Oral evidence: The Armed Forces Covenant in Action? Part 5: Military Casualties, HC 940Tuesday 1 April 2014

Oral evidence, 1 April 2014.

Witnesses

Air Marshal Paul Evans, Surgeon General, MOD, Rear Admiral Simon Williams, Assistant Chief of Defence Staff (Personnel and Training), MOD, Caroline Pusey, Head of Service and Veterans’ Welfare, MOD, Surgeon Captain John Sharpley (RN), Defence Consultant Adviser in Psychiatry, MOD, Jon Rouse, Director General, Social Care, Local Government and Care Partnerships, Department of Health, and Kate Davies, Head of Public Health, Armed Forces and their Families and Health and Justice, NHS England, gave evidence.

Chair

Okay, you’ve heard all the questions, what are the answers? Could I ask you please to introduce yourselves? Surgeon General, would you like to begin?

Air Marshal Evans

I am Paul Evans, the Surgeon General.

Rear Admiral Williams

Simon Williams, the Assistant Chief of Defence Staff for personnel and training.

Caroline Pusey

Caroline Pusey, Head of Service and Veterans’ Welfare.

Surgeon Captain Sharpley

John Sharpley. I am the Surgeon General’s Adviser on psychiatry and mental health care.

Jon Rouse

I am Jon Rouse. I am Director General for Social Care and have responsibility for Armed Forces’ health at the Department of Health.

Kate Davies

Good afternoon, I am Kate Davies and a Director in NHS England. I am the Head of Armed Forces, Health and Justice and Public Health.

Chair

Thank you very much. I was only partially joking when I said: “You’ve heard all the questions, what are the answers?” Let us begin with: how do you think the support for serving personnel with mental health problems has improved over the last five years? Who would like to begin?

Air Marshal Evans

I will start by saying—as I think was said earlier on—that by and large the care offered has considerably improved right from the battlefield, as it were, through to return home, looking at vulnerable groups, the seriously injured, and the people who work in the medical services. Before I hand over to John, I would say that generally it has improved considerably and our efforts in that area are very much concentrated. The Department of Health has worked very closely with us and Jon Rouse, who with me co-chairs the MOD/DH Partnership Board. Again the ongoing work into transition has improved considerably. I will hand over to John Sharpley first for the in-service side.

Surgeon Captain Sharpley

Five years is not quite the period that I would like to talk about. I would like to talk about 10 years ago, because that is when we probably started to improve our mental health care in terms of resources and people available to provide the care. In the last five years we have been working hard to improve things, for example, by improving the transition for veterans through implementation of the Murrison recommendations, and improving operational care to the physically injured. Perhaps here I could mention Role 4 and the Birmingham and Headley Court provisions. We have more people doing the business, as it were, and we are also probably doing more business. We are seeing more people come through the door because our commanders are now better educated about stigma, and because we have Trauma Risk Management—TRiM—which signposts people to mental health care. We are educating our primary care colleagues. So we have been doing an awful lot to improve things. The job is not done, of course. There is more to do, but I think that we have done a lot in the last five years.

Jon Rouse

Perhaps I could take that into the veteran sphere. There are two elements to this, both of which tell a story of improved services. First, there are the specialist services for the veterans themselves, including the 10 veteran mental health centres, the development of Big White Wall as an online provision, the 24-hour helpline, and the mental health network for veterans. These bring together good practice between the different mental health teams and providers. That is obviously a very important landscape. The second element is the improvement in community services. The big shift has been the development of the Improving Access to Psychological Therapies (IAPT) programme. Over the last five years it has grown from nothing to providing for over 600,000 people per year, which includes veterans and indeed the families of veterans and of serving soldiers, all of whom can access those services.

Kate Davies

The important thing for NHS England within the new commissioning landscape is not only the proactive work and what that means in terms of pathways, particularly for serving personnel and their families, but the work we are doing across CCGs, local authorities and public health to support parity of esteem of mental health services within the community. I can obviously only speak from within NHS England directly for the last year, but one thing that we have certainly done and is work on closing the gap for mental health. This is highlighted by particular pieces of work. The case studies include the circumstances of serving personnel and their families, particularly veterans and reservists. We have been very overt in ensuring that, through our commissioning networks, we highlight what those pathways mean for veterans and reservists. I am not sure that that has necessarily been done on a national basis in the way that we have been pushing it, particularly in the last year and the last six months, with the mental health concordat and parity of esteem.

Chair

When you say that you are not sure that it is being done on a national basis, does that really mean that you are pretty sure that it is not being done?

Kate Davies

Sorry, Chair. I am not sure how we could have evidenced that that was done consistently on a national basis before the commissioning network that we have now was created. For NHS England, the whole purpose of direct commissioning responsibility for armed forces and their families is to ensure that we provide services across the country and that we do not get a postcode lottery. This applies to England; obviously, I can’t talk for the devolved Administrations.

Mrs Moon

Who can talk for the devolved Administrations?

Air Marshal Evans

Jon and I co-chair the MOD/UK Department of Health Partnership Board, on which the devolved Administrations are represented at the strategic level. Clearly, we could say that by and large Scotland, Wales and Northern Ireland are very conscious of the need to look after their veteran communities. Each of those countries has a considerable number of veterans settling there. With NHS England now having been set up for a year, one of the things that we agreed at the last partnership board meeting was to set up a sub-group to look specifically across the devolved Administrations and the regions of NHS England to make certain that we have the evidence and the confidence that care is consistent across the country. That is just the sort of question that you are asking me, and that is what we intend to do in the next few months.

Mr Havard

The covenant is about what the MOD and therefore the Government are promising. How do you get a consistent application of what you are supposed to be applying? That is where I start from and what you are speaking to at the moment. I still have a few reservations about the fact that we are not terribly clear about what we are trying to apply, but we will come back to that. What interests me is that people, of course, are complicated. I’ll speak from the experience of my own community in Wales. People are boomerangs. Half of them are serving in Germany. They are not actually in England, but they will come to England and then they will come to Wales. They will be veterans and they will go from place to place. That will be equally true of the Scots, the Irish and everyone else. It is a United Kingdom issue in that sense, so what is going to happen with the cross-border stuff? We have some sort of unity in England and we have some sort of consistency in Wales—maybe—so what happens to the cross-border stuff?

Jon Rouse

First, it is based on really good relationships with the devolved Administrations. The principle, of course, is that the money follows the individual; that is the way we work the system, but, as I think the Surgeon General said, we have now been operating for a year under the current NHS England system of national, directly commissioned provision in England, and we can see that there are certain cross-border flows; we hear certain anecdotal evidence. I think it is the right time to take stock, compare the standards and approaches in each of the countries and ensure that standards are consistent. It’s a case of recognising that, within different commissioning systems there may be different emphases, priorities and approaches, but there is consistency.

Mrs Moon

The money follows the individual. How? Does the individual have a pot of money that someone dips into in the MOD, or is an unhypothecated sum of money sent to the devolved Administration? How does the money follow the individual and how do you ensure that that money is spent on the individual and not just dissipated?

Jon Rouse

First, it is based on, in effect, a tariff system, so a particular episode of care will cost a certain amount of money and then we reconcile, so it does not impact the individual directly at all. It is about knowing what care has been provided in which institutions.

Chair

How does the money follow the individual if there is no database of veterans?

Kate Davies

One of the things to emphasise is that as part of the new NHS framework, we now have NHS coding for all armed forces personnel and their families, so there is an appropriate resource supporting that patient care and pathway. That is particularly important for secondary care. What it means for CCGs, in terms of the money following the patients and the work that we do collectively with the MOD, particularly if there is rebasing or if men and women and their families return to a community and a GP practice in a CCG, is that resource also goes to that CCG and that GP practice as part of the individual’s care and support. I completely understand and agree that men and women and families cross borders all the time. That’s life—I’m a Davies. Part of that is about ensuring—we have done this on a number of occasions, collectively, I have to say—that we do work, with the Welsh Assembly and with Scotland, to check out some of the points, as Jon was saying, where that crosses over. That said, it absolutely is important, and I think that is why the partnership board has agreed, that we should take stock of that now and improve it as part of those pathways. That is also really important because there are 211 CCGs. We may know the position in, for example, Bristol or the north-west, but we don’t necessarily know that there is a consistent pattern, and we need to do so, as part of the patient NHS coding, regardless of where the push points are.

Chair

Can I just get this clear? There is NHS coding, which presumably amounts to a database of veterans. Is that right?

Kate Davies

What we are actually doing at the moment is ensuring that when a veteran is flagged up with a GP that that is part of the development of the mental health network and the work that we are doing in the very first year on this new development of prioritising the pathways of veterans and Reservists.

Chair

What do you say about that? Would you say that there is a database of veterans?

Air Marshal Evans

I would not say that there is a database that is catching 100% of veterans. I think that this is work in progress. We are identifying, as Kate said—within the serving community to start with—that, as part of commissioning practice for the future, everybody will have a NHS number. Our practices will be coded and we can follow a patient through the care pathway, whether they go to hospital X or hospital Y. That is an amazing improvement from where we have been in the past. That is the first position. If we then look at people becoming veterans, the vast majority of people—certainly those who have been in service for some time—will know the civilian GP that they are going to move to and the transfer of records and information is relatively straightforward. The difficulty we have is that when people leave the service relatively young, they may go and work abroad for the next five to 10 years. We lose track of them and don’t know where they have gone. Then they come back into England, Wales, Scotland or Northern Ireland and then register. I was at a meeting with senior GP colleagues from the NHS last week, and one of the things we are working on is how can we make certain that we link those people to the process as soon as they come back and register. One of the ideas is a drop-down menu that will ask, when someone registers with a GP in the future, “Have you been a veteran?” That sounds very straightforward, but that is a way that we will start to capture the totality of the numbers that we are talking about. To answer your question, I think to retrospectively capture all veterans—we are talking about four point something million in this country—is not going to be easy from that starting point, but I think we will get a transitional process that will improve that situation.

Chair

But luckily we have you working on that. We will come back to this later.

Mr Havard

This coding—is it an England number or a UK number? You just illustrated the point that I was making about the boomerang.

Air Marshal Evans

Exactly.

Mr Havard

That’s the problem. We recommended you did something like this years ago. I would chip them so that you can read them when they come through the door—make it easy for the GPs, because they are not that bright at asking the questions, but they are not going to ask the questions if they don’t know to ask the question. Your point about informing the GPs, which was made earlier, has been absolutely crucial in all of this. Is that going to be a UK system? Computerising records and all that goes wrong consistently.

Kate Davies

I can speak only for NHS England, as far as what I know and what I am commissioning and responsible for. This is very much about a NHS number. We are ensuring that we are doing that joint work across Wales and Scotland. So for example, we know for Scotland that if someone gets treatment in England, the payment will follow through the Scottish system. What is really important is to take a look back within the first year of NHS England to get a really robust way of looking at the trends and the data, so we can do some more work with GPs. We now have an agreement to do training with the Royal College of General Practitioners, particularly around Armed Forces and pathways, patterns of care and systems. We will do that as part of the partnership governance group and in the partnership with the devolved Administration—that would be the lessons learned. We are doing exactly the same for Scotland at the moment, with lessons learned on areas of work that they have been doing, particularly around public health and improving screening and immunisation. I think that is important to note.

Chair

We are getting way off the point here. Bear in mind that we will come back to this when we have Anna Soubry in front of us on 29 April. I should think that would be the right time.

Mr Havard

They will have a number when they are born, a number when you give it to them and another number if they are Reservists, presumably. We will have questions about that, so can you just have a think about that?

Chair

Anyway, we will come back to that in due course. I won’t ask about alcohol misuse, post-traumatic stress disorder and domestic violence, but we will write to you about that to ask how the incidence of those things has changed over recent years and what you are doing about it.

John Woodcock

I want to ask you the questions that I asked the previous panel—the charities—on the health problems of veterans. First, do you recognise the pretty difficult picture that was painted of the problems of the CCGs coming in and their lack of expertise with mental health?

Jon Rouse

I did not entirely recognise it, because the CCGs came from the PCTs that were before them, who were also commissioning mental health services, so there is a significant amount of knowledge in CCGs about mental health commissioning.

John Woodcock

Forgive me, but the point is that it is a significantly different system of procuring services. That is why we have been through all this change and why we now have GPs in the driving seat for it. It is either true or not that only a minority of GPs are switched on to the mental health needs of veterans, and if it is true, surely you recognise that as a problem.

Jon Rouse

I think it is an issue we have to address, and the way we are addressing that is that we have mandated Health Education England to prioritise training for general practitioners in terms of veteran and reservist mental health. We have asked them to appoint very quickly a specialist clinician in this area to lead the work, and we have given them an aim that by June 2015, every CCG in the country should have at least one GP who is specifically trained in recognising the needs of veterans and reservists.

John Woodcock

And that will be a recommendation?

Jon Rouse

It is a mandate. We are asking them to do it through the mandate from ourselves to Health Education England, so it is our expectation that they will put those things in place. They will be held to account for doing so.

John Woodcock

Do you recognise the issue of a lack of critical mass across any CCG area? Is that an issue? How do you tackle that?

Jon Rouse

I think it is an issue. This is very difficult, because there were previously 150-odd PCTs—there are 211 CCGs—so this has genuinely always been an issue to a certain extent. We have one big advantage now, which Kate alluded to earlier, which is that NHS England has certain direct commissioning responsibilities, as well as oversight of the CCGs. It can develop a single set of commissioning standards and roll them out through the infrastructure. This is difficult, because people talk about a postcode lottery, but one person’s postcode lottery is another person’s localism, and actually there is some really interesting and bespoke provision that is being developed in localities that you would not get if you had just a single national blueprint that was rolled down from on high. So there is a balancing act. We do need to ensure that there is consistency of standards, but by the same token we need to ensure that localities, linked to their community covenants, are able to develop localised responses as well.

John Woodcock

Briefly, you heard the evidence presented by the charities on veterans presenting particular issues sooner with Iraq and Afghanistan. Is there anything you would like to add to what you heard, or anything that you would offer a different perspective on?

Surgeon Captain Sharpley

The earlier presenting—we do not really know why that might be. I surmise that that is a success of the stigma reduction and the health promotion we have been doing, but I cannot prove that to you. So it will continue.

Chair

Apparently to good effect.

Surgeon Captain Sharpley

To good effect; it makes people present, but it means, of course, that we are going to see a steady rise in the number of people knocking on the door for mental health care.

John Woodcock

Kate, do you want to comment?

Kate Davies

I particularly want to comment on both, because I think it is also the development of the armed forces networks. We have a number of armed forces networks now that are particularly there to support the pathways and the transitions for the individual, and they are also there to work with CCGs around the consistency of their understanding of individuals’ needs, but also any specialisms that may arise. Going back to your original question around the CCGs, there is the autonomy around localism. Obviously, I sit here as a commissioner for NHS England centrally, but what is really important is that in those armed forces networks, particularly where there is good practice, we make quite sure that that is seen very quickly and that lessons are learned and duplicated. Also, where there are individual stories, what we have now is quite a strong network of putting together that passage of care around that individual. Those networks have also been very important to seeing that quicker response, as and when needed, for families as part of that overview.

John Woodcock

Finally, do you recognise that there is a problem with those who have traumatic brain injury being incorrectly diagnosed with mental health conditions? Do you have a sense of how significant a problem that is?

Surgeon Captain Sharpley

I don’t, actually. The two are different. They can co-occur.

John Woodcock

I can attest to that.

Surgeon Captain Sharpley

Right. That is why they can seem to occur together, and it is why we have in the MOD a centre of MTBI excellence, a project that is very near—

Chair

MTBI being mild traumatic brain injury?

Surgeon Captain Sharpley

Sorry, yes, MTBI being mild traumatic brain injury, also known as concussion. As far as I am concerned, the two are the same thing. In Headley Court we have a mental health team who see people with post-traumatic stress disorder and the usual mental health conditions. That is very close to the MTBI project, which sees serving personnel as well. The experience of the MTBI—as in mild traumatic brain injury—team, is that mental health conditions are not at a much higher rate than in the rest of the general population, which is unusual. The Americans have a different experience of that, but then the Americans have a different experience of a lot of things, which I am sure we do not have time to go into now.

Mr Gray

May I ask you to focus, as we did a moment ago, on the Reservists? It seems to me that there are two or three questions that need answering. First, SSAFA tells us that the incidence of mental health problems among the Reservists was higher than among the Regulars, which is interesting, but may or may not be related. The second question is: what are we going to do about the fact that they are geographically more spread than the Regulars and—I am asking it this way for the sake of speed, Mr Chairman—both those two things being related to the question of information that we can get about where veterans are, both Regulars and Reservists, and isn’t there a better way of handling it? Sorry, that was a rather long, jumbled question, but on Reservists—

Surgeon Captain Sharpley

May I take the first question, about the different rates of mental health problems? It is true that Reservists have a higher risk of post-traumatic stress disorder, but they also have a lower risk of alcohol misuse. If you consider the totality of mental health problems in Reservists compared with Regulars, you will find that it is relatively equivalent. When you convert the rates of illness to questions like, “How many psychiatrists or mental health nurses do you need to treat this group?” the differences are not so important.

Air Marshal Evans

Simon, would you like to come in on the chain of command position with Reservists, and I will come back on the other point?

Rear Admiral Williams

I think I would. Having heard from the expert clinicians of the armed services, I would just pick up on one point that they have all made: to be better and more effective at dealing with mental health problems, one has to change the culture of people like me in the command chain who have the responsibility to look after individuals within that chain. We have to understand a little more about mental health problems, be alert to mental health problems and encourage an environment in which those problems are easy to raise, and in fact we encourage people to raise them. That de-stigmatisation of this issue has been the single most important thing. That extends to the Reserve, because everybody that deploys now on operations—everybody, that is, in the Regular armed forces and the Reserve—has that de-stigmatisation message marbled throughout our command chain. Therefore those who go out into the Reserve, at the very least, are alert and aware that these problems may occur.

Mr Gray

Because we are not just talking about people being deployed; we are talking about all servicemen. They might be suffering from mental health difficulties, even though they have not been deployed. Is that not the case?

Rear Admiral Williams

That is absolutely correct. The characteristics I have just described are throughout the armed forces.

Mr Gray

The change of attitude that you described with regard to senior officers in the MOD, who tend to be Regulars, is common to all of the changes that are coming about because of Army 2020, but what can we do to change the approach of the Reservists? They don’t seem to know what is available to them or how to access it. How can we change the culture within the Reserve forces to make accessibility of the resources easier or clearer?

Rear Admiral Williams

I think that the approach to how we deal with the Reserve forces has been to bring them closer to the regular chain of command, to mirror, certainly in the blue services—

Mr Gray

That wasn’t what I meant. At the moment they don’t seem to know about it. What can we do to improve their awareness of what is available to them? For example, why don’t we have a database of all Reservists? Why is it not possible to maintain a database of Reservists, both those serving at the moment and veterans?

Rear Admiral Williams

We do know where all these Reservists are.

Mr Gray

How long back?

Rear Admiral Williams

Current Reservists.

Mr Gray

We know where current Reservists are, but I am talking about veterans.

Rear Admiral Williams

Veterans are a different issue entirely.

Mr Gray

That is what we are talking about. Sorry, I beg your pardon; it is veterans we are talking about. When you are a Reservist, you have been deployed, you come back and you leave. How do you keep track of those people who have left? We are talking about veterans, not those who are serving. Why is it not possible to maintain a database of Reservists who are veterans?

Rear Admiral Williams

I am not sure that anything is impossible in this area, but there are certain issues that we have seen in the way that armed forces personnel like to conduct themselves. Very many of them would tell you that they do not want to be tracked as a veteran. They wish to transition from the armed forces as an individual and they see no reason why they should be tracked, tagged, given any kind of number, stamped, when they move on to a career—

Mr Gray

I am not saying it should be compulsory, but surely it could be helpful to them. At the moment, they could not do so even if they wished to do so. No one is suggesting they should be tagged. That, of course, would not be right. My question to you was this: is there not some way in which the MOD could keep better track of our Reservists when they leave the service, particularly with regard to mental health care problems?

Air Marshal Evans

There are a number of areas that your question covers. Under the White Paper, there is going to be a greater involvement of the defence medical services in the provision of occupational health support to Reservists. Those who are mobilised are treated as Regulars, as you will know. Those who are not mobilised will have greater access than they had in the past. That will apply to occupational health—so, advice. That is a potential sign post. Admittedly, there will be all the problems of stigma and people coming forward, but those who come forward could be given the advice that is necessary. The second thing is that there will be greater support for rehabilitation for those who get injured during training, and mental health services will also be more available to Reservists in future. This links very closely with the work that we talked about with veterans and the developments within the NHS. Ultimately, for these patients when they are not mobilised, their GP is still an NHS GP. So the greater education we give the GP community in the NHS about veterans and Reservists, the more likely we are to capture the needs of those Reservists. As I say, there are processes as part of the new reserve forces White Paper that will help that in the future.

Rear Admiral Williams

Mr Gray, to come back and answer your question directly, that is the absolute essence of it. It is a positive handover from being a serviceman to being a veteran and a veteran as part of society. We have a pretty good National Health Service and provision in this country. Therefore what I am after is an adequate transition from the military to being looked after in a civilian sense. As for the practical ability to maintain tabs, addresses or whatever—I am not sure how much detail on veterans you would want to track—that would be a task of enormous complexity. We have certain areas of database—for example, we certainly know who we pay pensions to—and even for those people, in whose interest it is to get money—

Mr Gray

Hang on. Let me just suggest to you the reason for my question. It is said, and I think it is absolutely correct, that because Reservists do not have the regimental family and do not come from a particular base—they are spread around—they have greater difficulties than Regulars do. It is said, and I think it is almost certainly correct, that part of the greater problems they have with mental health, for example, is because they do not have the support of the regimental family. That is why SSAFA have identified that they have greater needs. It therefore seemed to me logical that the military would seek to keep better track of Reservists after they leave than Regulars. You seem to be telling me that that is too complicated. Is that correct?

Rear Admiral Williams

I think that would be a fundamental change in the MOD’s responsibilities—

Mr Gray

Yes, that’s right. We like those sorts of things—that is the purpose of a Select Committee.

Rear Admiral Williams

—and there would be a significant increase in the resource required to track all those people.

Mr Gray

Right, so you are saying that it cannot be done now. We might conclude in our report that it would be a good thing to do—we might not—and there would of course be resource implications in doing that. But the question to you was not about whether you can afford to do it, it was: would it not be helpful to Reserves’ mental care if better track was kept of them after they left the service? That is the question, to which, presumably, there is a very simple answer. You are quite right in saying that that may well have resource implications for the Ministry of Defence, but we are not tasked with looking into that here. We are tasked with looking into how we can improve the mental health care provided to—in this case—our Reserve veterans.

Rear Admiral Williams

Mr Gray, that is enormously helpful contextual guidance. If we are talking about a point that suggests that—

Mr Gray

It wasn’t guidance, it was a question.

Rear Admiral Williams

Well, you have helped me in understanding where you were coming from, for which I am grateful. The issue of whether the Reserves are so much worse off and the postulation that they have no regimental structure to be part of, I think I would take issue with. I think they do have a very strong—

Mr Gray

You are not here to take issue. You are here to answer questions, not take issue with those who are asking them, but please go on.

Rear Admiral Williams

Sir, I am absolutely not taking an issue with it, but you said “It has been said” that people who are in the Reserve are looked after very much less by their regimental organisations. I simply say that I know that that would certainly be the case for some, but not all. Very many Reserve regiments look after their own very well—indeed, both the serving and the retired are part of various associations and get that link that one would be after. That was all I was trying to say.

Chair

Admiral Williams, you heard the charities suggesting before that some of the Reservists appear not to know where to go for information. How can the MOD address that directly? I will then ask Caroline to come in.

Rear Admiral Williams

She is itching to come in. The issue to which you refer, Chair, was one of education. We have very many bits of service provision—we have the Veterans Welfare Service and the Service Personnel and Veterans Agency, as you know, which pertains to veterans’ support—that are there to provide appropriate support. We think we have a very positive success in selling that within the Regular and the Reserve, but it seems that we will never catch everybody. We must keep our focus on doing better in information and in ensuring that the Department and the armed services do every little bit they possibly can while people are in service—telling people what is available—and most particularly when they—

Chair

It sounds as though you may have a bit of work to do.

Rear Admiral Williams

Well, I would firmly accept that.

Caroline Pusey

I have a couple of points ranging over the issues that have been raised. First, we are in the process of commissioning two pieces of research that will give us some answers to some of these questions. One will look at the different mental health needs of Reservists and what we can do about those—that might begin to address Mr Gray’s question about whether a database would help, if we could do it. The other is looking at the efficacy of the current Reservist post-operational stress management systems. That will give us some evidence around some of this stuff. On communications, we think that we have made some progress in terms of communicating with serving Reservists, rather than those that are no longer Reservists, through the unit and use of new media, which makes it much easier to communicate to dispersed people in that way. And, as part of FR20, we have funded an additional communications post in main building to look at communicating with Reservists. A final point, just on the database. My understanding is that it is something that we have tried to keep in terms of Regulars and not particularly Reservists. It relies on them, as the Admiral said, to keep us informed of changes of address, but a lot of them do not want to. That makes it very hard and that would be equally true—I surmise potentially more so—for Reservists, who have got their own life and day job anyway, so would perhaps be less inclined.

Mr Gray

It would be interesting to see the outcome of the research. I simply comment in passing that Her Majesty’s Government keeps a detailed record of every cow, every sheep and every horse in Great Britain today; it is disappointing that we cannot keep track of every single Reservist, but there we are.

Chair

I don’t think we want their ears clipped.

Mrs Moon

May I also suggest that perhaps some of the work that you need to do is with MPs? Just tell us what is available, because they often come through our doors. When anyone comes through our door looking for help, the two questions my caseworkers ask are: “Were you in the Armed Forces? Or a member of a trade union? Because, if you were, we can sort it out.” Anything else gets more complicated. May I ask you about the defence recovery capability? How well is it working? Will it be large enough to deal with the problems that are coming its way?

Rear Admiral Williams

How well is it working? To take that point first, I think that it is improving rapidly. My predecessor, David Murray, was here in his charitable hat and, having taken over from him and moved the recovery capability on, it has shown very significant improvement. The provision is, I think, unique in an international sense in that the MOD is working with charitable partners to deliver a facility for serving personnel. It has certain characteristics, which were developed by the charities: in terms of the control of those in the defence recovery capability, how well we do in ensuring that each and every one of them gets the right kind of support during their individual recovery pathway. There are a couple of options open in terms of how you structure that. The way that we have gone at the moment, as Bryn Parry said, was for a distributed system. We have done that very much eyes open and we believe that to be the best way to deal with people who are in a recovery cycle; some of whom will be leaving the service. We believe that if you force them all into a centre, then it may not be the optimal thing for them, because you take them away from, perhaps, family and friends and other support. Most particularly, you may take them away from the very place that they are going to conduct their recovery transition from the service to the outside. So we support a distributed system, using our personnel recovery centres in an optimal sense, so flowing an individual from being looked after in his community by his regiment in his area through to the recovery centre at the appropriate time to get the intervention that that centre can provide, and then going back into that community to carry on and then coming back to use the recovery centres all the time as catalysts. That, I think, works pretty well. In terms of the enduring capability of the system, it is certainly sufficient for capacity. The charities, when they looked at the original figures that we planned for, put a little extra into the system, so I think that our current capacity requirements are something in the region of 170 beds and I think that that is exceeded by the current defence recovery capability, so the capacity is there. I do think that we need to walk forward with our charitable partners. We have talked a little about the year in since we declared full operational capability in the system. I wanted to get everybody together a year in to have a very open forum and to listen to the charities themselves as to what they thought was the best way ahead, to allow the Ministry of Defence to put its position for why it wanted what it wanted and to develop a number of those things and perhaps see whether there are areas, a year in, that we could do differently. That is planned and it will be led by me and my team, and it is absolutely designed to be open and inclusive and to listen to the people who are actually delivering the interventions.

Chair

When is that going to happen?

Rear Admiral Williams

That is planned for May, so it is about a year on from the full operational capability.

Mrs Moon

We are running out of time and I want to ask about the transitional protocol. Can I ask you for a paper telling us how the transitional protocol is working to ensure that MOD patient records are going into the NHS system? In particular, could you tell us the pros and cons within the devolved Administrations? We have had a lot of presentations on what is happening in England, but we would like to know that people have access to at least a minimum level of service wherever they are in the UK. Could you just give us that?

Chair

Or would you like to answer now? We are not quite running out of time, but if you are able to answer, answer quickly.

Air Marshal Evans

Of course we will produce a paper, but to reassure you, I think the work across England and the devolved Administrations is equally linked to ultimately getting the patient record transferred directly electronically. One of the problems is that not every NHS practice is fully electronic, and therefore just pressing a button when somebody leaves the service is still not possible for everyone. Also, we still have the bit in the middle where people disappear out of the country for two or three years to work abroad. Notwithstanding that difficulty, wherever you are in England, Wales, Scotland or Northern Ireland there is work ultimately to create an electronic record that is a single link that links everything together. We have made major strides on that. We tend to quote England because it has the biggest part of the population, but major strides have been made in the last 12 to 18 months on commissioning, patient choice and other things that are now part of everyday practice for serving personnel. The advantages of that moving forward, therefore, are very good and promising. I would like us to reach the stage at which there is one record for life. People will start off in the NHS, and we will have their record to look at in the recruiting office when they join the military—we will not literally have the record in the recruiting office, but the medical people will be able to see it during their assessment. The record will remain with us during service before ending up back in the NHS, so it is a complete through-life process. Five or 10 years ago we were not getting anywhere close to that. We had old Lloyd George records popping up at Smedley Hydro near Blackpool, but now I think we are a lot closer. I would not want you to think that we will be there within a very short space of time, because it is very dependent on the capability of information systems across the NHS GP network.

Jon Rouse

I think we are making really good progress. One of the good pieces of news is that, because NHS England commissions primary care, it can be quite demanding about IT systems—only four or five key systems tend to be used by primary care in England—so we can ensure that there is an ability to transfer data securely down what we call the NHS spine, the N3 network. When a GP registers the veteran, it should immediately come up that that individual has veteran status and a summary record will be transferred direct to the general practitioner from the Defence Medical Services.

Mrs Moon

Again, Mr Rouse, you refer to England.

Jon Rouse

Yes, I did.

Mrs Moon

I asked for the devolved Administrations.

Jon Rouse

We will do a note.

Chair

SSAFA suggests that the families of defence personnel who have been either killed or injured are not getting enough help, or at least that not enough progress has been made. What would you say?

Rear Admiral Williams

I think we have looked very hard, and we are continuing to review the support we provide post-bereavement. We have conducted improvements in visiting officer training, and we have looked at all the aspects, including listening to the charities and others that have a lot of experience of dealing with families during bereavement, and we are desperately trying to get the system right. It seems to me—certainly this is the feedback I have—that the system is improving. Disappointingly, we have had a lot of practice at it. But I think that we can always work harder to support families and bring them into the regimental and other support systems that we have, via the very large network of associations and other areas where the families can belong. We are using things such as the internet much more than ever we had, to allow families to connect to each other. For example, they are able to go on to certain forums that they can only get to if they have signed in; you have to pass a number of hurdles to get in. Certainly for deployed brigades, we find that to be very helpful for the families to talk to each other via the internet when an individual has been killed or seriously injured. In terms of facilitating and trying to work better at providing the broadest support we can, I think significant progress has been made. However, I am certainly not sitting here today saying that we have got it all sorted, because I am sure that is not the case.

Caroline Pusey

I think we have made significant progress in the past couple of years, but we are not complacent in this area at all, so we are consistently talking to SSAFA particularly, but we also engage with something called the bereaved families support group. We are consistently trying to hear back from people who have experienced this. As David Murray said, they are just completing a study, talking to recently bereaved families, so that we can make sure we are taking notice of their most recent experience. We are not complacent at all in this area. I guess that the only other point we would make is that clearly bereavement, by its nature, is a very challenging and personal issue, and the people who are providing the support are individuals as well. So, we can do as much as we possibly can to put the policies and the training in place, but the experiences that individuals will experience will be as a result of those individual judgments made on the ground. They are almost always made for the best reasons, but we could not sit here today and say that that would always give the right outcome.

Chair

You referred to a study. Was that study the result of the recommendation we made that you should carry out a review? If so, does it have any findings attached to it, and what are they?

Caroline Pusey

They haven’t reported to us yet. We understand that they have almost finished, and so we hope they will be coming to us very soon.

Chair

But you haven’t seen anything from that study?

Caroline Pusey

Not yet, but it will be very soon.

Chair

Okay. Moving on then—Madeleine Moon.

Mrs Moon

What about the long-term sustainability of the support being given to serving personnel? Are we going to be able to sustain it, especially to the seriously injured? Is that something that you think we are ready for? Are we planning that far ahead?

Air Marshal Evans

Yes, we are. In terms of the work that we have just commenced, by setting up a cohort study for the injured, there will be about 600 in that study, set up from Headley Court. It is quite important that we do that relatively soon, because we want to capture in the study as many of those severely injured people as we can. With the likelihood that more people will start to leave the service in the next 12 to 18 months as they finish their courses of treatment, it is really important that we start that work. We are now literally in the process of putting that study together. That will mean that we then have a cohort with a control group set aside that we can follow through for the next 50 years, if we want to, in terms of the effect of amputation—clearly we would not look at all amputees—on things such as the cardiovascular system, social well-being and the psychological effect. We will follow those people through and see what will be required, or not required, in the future. Your question was clearly related to sustainability of support. Without that evidence, we will not know, but I think that study will provide the evidence that will dictate to us where we look to seek improvements in the future. That is exactly what we did in changing people from the original C-Leg—microprocessor leg—to the next phase, which is the genium. That change has been based on evidence and clinical need. As a doctor, I would say that is really the way that we should be working the process through in the future. It is difficult to answer your question, but we are looking to keep ahead of the game in terms of our requirements: looking at research, doing the research and then delivering the appropriate care that our people need. That will be so important, not just in the next two or three years, but for what they may need in five, 10, 15 or 20 years’ time.

Mrs Moon

How you manage disability when you are a young person changes very much with the ageing process. The issue is making sure that that care is going to be able to keep up.

Air Marshal Evans

Absolutely right. We do not know; we could find that several of the people—50%—are in wheelchairs within 10 years of leaving the service. That is the sort of information we need to know. One hopes that, by giving them independence and the ability to function and get employment—maybe not in the military—that is the best we can do to get them to a point to deliver something useful for their lives ahead. That is obviously really important.

Mrs Moon

I cannot even begin to tell you how difficult wheelchair services are.

Jon Rouse

I just want to add that we have an opportunity to improve our aggregated information about veterans’ health needs by making better use of the national health survey. That would enable us to plan ahead better by comparing a different piece of data within that data set against the fact that that individual is a veteran. That is something that I do not think we have done very well previously.

Kate Davies

On sustainability, I think it is really important to recognise that there are some very important Department of Health programme moneys that are now with NHS England to commission particularly improvement in mental health and prosthetic services. That also links into wheelchairs and the LIBOR funding. An important part of sustainability is that we look at what it tells us about what we need to commission and how we need to commission it. Alongside that, in the first year we have agreed centrally to do some research on long-term living with disabilities and the impact of that, particularly for men and women. That is also about the long-term impact and how disability works with independent living. That research will have an advantage for the civilian population. That research was led by the sustainability element that we need to be aware of as part of commissioning and supporting that work that we are doing together.

Mrs Moon

What about long-term funding through the charity sector? Do you think that the money will continue to come in or is the cost ultimately going to revert back to the MOD?

Air Marshal Evans

I think there is a balance to be had, as the people from the charities suggested. To me, there is a very clear requirement in-service for the MOD to look to support our people wherever possible. I think that the charitable sector has a lot to offer in terms of research. There is no difference in medical research outwith the military where research is often helped and supported by charities, as is already happening. Sue from the British Legion was clearly saying that their work supporting the blast centre at Imperial College is making a big difference to us in medical research and in looking into areas of improvement, whether in terms of self-protection or the effects of blast injury. These are the sorts of areas where I would see, as a clinical person, real help from the charities in the future. But inevitably, as we go on, the MOD should be looking for support. This should be a collaboration where we are looking to work together as best we can. There is an obligation, clearly, on the MOD while people are on the service line.

Mrs Moon

May I say in conclusion that this Committee is a very mixed bag? We have two Welsh MPs and a Northern Irish MP, so we like to know what the devolved Administrations are doing. Every time you say NHS England, you scratch an itch. You do not have the figures for the devolved Administrations.

Air Marshal Evans

I apologise. I think we do have a knowledge of them. It is the way that we tend to answer things easily, rather than the mouthful of saying, NHS England and the devolved Administrations for Wales, Scotland and Northern Ireland, but they are very much involved in the partnership board. I am Welsh, so I can say that too—that is a difficulty that we have. But I do really mean that they are involved in that process.

Mr Havard

The Chairman is related to the King of Scotland, as was.

Chair

He, unfortunately, is dead. Can I draw attention to something you have just said? You were referring, in answer to Madeleine Moon, to the cost in future years possibly falling back on the MOD. You were talking about those still in service, were you not?

Air Marshal Evans

Absolutely, yes.

Chair

So for those who are no longer in service, if charitable donations reduce because Afghanistan is not in the public eye, the cost will presumably fall back on the NHS, will it not?

Kate Davies

Yes, Chair.

Chair

And that is something for which I hope the NHS is well-prepared now?

Kate Davies

I think that one of the things that is really important about being prepared is the Government structure that we have put in place to review and ensure that. That absolutely is crucial. So one of the things that is key is that the partnership board and now the joint commissioning group—which does look across borders, but actually that obviously is the joint commissioning group that I chair in partnership with Defence Medical Services—are planning to see what is up river as well as what is in front of us now. So whether we are talking about rebasing, about conflict or what that means for the information and evidence that we need to have about mental health, I have to sit here and say that one of the things that is absolutely crucial is that, as part of the armed forces covenant, there is no disadvantage. For NHS England and for other NHS commissioning bodies it is about quality for all. Actually, what we have got to ensure is that quality element is understood for all families, whether they are ex-mobilised Reservists, veterans or whether they are current. That is certainly part of the governance structure and is the biggest question that we are asking as we start this process.

Mr Havard

I assume you have the change of balance between the Reserves and Regulars very much in mind in all that work you are doing?

Kate Davies

Absolutely. It is our mantra. It is absolutely part of what we are doing. What is really important in the new commissioning structures within the NHS reforms is to be very clear to people about who commissions what and who pays for what. Very clearly, what we have had to do is not say: “Because I am Kate Davies, head of armed forces, then that means that that commission is for A, B, C and D”. If it is very clearly a CCG, local authority or a Defence Medical Services responsibility, we act constantly to ensure that we get that very clearly understood as part of that new structure.

Chair

Thank you very much indeed to all of you. All six of you managed to give us really useful evidence, so we are grateful to you for your restraint and your contribution as well. I am going to draw this evidence session to a close. Oral evidence: The Armed Forces Covenant in Action? Part 5: Military Casualties, HC 940 48