DASA mental health data describes only those military patients who have sought help for a mentalhealth problem through primary care and who have subsequently been referred on to the Defence MentalHealth Services provided at the MoD’s Departments of Community Mental Health. The data thus providesinformation about those personnel who are help-seeking and does not provide information about those whohave either been seen in primary care only or who have not sought medical help for a mental health problemat all.

13. There are a number of possible explanations for the higher rates of mental health diagnoses amongstmedical personnel. This could be due to more help-seeking behaviours being exhibited by professional medicalpersonnel. It can be supposed that such a group might have more positive views about mental healthcare thannon-medics and may have greater respect for professional treatment from colleagues they may know personally.Furthermore, medical personnel are more likely to be better placed to request referral as they will have greaterknowledge about the DMHS and its capabilities than non-medics. A higher referral rate by primary careprofessionals might be an attempt to provide extra help to those within their own profession or to ensure thatany fitness to practice issues are addressed (which are likely to be at the forefront of a primary careprofessional’s mind). It is important to note that the DASA DCMH data cannot elucidate the possibleprevalence of mental health disorders in those who do not attend a DCMH.

14. However, it is notable that most of the whole force surveys which have been undertaken with medicalpersonnel during and after deployment have failed to find any substantial global impact of operations upon themental health of medical personnel. There is good evidence that medical personnel are significantly differentto the Armed Forces as a whole in terms of their mental health status, as is the case in the civilian environment.

15. Previous research, such as the aforementioned study on mental health and operations in Iraq, indicateswhat appears to be a mild (negative) deployment mental health effect for medical personnel who served inTELIC 1–5. Ongoing research suggests that this may well be restricted to medical personnel who served withfront-line units. However, the overall size of this effect appears small and further research is needed to clarifythe possible reasons for this. It may simply be because of greater exposure to potentially traumatic events inthe same way as happens to combat troops who serve in frontline areas.

Data Context

16. DASA have made some changes to data collection and validation from July 2009 onwards. Prior to July2009, the MoD identified individuals who had previously attended a DCMH and removed them from theanalysis. The Department now include all new episodes of care, including both first referrals and patients whowere seen at a DCMH previously, were discharged from care and have been referred again for a new episodeof care and, as a result, the numbers are expected to increase.

Question 484—Psychological support for those medics deployed in Afghanistan, in particular, at CampBastion

17. Medics deployed to Afghanistan have access to the same psychological support offered to all Servicepersonnel, and utilise both TRiM and the standard Decompression process.

18. They have access to the mental health services in theatre, including whilst at Camp Bastion. This includesaccess to Field Mental Health Teams that comprises full time community mental health nurses and periodicclinics by consultant psychiatrists, who are available to provide any care and treatment needed. In addition,should the need arise, a UK-based team of a psychiatrist and mental health nurses are available to deploy toAfghanistan at short notice.

Question 495—Waiting times for referral and treatment under the contract with the South Staffordshire andShropshire Foundation Trust

19. There are no waiting times for referral or treatment into the South Staffordshire and ShropshireFoundation Trust contract. The requirement for the contract is that an acute bed is made available for physicaladmission of the patient within 4 hours of the request for a bed being made. This applies 24 hours per day 7days per week. The Trusts involved in the contract are currently meeting the admission criteria withoutexception and indeed beds are generally allocated immediately.

Question 500—Confirmation that those medically discharged get the full resettlement package even if theyhave served less than four years

20. All medically discharged personnel, regardless of how long they have served are entitled to the fullresettlement programme.

Question 522—Use of the compensation received for injury

21. The MoD is unable to provide independent financial advice to individuals. However, officials are workingwith a charity partner to identify how the provision of money guidance and financial advice can be further


expanded through the development of a tri-Service package. This includes raising individuals’ awareness ofschemes such as trust funds.

22. Currently, when an individual receives compensation through the Armed Forces Compensation Scheme(AFCS) the notification of award letter issued by the Service Personnel and Veterans Agency includesinformation on the use of trust funds. This informs the recipient who has received a lump sum payment thatthe award could be placed in a personal injury trust fund. If the lump sum is put into a trust fund within 12months of receipt, it should be disregarded for the purposes of assessing entitlement to income-related benefits.However, the detailed application of the relevant rules is a matter on which the individual should seek advicefrom the Department for Work and Pensions, from an independent financial adviser or from one of the ex-Service organisations with expertise in such matters.

23. Details relating to the option to place an AFCS lump sum award into a trust fund are included withinthe AFCS training package aimed at key personnel within the chain-of-command who provide information ona wide range of issues.

Question 533—JSNA

24. In 2007, section 116 of the Local Government and Involvement in Health Act introduced a duty for localauthorities and PCTs to undertake a Joint Strategic Needs Assessment (JSNA) of the health and social careneeds of the area. Subsequent statutory guidance described JSNA as “the means by which they [local partners]will describe the future health and social care needs of the population” (HM Government, 2007, paragraph3.28). This is expected to be carried out jointly by the Director of Public Health, the Director of Adult SocialServices and the Director of Children’s Services, under the duty which commenced on 1st April 2008. Thiswas later reinforced in best practice guidance published in December 2007, which sets out expectations withregards to (Department of Health, 2007):

— The various stages of JSNA.

— Stakeholder and community involvement and engagement.

— Timing and duration.

— Links to other strategic plans.

25. In particular, JSNA is defined as “a systematic method for reviewing the health and wellbeing needs ofa population, leading to agreed commissioning priorities that will improve the health and wellbeing outcomesand reduce inequalities” (Department of Health, 2007, p 7). Conceived as a continuous process, JSNA shouldbe underpinned by effective partnership working, community engagement and evidence of effectiveness, witheach JSNA reflecting unique local circumstances. Focusing on current and future needs (over at least three tofive years, but also including a longer term assessment), JSNA should align with three-yearly Local AreaAgreements (LAAs) and should link to a range of additional local authority and PCT strategies and plans.

Question 534—Details of the Armed Forces Networks and how they operate

26. The Armed Forces Networks have been established in each of the 10 existing Strategic Health AuthorityAreas in England. Their purpose is to help bring together and coordinate services for ex-Service personnelwithin that area, and in doing so go further towards ensuring that access to relevant healthcare is as easy aspossible for veterans.

The “mission statement” for the AF Networks is as follows:

— To provide regional NHS leadership, advocacy and points of liaison for Military Health issues.

— To work with regional military, social services and third sector organisations to ensure thedelivery of Armed Forces community programmes.

27. There is a requirement in the current Operating Framework for SHAs to ensure that these continue aspart of the transition process of the changing NHS. The Networks have been a major success in delivering theArmed Forces, their families and veterans agenda at a local level. Where difficulties have arisen at a locallevel, the local military health champion, who is the lead person in each Armed Forces Network, have workedclosely with the appropriate organisation to ensure that they are dealt with quickly.

Question 539—Explanation of how the national priority for treatment of veterans works in the devolvedadministrations

28. The Ministry of Defence and the Department of Health are not able to comment on Healthcare matterson behalf of the Devolved Administrations. The Department of Health wrote to each of the DevolvedAdministrations seeking an explanation of how the national priority for treatment of veteran’s is beingsupported by the Governments of Scotland, Wales and Northern Ireland.

Scotland

29. In July 2008 the Scottish Government published its paper “Scotland’s Veterans and Forces’Communities’: meeting our commitment” which sets out the Scottish Government’s commitment to Armed


Forces’ personnel, their families and to veterans. It also sets out the Scottish Government’s action within itsdevolved responsibilities. One of the first commitments to be achieved was to extend the Priority Treatmentscheme to allow all veterans priority access to treatment for Service-related conditions. Chief Executives ofNHS Boards were informed of the extension via Chief Executive Letter (CEL) 8 (2008).

30. Priority treatment for veterans is publicised through leaflets that are widely available at locations suchas GP practices. In addition, the new patient registration form to register with a GP practice in Scotlandincludes a question about former Armed Forces Service which helps to raise the GPs’ awareness of patients’veteran status. The voluntary sector in Scotland is actively involved in raising awareness among veterans abouttheir entitlements to priority treatment in NHS Scotland, under certain circumstances.

31. If a patient informs the GP of their veteran’s status and the eligibility for priority treatment in the NHS,the GP includes this information in the referral letter, where a referral is considered clinically appropriate, andagreed with the patient. The patient is then offered an accelerated appointment at the discretion of theconsultant, taking account of the clinical need.

Wales

32. In June 2008 the Welsh Government published Welsh Health Circular 051, setting out its commitmentto prioritise improving the health and well-being of Service personnel and veterans in Wales. This extendedthe provision of priority NHS treatment from war pensioners to all veterans who have a health problem asresult of their Military Service.

33. In February 2011, the Welsh Government also wrote to all GPs reminding them of this commitment andthe process they should follow to ensure veterans are identified for the receipt of priority treatment.

34. In 2010–11 the Welsh Government published an Annual Operating Framework target for Local HealthBoards (LHB) which reminded them of their obligations to veterans, by requiring them to specifically considerthe needs of Service personnel and veterans when planning services. This requirement is supported withinLHBs by the appointment of Veterans’ and Armed Forces Champions who advocate for veterans and Servicepersonnel to ensure that their needs are reflected in service plans and provide, disseminate information, betweenLHBs and others.

35. The Welsh Government is currently considering further training and information needs whichcompliments work currently underway both within the NHS and working with Third Sector partners in Wales.

Northern Ireland

36. The provisions of section 75 of the Northern Ireland Act 1998 prevents the Department of Health, SocialServices and Public Safety (DHSSPS) and the Health and Social Care (HSC) sector in Northern Ireland inproviding war veterans with priority over other individuals with respect to healthcare treatment.

37. The DHSSPS drew up “A Protocol for Ensuring Equitable Access to Health and Social Care Services”in 2009. This commits the Department and HSC to ensuring that war veterans receive equality in access tohealthcare provision across Northern Ireland and that the HSC must be responsive to the needs of war veteransas a particular population group amongst other population groups within Northern Ireland.

38. To give effect to this commitment an Armed Forces Liaison Forum was established consisting ofrepresentatives of the Department, HSC and war veteran organisations and other military stakeholders. TheForum meets on a regular basis.

Question 549—Explanation of how the charities and the MoD are supporting the children of seriouslyinjured Armed Forces personnel

How MoD are supporting the Children of seriously inured Personnel

39. The Directorate Children and Young People (DCYP) was established in 2010 by the Ministry of Defenceso that children and young people worldwide, who belong to the Armed Forces community are notdisadvantaged due to their links with the Services. DCYP are working closely across organisations within theMoD, Other Government Departments, Service Families Federations, and external organisations and charitieswhich focus on improving the lives of children and young people.

40. Service Children’s Education (SCE) provides education for the dependent children of Armed Forcespersonnel and UK based civilians serving overseas. It is the key delivery partner to DCYP. Where the familyof an injured Armed Forces member are located overseas, SCE provide access to professional Social Workersand Educational Psychologists to support those families and children.

41. The Children’s Education Advisory Service (CEAS) provides Service families with expert, non-legaladvice and information about all aspects of children’s education and now forms an integral part of DCYP.CEAS maintains a database of independent schools which are used to dealing with the Service community andwhich offer bursaries to support Service children where a parent has been medically discharged as a result ofan operational-related injury. The existence of those schools is brought to the attention of the Service


community annually. CEAS also provides help and support to families who have to relocate and change schoolsfollowing the medical discharge or loss of a parent as the result of operational deployment.

42. In March, the Ministry of Defence’s PUS agreed that through the Grant-in-Aid mechanism, relief forschool fees for children whose parent had died whilst serving may be accessed, giving a clear message aboutthe Government’s commitment to compassionate support.

43. It is of note that in September, The Duke of York’s Royal Military School (DYRMS), set up in 1801specifically to cater for the orphans of those who had fallen in the 1793–1815 Anglo French war, achievedacademy status. Within the Grant-in-Aid scheme, the MoD intends to provide similar relief with regard toDYRMS bursaries where a child’s parent dies as a direct result of operations or active duty. Applications willbe considered on a case-by-case basis.

44. In May the government announced a fund of £3 million per year over the next four years to supportschools with Service children among their pupil population, during periods of movement into or out of theirarea of Service units, including large-scale deployments. The fund is controlled by DCYP who have launcheda concentrated communications campaign to alert Local Authorities throughout the whole of the UK, as wellas internal MoD civilian and Service personnel, about the fund. Details are on the DCYP website.

Role of Charities in supporting the Children of injured personnel

45. Each of the three Services is responsible for the welfare of their Service personnel, families anddependants. This welfare support network is provided by the Naval Personnel and Families Service (NPFS),the Army Welfare Service (AWS) and, for the RAF, the Soldiers, Sailors, Airmen and Families Association(SSAFA)—Forces Help.

46. The Soldiers, Sailors, Airmen and Families Association (SSAFA)—Forces Help also facilitates a supportnetwork specifically for the family members of injured Service personnel. The “Support Group for the Familiesof Injured Service Personnel” (FISP) is a tri-Service group that offers family members the opportunity to meetand talk with others whose relatives have also been injured while serving in the Armed Forces. It meetsregularly at a variety of locations around the country providing mutual support and allowing families to benefitfrom shared experiences, information and advice.

47. There are other bodies, services and activities which meet the needs of bereaved families. These includeaccess to appropriate counselling services once a need has been identified through the normal welfare supportnetwork. This may entail making use of national organisations such as the Child Bereavement Charity orCRUSE (which has a Service-specific element), or more Service-specific bodies such as SSAFA support groupsfor bereaved families and for bereaved siblings. Families Activity Breaks provide activity holidays for bereavedService families where informal counselling is available for children.

28 September 2011

Further written evidence from the Ministry of Defence

What is the MoD policy on the redundancy of those who have stayed in service after being injured onoperations?

It is MoD policy that no individual who is medically downgraded after being injured on operations willleave the Armed Forces through redundancy or otherwise until they have reached a point in their recoverywhere it is right for them to leave. Those who wish to apply to be considered for redundancy will be consideredalongside others in the redundancy field. Redundancy is not being used in place of the established medicaldischarge process, and the Department does not use medical employability data as part of the redundancyselection criteria.

How many injured Service personnel have been made redundant in the latest rounds and how many are intrain in the current and future rounds?

In the first tranche of the latest rounds of Armed Forces redundancies, a number of Service personnel havebeen identified whose employment status indicates that they have been medically downgraded. However, noindividual has been identified as having their medical status downgraded because of an injury sustained whileon Operations.

As at 1 September 2011, of those selected for redundancy in the Army, 34 individuals have been identifiedas permanently medically downgraded. Those who were temporarily medically downgraded, for whateverreason, were exempted from selection as non-applicants. In the Navy, 310 individuals selected for redundancywere identified as permanently or temporarily downgraded. In the RAF, 247 individuals selected for redundancywere identified as permanently or temporarily downgraded.


Modelling is currently underway to identify suitable areas for tranche 2, which will also inform subsequenttranches; however, no individuals have yet been selected.

26 October 2011

Written evidence from the Royal Navy and Royal Marines Widows’ Association

The Royal Navy and Royal Marines Widows’ Association (RN&RMWA) was formed over two years agoto provide support, information and friendship to those widowed whilst their partners were serving with theRoyal Navy and Royal Marines. It also offers Associate Membership to those whose partners died after theyleft the Service. Members include those whose partners were killed in action and also those who have died inaccidents and of natural causes; no distinction is made.

The welfare support given to members deals with a range of experiences, many positive but some negative.It appears to be the case that, over time, there has been a general improvement in the way widows are treatedby the System. In particular, there have been significant improvements in the Welfare Package delivered bythe Naval Service. This is, we presume, a consequence of the current high operational tempo and the numberof service personnel who have been badly injured or killed in Iraq and Afghanistan.

However, there are several issues that we would like to raise for discussion:

— One issue which seems to crop up regularly is communication, described by one of ourmembers as “profoundly hit and miss”. The onus, it seems, is on the spouse/partner toinvestigate and seek out information rather than the Services coming forward with all theappropriate details. Examples include a lack of information regarding the financial packageand pension entitlement, and also, in a few cases, the nature of the death. As you willappreciate, this is a very stressful time for those who have lost someone and not a time whenthey should have to proactively seek information. There is a perception of the System puttingup defensive barriers to protect itself rather than being open and honest in sharing whatinformation it has with the bereaved partner.

— Paradoxically, and following the point above, it seems there is a wealth of informationregarding what is available from the Ministry of Defence and the various Service charities,but very often it is difficult to access. A website and telephone helpline centralising all theagencies and charities might be helpful.

— We are unsure whether there is financial parity between a member of the Armed Forces killedduring their service and other public sector key workers killed whilst on duty? It is felt bythe widows that they should not be financially penalised and their standard of living affected,especially those who lost their partners on operations. The proposed changes to the waypensions are calculated will not alleviate this issue and widows will continue to rely oncharities to fill the gap.

— The Visiting Officer (VO) plays an incredibly important role in the weeks and monthsfollowing bereavement, and a positive relationship between the VO and the spouse/partner isvital. We know of many instances where this is the case and VOs have gone beyond the callof duty. However, this is not always the case. Some of our members have been givenmisinformation by VOs regarding a variety of issues, and some relating to financial supporthave subsequently taken years to sort out. Rather than give the wrong information, if a VOdoes not have the answer it is far better if they acknowledge this, seek it out, and come backto the spouse/partner. VOs must be consistent, honest, available and well informed.

— Members of our Association have in recent years participated in VO training days inPortsmouth. Also participating have been bereaved parents and family members of thoseseriously injured. These training days have proved extremely useful and informative to thoseattending. Listening to personal accounts and experiences of good and bad practice hasincreased awareness of what works and what doesn’t.

Lesley-Ann George-TaylorChair

Bridget RobisonTreasurer

20 April 2011


Written evidence from Soldiers, Sailors, Airmen and Families Association (SSAFA) Forces Help

1. Preface

1.1 Although it is understood from the Terms of Reference of this inquiry that the focus is upon membersof the Armed Forces and civilians wounded in the Service of their country, and their families, and that it isimplicit that this relates principally to operations in Iraq and Afghanistan, it needs to be emphasised that byfar the majority of Service personnel classified as Long Term Sick by virtue of injury or illness are not directlycaused by those operations.

1.2 Although of less high profile than the often very visibly wounded amputees, this very substantial group,including those with both physical and mental health problems, is just as deserving of treatment andrehabilitation.

Taking the Committees areas of interest in turn:

2. Current treatment and rehabilitation

2.1 The Armed Forces and MoD, together with NHS and other Agencies, now have in place world classfacilities for clinical treatment and rehabilitation.

3. Treatment and Rehabilitation in the longer term

3.1 This depends on what is meant by the “longer term”, as even for those wounded in the earlier stages ofIraq and Afghanistan, it is probably too early to assess and the majority of high profile wounded have not yetbeen discharged from the Armed Forces , even though in some cases this might have been in their overallbetter interest. Keeping wounded in service as a matter of policy, when it is clear that they are highly unlikelyto ever regain their former combat employment, is probably an act of misguided compassion. Their future andability to settle as civilians is probably better served by starting the process as early as psychologically andphysically possible.

4. Effectiveness of support processes on return to work or discharge

4.1 The Personnel Recovery Units as part of Army Recovery Capability are designed to assist with this butthese are only at a very early stage, and not yet fully operational. Again it should be emphasised that the“wounded in action”, although very important, are a minority of those classified as Long Term Sick. ThePersonnel Recovery Centres based upon newly built premises in garrisons are welcome new assets but there isa difference between providing real estate to accommodate, as opposed to the soft services need to deliver. Theemphasis upon Command and Control as opposed to treatment and management is understandable in a militarysetting and culture but might not be the most conducive to recovery, rehabilitation, and moving on byindividuals. There is a real risk of institutionalization by corralling, sometimes in locations which althoughconvenient for the chain of command, may not suit the individual. It is where you are going which is moreimportant than where you have come from.

5. How effectively does MoD work with Local and Health Authorities

5.1 There is no general answer to this as much depends upon where and which Authority and it is in mostcases too early to tell. The Military Covenant should improve this but already there are some very goodexamples of best practice by NHS Trusts and Strategic Health Authorities under the umbrella of DH sponsoredArmed Forces Forums—South West Region has already provided an impressive lead. Local Authorities are adifferent matter and this is much more patchy. It needs to be re-emphasised, though, that the numbers ofwounded are still very small compared with the overall patient population dealt with by NHS. It probably doesnot augur well that both Primary Care Trusts and Strategic Health Authorities are disappearing with imminentreorganization, at the same time as major budget savings are being made in both Health and Local Authorityprovision and MoD is undergoing constant change—particularly with the churn of Armed Forces personneland civil servants.

6. The role of the charitable sector in providing support to personnel and their families

6.1 Speaking from the standpoint of SSAFA Forces Help, as a charity committed for 125 years to relievingneed, suffering and distress of Service and ex-Service personnel and their families, the approach has alwaysbeen to concentrate upon real assistance by provision of highly practical services in both health, social care,and where necessary, accommodation. These “expert” services are generally those where public funds(including MoD) cannot or should not provide. SSAFA, for example, provides specialist support groups forbereaved families, as well as for families of the wounded—families are defined very widely including allgenerations from grandparents to siblings. Another example is The Norton Houses at Selly Oak and HeadleyCourt which provide home from home accommodation, free of charge, so that families can be together in asupportive environment close to clinical facilities. It is strongly believed that these kinds of relativelysophisticated provisions for complex needs are a far better use of resource than extensive charitable spendingon vanity real estate projects in Army garrisons which, arguably, might be more appropriately provided fromthe public purse.


7. How well do Armed Forces and MoD treat mental health problems of returnees from conflict zones

7.1 In general both proactive and preventative mental health measures are well provided for Servingpersonnel from a clinical perspective. There are three areas of concern however. Firstly that sections of ArmedForces culture still regards alcohol abuse as an acceptable normal pattern. This is a significant exacerbatingfactor in mental health. Secondly there is widespread reluctance for Serving personnel to report sick to militarydoctors for mental health concerns, due to perceived potential career limitation. Thirdly, in the UK, the familiesof Serving personnel, who are directly affected, do not enjoy the same level of mental health support as thoseposted overseas eg in British Forces Germany (BFG) since they are NHS patients and accessing appropriatecommunity mental health services is often a postcode lottery although, again, there are some good examplesof innovative NHS provision, including the Catterick IAPT scheme. For those families stationed abroad (egBFG), community mental health provision is the same as for serving as MoD is responsible, with SSAFA inBFG, for providing community mental health and social work services. Providing integrated mental healthsupport for families as a whole has much to commend it.

8. How are families of those wounded in action or bereaved supported?

8.1 The Armed Forces and MoD provide support in a variety of ways, understandably concentrating mainlyon the immediate duty of care as an employer. Although mainly effective at what it can achieve in the shortterm, it is realistically limited both in time and space. Part of the grieving and loss process is anger and hostilitytowards the perceived agent of the loss—in this case the Chain of Command and MoD. It is very often easierfor a completely independent but skilled entity like SSAFA to provide no-strings support—particularly helpingindividuals to help themselves and helping others in similar circumstances, by enabling Support Groups. Wewould be pleased to brief the Committee at greater length on the variety of Support Groups provided bySSAFA to support a wide variety of families affected by the bereavement of, or injury to, Serving personnel.(Jane Barnes, an expert in this area, could be made available to give further evidence.)

9. Are there differences for members of Reserve Forces

9.1 Intrinsically there should be no differences, except those driven by location and other circumstances ofthe Reservist’s family. As they do not generally live in immediate proximity to military bases and tend to bewidely spread, this is an organisational rather than generic problem. There is a view that being “outside thewire” can isolate Reservist families and that civilians do not understand their peculiar problems. In somerespects, however, being embedded within a stable civilian community can be an advantage.

9.2 Notwithstanding the observations concerning the inconsistent nature of health care for families of Regularpersonnel, there is some evidence that Reservists and families of stable residence are able to access NHSservices more effectively and with greater confidence.

10. Compensation to injured and their families

10.1 The revised financial compensation packages noted by Lord Boyce are generally fair. Comparisonsmade with other compensation schemes are generally not relevant. It is not generally explained that ArmedForces Compensation Scheme lump sum payments are tax free and the associated Guaranteed Income Paymentsfor more serious injuries are not only tax free but also for life. It is a matter for concern that when large sumsof money are granted, often to quite young financially unaware people, that the appropriate level of advice onprudent investment is lacking. Complications do arise in the matter of compensating families, particularly forthose in complex personal relationships, but this is not inherently a problem of the financial adequacy of theCompensation Scheme.

25 May 2011

Written evidence from Help for Heroes

“A man who is good enough to shed his blood for his country is good enough to be given a fair deal afterwards.More than that no man is entitled to, and less than that no man shall have.”

Theodore Roosevelt, Springfield, Illinois, 4 July 1903

Background

The charity Help for Heroes (H4H) was launched on 1 October 2007 in order to provide direct, practicalsupport to those injured or affected by their service in the Armed Forces (including their families). H4H’scharitable objects are fairly wide but in order to avoid overlapping with other charities, the decision was tofocus on supporting those affected by current conflicts, ie post 9/11. (H4H Charitable Objects; Appendix 1)

Initially intended to be a single focus appeal to raise money to help provide a swimming pool at the DefenceMedical Rehabilitation Centre (DMRC) Headley Court, it quickly became apparent that there was huge publicsupport for the charity’s simple stance of being “non political, non critical, we just want to help”.


Funds have now been directed to both capital projects, such as the Rehabilitation complex at Headley Courtand the new wings at Combat Stress and St Dunstan’s, as well as towards individuals through the QuickReaction Fund (QRF) and Individual Recovery Programme (IRP) funds.

H4H operates a “money in, money out” policy and seeks to grant all funds received less reserves held tomeet the charity’s anticipated fixed support costs for the coming year. Overheads are kept to a minimum andare offset by income from the Help for Heroes Trading Company, which sells merchandise and licenses itsbrand to create revenue, which is gifted across to the charity. The charity currently (2009–10 audited accounts)is 104.5% “efficient” and of the £100 million received, £95 million has been spent or allocated to either capitalprojects or funding for individuals.

H4H works closely with other Service charities especially ABF—The Soldiers Charity, Combat Stress,BLESMA, SSAFA Forces Help, The Royal Navy Royal Marines Charity and many others. In some casesfunding capital projects and in others using them to help distribute funds to individuals. (Summary of grantsto date; Appendix 2)

H4H is currently involved in a large capital project, in partnership with MoD and The Royal British Legion(TRBL) and others, to build a series of Recovery Centres at Catterick, Colchester, Plymouth and Tidworth and,in due course, to upgrade or provide further centres at Edinburgh (currently a “pathfinder” project launched in2009 with Erskine and now funded by TRBL) and in the Midlands. The PRCs are intended to act both as anassessment and preparation phase for the wounded, injured or sick individual (WIS), a ‘launch pad to life’, aswell as a short-term residential capability.

H4H draws no distinction between the three Services, Regular or Reserve Forces and it supports both thoseinjured in training and in action. Increasingly it is providing support to those who have left the Services.

The total commitment to this Defence Recovery Programme is in excess of £100 million. (Appendix 3;Defence Recovery Capability and Overview)

The Road to Recovery

1. H4H views the recovery process as a long road that begins at the point of injury, goes through Aeromedevacuation to the Birmingham group of hospitals, continues at DMRC Headley Court and beyond.Rehabilitation at Headley Court or the Regional Rehabilitation Units (RRUs) can continue for months or eventwo or three years before the patient is ready to accept that the time has come to move on. Then there is theRecovery phase, transition and then lifetime support. The family of the injured serviceman or woman is asimportant; “wounded soldier; wounded family”.

2. Injuries are often multiple with an increasing number of amputations combined with blast and minor braindamage as well as the psychological impact on a young man or woman of having life changing injuries. Theinjured carry a portfolio of problems that need to be addressed holistically.

3. The injuries sustained are different from those experienced in civilian life and need different, or at leastmore comprehensive, care. In a bad case a man might say “my prosthetics don’t fit, I’ve lost my job, my wifehas left me and I’m having nightmares”. These are not separate issues; they are all the result of treading on anIED and need to be addressed together and by people who understand the military mind.

Concerns of the Wounded

4. The typical patient is 22 years old, fit, poorly educated and with little ambition other than to return toduty and the life he enjoyed pre injury. He would prefer to stay in the Services where he has good medicalcare and he knows he can upgrade his prosthetics when needed. He needs time to adjust to his new situationand a period of adjustment of around three years is quite usual (and was identified by plastic surgeon ArchieMcIndoe in 1945). In that period of adjustment he may suffer from depression, survivor guilt, anger, alcoholor drug abuse and a profile similar to that of bereavement. If he leaves the Services before he has adjusted andis prepared to move on, there is a danger that he will suffer further depression and resentment and begin on adownward spiral of despair.

5. While the WIS Serviceman may wish to stay in the Services, it may not be practical for him to remain inthe front line unit nor may there be sufficient job opportunities elsewhere to ensure a fulfilling future. It maybe in the interests of both the individual and the Services for him to leave but H4H believes that it is vital thathe does so only when properly prepared and ready.

6. The WIS individual has concerns about his future out of the Services. He worries about accessinghealthcare, especially advanced prosthetics support, mental health, rehabilitation facilities, financial andemployment advice, housing, loss of the Service family fellowship and access to specialists who “understand”his problems.

7. His family shares these concerns and while they remain unclear, he is reluctant to leave the security ofthe Services for the unknown, even if that holds back his recovery. He would prefer to stay in the Services,unfulfilled, rather than be “thrown out onto Civvie Street”.


A Lifetime Duty of Care

8. Service personnel risk death or injury in the line of duty. The unique nature of their job is recognised inthe Military Covenant and so, if they sustain injuries as a result of their service, they should expect the verybest treatment. While that may be available on the NHS it is not always easily accessible by the WIS nor dothose treating them understand them as special cases.

9. The responsibility to provide that special and lifetime support cannot rest solely on the MoD, NHS, localauthorities or indeed the Service Charities, but instead should be provided in a coordinated and comprehensivepartnership with each partner playing a defined and coordinated role.

10. The support provided needs to be easily accessible and clearly signposted to both the WIS and his family.When things go wrong, it should not be up to the individual to spend time searching for what should be hisright. While all the relevant agencies are undoubtedly there and doing a good job, finding the relevant one canbe very confusing to the individual who is desperate. As one partner said recently, “my boy has fought enoughbattles, now he needs someone else to fight his battles for him”.

An Opportunity to Create a Comprehensive Road to Recovery Support Network

11. With public support for the Armed Forces at a very high level in general, and for the wounded inparticular; there is real opportunity to create a lasting and comprehensive network of support. There are keyphases along the road to recovery:

(a) The immediate life saving and evacuation from the theatre of war.

(b) Initial hospitalisation, typically at Queen Elizabeth Hospital and other centres in Birmingham.

(c) Rehabilitation at DMRC Headley Court.

(d) Assessment and decision as to future Service potential, “stay or go when ready”.

(e) Recovery and creation of an Individual Recovery Plan (IRP). The WIS works with his PersonnelRecovery Unit (PRU) officer to agree what he wants to do and how to get the skills to achieve it.

(f) Return to duty if a fulfilling future is available or transition out into civilian life, properly preparedwith suitable job, housing, medical, prosthetic, psychological and financial support.

(g) Supported transition. A monitored and supported early stage of transition with a “return andrecock” option available to those that need it.

(h) Long term lifetime support from easily accessible, regional centres of excellence.

Recommendations

12. The first three phases outlined are working well and MoD is working with H4H and TRBL and otherservice charities and agencies to provide support up to the point of exit. The PRCs provide the potential tobecome the regional Support Hubs or “one stop welfare shops” for transition and long term support.

13. It is recommended that further centres be established in the Midlands and Scotland to supplement thosealready under construction at Catterick, Colchester, Tidworth and Plymouth. The centres should both cater forthe assessment and transition of those leaving the Services but also as the regional single focus centres ofexcellence for those who have left.

14. The centres would act as regional beacons to those who need support. The former WIS Servicemanwould know that he or his family has only to telephone, email or walk in and say “help” for the various supportagencies and charities to be able to provide it, comprehensively, in one place. The boy would not have tobattle; they would do that for him.

15. The centres would be linked to all local services including the NHS and local hospitals. If a formerServiceman needed an upgrade to his prosthetic or follow up surgery at a designated specialist hospital, thecentre would be the hub to support him. He could stay there while undergoing pre op and post physio and hisfamily would be able to access welfare support while with him. Ideally that pre and post op physio would beavailable from the 14 existing RRUs, the former WIS staying in the centre as a veteran while accessing thespecialist physic support he had while still serving.

16. The centres would offer other services, such as adaptive sports and activities, nutrition advice, mentoring,a job centre and a social focus for those who would benefit from the fellowship of those with similarbackgrounds or issues.

Next Steps

17. H4H is developing this concept at Tedworth House near Salisbury. A pathfinder Support Hub workingwith key delivery charities, NHS and local authority participation will be trialed during 2011 and early 2012.If successful, the concept will be rolled out to a similar centre at Catterick by mid 2012.


Coordination Role

18. If the support to the WIS is to be truly comprehensive, it needs to be coordinated. Currently the DefenceRecovery Steering Group (DRSG) sits within the MoD at Defence level and provides a coordination role toensure that the three Services’ recovery capabilities are linked and aligned. Similarly COBSEO, the Servicecharities confederation, seeks to coordinate the efforts of the key Service delivery charities.

19. There is a need however, to create a super coordination role to link this effort beyond the MoD andService charities. The role would sit outside MoD, report to the Cabinet Office and be of senior IndependentCommissioner or Ministerial level and work with MoD, Service charities, housing, health service includingprosthetic support and mental health, welfare, local government etc to ensure a fully coordinated Road toRecovery for our wounded, injured and sick service personnel, for life.

Bryn Parry OBECo Founder and CEO

25 June 2011

APPENDIX 1

H4H CHARITABLE OBJECTS

1. To assist persons who are currently serving or who have served in the armed forces, and their dependants,by advancing any lawful charitable purpose at the discretion of the Trustees and in particular but notexclusively:

— to promote and protect the health of those that have been wounded or injured whilst servingin the armed forces through the provision of facilities, equipment or services for theirrehabilitation; and

— to make grants to other charities who assist members of the armed forces and their dependants.

2. To promote and protect the health of those that have been wounded or injured whilst providing servicesto, or in conjunction with, and in either case under the direction of the commander of, the armed forces, in anarea of conflict or war and to provide benefits to the dependants of such persons who are in need.

For the purposes of clause 2, a reference to the commander of the armed forces means the Commander ofHer Majesty’s Armed Forces, and his officers, or, where relevant, of any allied military body with whom HerMajesty’s Armed Forces is working during combined operations.

APPENDIX 2

SUMMARY OF GRANTS TO DATE

Help for Heroes Grant Awards to June 2011 Total Value £K

Capital Projects (non PRCs) 13,365PRC’s Capital projects & associated running costs 61,250Resettlement 560Adaptive Training & Sports 728Welfare & Outreach programmes 2,220Quick Reaction Fund 6,000Individual Recovery Plans 11,000Restricted Funds to DMRC & RCDM 76Totals 95,199


APPENDIX 3

DEFENCE RECOVERY CAPABILITY & OVERVIEW

?

Edinburgh/Glasgow

Ca�erick

RAFHonington

Colchester

TidworthPlymouth

Headley Court

?

RCDMQEHDNRC

BBCC

Arrival in the UK

Army

RoyalNavy

RAF

Tri service

Key:

This is supported by ArmyPRUs, based in brigadeareas

MidlandsPRAC?

Defence Recovery Capability& Overview

Plymouth Tidworth Headley Court Colchester Ca�erick Edin’h / Glasgo

Audience RoyalNavy /RoyalMarines

Army Tri service Army Army Army

Service(s)delivered

Physicalrehabilita�on

IRP deliveryAssessmentVeteran&family support

Physicalrehabilita�on

IRP delivery IRP deliveryAssessmentVeteran&family support

IRP delivery

Servicedeliveredby:

RoyalNavy /RoyalMarines

H4H&Army inpartnership

MOD Army H4H&Army inpartnership

Army

Fundedby: H4H (cap. costs) H4H (cap. andop. costs)

MODH4H ( cap. costsof rehabilita�oncomplex)

H4H (cap. costs)TRBL (op. costs)

H4H (cap. costs)TRBL (op. costs)

H4H (ini�algrant)TRBL (op. costs)

KeyMilestones P1: Sept 2012P2:Oct 2012

IOC: July 2011FOC: Sept 2012

N/A FOC:Mar 2012 IOC: Sept 2011FOC:Oct 2012

N/A (Long termplan TBC)

Written evidence from the Royal British Legion

About The Royal British Legion

The Royal British Legion (the Legion) aims to be “the No 1 provider of welfare, comradeship, representationand Remembrance for the Armed Forces community”. We are one of the UK’s largest membershiporganisations and provide financial, social and emotional support to millions who have served and are currentlyserving in the Armed Forces, and their dependants.

The Legion is the largest welfare provider in the Armed Forces and veterans charity sector. In 2008–09 theLegion delivered over 154,000 support service interventions and spent, on average, £1.2 million per week onits welfare work.


1. How the Armed Forces and the MoD treat and rehabilitate injured personnel once they are evacuated fromthe battlefield

1.1 The quality of trauma care on operations in Iraq and Afghanistan has progressed to allow an unexpectedsurvivors rate of 25% which compares to some of the best NHS hospitals in the UK.8 The Queen ElizabethHospital in Birmingham has now opened and is treating patients in the ward with a military environment; theRoyal Centre for Defence Medicine (RCDM).

1.2 We understand that strategic plans for the future of the RCDM rehabilitation are underway, and earlyadvice on the location would be welcome. This will help the voluntary sector to plan complimentary supportto any new facility in the UK.

1.3 The Legion can only comment on the written and anecdotal evidence reported about the treatment intheatres of operations, Birmingham (RCDM) and Surrey (Defence Medical Rehabilitation Centre (DMRC)), aswe only occasionally have direct contact with those undergoing treatment.

1.4 We would like to highlight that the evidence we have seen has been overwhelmingly positive, in termsof the treatment and care provided to those injured in theatres of operations. The position is summarised wellby the National Audit Office (NAO) press statement below:

National Audit Office—Treating Illness and Injury arising on Military Operations, February2010, Press Statement:

A report released today by the National Audit Office has found that the clinical treatment andrehabilitation of service personnel seriously injured on military operations are highly effective. Thereport notes, however, that the rate of illness and minor injury among personnel on operations hasalmost doubled in three years.

Military commanders, and the patients to whom the NAO spoke, have confidence in the clinicaltreatment provided at medical facilities in Afghanistan, at Selly Oak, the main hospital for seriouslyinjured troops, and at Headley Court, the MoD’s main rehabilitation facility. The quality of care forthe seriously injured is demonstrated by the number of what are medically known as “unexpectedsurvivors”, with the Department’s strength in clinical care underpinned by a clear focus on traumacare.

Medical capacity at both Selly Oak and Headley Court has been sufficient to deal with casualties todate, but it is under increasing pressure. In addition, the main field hospital in Afghanistan—CampBastion—is currently coping with casualty levels, but working close to capacity. Contingency plansfor providing further capacity back in the UK for care for injured Service personnel have recentlyimproved, but should be developed further.

Reported rates of disease and minor injury in Afghanistan have almost doubled from 4 to 7%. TheMoD’s data does not allow it to identify the significance of any of the individual causes of theincrease in illness or minor injury which are likely to include the basic living conditions at someforward operating bases, the intensity of operations and improved reporting. Preventing minor illnessis preferable to evacuating troops for treatment and would minimize the impact on military capability.

The MoD has taken steps to provide support on operations to personnel at risk of developing mentalhealth conditions but there are weaknesses in follow-up for those service personnel who deployindividually or move between units following deployment.

522 military personnel were seriously injured on operations in Iraq and Afghanistan between October2001 and October 2009. Personnel on operations have attended medical facilities 125,000 times forminor injury and illness since 2006 and a further 1,700 times for mental health conditions. The NAOhas estimated that the cost of medical care provided as a result of military operations was £71 millionin 2008–09.

1.5 The Legion has not received specific complaints regarding the medical treatment of those injuredduring operations.

1.6 However, the Committee may like to note the results of civil actions arising from clinical negligence inthe relation to the MoD and Defence Medical Services (DMS). It should be noted that negligence cases againstthe MoD must prove a causal line to the injury or illness suffered as well as providing negligence, it is notsufficient to prove negligence alone.9

EXPENDITURE ON CLINICAL NEGLIGENCE CASES 2006–07 TO 2008–09

2006–07 2007–08 2008–09

Number of claims received 67 86 55Number of claims settled 23 16 22Amount Paid (£) £3.0 million £3.7 million £8.1 million

8 Treating Illness and Injury arising on Military Operations, National Audit Office Report, February 2010, p 5.9 Ministry of Defence, Claims Annual Report 2008–09.


1.7 We would also ask the Committee to note the Fortieth Report 2011—The Armed Forces’ Pay ReviewBody, in relation to the manning requirements of the DMS. The report notes the following:

— In April 2010, the trained strength of DMS was 85.2%.

— There were 520 trained Medical Officers (MOs), a shortfall of 32% against the requirementfor 770.

— The situation is improving, but shortfalls and operational requirements are currently beingmet by Reservists, other allied forces and specialist NHS staff and contractors.

— The BMA [British Medical Association] and BDA [British Dental Association] haveexpressed concern about the continuing shortfalls in DMS manning.

— DMS staff members were generally pleased with the frequency and duration of deploymentsand the support they received, though this was not true for all individual specialities.

— While the MoD report that moral in the DMS is good, the Continuous Attitude Survey resultswho that Medical Officers are “neutral” or “satisfied”.

2. How the MoD and the Armed Forces treat and rehabilitate personnel in the longer term

2.1 The Legion has recently carried out a qualitative research study regarding the impact of Service relatedinjuries. While this qualitative study represents a small sample of those who have been injured, the results willassist the Committee in understanding the impact that serious injuries have on individuals over the longer term.

Health, welfare and social needs of the Armed Forces community: a qualitative study(Chapter 1—Those injured by Service, and their families), The Legion, 2010

Of the 20 respondents injured within the last five years, all were male, nine were still serving in theForces and eleven were veterans. Length of service ranged from three to 24 years; the nature of theinjury was usually combat-related. Many injuries had resulted from Improvised Explosive Devicesor being shot. These had caused physical impairments (loss of limb, head injuries) and resultingneurological and mental health problems (for example Post Traumatic Stress Disorder). Only a quarterof respondents had a routine training or sports injury, or an illness (for example, Lyme Disease).

In many cases, the nature of the injury (and any resulting PTSD) is unique to Service personnel.

Injured/ ill respondents reported that their condition had a major impact—physical andpsychological—on their way of life. The majority were concerned that their situation would onlybecome worse:

“It has totally changed my life and that of my family.”

“ It has had a massive psychological impact—it’s not part of a soldier’s psyche to have peoplehelping you.”

Half of those injured within the last five years, spontaneously discussed either the loss of their job,or being restricted to lower paid jobs/ jobs which did not reflect their skills and training:

“I can no longer do the job I was trained to do”.

A few also mentioned being restricted in their participation in certain sports, leisure activities and intheir ability to play with their children.

Over half of injured respondents had to cope with physical difficulties such as restricted walking,reduced lifting/reaching capabilities, pain, fatigue, lack of sleep and discomfort when driving:

“The mind is still there, I just can’t physically do what people of my age can do.”

Cognitive difficulties and mental health issues such as memory loss, mood swings and depressionwere also discussed. Two respondents with PTSD reported suicidal thoughts and the breakdown oftheir marriages.

Despite frustration at the changes in their lives, some of the more recently injured respondents gavethe general impression that they were trying to make the best of their situation:

“My situation may not improve but I will get better at adapting.”

Those leaving Service accommodation as a result of their spouse’s medical discharge had not receivedassistance in finding alternative housing.

Where concerns were reported by relatives, they tended in the case of partners to focus on the impacton children, and, in the case of parents, to be articulated as distress at their son’s situation. One offconcerns related to coping with a partner’s anger and the possible effect on the marriage:

“He came back a different person, he shouts a lot and this gets me down.”

2.2 While a small sample, the Legion believes that the comments above are a reflection of the feelings andexperiences of those who have suffered life changing injuries as a result of their Service in the Armed Forces.

2.3 However, it is also worth noting that significant improvements have been made to the support that thosewho are injured by Service over recent years, and further work is underway.


2.4 These initiatives include:

— the imbedding of welfare staff at both RCDM and DMRC;

— ensuring that Armed Forces personnel are treated within a military environment;

— policy change to ensure that those still receiving medical treatment are retained in Serviceuntil their recovery plateaus; in place of the 18 month time limit for recovery;

— review of the recovery pathway and the immanent implementation of a full recovery andtransition assessment;

— new facilities for those who aren’t able to recover at home or at DMRC, through the PersonnelRecovery Centres and the Battle Back Centre (funded by the Legion and Help for Heroes); and

— the current review of prosthetic provision both within the Armed Forces and from the NHS.

2.5 While there is still work to be completed, significant attention has been given to ensuring the bestpossible care and recovery for those injured by Service. The one issue that the Legion would like to highlightis the possible longer term effects of the extremely high levels of support, which are currently being providedby the MoD and the voluntary sector; in particular, the expectations that this raises.

2.6 The Department of Health has already identified that they are not able to provide the same level of careand support that those in Service receive. This is simply the reality of the National Health Service(s) and theneed to provide fair and equitable treatment to all. The expectation that people will receive the same level ofsupport as they receive while they are serving is currently unrealistic. We believe that the MoD need to payattention to not setting individuals up for a long series of disappointments, by providing clear informationabout what will be provided post-Service by the state, and the early engagement of the voluntary sector so thatadditional quality of life services can be provided.

2.7 We would also like the Committee to closely examine how the system of Priority Treatment healthcaresystem for veterans, who are injured by Service, works in reality. Typically, the number of health professionalswho know about Priority Treatment, or how it operates, is very low.

2.8 In a 2009, the Legion undertook a survey of 500 GPs,i 81% of those questioned said they knew “notvery much” or “nothing at all” about Priority Treatment. Furthermore, 85% had not informed secondary careproviders of a veteran's entitlement to Priority Treatment in the past 12 months.

2.9 A further survey of 491 War Pensionersii found that only 11% reported being treated ahead of non-emergency patients on their most recent visit to hospital for their Service-related condition compared to 10%in a previous survey carried out in 2007. Of the War Pensioners surveyed only 36% knew of their entitlementto Priority Treatment.

2.10 Despite a significant amount of publicity surrounding the extension of Priority Treatment in January2008, our surveys show little improvement in awareness or delivery of the scheme.

2.11 The majority of eligible veterans are still not receiving the priority they deserve. Messages aboutPriority Treatment are not getting through to GPs and while it would seem that awareness is growing amongveterans, it remains too low.

2.12 It is vital that the Government finds a way to communicate the details of Priority Treatment moreeffectively to GPs and veterans and implements a scheme that actually works in practice. If this cannot be donethrough existing arrangements the Government should look for other options that would fulfil its commitment toproviding a lifelong duty of care for those who serve.

3. The effectiveness, or otherwise, of the process involved in supporting personnel when they either return towork within the Armed Forces or if medically discharged, require support finding work, accommodation andfurther medical support (please see above on this last point of medical support)

Finding work within the Armed Forces

3.1 The psychological effects of medical downgrading and alternative employment within the Armed Forceshas been a research question considered by KCMHR, their 15 year Report provides a summary of their findings.

KCMHR—15 Year Report—Medical DowngradingMedical downgrading (being unfit for operational deployment) is another area of hiddenpsychological morbidity. Those who are medically downgraded make up 7 to 10% of the total strengthof the Armed Forces. Being downgraded was associated with a doubling of the risk of havingpsychological problems, and this was particularly marked in those with chronic physical illness. Thisis in keeping with the general population literature, which consistently reports the hiddenpsychological burden of chronic physical illness. Given that was also know that psychologicaldisorder is a major factor determining prognosis, functional impairment and treatment outcome, thisis an area where the military need to explore the role of psychological treatments.

3.2 The conclusions from KCMHR are aligned with the findings of our own qualitative research (please seebelow), which demonstrates that retention in Service is not always the best for an individual. We have alsoreceived several reports that the MoD is now presenting options for employment within the Armed Forces


alongside the possibility of discharge; if the later is opted for, individuals are being offered a “discharge formedical reasons” rather than a “medical discharge”.

3.3 This does not seem like an important distinction. However, if the individual in question has not completedfive years Service, it will mean that they will not receive a full resettlement or CTP (Careers TransitionPartnership) package. It will also mean that they are not automatically referred for an assessment forcompensation under the Armed Forces Compensation Scheme (AFCS) (as is the case for all medical discharges,where a claim has not already been made).

Health, welfare and social needs of the Armed Forces community: a qualitative study (Chapter1—Those injured by Service, and their families), The Legion, 2010

Nine [of the 20 interviewed] of this group were still serving in the Armed Forces at the time of theinterview. One was due to be medically discharged in July; of the other eight, all had experienced atleast a minor change to their role following their injury. Four were happy in their new role, and fourwere not:

“I would like to continue in this instructor role—I’m very happy. However, some days I feelguilty about not being with the lads if they are out on tour.”

“I’m in a static office job now—it’s very different from the commando role. It’s away from myaspirations and very frustrating.”

Eleven of the recently injured respondents were no longer serving, having been medically discharged.Not everyone articulated a reaction but a few expressed disappointment at having had to leave theServices, and a small number were pleased:

“I was not happy about leaving the Army—I loved my job.”

“I was glad to leave, it was better than being given some awful desk job”.

A small number of these veterans were unemployed, the rest were in some form of employment.

Most of the recently injured respondents reported that their injuries/ illness had affected the type ofrole (Service or civilian) they could undertake:

“I have to think about how I can match my skills with my (physical) capabilities—it’s notnecessarily what I would have chosen to do”.

Additionally, subsequent roles did not reflect the level of training and skills which had been acquiredprior to their injury/ illness:

“It’s hard to convert military skills to general skills.”

This group also discussed the curtailment of promotion prospects (Service and civilian) and the lossof future potential earnings:

“I’m now in a security role—it’s not ideal and it’s less pay than I am capable of.”

A couple of respondents reported a sense of loss of identity following medical discharge.

3.4 This range of views helps to demonstrate the difficulties with applying policy at a national level withregard to retentions in Service, medical discharge, and ensuring skills and training are identified to enable thebest possible prospects post-Service. The new transition assessment being introduced by the MoD PersonalRecovery Capability (PPC) should assist with this issue, as the individual will be included in the decisionmaking process, and if being discharged, will have a plan, which will include training. However, this processis still in development, and is, as yet, untested. We are hopeful that this will develop into a robust vocationalassessment for those being medically discharged.

3.5 The current CTP or resettlement arrangements demonstrate that the vast majority of those who undertakethe resettlement activities are in employment six months post-discharge;10 while the current figure of 91.8%has reduced over recent years, it is still high when considering UK unemployment figures. All those medicallydischarged from the Armed Forces are entitled to CTP, regardless of length of Service, and the overall take upof CTP was 95.4% of all those entitled (see above for issues relating to entitlement).

3.6 The current list of training and skills courses available from the CTP is limited, and needs to be reviewed.We would like particular attention to be paid to issues raised in the Armed Forces Covenant Task Force Report,undertaken last year; particularly life skills. The CTP training courses should also be reviewed in light of“unexpected transition” ie those needing to change career, who have never thought that they would, or do nothave a clear direction of what would be useful for them. It would be particularly helpful if the list couldinclude “softer” or “personal management skills” courses, such as a course to translate military skills intocivillian skills for a CV or household budgeting.

Accommodation

3.7 Social housing allocations are a concern for the Legion as our research and welfare services have foundthat both the serving personnel and veterans often experience difficulty accessing suitable accommodation; this10 Report on the career transition partnership; Operations during financial years 2007–08 and 2008–09. Directorate of Resettlement,

Tenth Report.


can be particularly acute for those who haven’t planned to be discharged (such as those being medicallydischarged).

3.8 Current Homelessness Act 2002 provides priority need for those who are vulnerable due to Service inthe Armed Forces, but this is extremely subjective, and anecdotally, rarely used as people with significantvulnerabilities due to mental or physical health will normally be covered by other priority need categories. Ifthe Government would like to ensure the accommodation needs to those injured by Service are met, then thisdefinition of priority need should be revisited.

3.9 Despite the recent reform of the local connection legislation11 Armed Forces personnel still find itharder to access social rented accommodation because of the mobile nature of their employment. The vastmajority of recruits upon signing up will be based in an area away from their home town or locality. This willusually continue throughout their military career.

3.10 Being located outside of the home area means an individual or accompanying family usually becomesineligible for a place on a housing waiting list in their home area. If they are entitled to remain on a waitinglist they will be considered in the same light as someone applying from outside the area or with no localconnection. The household cannot “clock-up” waiting time priority, and so when they return to the area afterService, they find they are treated by the allocation policy in the same way as someone who no local connectionor historical link to the area.

3.11 Furthermore, due to the mobile nature of Service life, personnel and their families are usually not basedin one area for a long enough to gain sufficient priority, in terms of waiting time, for an allocation. As a result,there is little incentive for Service personnel to register on housing waiting lists. Therefore, Service personnelfind it very difficult, on discharge, to access social housing in either their home area or areas where they havebeen based.

3.12 As a result, Service personnel are disadvantaged by the mobility of their employment. In terms ofaccess to social rented housing, an individual would be in stronger position if they chose not to serve, butinstead remained resident in their home town or area.

3.13 The Government has attempted to address a similar problem with Service mobility and NHS waitinglists. Waiting time accrued by Service families in one area of the country is transferred with them to anotherPrimary Care Trust (PCT) in a different part of the country. The Legion believes that the Government shouldexplore the possibility of legislating to introduce a similar system for social housing waiting lists.

3.14 The Legion has studied the allocation policies of many local authorities and has so far found none inEngland that attempt to address this mobility disadvantage. Midlothian Council in Scotland is an example ofan authority that has looked to address thus issue. They award a level of priority to an applicant for housingif, “the person is a full time member of HM Forces and prior to joining the forces previously lived in Midlothianand is due to return to civilian life.” The Government and this guidance in particular should be encouraginglocal authorities throughout the UK to adopt this, or a similar approach.

4. How effectively the MoD works with local authorities and health authorities to put the right level ofsupport in place and whether different levels of support are provided in different regions of the UK

4.1 It is fortunate, in more ways than one, that the number of people needing significant support and thetransfer of full time or continuing care from the MoD to local authorities, or indeed the NHS has beenextremely low.

4.2 Only two years ago, some severely injured Service personnel were experiencing particular problems ingetting local authorities to provide funding for social care and home adaptations, where the individual wasmoving back to an area following an absence due to Service or moving back to be supported by their family.These issues seem to have been overcome with the cross-government commitments outlined in the CommandPaper. However, as funding becomes and issue both within local authorities and NHS continuing care budgets,this might again become a problem. Lack of funding seems to be the main issue when difficulties arise, withlocal connections being cited as the reason.

4.3 The Department of Health (DH) and the MoD are currently working on new protocols for continuingcare and the transition from the Armed Forces (the Transition Protocol). There are a number of issues arisingfrom the testing of this protocol; including the over involvement of family and the Chain of Command indeciding what is best for the patient. The current protocol is being drawn up with a process including PCTs—the Legion is concerned that when these are removed (under the proposals contained in Liberating the NHS)the process will be lost. It is also difficult to imagine how the process will be taken forward with GP Consortia.11 Circular 04/2009: Housing Allocations—Members of the Armed Forces, Department of Communities and Local Government,

April 2009.


5. How well the MoD and the Armed Forces identify and treat mental health problems which develop inpersonnel returning from areas of conflict

5.1 There are two initiatives that have been introduced by the last Government in an attempt to identify andreduce the mental health effects of active deployment, namely Post Operational Stress Management (POSM)and Trauma Risk Management (TRiM).

5.2 The POSM programme consists of a 36-hour “decompression” period in Cyprus for personnel followingdeployment to Iraq or Afghanistan. This gives them the chance to mentally and physically unwind and talk tofriends, colleagues and superiors about their experiences. The period is also used to monitor and identifypersonnel who could be vulnerable to post-operational stress and stress-related conditions and all personnel areoffered a briefing on post-operational stress.

5.3 Further, medical personnel are available during POSM and individuals are encouraged to see them ifthey have concerns or experiencing difficulty. The evaluation of the POSM programme has not been madeavailable, but anecdotal evidence supports POSM as having a positive impact. However, there is other anecdotalevidence to support the view that alcohol plays a significant part of POSM, policy makers should considerwhether or not this masks any issue which might be present and whether or not this is the best time forassessment and screening for mental health conditions.

5.4 The Legion would like the MoD to consider other opportunities for mental health screening. However,the evidence to support the need or effectiveness of screening remains unclear. KCMHR: A Fifteen Year Reportsummarise the evidence as follows:

KCMHR—15 Year Report, Section 7—Mental Health Screening—Summary

— Mental health screening prior to deployment has not been shown to reduce postdeployment ill health, and would have adverse consequences for some individuals in theArmed Forces.

— Mental health screening after deployment is practiced in other countries, but is not yetsupported by evidence of benefit.

— Possible disadvantages include number of false positives, natural history and lowprevalence of PTSD and continuing stigma/barriers to care.

— The issue is now being address by a UK randomised controlled trial of postdeployment screening.

5.5 KCMHR continue its studies to investigate the benefits or disadvantages of screening, and develop toolsfor the identification of the PTSD; Dr Murrison notes this in his report Fighting Fit. We believe that screeningshould and could be used, once an objective tool is developed, particularly at discharge.

Fighting Fit—Dr Murrison, 2010

The King's Centre for Military Health Research (KCMHR) has secured US funding to determine theefficacy of PTSD screening tools in a randomised controlled trial using a naive UK Servicepopulation. The MoD should encourage research to develop a PTSD screening tool, ensuring that thework is capable of generating data that will be of benefit in a UK context. Any tool would need tobe capable of being validated for use with UK personnel.

5.6 TRiM is a relatively new approach to mental health assessment which was pioneered by the RoyalMarines. TRiM differs from traditional debriefing in that it is not delivered by mental health professionals, butby serving military personnel following training. It stays firmly within military culture and does not involveanyone from outside the unit. It is not always directed towards emotional expression but towards assessingwho might be at risk of developing later problems (KCL, 2006).

5.7 A further debriefing programme called ‘Battlemind’ is currently being evaluated by the KCMHR.Battlemind originated in the US where Service personnel are encouraged to become aware of behaviours andreactions they may have had in their deployment combat roles, which may not be appropriate behaviours andactions in their civilian lives and family roles. In this way, Service personnel are encouraged to identify thesewarning behaviours and are encouraged to seek help early.

5.8 The Legion is fully supportive of these intervention strategies both post-operations and during Service.However, the Legion recommends that there is a review of the success of POSM and TRiM programmes andtheir impact. The Legion also recommends that if the Battlemind programme is proven to have positive results,over and above the results of current post-deployment debriefings, that it is rolled out throughout the ArmedForces and extended to include families.

5.9 The movement from military health services to NHS services and the movement from a military cultureto normal civilian life can be a difficult process for some individuals. Many common problems revolve aroundalcohol misuse, housing and employment, for others, particularly those injured by Service; they extend toaccessing health and social care. The Legion recognises that Early Service Leavers (ie those compulsorilydischarged or serving less than four years) are particularly vulnerable in many of these areas, but particularlymental health. Currently, there is little in the way of transition support for Early Service Leavers, even thoughthey are regularly identified as the most vulnerable.


5.10 The Legion recommends that the needs of Early Service Leavers are addressed and specific transitionpackages explored to support, prevent and provide early intervention for mental health risks associated withtransition problems.

6. How the MoD and the Armed Forces support the families of those wounded in action, in particular, thosefamilies of bereaved personnel

Health, welfare and social needs of the Armed Forces Community: a qualitative study (Chapter1—Those injured by Service, and their families (Summary)

Relationship difficulties or breakdowns as a consequence of injury/ illness seemed to be moreprevalent than among the general UK civilian population.

Although all interviewees had received some support, most felt that they needed further help. Theirgreatest perceived needs were for a designated contact to outline the assistance available to them,financial assistance and legal advice. Family members of the injured mentioned the need for bettercommunication about their relative’s condition.

Gaps in service provision resulted mainly from lack of knowledge about availability of andentitlement to services. Respondents suggested that information would be useful at the time ofmedical discharge, when people cease to enjoy the protective care of medical teams.

Pride, the ‘making do’ mentality, and weariness from difficult compensation claims were otherreasons why assistance had not been sought.

Chapter 5—Family Members of those who have died (Summary)

The group of respondents defined as family members of those who have died while serving in theArmed Forces within the last five years exhibit a mix of health, welfare and social needs.

In common with the general UK civilian population, the effects of their bereavement weredevastating. Unlike the civilian population, however, some of these respondents were dealing withunusually traumatic causes of death, specific to combat situations.

Additionally, Service related deaths appear to require a greater degree of ‘administration’ than civiliandeaths: for example, accessing wills and insurance cover, proving paternity in the cases of unmarriedpartners, attending military inquests and claiming financial entitlements specific to a Service relateddeath.

Just as in civilian bereavement, the effects of bereavement on the respondents included depression,changed financial circumstances, self imposed social isolation and difficulty in forming newrelationships and friendships. Marital problems had the potential to develop when the bereavedparents dealt with their grief differently.

A group with specific needs within the Service population is parents who have lost a son or daughter,are no longer the next of kin and have a poor relationship with the spouse or partner of the deceased.

All the respondents had received some form of support during their bereavement. The great majorityhad received Service support and were unanimous in their praise, though they characterised thesupport that was available as short term and practical (organisation of funeral, initiation ofcompensation claim) rather than emotional or long term.

Just under half the group had received support from their GP, and a similar number had receivedcounselling. The counselling was considered to have had varying degrees of success.

Although all interviewees had received some support, most felt that they needed further help. Theirgreatest perceived needs were for long term counselling from a counsellor with military understandingand comparable experience, proactive contact from the Services and charitable organisations, theopportunity to contact people in similar circumstances, and financial assistance (for example, toattend memorial events).

Families of injured Armed Forces personnel

6.1 Relationship difficulties, or issues associated with having caring responsibilities are the main problemsbeing faced by the families of those injured by Service. Again, there have been significant improvements overrecent years to improve the support families receive; this has come from both the MoD and the voluntarysector (in the main the Legion, Cruse and SSAFA Forces Help).

6.2 The MoD could provide some further support, but providing relationship counselling to those who arehaving difficulty (this is funding by some Services at the moment, but is not universal). Including familymembers in the process of medical discharge (where the Service person has agreed) would also be useful inhelping families to learn about the support available to them.

Bereaved Armed Forces families

6.3 As well as the research outlined above, the Legion has also held two events with bereaved families, toconsider their support needs, not just following the bereavement, but also during the investigation into a Servicerelated death. We have been working with the MoD and the Ministry of Justice to secure improvements for


bereaved families, and some progress has been made. We are pleased to report that Dr Murrison’srecommendation in his report Fighting Fit, to provide access to the Big White Wall for Service personnel is tobe extended to bereaved families.

6.4 Further, significant reforms have been included in the Coroners & Justice Act 2009 (“the Coroners Act”)to help address concerns raised by bereaved Armed Forces families. The substantive improvements, which areunder treat through the removal of the Chief Corner, are outlined below. The Government has proposedlegislation in the Public Bodies Bill to remove the new post of Chief Coroner from the Coroners Act; followingyears of debate and reform.

Transfer of inquests between jurisdictions—Chief Coroner oversight

6.5 The Coroners Act made provisions for formalised arrangements for the transfer of inquests to coronersin different jurisdictions, to be overseen by the Chief Coroner [Coroners Act S2(5)]. This section introducesparticularly important measures aimed at improving consistency and quality of investigations. In 2008, therepatriation of deceased military personnel moved from RAF Brize Norton to RAF Lyneham. In effect, thismoved the jurisdiction from Oxfordshire Coroner to the Swindon and Wiltshire Coroner. Additional resourceswere made available to Swindon and Wilshire to ensure that issues around the backlog of military inquests didnot return.

6.6 To further assist with timely inquests for bereaved Armed Forces families, a policy was introduced toonly retain investigations in Swindon and Wiltshire if the incident involved multiple fatalities, with otherinvestigations (single fatalities) being transferred to the coroner closest to the next of kin. While this addressedissues of backlog, and improved access for family members, an unintended consequence was that thisintroduced inconsistency in the quality of service or investigation for military families.12 It also meant thatcoroners with no previous experience or knowledge of military investigations were now being used to completemilitary inquests.

6.7 The Legion believes that these issues would be addressed through formalised arrangements for thetransfer of inquests between jurisdictions and oversight by the Chief Coroner. The Coroners Act also madeprovisions for the Chief Coroner to direct a senior coroner to complete an investigation; we believed that thiswould improve quality through directing investigations to the most experienced or knowledgeable coroner,where the circumstances dictated. The provisions of the Coroners Act also allow the Chief Coroner to liaisewith the Lord Advocate (Scotland) for the transfer of deaths for investigation in England or Wales.

6.8 The Legion does not believe that the Ministry of Justice or the Lord Chancellor would be able to performthese duties without the same resources, including a dedicated team.

Provision of best practice, directions and standards

6.9 One of the significant activities of the Chief Coroner was introduce best practice guidance for coroners,to improve quality, transparency and accountability. Specific to the Armed Forces, guidance was to beproduced on:

— Assembling a jury for deaths of Service personnel where the deceased was aged under 18years, or on a training establishment.

— Procedures for conducting investigations into the deaths of Service personnel, including howto obtain evidence from allied nations (friendly fire incidents).

— When a coroner may consider holding an inquest (or part of an inquest) in camera on thegrounds of national security (including inquests involving Special Forces).

— The timeliness of coroner investigations, ensure that we don’t return to waiting times of upto three years for an investigation into a Service death.

6.10 The Government has stated that this guidance could be produced by the Lord Chancellor, but againresources would be required, negating any cost saving through the abolition of the Chief Coroner.

Monitoring and training

The Coroners Act places duties on the Chief Coroner to:

— monitor investigations into Armed Forces (deaths active Service, preparation for activeService or training); and

— ensure that coroners who conduct investigations into Armed Forces deaths are suitably trainedto do so.

6.11 The Coroners Act also provides for the Chief Coroner to make regulations (with the agreement of theLord Chancellor) regarding the training of coroners, which can include the kind of training to be undertaken,the amount of training and the frequency.12 Last month, for instance, three separate military inquests were rushed through in a single morning session.


6.12 The Government has indicated that these duties may pass to the Lord Chancellor, but again issuesaround independence and resources need to be considered carefully. Independence is a particular issue forconsideration, particularly as the “employer”, in the case of Service deaths, is the MoD. If these responsibilitiesare passed to the Lord Chancellor, the oversight of one Government department will simply fall to a CabinetMinister; with no clear distinction between Government, Parliament and the Judiciary.

Appeals

6.13 Through the abolition of the Chief Coroner, the Government are seeking to remove the right to appealintroduced on to the statute book by the Coroners Act. The Coroners Act introduced an appeals process to thecoroners system, something well overdue and uncontested during the reforms. The Coroners Act providesprovision for appeals regarding the following decisions:

— Whether to conduct an investigation.

— To discontinue an investigation.

— To resume an investigation.

— Not to request a post-mortem examination.

— To request an additional post-mortem examination of a different kind.

— Notice to appear, give evidence, produce evidence or conduct testing.

— Whether there should be a jury at an inquest.

— Notice to exclude persons from all or parts of an inquest.

6.14 The appeals process is fundamental to the reforms of the Coroners Act. It ensures a modern, transparentand accountable process into the investigations. It provides families with an important avenue to challengedecisions made by coroners. The alternative being offered is to continue with the process of Judicial Review anda complaints system, which are more complex and expensive, and again will need to be resourced appropriately.

Letter from Bereaved Family Member, 9 July 2008 (name and address supplied)

“This process leaves us still today, over two years since losing our son, bereft of not only losing ourson but of any sense of being treated with respect and receiving any natural justice. The MoD is apowerful machine and if our ‘small voice’ can be used to make the experience of other families thatinevitably will be following in our footsteps a more transparent and open process can be achieved,then writing this today has been worth the heartache and pain in reliving not only the traumaticpictures of that very fateful day but the experience of what we have had to endure over the lastcouple of years.”

7. If there are differences in the way that members of the Reserve Forces are supported

7.1 There is some additional healthcare support provided for Reservists. The Reservists’ Mental HealthProgramme (RMHP) was introduced in November 2006 for demobilised Reservists who have been deployedoperationally since 2003. The programme offers assessment and treatment. The RMHP is based at the ReserveTraining and Mobilisation Centre (RTMC), Chilwell, Nottinghamshire, but referral must be by the ReservistsGP.

7.2 The Legion welcomed the RMHP as an important element in addressing the particular problemsReservists can face after active Service. Reservists are more vulnerable to feelings of isolation on return fromdeployment than Regulars, as they immediately return to civilian life and do not have the chance to re-adjustwithin a military environment.

7.3 Additionally, Reservists are not part of the military family in the same way as Regulars, so cannot easilyaccess informal or informal support from people who have had similar experiences. This isolation leaves themmore vulnerable to developing mental health problems on their return from deployment. However, there aresome concerns that the RMHP is being under-used due to a lack of awareness of the programme among bothGPs and Reservists.

8. How injured members of the Armed Forces, civilians and their families are compensated

8.1 The Legion has, and is, fully involved in the process of review of the AFCS. While some of the issuesraised during Lord Boyce’s review are yet to be implemented, the Legion is supportive of the recommendationsand the process for implementation.

8.2 However, the Committee might want to consider the growing gap in levels of available compensationbetween the AFCS and the War Pension Scheme (WPS); taking into account that those injured or killed onoperations before April 2005 need to apply to the WPS for compensation and can only do so followingdischarge from the Armed Forces.

9 September 2011


Referencesi Ipsos-MORI online questionnaire completed by 500 GPs across England and Wales. Fieldwork was conductedbetween 13–23 March 2009. Data weighted according to age, gender, region (Strategic Health Authorities inEngland, plus Wales), practice size and practice list size to reflect the profile of GPs in England and Walesii Interviews were conducted by Ipsos-MORI among 491 people who had been helped by the Royal BritishLegion (RBL) to successfully claim War Disablement Pension and agreed to take part in the survey.

The sample was supplied by the RBL and consists of a database of Legion members they have helped to claimWar Disablement Pension and AFCS. Prior to interviewing, these Legion members were sent a letter on behalfof RBL and asked if they would like to take part in the survey. The sample database used for the surveyconsists of 1,728 Legion members who did not contact RBL with a refusal to take part. Fieldwork wasconducted between 27 April and 6 May 2009. Where results do not sum to 100%, this may be due to multipleresponses, computer rounding or the exclusion of don’t knows/not stated. Results are based on all respondentsunless otherwise stated. Data are unweighted.

PTSD Resolution

PTSD Resolution was created as a charity to provide free, immediate, local, brief, effective therapy toveterans suffering from post-traumatic stress, in the context of NHS figures:

— 5 million veterans in the UK.

— Of whom 1,360,000 have a “common mental health disorder”.

— And 240,000 suffer from Post Traumatic Stress Disorder (PTSD).

— Combat Stress claim to have a case load of 4,600, and 1400 new referrals last year.

— Some 3,000 veterans are in prison.

PTSD Resolution is receiving an average of two referrals per week, and to date have treated or are treating165 people. We have 200 therapists all of whom could accept, say, six referrals per year (one every twomonths). This would make a significant contribution to easing the problem.

Our views are specifically to do with the treatment of Veterans’ mental health. I have attached these viewsas an Annex to this letter.

1. How do we see the role of the charitable sector in providing support to personnel and their families, inparticular, whether the demarcation between the state and the voluntary sector in the provision and fundingof services is appropriate

1.1 At present funding is channelled to certain well-established third sector organisations (Combat Stress,RBL, SSAFA, etc,) and these charities guard their funding and operational territory for their traditionalpurposes. From experience, they are disinclined even to consider new charitable applications for their funding,or new operational approaches which they might be able to adopt in order to increase efficiency andeffectiveness within themselves.

1.2 Equally, the case of Help for Heroes is instructive. Their huge, popular appeal and consequent financialsuccess is at the expense of other charities, but their charitable purposes are directed to capital projects andvictims of current conflicts, and in the case of mental health they have told us that they defer entirely toCombat Stress as their “gateway”, because they say they have no understanding of the mental health problem.Their current effort in the mental health field is to fund the six Army Recovery Centres in conjunction withCombat Stress and the RBL so reinforcing the status quo in which established charities continue to operate asbefore, though with more and better buildings.

1.3 Thus the arrival of H4H has had a paradoxical effect; a new charity has entered the field with a boldnew approach but has had the effect of cementing existing structures and making it harder for innovative newentrants to gain any foothold in the field, or to raise their own funds.

This suggests two choices:

— not to intervene in the current distribution of state and charitable funding, but to encouragethe large charities to develop a broader engagement with the smaller, more flexibleorganisations so as to use those services which they have developed that are particularlyeffective; or

— for Government to establish a process by which smaller charities can bid directly forcentral funding.

1.4 There would be an argument for COBSEO to manage such a scheme, were it a more flexible,authoritative, learned and proactive organisation.

1.5 The current DoH plan to create ten regional Armed Forces Networks is an interesting initiative whichcould have the potential to bring the state and voluntary sectors together at regional level. However itseffectiveness varies across the country depending on the energy of the regional co-ordinators and the attitudes


of the dominant members towards the third sector. For example, the London group is exploring ways ofintegrating smaller third-sector providers into the veterans’ healthcare picture, but the Midlands group haseffectively collapsed after the first meeting as the third-sector members saw no point in attending further.

2. How well do the MoD and the Armed Forces identify and treat mental health problems which develop inpersonnel returning from areas of conflict?

2.1 Although the newly developed systems such as TRiM and decompression are adjuncts to the traditionalconcepts of leadership and training, there are still reasons why returning personnel choose not to reportemotional and behavioural difficulties.

2.2 It is widely asserted that people do not report mental health problems because of the “stigma” that suchproblems carry. “Stigma” is an abstract concept that is very unhelpful in this context. People do not report forpractical reasons: self-preservation in a macho culture, self-esteem, the desire to protect their careers and, insome cases, the perception that treatment may involve distressing and intrusive discussion of painful memories.

2.3 In any case, the MoD can never have the true picture because the society from which they draw theirpersonnel is one where people prefer not to publicly “confess”. It may be that the third sector has a better ideaabout military mental health for this very reason: we are unconnected to their careers.

2.4 One practical way to address this is to allow more flexibility in choosing routes to treatment, and for theDCMS practitioners to be more flexible in their treatment approaches; allowing re-exposure to happen in thevisual mode without forcing sufferers to recount their history verbally, for example, as practised by PTSDResolution and the “third-wave” Trauma-focussed CBT approaches.

2.5 One area where this is particularly relevant is the “official” insistence on separating drug and alcoholusage from trauma. Numerically it is true that alcohol problems far outweigh post-traumatic stress disorder asa diagnosis of soldiers’ problems. However, Resolution’s own research suggests that the alcohol problem isparticularly likely to arise in soldiers who have trauma that is clinically significant but undiagnosed. Someveterans’ charities, like Combat Stress, specifically exclude PTSD treatment for people who are drug- oralcohol-dependent, but this seems irrational to Resolution; we take the view that if someone is using a drug tosuppress emotional distress it makes sense to treat the root cause of that distress.

3. What are the differences in the way that members of the Reserve Forces are supported?

3.1 While Reservists seem to be more vulnerable to mental health problems, they may actually be able toaccess better mental health care than regulars, because in some areas of the UK they can exercise a choice intheir route to and mode of treatment. In Sandwell, for example, the NHS IAPT programme will be referringmilitary cases to a choice of therapists from the NHS and MIND, depending on which would suit them best.Additionally, as in other parts of the UK, they can call on PTSD Resolution which will provide treatment freeof charge to Reservists.

3.2 This choice does not exist across the whole UK—some areas have an 18-month waiting list for NHStrauma services. Resolution therapists are available immediately wherever a Reservist may be.

3.3 However, while the regulars are, in theory, under the supervision of their units, the Reservist is returnedto his or her employer, who may or may not have an understanding of the difficulties that may emerge,particularly post-traumatic stress. More can be done to educate employers and encourage them to fulfil theirresponsibilities for good governance by training them in trauma awareness as, for example, through theResolution Trauma Awareness Training for Employer programme (TATE). A recent request to SaBRE toconsider this suggestion was met with unequivocal rejection, reflecting the closed mentality of mostfunctionaries in this field.

4. Conclusion

4.1 The era of large-scale medical trials and state-prescribed treatments is, in any case, drawing to end.Personalised medicine acknowledges that people are different in their genetic make-up and that they responddifferently to medicines as a result. Given that the use of large-scale randomised trials in psychiatric treatmentswere always controversial, the arrival of personalised medicine is an opportunity for the government to acceptthat individuals vary widely in their response to different treatments and that what works for one person maywell not work for another.

4.2 Rather than see this variance as an irritant, we suggest that the DoH and MoD should respond by invitingall providers with an interest in this area, to collaborate in a new, open practice and research network, freefrom dominance by any individual vested interests or therapeutic dogma, where evidence from outcomes inindividual practice and cases, is used to guide treatment. We also suggest that all funding should be outcome-based, and that a central fund should be made available to conduct independent outcome research so that wecan know, for the first time, whether the charitable and state funds used to support service personnel are beingspent usefully.


4.3 Additionally, we look forward to the outcome of the DoH consultation on treatment acceptability—it isunderstood this will include the expressed wishes of the Surgeon-General, COBSEO and Combat Stress to findsome method of “approving” or “accrediting” third-sector treatments.

4.4 Apart from funding and treatment approval, the remaining obstacle to third-sector organisations’acceptability will be the question of governance. We urge the Defence Committee to use whatever influence itmay have to ensure that the outcome of the Council for Healthcare Regulatory Excellence (CHRE) exerciseprovides an effective, reasonable, comprehensible and achievable mechanism by which third-sectororganisations can be recognised as “Qualified Providers” by the NHS, MoD, COBSEO, RBL, SSAFA, CombatStress and every other party involved.

25 August 2011

Written evidence from the Royal College of Physicians

Introduction

1. The Royal College of Physicians (RCP) welcomes the House of Commons Defence Select Committee’sinquiry into The Military Covenant in action? Part: 1 military casualties. We value the opportunity to provideevidence.

Comments

2. In responding to the call for evidence we have liaised with the Joint Specialty Committee on RehabilitationMedicine (joint between the RCP and the British of Rehabilitation Medicine [BSRM]). We have also receivedwider feedback from rehabilitation medicine doctors working in NHS artificial limb clinics and communitybrain injury rehabilitation teams. We have also sought comment from RCP fellows who work in the ArmedForces (especially at Headley Court).

3. We recognise the high standards of initial care and early rehabilitation provided by the Military Services.Those injured in today’s war zones frequently have extremely complex, severe, injuries, often affecting manybody systems. Because of the high standard of early care, military personnel now survive injuries that inprevious conflicts would have led to death; but therefore there are now more survivors with severe, complexdisabilities. We welcome the emphasis on ensuring that those so affected have access to whatever technicaldevices can help, even if such devices are costly. We would draw attention, however, to the fact that advancedtechnology is not the only, or complete, answer to such difficulties.

4. We are aware that the committee has visited Headley Court and has a clear view about DefenceRehabilitation.

5. In addition, we are aware of the review of prosthetic provision for Service veterans conducted by DrAndrew Murrison MP. We believe that the main concern, highlighted there, is over the transition of thesepatients into the NHS. We also believe that Dr Murrison has recommended that additional funds for prostheticsshould be made available. This is important as despite Department of Health reassurances that veterans willreceive some form of priority there is currently no funding for this and currently no clear view of how todeliver it.

6. Within NHS rehabilitation there has traditionally been a structural approach towards delivery focussed onspinal cord injury, brain injury and prosthetics. It should be noted that many military patients do not fall intothese categories and may not require formal rehabilitation once they leave the Service. However, some do needongoing mental health/prosthetics and the transition process for these individuals will be key. There are alsoissues about the payment of the social care budget for those (usually brain injury) patients who have beeninjured in the Service.

7. Helping people with complex disability is the everyday task of Rehabilitation Medicine Consultants, asdescribed in a recent RCP report.1 It is natural that they should have an interest in the care of those disabledin the current conflicts. The concept of a “rehabilitation prescription” by a Rehabilitation Medicine Consultant,as envisaged in the development of Regional Trauma networks, is a natural parallel for transition of militarypersonnel to civilian services. However, in fairness, we must acknowledge that this concept, and serviceprovision to work the prescription through, is only just developing.

8. We recognise that there may be problems in ensuring appropriate transition to NHS services. Contactsbetween Ministry of Defence (MoD) staff and NHS staff are not necessarily well defined. As the structure ofrehabilitation services varies greatly from one region to another, it is easy to anticipate difficulty for MoD staffwho may not have knowledge of NHS and social service provision and organisation in disparate areas. Perhapsa national strategy for rehabilitation would help. Some comments returned reflect on the possible value of thePersonal Support Officer in assisting an ex-Serviceman’s transition to NHS services. In countries outside theUK, the services of that post might be discharged by a “Rehabilitation Councillor” (the title varies from countryto country); but in the UK there has never been widespread establishment of such a profession. Perhaps thePersonal Support Officer role will provide a model of what might be required by non-military personnel also.


9. Experts in rehabilitation medicine who work in the NHS have concerns over the capacity of existingservices to absorb the numbers of people involved. This is because rehabilitation services are under-providedin many areas with a shortage of critical professions. A recommended increase of 50% in the number ofRehabilitation Medicine consultants has not been achieved in hospital or community settings; clinicalpsychologists are in short supply; and some specialist prosthetists (perhaps especially upper limb prosthetists)are scarce. There is real concern that these (new) needs will exhaust existing supply. The gap is unlikely to beaided by the current intention to provide assessment of equipment through “any qualified provider”; as indicatedabove, the complexity of problems experienced by those injured by conflict demands expert, experiencedassessors.

10. Specifically, it should be noted that:

— Comprehensive community brain injury rehab services, including psychology and long termsupport for PTSD and cognitive/behavioural difficulties and vocational rehabilitation are notavailable in many areas.

— NHS artificial limb clinics cannot afford to provide the level of prosthetic provision ofHeadley Court.

— Most NHS limb clinics have no experience of supply, maintenence and trouble shooting withvery expensive components. Few centres have experience of training bilateral above kneeamputees to walk.

— Providing an obvious two tier service of prosthetic prescription within a single NHS clinic toveterans and civilians is likely to create resentment and raise demands from civilian patientsfor similar prostheses.

11. The staff of the combined services rehabilitation unit at Headley Court have gained great experience intreating people with multiple limb loss, sometimes associated with emotional and cognitive complications ofbrain injury. They are able to provide artificial limbs with very sophisticated components to give their amputeesthe greatest opportunity to resume their preinjury activities and independence.

12. There is concern that this level of service to amputees can not be provided within existing resources atNHS artificial limb clinics, where the great majority of new patients are older and much less active, and sufferfrom multiple complications of diabetes. Formal psychology support within the amputee rehab services isavailable in only a small number of larger clinics. Few NHS clinics have experience of supplying the mostexpensive components, eg the C leg or Touch Bionics myoelectric hand, because their component budgetscannot afford them.

13. NHS artificial limb clinics will not be able to replicate the prescribing pattern which veterans dischargedfrom Headley Court will have come to expect eg a veteran recently transferred to a local NHS clinic, with fivehigh activity prostheses for a single below knee amputation. Component costs to replace these might be £6,500,compared to approx £350 for a single prosthesis for a typical NHS patient. A clinic of this size might expectto supply or replace one such high activity prosthesis each year among NHS patents. Maintenance costs for aC leg for an above knee amputation are £2,000 per year, after initial purchase of £9,000. Most NHS patientsprosthetic knees would cost less than £1,000 with minimal annual maintenance costs. Annual budgets are setand managed assuming that activity and demand is the same each year, and do not have the capacity toaccommodate these extra costs.

14. Amputees spend many hours at artificial limb clinics and discuss their experiences and artificial limbs.NHS patients will likely request the same sort of prostheses which they see Headley Court patients wearing.There are likely to be 10 NHS patients of similar fitness and potential to each veteran transferring to NHSclinics, and even a modest increase in cost and sophistication of prostheses of this larger population wouldcreate a greater financial demand than that of the individual veteran. Without an increase in funding, this willlead to tension and dissatisfaction, as raised expectations cannot be met. This may be particularly obviouswhen policeman, firemen and others injured during the course of supporting the community are offered standardNHS level of prescription.

15. Two particular questions in the Consultation deserve special comment. The first is the need for peoplewith psychological problems to be supported. Many people with any form of disability have associated moodor emotional difficulties, and the majority of these problems form part of the work of Rehabilitation teams; ifthere are sufficient teams, these problems will receive help. The more complex problems of PTSD may moreappropriately discussed by other specialties, but our colleagues have commented on poor provision of healthand social sector support for those with this diagnosis. The specialty of medical rehabilitation, however, isconcerned with ongoing cognitive problems of those with neurological injury, and there are concerns whetherthese often under-recognised difficulties are adequately treated. Currently, we doubt that local services in manyareas are sufficient for this, and we recommend this receives particular attention by the Committee.

16. Finally, there is the question over Vocational Rehabilitation. The British Society of RehabilitationMedicine (BSRM) has published a report specifically on the vocational needs of those with long-termneurological disorders.2 Again, provision of the specialised services required is patchy, whether from statutoryor independent sector providers. If existing services were adequate, the needs of those disabled through conflictcould probably be absorbed; but currently we feel these services, taken in the round, are insufficient.


17. In summary, therefore, we feel that the consultation is timely. The needs are complex, and demand thehighest standards of training and experience of rehabilitation service provision. We feel that there are servicesof sufficient quality to address these needs, but that the quantity of high-quality services needs urgent expansionfor ex-Servicemen to receive the services they deserve. Overall, we strongly believe that special funding willbe necessary for the NHS to continue the style of prosthetic provision and multidisciplinary rehabilitationstarted at Headley Court. To ensure veteran amputees with particular complex needs, for instance three limbloss, visual loss, brain injury, we suggest funding and administrative provision should be made to allow veteransto attend veteran clinics at NHS regional centres or perhaps Headley Court.

9 September 2011

References

1 Royal College of Physicians Medical Rehabilitation in 2011 and Beyond London: 2010.

2 British Society of Rehabilitation Medicine Vocational Assessment and Rehabilitation for People with Long-Term Neurological Conditions: Recommendations for Best Practice. London: 2010.

Written evidence from Lesley Griffiths, AC/AM, Minister for Health and Social Services,Welsh Assembly Government

I am writing with regard to your correspondence with my officials asking for a written statement on issuesrelating to transition from Military Service to civilian life.

Our Servicemen and women do an outstanding job and we owe veterans a debt of gratitude and a duty ofcare, particularly when veterans develop health problems as a result of their Military Service. I therefore takemy responsibilities for veterans’ health seriously and I am committed to ensuring a range of high qualityservices are available to provide the treatment deserved.

1. The Welsh Government is working with the Ministry of Defence (MoD) to forge stronger links betweenthe military and the NHS in Wales to benefit Service personnel once they are discharged. Welsh Governmentrepresentation, at official level, on the UK/MoD Partnership Board is key to ensuring Welsh needs arerepresented. Whilst Armed Forces policy is not devolved, health services are, so the Welsh Government hasan important role to play in aiding the transition of injured service personnel to the civilian health infrastructureand in ensuring their continued healthcare in line with our commitment to veterans.

2. A Wales-specific care pathway for injured/ill Service personnel discharged into Wales is being developedfor severely injured personnel, being led by the Welsh Government and MoD. The scheme also includes thetransfer of medical records from MoD to GPs. This work is part of the Concordat between the MoD and theWelsh Government.

3. Although the majority of treatment of injured Service personnel is carried out in various locations aroundEngland, the Ministry of Defence’s Vale of Glamorgan (St Athan) base in Wales, is available for those sufferinglife-changing injuries in Afghanistan and Iraq. Patients are referred to St Athan for on-going treatment, afterbeing discharged from acute care at Selly Oak, in Birmingham, or Surrey’s Headley Court. NHS treatment forspinal injuries and neuro-rehabilitation is available in Rookwood Hospital (Cardiff) for South Wales, and bythe Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust in Oswestry covers NorthWales for those discharged from the Services.

4. The Welsh Government is committed to ensuring the best possible standard of prosthetic provision forpersonnel who have lost limbs as a result of their military career. Welsh Ministers are aware of the work of DrMurrison, MP, in relation to prosthetics provision and await publication of his report. While his report considersprovision in England, the Welsh Government will take due account of the recommendations in considering itshealth service provision and the needs of veterans in Wales.

5. Welsh Ministers have prioritised improving the health and well-being of Service personnel and veteransin Wales. To support this the Annual Operating Framework 2010–11 target is “to consider the needs of veteransand armed forces personnel when planning services”. Health bodies also have an obligation to offer prioritytreatment and care for veterans whose health problems result from their Military Service as elsewhere inthe UK.

6. All Welsh Local Health Boards and NHS Trusts have Veterans and Armed Forces Champions at Boardlevel in place. Champions advocate for veterans and Service personnel to ensure their needs are reflected inservice plans. The Welsh Government also funds and supports the Health and Wellbeing Service for Veterans,allocating £485,000 to the Service annually. The Service builds on a successful pilot scheme in Cardiff and theVale of Glamorgan and is now being rolled out across Wales, with clinical and other appointments currentlybeing finalised. An official launch of the Service is planned in October. The Welsh Government also workswith and funds third sector bodies such as Combat Stress and Cruse Bereavement Wales, which work withcurrent and ex-Service personnel.


7. In February 2011 the National Assembly for Wales also published its own report into post traumatic stressdisorder (PTSD) services in Wales. This highlighted good practice currently underway, but also made a rangeof recommendations to develop services further. The report was fully accepted by my predecessor and we areworking with our stakeholders, including colleagues in the UK Departments of Health and MoD, to take theserecommendations forward.

12 September 2011

Written evidence from Nicola Sturgeon MSP, Deputy First Minister and Cabinet Secretary for Health,Wellbeing and Cities Strategy, Scottish Government

I am very grateful for your 11 August letter inviting a Scottish Government perspective on the support givento members of the Armed Forces and civilians wounded in the Service of their country and to their familiesthat is subject of an inquiry by the House of Commons Defence Select committee.

The courage, professionalism and dedication of our Service personnel is rightly recognised andacknowledged by the people of Scotland. The news that Armed Forces personnel have been injured or tragicallykilled on operations is met with great sadness but an equal determination to do all possible to ensure they andtheir families receive the best care and support. The Defence Medical Services are at the forefront with theirworld class medical staff and facilities both in the field and back in the United Kingdom. However, as yourCommittee rightly recognises, the NHS has a significant role to play and I am delighted to take this opportunityto reaffirm that the NHS in Scotland, working with its strategic partners in the statutory and voluntary sectors,has and will continue to deliver the highest quality medical services as and when they are required.

The delivery of the commitments contained within the 2008 Service Personnel Command Paper and the newArmed Forces Covenant, both welcomed and supported by the Scottish Government, have helped shape ourpolicy development in regard to the provision of heath services to the Armed Forces community. Against thatbackground, we have developed a range of initiatives and introduced specific practice designed to address thehealth needs of Service personnel. Details of these are contained with the attached submission to yourCommittee.

1. Responsibility for the treatment of Service personnel injured on operations is a matter for the Ministry ofDefence and the Defence Medical Services. However, the Scottish Government and the NHS in Scotland canand does play a role in assisting with treatment where appropriate. This is particularly the case where anindividual is scheduled for discharge from the Services.

2. Armed Forces personnel injured on operations or in the course of their service are treated in a number ofsettings. The most seriously injured might be treated at the Queen Elizabeth 2 Hospital in Birmingham and atHeadley Court. Others may receive treatment and other medical support at one of the six Ministry of DefenceHospital Units (MDHU) attached to NHS facilities (though there are none presently in Scotland) while otherinjured personnel, having been treated at one or more of the aforementioned facilities will be rehabilitated ata Personnel Recovery Centre (one of which is in Edinburgh). In addition, some Service personnel will betreated at specific NHS facilities in Scotland where the expertise is appropriate to the injury being treated.Finally, a number of injured personnel may be moved after initial treatment at Queen Elizabeth 2, HeadleyCourt, MDHU and a Personnel Recovery Centre to NHS facilities in Scotland to be nearer home and familyas a means of aiding recovery, where such a move is clinically appropriate.

3. More generally, the Scottish Government has registered an expression of interest to host two RAMP 3facilities within NHS Boards in Scotland.

4. The Scottish Government acknowledges that there are unique and diverse health needs for both servingmilitary personnel and those leaving the Services as a consequence of ill-health or injury, as well as for veteransfor whom a health condition, whether physical or psychological, may take many years to become manifest andmay not be obviously linked to their period of Service. Accordingly, initiatives and the provision of specificservices have been developed across a range of Health disciplines in order to specifically meet the needs andaspirations of the Armed Forces and veterans’ community.

5. Dental services provision in areas with increased Forces population has been developed. Access todentistry has improved since, the number of dentists in training has increased and outreach teaching has beenexpanded across Scotland allowing treatment from senior dental students. Additionally, the Scottish DentalAccess Initiative provides funding to set up new practices and allow existing dental practices to expand. Oralhealth improvement initiatives such as the “Childsmile” programmes are being rolled out across Scotland, andthese benefit Forces families as well as the wider community. Most recently there has been some earlydiscussion at NHS Board level to develop joint working with Forces’ dentists to ensure access to out of hoursemergency dental care for Forces personnel.

6. In addition, support proposals to increase the level of health service awareness of Forces/veterans’requirements have been developed. In encouraging the Armed Forces to involve the NHS in joint activitiescontact has been made with NHS Education for Scotland (NES), the British Medical Association (BMA) andthe Royal College of General Practitioners (RCGP) Scotland to look at appropriate joint training for ContinuingProfessional Development (CPD). This is mainly to raise awareness of the issues and constraints faced by


Armed Forces and NHS healthcare professionals, their patients and families. These organisations acknowledgethat good local professional relationships can have a significant benefit for the delivery of high qualityhealthcare services and also benefit patients, their families and healthcare professionals themselves.

7. RCGP Scotland has made links with the Regional Clinical Director of the Army Primary HealthcareService (Air Force and Navy will be included later). A meeting took place in July 2010 suggesting someinitiatives which should be explored such as, Modular Quality Practice Award (mQPA); Modular PersonalEducation Plan (PEP), which is an on-line personal assessment tool allowing an individual to create his or herown personalised module; and Alcohol Screening and Brief Interventions, a one day workshop on how to dealwith this issue, including identifying and delivering brief interventions. Further action rests with the ArmyPrimary Healthcare Service.

8. In May 2009 the Scottish Association for Mental Health (SAMH) published guidance (Life Force) onhow to provide support to veterans with mental health problems. Life Force is written for community basedsupport agencies (including voluntary sector, services provided by NHS Boards and local authorities) and hasbeen distributed to GP Practices and Primary Care services, to enhance the information and assessmentprocesses for primary care professionals about veterans’ specific health and community needs. The guideprovides practical advice, and it challenges assumptions and generalisations which can often adversely affectveterans seeking support.

9. Work is underway in eHealth (and IT) which will contribute to improving the healthcare for Armed Forcespersonnel, their families and the veteran community. Measures being rolled out include: the possible identifyingof veterans in their health records (with their consent and where there are no obvious security risks). A proposalof whether it might be possible for GP records, or a summary of that record, to follow Armed Forces personnelinto Service and return to their GP on discharge is being actively considered. The GP Registration form nowincludes questions on Forces’ status.

10. On 13 February 2008 the Scottish Government issued Circular CEL 8 (2008) to all NHS Boardsexplaining how Armed Forces veterans should receive priority access to NHS primary, secondary and tertiarycare for any conditions which are likely to be related to their Service, subject to the clinical needs of allpatients. This includes those not in receipt of a war pension, and those who have served as reservists. EachNHS Board has appointed a member of staff to ensure the guidelines set out in the Circular are followed.

11. The Veterans First Point (V1P) service delivered in partnership with the Scottish Government and NHSLothian has been operational for more than two years, and is making a significant contribution to improvingcare and support for veterans and their families. Operating on a drop in basis, the service provides a “one stopshop” for assistance to veterans and their families, no matter what that need might be.

12. Since opening more than 300 veterans have used V1P, and encouragingly around half of these clientshave self referred. Accessibility is a key aspiration for the service and it is encouraging that the credibility ofthe service continues to develop within the veterans’ community. The service received a good review in therecent evaluation of the six UK based mental health pilots conducted by Sheffield University.

13. We know that veterans are presenting with a multiplicity of complex needs including not only healthmatters but on financial, employment, housing and other issues. A co-ordinated approach to responding tothese issues includes the key role played by Peer Support Workers (two thirds of whom are veteransthemselves); delivery of robust clinical assessments and evidence based treatment programmes; and theinvolvement of partner agencies such as Citizens Advice Scotland, Scottish Personnel and Veterans Agency,Combat Stress and others.

14. The new commissioning arrangements put in place from April 2009 with NHSScotland and CombatStress for the provision of specialist mental health services for veterans continue and have been working well.The arrangements have not only helped to improve the quality of specialist mental health services accessed byveterans and their families living in Scotland but have helped also to improve joint working and relationshipsacross NHSScotland. The Scottish Government provides under this arrangement through NHS Ayrshire &Arran as host Board £1.2 million per year to improve access to specialist assessment, treatment, education,advice and welfare support for veterans across Scotland.

15. The Scottish Government also continues to fund the Combat Stress outreach service operating acrossScotland with £560,000 funding made available over 2008–11. Funding continues at £200,000 per annumto 2014.

16. Two Regional teams operate across the East and West of Scotland, with the Scottish Government fullyfunding the East Team. The outreach service seeks to respond quickly to the needs of veterans with a mentalhealth problem related to their Service and provide support tailored to the individually assessed needs of theveteran. The community outreach model has provided greater opportunities for earlier interventions; improvedcontinuity of care; a focus on recovery; improved carer support; and through the CPN, a clinical specialist ableto engage with local community mental health services on an individual veterans needs with a much greaterdegree of personal involvement and influence.

17. Delivery of the Government’s wider mental health programme also directly benefits veterans and theirfamilies. A key part of this is our efforts to respond better to depression, anxiety and stress and as the most


common mental health problems in the general population, many veterans will present with these conditions.We are working with NHS Boards and NHS Education for Scotland (NES) to increase access to psychologicaltherapies as a treatment with a solid evidence base for effective interventions. We have set a HEAT target forNHS Boards to deliver faster access to psychological therapies which means that, from December 2014, no-one should have to wait more than 18 weeks from referral to treatment. We are also updating the Matrix guideto delivering evidence based psychological therapies to include evidence of effectiveness of particular therapiesin respect of trauma.

18. From early September, we will also be consulting on a new mental health strategy for Scotland to bringtogether the work to improve mental health services and mental health improvement. Proposals intend to buildon the current approach and seek stakeholders views on the direction of travel for the next three to four years.We hope the veteran’s community will participate and let us know their views.

19. A £300,000 prosthetic limb project has been started at NHS Lothian Rehabilitation Centre. Training onfitting and maintenance of the most clinically appropriate and cost effective prosthetics for each individual isbeing rolled out in Scotland with the co-operation of the five rehabilitation centres in Edinburgh, Glasgow,Dundee, Aberdeen and Inverness. All have been provided with alignment equipment and staff trained in itsuse. Interested professional nominees from each Centre will be champions for this project. The intention is toensure that veterans who lose limbs whilst in Service receive a similar standard of the most clinicallyappropriate and cost effective prosthetics for each individual from NHSScotland to that provided by the MoDDefence Medical Services.

20. More generally, the Scottish Government is examining how the cost of travelling to Edinburgh fortreatment is to be met. The Scottish Government will examine the model used for the Assisted Travel Schemeand the possibility of delivering the treatment in other areas rather than just Edinburgh.

21. On 22 January 2009 the Scottish Government issued a circular CEL 3 (2009) to NHS Boards confirmingthat Service personnel and their families who move between areas will retain their relative point on the pathwayof care within the national waiting time targets. Similarly, when patients move across the UK, previous waitingtime will be taken into account with the expectation that treatment will be within national waiting timestandards. An electronic referral system will be implemented and guidance is being devised on waiting timesand expected to be issued this year. This will lead to equivalent waiting times for treatments for Servicepersonnel and their families to those in the community.

22. Each NHS Board has designated a senior member of staff with local responsibility for ensuring theimplementation of the guidance and addressing any barriers. A named contact in each Board has been providedto the MoD to ensure timely and effective communications. Future updates of waiting time guidance willinclude an explanation of the actions required. Requirements will be reinforced at regular waiting time reviewmeetings. A formal review of the effectiveness of arrangements will take place and we will produce a summaryreport covering the first year of implementation.

23. The Scottish Government’s eHealth Directorate has examined what, if anything, eHealth could do toimprove healthcare for the Armed Forces Community in Scotland. Four areas were identified:

— Positive Patient Identification—making sure NHSScotland’s CHI was used.

— Electronic access to laboratory results.

— Enhanced services around NHS GP registration.

— Priority access to healthcare (where appropriate).

24. Provision of a Community Health Index (CHI) number to all personnel serving in Scotland is requiredto enable positive patient identification and effective communication, including participation in the NationalBowel and Breast screening programmes.

25. An initial matching exercise found that while 48%, of the military personnel currently based in Scotlandhad an existing CHI number, the remainder would require allocation of a new one. Work is underway to scopeout requirements to allocate CHI numbers for all military personnel serving in Scotland ensuring a “best fit”with NHSScotland national systems.

26. More generally, the Scottish Government’s Armed Forces & Veterans Champion chairs a twice yearlymeeting with senior representatives from each of the NHS Boards (designated as NHS Armed ForcesChampions) in Scotland, together with senior military figures and representatives of the Third Sector, toexamine health issues impacting on the Services community. Should there be any concerns around transitionarrangements for those moving from military to civilian care then they can and are raised in this forum.Moreover, the Scottish government has an excellent working relationship with the Services through the FirmBase Forum in Scotland at which there is ongoing dialogue and information exchange around NHS support forthe Armed Forces based in Scotland.

13 September 2011


Written evidence from Jeremy Harbord, trustee of a regimental charity

The major Service charities have been closely involved in the debate about the Military Covenant for sometime now and recently gave evidence to the Commons Defence Committee.

One aspect that seemed to be missing from that evidence was a view as to what should be done withregimental associations and how to make best use of them and their membership.

As regimental associations play such a key role at the heart of Service welfare and act as the enduring bridgebetween serving and retired communities, any overall plan for veterans’ support should include a carefullyconsidered and fully integrated role for the associations.

As a trustee of a regimental charity, my aim here is to suggest potential and prompt questions for furtherreview by COSBEO and its members.

Summary

1. Now that increased funding is coming through from the MoD and herculean private initiatives, notablyH4H, the greater need for future support for veterans has become more a question of people rather than cash,not just to help casualties and the bereaved to transition away from dependency on MoD support, but to provideaccess to support over the very long term, including for those majority of veterans and their families who havenot been casualties or bereaved as a result of operations.

2. The Defence Committee recently heard evidence of the need “to create the overarching architecture todeal with the veterans community” (Air Vice Marshal Tony Stables, COBSEO) and how, “to help veteransdownstream, we need to know where they are and who they are” (Cathy Walker, SSAFA).

3. Within the context of the Army this has historically been exactly the preserve of regimental associations,whose core objects are, “helping members to stay in contact” and “helping members who are in hardship ordistress”. Unfortunately, despite the best of intentions, they are limited in their activities by poor resources andhamstrung by such issues as Data Protection.

4. They deserve closer scrutiny because although they already generously help the injured, bereaved and alltheir veteran members in need, they are capable of much more—if given the tools.

5. With a coordinated boost, including help to upgrade corporate governance and access to a modern,networked communications platform such as a secure version of Facebook, they would be excellently placedto provide the long-term continuity of support at the really very local, personal level required, that is currentlyabsent from any plans.

6. Why reinvent the wheel when excellent foundations are already in place?

7. Regimental associations and charities comprise a multitude of different entities, some wholly autonomousin a legal sense, others only partly, as in a practical sense they need to rely on involvement and support fromthe serving community. Because they cannot be easily pigeonholed, they are no doubt viewed by the MoD assomething of an “awkward” squad and so best left alone to carry on doing their own thing: easier to deal withthe top tier of major charities who can in turn deal with the smaller ones.

8. Yet regimental associations and their charities enjoy immense reach. They lie at the very heart of theveterans community, represent “the face” of Army welfare and offer precisely the sort of scope for providinglong term, close, personal support that the major Service charities—whose strengths are providing funding andspecialist support—lack.

9. This is because regimental associations are people networks par excellence and exemplars of mutualsupport systems with long experience despite limited resources. This means they can help to identify possiblewelfare cases at an early stage, and also coordinate how to deal with it. “All our members are our welfare eyesand ears”, as one association President has put it.

10. For instance, a regimental association can organise volunteer members to act as “guides”, to ensure thata veteran is physically accompanied to the bank to set up an account, helping with the forms; to get financialadvice that the MoD lays on and to ensure it is actually followed through; to visit recovery centres; and tosearch for suitable accommodation. SSAFA and other large Service charities already do much of this brilliantlybut regimental associations have the scope to be much more extensive, much more local to the point of needand over a longer timeframe.

11. Oddly, none of the major current plans for improving veterans support seem even to acknowledge theexistence of regimental associations, much less factor them in or propose how to improve their capability. Nordo recent studies appear to appreciate fully either their current worth or their future potential.

12. In summary, regimental associations are ideally placed to help meet the increasing but more complexchallenges ahead as they are bodies that veterans already feel the closest affinity to, and trust—providing linksto their old mates and their former regiment. However, to get the best out of them, they must be put more in“the loop” than is the case at present, and “the loop” needs to be much smarter.


Possible Initiatives

13. Possible initiatives to get the best out of regimental associations might focus on two areas:

13.1 Improving Governance: by providing centralised resources to make regimental associations moreeffective, for example, by providing training for trustees, not just for better corporate governancebut to ensure more effective grant making—to unlock the millions of pounds already held byService charities—and fund raising. After all, as well as their own cash, they are dispensing fundsfrom the taxpayer and the larger charities such as RBL and the ABF, who have a duty to ensurethat their cash is being expended properly and effectively.

— No compulsion, but a setting of standards (including possibly kite marks for excellence) backedby the provision of training necessary to achieve those standards

13.2 Building A Network: by creating the architecture to connect all such associations and charities ina secure network, perhaps called “ForcesNet”, on a communications platform which would alsoconnect the MoD, corps, regiments and the individuals themselves from Day 1 of their joining up.

— Possibly as an adjunct of JPA, with a section called “Your CV” containing an individual’s livingrecord of accomplishments automatically produced in a CV format which the individual couldamend, ready for ultimate transition to civilian life.

— Addresses the overall problem of the multiplicity of Service charities, not just regimentalassociations: futile to try to merge them, so instead, overarch them all by improving how theyinterconnect.

— Takes the burgeoning Casework Management System to a much larger scale.

14. With today’s technology, these objectives are not only achievable but vital and would additionally enableData Protection issues to be dealt with upfront in the simplest and most coordinated way possible.

15. MoD involvement for any initiative will obviously be vital but to attract its full engagement, it needs toknow from the outset what the limits on its liabilities will be, as part of the overriding question, “How farshould the military covenant be reasonably expected to go?”

16. From a holistic viewpoint, it does not take much imagination to see how such further support for veteranswould additionally provide spin-off benefits for the Big Society and Homeland Security, and build nationalresilience, tying in with plans for the Future Of The Reserve Forces (FR20).

17. To date, hardly anyone except perhaps the Military Covenant Task Force seems to have recognised thewider picture that all these various strands amount to—or if they have, there seems to be no evidence they aredoing anything about it.

The Aims of a “ForcesNet” Type Network

18. The overriding aim of something like a ForcesNet would be to save people time communicating, to makeit easier, so that the perennial excuse of “lack of time” given by someone avoiding involvement in manyService and veterans matters, would no longer apply.

19. Secondary aims would be to:

19.1 Act as a portal to the internet, directly relevant to the Armed Forces community.

19.2 Help Service related organisations to stay up to date and relevant.

19.3 Provide common protocols for future internet development.

Essentials for a Successful Network

20. In order to succeed, a ForcesNet type network should:

20.1 Overarch everything, so as to allow direct contact between any ForcesNet member and another,always subject to personal preferences.

20.2 Form the permanent, interactive, database for every individual’s membership of his or herregimental association with name and contact details, for possible access also by any other agencythat the member links to via ForcesNet, without disclosing any personal information unless themember gives specific permission.

20.3 Enable a member to send and receive emails from their normal personal email address, but viatheir ForcesNet email address, ie so all emails mask any personal information unless the memberspecifically allows it.

20.4 Be secure.

20.5 Be authoritative.


Benefits of a “ForcesNet” Type Network

21. A ForcesNet would be more comprehensive than the current maze, and:

21.1 Help veterans by acting as a very real social service, so that they can help themselves and eachother better, just when state funding is being squeezed and greater burdens are falling on theprivate sector.

21.2 At least create a permanent “virtual” address even if an individual changes his or her physicaladdress many times, or loses contact with the Services.

21.3 Enable all users to instantly connect with each other even if they do not know each otherbeforehand, and facilitate greater coordination between Service and ex-Service communities forinnumerable other opportunities besides just Casework Management of welfare cases (anoutstanding first step and an example of what should be replicated a hundred times over in otherareas).

21.4 Create a direct link between the MoD and veterans.

21.5 Help serving commanders to deal with commercial and governance issues.

21.6 Give the whole regimental system a boost, enabling it to be much more effective and relevant inthe 21st century.

21.7 Enable serving personnel to keep up to speed and “in the loop” about association matters whenserving at ERE, so that when they become trustees they can become effective sooner.

Existing Networks

22. Existing Service sponsored or Service related networks include:

22.1 ArmyNet—but this only focuses on linking serving soldiers and their families.

22.2 Veterans-UK—which is only an information hub; useful but under resourced and basic; as regardsveterans, SPVA is primarily a pensions delivery unit.

22.3 The Sandhurst Foundation—which has only made a small start, for officers, but can nonethelessprovide useful lessons.

22.4 Over 500 unofficial military related websites which the MOD seems to have given up trying toregulate as “mission impossible”.

22.5 Countless other official and unofficial groupings, from regimental associations to small reuniongatherings—all using their own different internet strategies.

Problems Faced by Regimental Associations

23. Problems include:

23.1 Poor resources.

23.2 Most rely on just a handful of active volunteers and find it difficult to recruit more as associationofficers because people cannot spare the time.

23.3 Few individuals with business or professional experience participate (as so many such people aretoo busy to attend meetings or live too far away or are deterred by the procedural processes).

23.4 Associations hold accurate contact details for perhaps only 5–10% of potential membership andare hampered by Data Protection.

23.5 No records for most welfare claimants whose details are typically forwarded by SSAFA or theRBL to the relevant associations, as being association members.

23.6 Mixed standards of governance and minimal training.

23.7 Frequent rotation of serving personnel acting as trustees who take time to become effective.

23.8 Difficulties managing change and lack of skills for major IT upgrades.

23.9 E-communications are by mass, insecure, emails.

23.10 Little use of secure, online, discussion forums which can avoid the need for physical meetings—and thereby attract higher calibre professionals who are short on time.

24. It is remarkable that despite their clear public benefit, no one has ever tried to help the associations enmasse to do a better job. Why create new “offices of veterans” affairs at local levels when better empoweredassociations would be cheaper and more effective?

Further Background

25. The present lack of a comprehensive network connecting all sides of the Armed Forces communitymeans that resources are too often being misallocated and all sides are far less effective than if they couldcommunicate together more easily and see the bigger picture. For instance:

25.1 The Services are blind to the full range of talents and usefulness of veterans—indeed just knowingwho most of them are.


25.2 Serving commanders enjoy very little access to the best business and professional advisersavailable from the veterans community.

25.3 Service charities overlap each other with uncoordinated fundraising activities.

25.4 Many Service charities hold more money than they need but cannot find sufficient worthy veteransto give to, while other charities have too little money to meet claims.

25.5 Veterans are hampered in their abilities to help each other; bewildered by the different agenciesavailable to help them and the jungle of options on the internet; and deterred from public, unofficialwebsites like Facebook due to security worries; all very confusing, especially for an individualwanting help who is unfamiliar with the system.

25.6 Operational casualties waste compensation payments for want of suitable advice

25.7 The MoD has lagged internet development for the serving Armed Forces, at least the Army*, andwhen it has come to the retired community, lamentably much more so (*Def PR(A) XX/07 12/4/07 Web audit).

25.8 Information portals like “Start Here” lack the vital human interaction which veterans demand,

Points of Difference from Recent Studies on Regimental Associations

26. Compared with recent studies of regimental associations, this paper differs in a few key respects:

26.1 It recognises the importance and benefit of regimental loyalties, a concept not easily understoodby someone who has never served themselves. Few soldiers consciously join a particular regiment.However, the fact is that once they have joined, tribal loyalty becomes strong and endures for life.Other studies seem not to have fully comprehended this.

26.2 It sees the overriding value of the internet as lying in its ability to link people with shared passions,and the power of the resulting networks which this makes possible. Other studies seem only toview the internet as a database that can be mined for information: an understandable point of viewwhen the internet was in its early stages but the connectivity of networks enabled by the net hasbeen the outstanding feature for a while now.

26.2.1 Other studies have ignored social media and its implications, and the myriad unofficial, as wellas official, Service-related web forums like ARRSE.

26.2.2 They therefore fail to appreciate how veterans can, at the simplest level, help each other—without any outside input or cost.

26.2.3 And correspondingly fail to deduce how such forums constitute a very real, mutuallysupportive, “social service” all by themselves.

26.3 The concept of a single point of contact such as a Veterans Helpline offers simplicity but theprocess would work just as effectively if all sides were fully networked so as to create a “ring”.The result would mean that a veteran in need would only have to contact any part of the ring to beinstantly brought into the system. In other words, if the veteran preferred to contact his regimentalassociation first because he wished to speak to a familiar voice, the follow up would effectivelybe the same as if he had contacted the Helpline or RBL or SSAFA.

26.4 A bigger hierarchy, including a Veterans Commission, to oversee veterans affairs would be veryhelpful but this does not provide a complete answer to cases of individual need, much less aspeedy one.

26.5 By contrast, a networked solution, as proposed in this paper, would produce a flatter structure.Demand would meet supply much faster than any hierarchical approach, although this willnecessarily create administrative problems from time to time. (See General Stanley McChrystal’sextremely successful strategy in Iraq using a networked solution, as in, “It takes a network todefeat a network”).

26.6 This paper fundamentally disagrees with the simplistic proposal for every ex-Service charity toconsider consolidation and merging, so as to serve better the needs of current veterans. This hasbeen tried before and is extremely difficult when dealing with separate legal structures. Theseissues become irrelevant with the networked route. Mergers and consolidations of charities becomealmost unnecessary and more likely to damage effectiveness—because of the inevitable damageto morale, as opposed to compounding existing loyalties—than boost it by any nominaladministrative efficiency.

26.7 This paper introduces the new idea that it will be best to start an individual’s record, not towardsthe end of Service (even though that would prima facie appear most logical), but from Day 1,so that:

26.7.1 The individual is already familiar with his personal records well before he leaves, in largemeasure because he should by then have “bought in” to the invaluable benefit of developinghis CV from the very start of his Service (actually, computer-generated for him initially andso presented “on a plate”).

26.7.2 He benefits psychologically from the confidence boost everyone feels whenever they sit downto list their accomplishments.


26.7.3 He can build up a feel for his possible worth and employment when he becomes a civilian indue course, beyond the extent of just his confidential report.

26.7.4 Any question by the individual along the lines of, “What’s in it for me?” as regards hismembership of his regimental association, can be soon answered in his Service career: itrepresents a key catalyst that will help him in the ultimate transition back to civilian life.

26.7.5 Transition to civilian life is no longer the traumatic change it has often been for so manyleaving the Services, with so many changes needing to be made just before leaving, forexample, the terror of having to write a CV for the first time at the age of 40, 50 or even older.

26.8 MoD concerns about retention of individuals who have a clearer idea of their worth as a civilianwould be misplaced, especially now that FR20 will see the regular/reserve ratio move to 70/30with the Armed Forces becoming more reliant on reserves, similar to the US National Guard, withthe result that more individuals will be moving back and forth between regular and reserve Servicemore frequently.

The Benefits of a Regimental Association compared with Social Media like Facebook andYoutube

27. Many ex-Servicemen keep in touch via the likes of Facebook, ARRSE, Forces Reunited or smaller socialnetworks, which are excellent for maintaining contact with a number of your old friends and are to beencouraged (following the principle that the value of any network lies in the number of its members, so themore networks with the more people, the better, if you can have access to them).

28. However, an association carries the major benefits of:

28.1 A structure that can endure—a trust can have an infinite lifespan.

28.2 Clear rules about membership.

28.3 Greater security.

28.4 Money.

28.5 Tax breaks for donations and legacies (if a charitable trust).

28.6 Closer connection with the serving community.

28.7 Closer and more authorative access to MoD and welfare agencies, in cases of need.

29. Both routes have value but in different ways and should be viewed as complementary.

The author is an IFA and non-practising barrister who formerly served in the Regular Army and the TA.

22 September 2011

Written evidence from Kevan Jones MP,former Parliamentary Under-Secretary of State and Minister for Veterans

1. Between 2008 and 2010 I was Parliamentary Under-Secretary of State and Minister for Veterans, havingresponsibility for devising and implementing the Army Recovery Capability (ARC) and all other policy areasrelating to veterans.

2. The aim of establishing the ARC was to provide enhanced support to assist sick or injured soldiers,regardless of cause, in order to successfully return to duty or transition into civilian life. The ARC seeks to bea care system for life; despite public focus on the early years of post-Service life, it concerned itself with amore sustained emphasis on through life care.

3. The plans were announced on 11 February 2010. Under the ARC, educational, occupational and welfaresupport has been delivered to soldiers in a military environment. The scheme has been delivered in partnershipwith the Service charities such as the Royal British Legion (an organisation with a well-developed expertise inrehabilitation and managing care facilities) and Help for Heroes, as well as other Government departments.The support of these bodies has been indispensible, and I am very grateful for the assistance and financialbacking they have provided for this project. Help for Heroes, for example, donated £20 million to the buildingof the Personal Recovery Centre (see below) in Colchester.

4. The ARC has sought to bring together a range of services into a single programme. It has either returnedindividuals to duty or taken them to a point where it is right for them to be discharged, however long it takes.The ARC formed an important part of the previous Government’s policy, outlined in 2008 in the ServicePersonnel Command Paper, to deliver world-class services for the men and women who serve in our ArmedForces.

5. The ARC revolves around the needs of the individual and what is right for his or her recovery needs,focusing on what personnel can do, not what they cannot. One of its aims was to allow commanding officersto focus on operations, confident that the needs of their wounded, sick and injured soldiers were being met.

6. The ARC has four main components:


7. Personnel Recovery Branch—This was designed to co-ordinate all elements of the ARC and provide thefocal point for all aspects of support to the transition of wounded, injured and long term sick personnel. It aimsto keep track of all those who enter the recovery process, to the point of discharge and beyond, and developsemployment opportunities for those leaving the Army. Previously, there was no centralised management systemfor those with injuries in active Service or post-Service life, and a more ad hoc approach, in which manyslipped through the net, was used.

8. Personnel Recovery Units (PRUs)—A co-ordinated network of 12 Personnel Recovery Units wasestablished to provide support and guidance to personnel on a recovery pathway. These units were dispersedthroughout the UK, with each region led by a commanding officer, who in turn has been guided by thePersonnel Recovery Branch. The capability has provided occupational therapists, welfare staff, and links totraining and educational organisations, charities and other Government Departments, ensuring that a holisticand fully joined-up service is provided.

9. Individual Recovery Plans—Every person on a recovery pathway has had a tailored recovery plan, whichis developed, co-ordinated and managed by a Personnel Recovery Unit. This has ensured that individuals havebeen able to access the particular support they have needed at each stage of their recovery.

10. Personnel Recovery Centres (PRCs)—Experience shows that injured personnel find a militaryenvironment conducive to the best possible recovery, so we decided to provide purpose-built PersonnelRecovery Centres around the UK. These centres, built by Help for Heroes and run jointly by the Royal BritishLegion and the Army, will provide a residential base for those who need it. Each centre will be located insideor close to Army sites, enabling access to Army facilities and support from the Army, including existingmedical, educational and other garrison facilities. A pilot centre was opened in Edinburgh in 2009. The firstpurpose-built PRC is being constructed in Colchester Garrison, and should be completed by Spring 2012.Further PRCs are under construction in Plymouth, Catterick and Tedworth House.

11. Additionally, the 2008 Service Command Paper also served to raise awareness of veterans’ issues acrossmany central Government departments successfully. For example, the DoH introduced a veterans’ trackingsystem, whereby former servicemen and women have their periods of Service flagged up on their NHS healthrecords. Furthermore, the DWP introduced veterans’ “champions” in Job Centres nationwide, meaning thatformer Servicemen and women receive job advice better tailored to their specific needs and skills background.

12. Its aim was also to ensure that the same type of awareness and coordination were installed at local level.This was achieved by the Welfare Pathway, which has been piloted by local authorities in Hampshire, Wigan,North Yorkshire, Fife and Kent. These have provided veterans with extra advice and support in making thetransition from Service to civilian life. The Welfare Pathway was not about fundamentally re-designing post-Service care, but instead aimed to co-ordinate the existing channels of advice and support more fluidly. Thisnetwork of joined-up, locally tailored veterans’ support has been followed by the current Government’s ArmedForces Community Covenant.

13. The charity sector is vital, and is absolutely essential for delivering these services, but it certainly needsto be better co-ordinated. The Confederation of Service Charities (COBESO), for example, has made it quiteclear that the work done by the Service charities, as effective as it is, could be more effective and more efficient.Greater rationalisation is needed. Therefore, I see no need no need for new charities in this sector.

3 October 2011

Written evidence from Edwin Poots, MLA, Minister of Health, Social Services and Public Safety,Department of Health, Social Services and Public Safety, Northern Ireland Government

1. Northern Ireland has had, since 2008, a locally-based Army presence, 38 (Irish) Brigade and 19 LightBrigade, headquartered in Thiepval Barracks, Lisburn, and with posts at Palace Barracks and KinnegarLogistics, Holywood and Ballykinler, Newcastle (all in SEHSCT area). The RAF also has a Joint HelicopterCommand Flying Station at Aldergrove. 38 Brigade comes under the command of 2 Division, which is theregional Division for Scotland, the North of England and Northern Ireland, and it is now the Regional Brigaderesponsible for administering the Territorial Army within Northern Ireland—204 (North Irish) Field Hospital(Volunteers), based at Hydebank TA Centre, South Belfast, with Squadrons based in Ballymena, Newtownardsand Armagh.

2. For serving personnel, primary care is provided by the Defence Medical Services (DMS) in partnershipwith the Belfast HSC Trust through the NI Military Patient Administration Cell (NI MPAC); their families uselocal primary care services on the same basis as the rest of the resident population. Secondary Care is providedfor serving personnel (often involving accidents while on training) by Belfast City Hospital.

3. Northern Ireland does not receive casualties directly from operational deployment; these patients aretransferred directly from the field of operations to the Royal College of Defence Medicine facility at thenew Queen Elizabeth Hospital in Birmingham (formerly Selly Oak Hospital), followed by recuperation andrehabilitation at the Defence Medical Rehabilitation Centre Headley Court, near Epsom in Surrey.Rehabilitation at Headley Court often takes up to two years, and occasionally longer. Although a transition


protocol (between DMS and NHS/HSC) is in place throughout the UK, this is currently being piloted and wehave not yet had patients returning to Northern Ireland after rehabilitation.

4. Health service personnel, working as TA Reservists, are vital to deployment capability. In 2009 the 204(North Irish) Field Hospital (V) deployed to Afghanistan for a three-month tour of duty. Their next tour willbe early in 2012.

Healthcare Protocol for Military Personnel

5. Within the existing legislative framework, and specifically the Equality legislation, the Department hasworked to ensure that members of the Armed Forces, their families and veterans have equitable access tohealth and social care services. In 2009 the Department published “Delivering Healthcare to the Armed Forces:A Protocol for Ensuring Equitable Access to Health and Social Care Services”. The aim of this document isto establish a framework of assurance which will ensure that serving members of the Armed Forces, theirfamilies and veterans suffer no disadvantage in accessing health and social care services, and have equality ofaccess to these services in common with everyone living in Northern Ireland.

Establishment of an Armed Forces Liaison Forum

6. Following publication of the Armed Forces Protocol, the Department established an Armed Forces LiaisonForum. This provides a single point of contact with the Department and with the Health and Social Care systemfor representatives from the Defence Medical Services, HSC staff and veterans’ organisations to discuss healthand social care issues of mutual interest. The Forum meets two to three times a year, most recently in April2011.

MoD/UK Health Departments Partnership Forum

7. The Department, together with the other four UK countries’ Health Departments and the MoD, aremembers of the MoD/UK Health Departments Partnership Board (PB). Its purpose derives from theGovernment’s commitment for the Armed Forces to have the best clinical support to ensure a fit and healthyService population ready to deploy at any time, and it provides a framework within which the 5 Departmentscan work together to improve the health and healthcare of the Armed Forces before, during and afterdeployment, and of their dependants and Service veterans.

8. The PB is supported by a Joint Executive, two Working Groups—People and Services—and an NHSArmed Forces Network, linking in to the Strategic Health Authorities in England and DevolvedAdministrations. The Armed Forces Liaison Forum is the Northern Irish equivalent to the Armed ForcesNetworks, bringing together the key interests at local level, and “sits in” at (virtual) Networks monthly meetingsto keep abreast of national developments.

MOD/UK DH PARTNERSHIP BOARD GOVERNANCE MODEL

MoD/ UK DH Partnership Board

Effective partnership between MoD/UkDepartments of Health including joint

strategy and policy development

People WorkingGroup

Personnel relatedissues

Delivery via NHS Networks witheach Administration

DH England /MoDJoint Executive

Service WorkingGroup

Medical services andNHS / DH interface

related issues.


Prosthetic Limb Provision

9. The Armed Forces Covenant commits the four UK Health Departments to a number of actions in theHealth context which emanate from “The Nation’s Commitment”,13 the Command Paper published in 2008designed to end any disadvantage that Armed Service, with its frequent movement from base to base aroundthe country or overseas, imposes on Service personnel and their families. Once such commitment is that ex-Service amputees will ensure top-quality prosthetic provision. Northern Ireland has committed to ensure thatthe standard of prosthetic limb provision to injured Armed Forces personnel by the Defence Medical Serviceswill as a minimum be matched by the HSC system. This commitment is enshrined in our Armed ForcesProtocol.

Retention of Place on NHS Waiting List

10. Another key commitment is the preservation of individuals’ places on NHS waiting lists when they aredeployed to other bases. When patients move to Northern Ireland, their previous waiting time will be takeninto account, with the expectation that their treatment will be delivered within HSC waiting time standards. Aswith any person moving between hospitals within the UK, Armed Forces personnel and their family memberswill be treated as quickly as possible in order of clinical priority. Our Equality legislation, which since 2010is mirrored in England, prevents Service personnel—or any other group—being given preferential treatmentfor any other reason.

Veterans’ Issues

11. The majority of veterans in Northern Ireland have seen active Service here during the Troubles. Due tothe nature of their Service and the associated risks, many are reluctant to volunteer information to clinicianswithin the health service for fear of possible compromise. Combat Stress (see more below) reports that anumber of their clients still find themselves under direct threat and have been advised on their personal securityby the Police Service of NI. This makes it difficult, not only to gauge with any accuracy how many veterans14

there are in NI, but also for Service and ex-Service personnel to have their past experiences, which may havea continuing direct impact on their physical or mental health, acknowledged and addressed.

12. Veterans returning from Service are clearly returning to a different environment from that of the rest ofthe UK. Combat Stress reports that the recent increase in attacks has impacted on their clients, who areexperiencing increased anxiety levels and hyper-vigilance as a result. Most have now reverted to implementingpersonal security measures they once practiced whilst in Service.

Mental Health Services

13. The Armed Forces Protocol states:

“It is recognised that Armed Forces personnel with mental health problems will have access to out-patient, day-case, and inpatient treatment as necessary from the Defence Medical Servicesoccupational psychiatric service. Armed Forces families and Veterans will have access to mentalhealth services within the Health and Social Care system on a similar basis to other members of theNorthern Ireland population”.

Improvements in Mental Health Services

14. Members of the Armed Forces, their families and veterans benefit from service developments andimprovements in community and inpatient mental health services. The development of these services inNorthern Ireland has been a Ministerial priority in recent years, underpinned with considerable investmentparticularly in the areas of community mental health services and psychological therapy services.

Engagement with Defence Medical Services and Veterans’ organisations

15. The Department recently facilitated a meeting between senior mental health service managers,Departmental policy leads on mental health and representatives from Defence Medical Services, Veterans’organisations and Carecall (current provider of psychological therapy to the Aftercare Service). The purposeof the meeting was to identify and resolve any interface issues on the referral of military personnel/veteransto/from mental health services. Existing security arrangements were discussed, and following the meeting theDepartment issued a letter to Trust Chief Executives reminding them of the existing arrangements, which weregenerally felt to be satisfactory.

16. There were no particular issues identified in relation to accessing mental health services or the qualityof services provided, but the decision was taken that mental health issues should form a standing item on theAF Liaison Forum agenda. Referral and discharge arrangements were discussed and contact details wereexchanged to enable any issues to be quickly resolved between military medical staff and senior mental health13 The Nation’s Commitment: Cross-Government Support to our Armed Forces, their Families and Veterans Cmnd Paper 7424,

July 2008.14 Defined as anyone who has served for one day.


service managers. Veterans’ organisations have undertaken a round of visits to Trusts to meet key servicemanagers and explain the services and support they offer to ex-Service members and their families.

17. In relation to inpatient mental health services, the Defence Medical Services expressed interest earlierthis year in contracting with a Health and Social Care Trust for the provision of one or two dedicated psychiatricbeds. A bed specification was forwarded to all Trusts for consideration, but none responded positively.

UDR/Royal Irish Regiment Aftercare Service

18. An Aftercare Service for former members of the Ulster Defence Regiment and Royal Irish RegimentHome Service Battalions, coincident with the disbandment of the Home Service element of the Royal Irish,was implemented in 2007 at the end of Operation Banner, within the context of a normalising NI. It was to bemanifestation of an MoD commitment announced in March 2006 by the Armed Forces Minister and isdescribed as “a cost-effective solution to a unique problem”; providing welfare, medical, vocational andbenevolence support to eligible veterans and their dependants in order to reduce suffering attributable to, oraggravated by, their Service.

19. The Aftercare Service is a response to particular veterans’ needs articulated at the time by HQ RoyalIrish and agreed by the MoD which are still current and relevant. Through offering a combination of practicalhelp and advice, emotional support, signposting, befriending, vocational and social supports, it aims to achievea reduction in the detrimental effects of Military Service suffered by the veterans’ community, includingfacilitating access to specialist expertise from across a wide range of charities and statutory bodies. In particular,the Service addresses mental and physical incapacity related to Service through the provision of psychologicaltherapies and physiotherapy to the veterans’ community requiring treatment.

20. Specifically, the Service provides:

— Continuity of emotional support within a broad Regimental family.

— A range of confidential, trusted care services to the veteran community, especially those mostaffected such as bereaved parents, widows, disabled ex-soldiers and their families.

— Raising awareness and signposting to other support capabilities.

— Swift access to specialist medical support where the condition is directly attributable to oraggravated by military Service.

— Signposting and developing trusted access to other providers, including Combat Stress,SP&VA, DHSSPS.

— Benevolence financial support for mobility aids.

— Detailed insight of current job market requirements, and re-skilling and upgrading ofqualifications.

— Identification, articulation and processing of confidential applications for benevolence.

21. In short, the Service provides holistic engagement with the individual. It has been in existence for3½ years and has helped around 14,000 individuals to date.

Combat Stress

22. Combat Stress (CS) provides welfare support and short term inpatient treatment to clients in order tohelp them manage their conditions and improve their overall quality of life. They currently have 775 activeclients in Ireland, 59 of whom reside in Southern Ireland. All have served in the British Military (RAF, RNand Army) and each has suffered from a stress-related injury due to their Service. CS have three welfareofficers and an admin support team based in Belfast, although they refer all their clients requiring inpatientprovision to their treatment centre in Ayrshire, Scotland, which accepts suitable clients from Scotland, Irelandand the north of England. At present demand outstrips supply, with 45 clients currently waiting to attend the25-bed treatment centre (April 2011 figures).

23. CS are in the process of recruiting a Community Outreach Team for Ireland, and it is intended that theywill be able to act as a link into local mental health services and primary care. It is anticipated that the teamwill be functional in the summer of 2011.

17 October 2011

Printed in the United Kingdom by The Stationery Office Limited12/2011 016089 19585

The Armed Forces Covenant in Action? Part 1: Military ...€¦ · London: The Stationery Office...

Documents

Transcript of The Armed Forces Covenant in Action? Part 1: Military ...€¦ · London: The Stationery Office...