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Armed Forces: Post-service Welfare

Volume 724: debated on Thursday 27 January 2011


Moved by

To call attention to the physical and mental rehabilitation of military veterans and their post-service welfare; and to move for papers.

My Lords, I rise to call attention to the physical and mental rehabilitation of military veterans, and to issues of post-service welfare. I welcome this opportunity to bring before the House an issue on which I think every Member will share the wide public concern at the present time. I am grateful for the number of noble Lords who are determined to speak in the debate. I know that the noble and gallant Lord, Lord Boyce, who takes a keen interest in these matters and speaks with great authority, cannot unfortunately be here. He has a cast-iron excuse; he has to appear before the Iraq inquiry today, so the House will realise why he cannot here. I have also received an apology from the noble Viscount, Lord Brookeborough, who takes a keen interest in these matters because of his military background. He has duties to Her Majesty as a Lord in Waiting at an investiture, so he, too, cannot be here.

It is no secret that the issues that we discuss today are in the public mind overwhelmingly because of the consequences of Operations Telic and Herrick. These were the names given to the campaigns in Iraq and Afghanistan. However, I make clear that my observations relate not just to the casualties of those conflicts. I include those who served in Korea in what was a particularly nasty war for many. Some of my contemporaries, and some who I expected to see at university, did not come back from that bloody encounter. The mass Chinese attacks in some ways resembled World War I. As a national serviceman, I saw active service at the time, and some of my colleagues still bear the scars. I include also the veterans of the Falklands. I have seen many who faced the consequences of the Troubles in Northern Ireland, and of the brave work of our forces during that time. I include members of the security forces and of the RUC. Many noble Lords will recall that we are also approaching the 20th anniversary of the ending of the first Gulf War and the liberation of Kuwait. Many casualties occurred in that conflict.

I note one thing from recent discussion of these issues. I do not recall any discussion during my time as Secretary of State of the military covenant. It was taken for granted, it was implicit and, if pressed, people recognised that of course there were obligations. However, as the casualties and the challenges that we now face have grown, the importance of that implicit covenant being respected is now being put into written and public form. We now even have the niceties of deciding whether we have a no-disadvantage covenant or a citizen-plus covenant. These are the two alternatives: whether the objective should be that no one should suffer any disadvantage from their service, or whether the nation recognises that in some ways they should have enhanced recognition—citizen plus—for the service that they have given.

It is no secret that the pressure that we feel on this has to do with the length of the campaigns. I was involved in the first Gulf War, which was over almost in the twinkling of an eye. The build-up took months, but the whole campaign to liberate Kuwait took barely two months, with an air campaign and what was almost a five-day land campaign to free Kuwait from the Iraq invasion. Now we see that we have spent nearly 10 years in Afghanistan. We have been in Iraq for eight years. Will the Minister confirm the figure I heard that 180,000 service people are now veterans of either Iraq or Afghanistan? That is the scale of the challenge that we face. There is no question that while we very properly pay our respects, and the Prime Minister, the Leader of the Opposition and we in this House express our condolences to those who lose their lives, many of us recognise that the real and lasting tragedy is the scale of the appalling injuries that many come back with.

That is of course a consequence of the triumph of medical progress. I saw that in Northern Ireland; if we could get someone to hospital when they were still breathing, there was every chance that their lives could be saved. Many people who previously would never have survived are now coming back with appalling injuries, but medical triumphs ensure their survival. That places heavy obligations and liabilities on their families, and on society as a whole, which has asked them to embark on those dangerous challenges.

After the scratchiness of this House too often in recent days, I pay tribute to what the previous Government did. I do not admire the campaigns in which they got us involved, but I recognise that they introduced a number of helpful measures, and I am very pleased that the present coalition Government recognise the importance of carrying on that work. I pay tribute to the incredible skill and wonderful competence of the medical profession, all the way from the combat medics on every patrol to the helicopter that may convey them back to Camp Bastion, to Camp Bastion itself, and to the outstanding treatment that they receive on transfer by air transport back to this country, into Queen Elizabeth Hospital Birmingham and then on to Headley Court. This is a service and a quality. Someone can go out on patrol, and the next thing they know they are waking up 24 hours later in a hospital in Britain, getting the best medical attention that anyone could wish for.

Of course, that is when the challenge really develops. In this connection, there is no question that this is not just a job for the Government or the public services. One of the most moving things about recent events is the way in which charities have become such a key part of that activity. I doubt whether there is a single Member of your Lordships' House who has not had some contact with Help for Heroes, Combat Stress, ABF The Soldiers’ Charity or the Royal British Legion. The Royal British Legion has just given its biggest donation in its history, £50 million over the next 10 years, to help some of those centres. Help for Heroes has made huge investments because of the response to its fundraising, which is recognition of public concern. I should declare an interest, because I am an ambassador for Alabaré Christian Care & Support, which has now established five homes for veterans. My sister happens to be the chairman of an organisation called the Community Self Build Agency. As part of a very enterprising idea, it is now getting self-build schemes going to help ex-servicemen veterans with housing, in which they do the building themselves and rebuild their life, their competence and confidence.

I am delighted to see the noble Lord, Lord Glenarthur, here. As we recognise the role of full-time servicemen, there is a particular challenge in this situation for reservists. They often come straight out of civilian life, they do not have the comfort and surroundings of the regimental family, and they are often scattered in different parts of the country. They come back from some of the most challenging combat situations and find themselves immediately back on civvie street among colleagues who do not understand anything of what they have been doing. We need to recognise their particular challenges.

We need to provide in so many ways, including financially. It is interesting that SSAFA and the Royal British Legion said that 60 per cent of the cases that they deal with are problems with debt management. In this connection, the noble and gallant Lord, Lord Boyce, conducted an important review. I hope the Minister can confirm that the Government are carrying forward the Armed Forces compensation scheme review, because finance is obviously important. Far too many of our servicemen coming home are homeless. We need to give them proper access to social housing and advice as to how to access it. There needs to be proper recognition by local authorities of the priority that they should give to returning servicemen to ensure that they do not get left out.

The mental challenge will be with us for a long time. Although some physical injuries are all too apparent, the mental injuries may not be. We know that it may be 14 or 15 years before people become aware of them. The new provisions, which mean, as I understand them, that everyone is assessed on leaving the services for their mental health condition, are very important. We also need an outreach programme to check up on people. I commend Dr Liam Fox and Andrew Murrison, who both have the advantage of being doctors. They have for some time, when in opposition and now in government, taken a particular interest in mental stress. The point that Dr Liam Fox made in an article which some might have read in the Sun today is that people with mental health difficulties are the least likely to go to their doctors. We need to ensure that the Defence Medical Services give the NHS access to the records of patients who become patients of NHS doctors, so that they can be aware of some of the background. I pay tribute to the reservists who are doctors and who have already served in Afghanistan and Iraq, but doctors who have not served need help. I recognise the interest that the BMA is taking in that area to see how we can get more advice to doctors who have to deal with situations with which they have never previously had to deal with their civilian patients.

The issue is the strain that people face and the linkage between the Defence Medical Services and the health service, as the health service is now, impressively, gearing up to handle these situations. It is a matter of experience. It stretches all the way to the tragic shooting of the congressman in Tucson, Arizona. People said that her luck—and I hope that that luck will continue—was that one of the surgeons who treated her had experience of serious injuries in Afghanistan and knew the instant action that was needed. That has undoubtedly given her the chance that she has now, which she would not otherwise have enjoyed.

Yesterday we had a further reminder of the tragedy with the 350th fatality in Afghanistan and the name of the serviceman who had lost his life being announced. We do not publish in any great detail the number of those who are wounded, and do not draw attention to the severity of some of those injuries. The Ministry of Defence has invented the phrase “life-changing injuries”, which, as we know, covers some very serious injuries indeed. Through-life support—not just support when there is public interest, as now, when we are very aware and when Wootton Bassett brings to people's attention so frequently the challenges that we face—is critical.

Our duty in this is to recognise the words of the Army Doctrine Publication:

“Soldiers will be called upon to make personal sacrifices—including the ultimate sacrifice—in the service of the Nation. In putting the needs of the Nation and the Army before their own, they forego some of the rights enjoyed by those outside the Armed Forces. In return, British soldiers must always be able to expect fair treatment, to be valued and respected as individuals, and that they (and their families) will be sustained and rewarded by commensurate terms and conditions of service … the system’s loyalty to the individual—its obligation in the Military Covenant—is manifested in justice, fair rewards and life-long support to all who have soldiered”.

Many have stood on Remembrance Day, as I have on many occasions, saying, “We will remember them”. That, I think, should be our motto as we look at the through-life support that we owe those who have bravely served our country in appallingly difficult circumstances and who deserve nothing but our fullest support in the years ahead.

My Lords, I thank the noble Lord, Lord King, for introducing this timely and very important debate. I do not pretend to speak from any great knowledge of the military. Although my uncle and grandfather were military men, they died when I was a child, and national service, which meant that most families knew someone close who was in the services, ended when I was a teenager. In other words, I am one of that greater part of British society who have had no exposure to, and little understanding of, military life or the commitment, loyalty and sacrifices that, today, our young women and men who join the armed services make on our behalf.

I have one redeeming feature that makes me want to take part today. I have a beloved god-daughter who chose the Navy as her career. Her experiences, commitment and enjoyment of the service, as well as the maturity and wisdom she has gained, made me realise how much I needed to learn. I have also had the great advantage of taking part in the Armed Forces Parliamentary Scheme, which aims to give parliamentarians such as me who have had little exposure to our armed services the chance to get some hands-on experience. I cannot commend the scheme too highly. It is run by the redoubtable Sir Neil Thorne, and it is a no-holds-barred opportunity to get under the skin of one of the services, as well as to gain an understanding of the generic issues that affect the Ministry of Defence and the services as a whole. I spent 22 days, over a year, with personnel at all levels and in a range of locations, including on board HMS “Liverpool” in the Falklands, listening and learning. I was impressed with the leadership, professionalism and care for the “Navy family” that I witnessed.

However, particular issues came to my attention that I feel are relevant to this debate. During that year, I was able to see for myself the reciprocal relationship that lies at the heart of the military covenant, which was referred to by the noble Lord, Lord King, and which I have no doubt will be explored in greater detail in a debate later today in your Lordships’ House. Under the military covenant, the Government expect the Armed Forces to carry out their duties in defence of the state to the best of their ability, up to and including the possibility of death in action. In return, the Armed Forces expect that they and their immediate dependants will be cared for and supported both during and after service, and it is the importance of that two-way expectation and understanding which prompts my remarks today.

Given our country’s continuing role in the military campaigns in Iraq and Afghanistan, it is right that there should be a high level of public, media and political interest in the welfare of both serving members and veterans of the Armed Forces. That interest is frequently focused on the level of support that many veterans receive for physical and mental health problems once they have left the services. While focusing in this debate on veterans, I pay tribute to those currently in the service who give so much of themselves on our behalf. Too often, we, the public, realise only in times of conflict what they do for us, yet I know from my talks with serving men and women how much they feel that out of sight means out of mind.

There are currently some 5 million veterans in the UK with 8 million dependants. Of the 24,000 servicemen who leave the Armed Forces each year, most transfer seamlessly to civilian life, but a significant minority do not. Common mental health problems affect about one in four service personnel and veterans; alcohol abuse affects about one in five; and post-traumatic stress disorder one in 20. Other problems follow from this. Estimates suggest that around one in 10 homeless people in the UK are former members of the Armed Forces. A 2008 Prison Officers’ Association survey found that 8,500 veterans were in custody at any one time in the UK following conviction of a criminal offence. A further survey in 2009 found that 12,000 former armed services personnel were under the supervision of the probation service in England and Wales on either community sentences or parole. At that time, therefore, twice as many veterans—some 20,000—were in the criminal justice system as were serving in military operations in Afghanistan.

Noble Lords will be aware that many initiatives have been instigated to address these issues and to improve mental health services for our veterans. As the noble Lord, Lord King, affirmed, the previous Government had a strong track record, with the Armed Forces Bill in 2006, ensuring forces’ pay increases and investing in rehabilitation facilities. There was the £2 million package of measures, announced in April last year, which included the employment of 15 community psychiatric nurses to work in mental health trusts alongside existing specialist teams, the creation of a 24-hour helpline, and improved education and training of GPs to help them to identify veterans suffering mental health problems.

These initiatives will involve the veterans’ mental health charity, Combat Stress, and the Royal British Legion. I welcome these moves, which are clearly very much needed, and I express my admiration and support for the work already being done by these and other bodies, such as the Mental Health Foundation. I also warmly welcome the MoD’s excellent 2010 Fighting Fit report on the provision of mental health services for veterans and service personnel. I welcome, too, the endorsement in the other place by the Secretary of State for Defence, Dr Liam Fox, of the report’s key recommendations, including the creation of a Veterans Information Service to ensure follow-up of veterans after 12 months.

I refer also to the December 2010 report of the Taskforce on the Military Covenant. This comprehensive and eloquently argued document also supports the Fighting Fit report, and I hope that, in his response, the Minister will be able to indicate the Government’s response to the report’s recommendations. Clearly, much is now being done to improve access for veterans to support, but much more needs to be done both to understand the origins and range of mental health problems that veterans may have and to provide accessible and appropriate services.

It is that last point that greatly concerns me. On leaving the services, the healthcare of veterans moves from being the responsibility of the MoD to that of the NHS, where they are treated alongside the rest of the UK population. However, many reports cite a lack of knowledge among GPs about the particular needs—especially the mental health needs—of our veterans, leading to a lack of referral to such specialist mental health services as are available. Can the Minister confirm to the House that the reorganisation plans for the NHS, which rely on GP decisions, will take this into account, as they must if veterans are to get proper treatment?

There is currently tremendous public sympathy for veterans who find themselves in difficulties in civilian life. As the Report of the Taskforce on the Military Covenant report suggests, it is vital that we turn that sympathy into empathy. Our service men and women have given their all for our country; it is only right that we should reciprocate that support and provide the services that they need. We must play our part to ensure that they do not fall between the gaps.

My Lords, I apologise that this debate has been cut to two hours. Perhaps I may encourage all other Members to emulate the excellent example just set and sit down when the Clock is still saying seven minutes.

My Lords, I shall bear that in mind. This is one of those debates in which everyone will have said everything about the subject before, but we need to say it again and again to remind people of the problems. It is also a debate in which, fortunately, we are able to have a degree of political unity.

The problems facing our military existed before the two most recent conflicts, but they had not forced their way into our attention in the same way. When they did surface, the previous Government reacted with surprising speed, considering the political process. They took the matter seriously and started to address it, and for that I thank them. However, the fact that they had to do so indicates that we had not addressed the problems correctly beforehand. Smaller conflicts involving less immediately politically sensitive issues and smaller numbers of people meant that the problems relating to the armed services had been ignored for a very long time, as had the need to prepare our personnel for life after the armed services. We must all take a degree of blame for that.

Basically, we take very young people and put them into the military preferably for fairly long periods—the British Army likes long-service troops. They are told what to do and we do not prepare them for life outside. That is becoming increasingly apparent. I do not doubt that steps have been taken to improve that, but that was not done before. The fact that you are trained to be an excellent infantryman is apparently not the best preparation in a flexible job market, where IT skills are increasingly required and accuracy in handwriting is more valued in the workforce than ever before. The two are not compatible.

What can the military do? Its primary objective is to produce good service men and women and to make sure that they are ready to do that job. It is understandable that this issue has not been addressed properly. Taking on the idea of the military covenant, which has always been there, although I became aware of it only about a decade ago, we have to try to get involved in how we prepare people for life outside. Let us say that we have an 18 year-old young man, or possibly younger, almost fresh from school, who is placed in an environment where there is a structure. He is not expected to fill out forms or to decide things for himself and he is taken away from parents who could show him how to do that. He is trained for 12, 15 or whatever large number of years and we then we place him outside. Making sure that that transition is well managed will make everything else easier.

I come to the more obvious questions about those who have been severely injured and the more process-driven points, which I hope my noble friend will be able to answer fully, such as making sure that medical records are transferred more frequently and that doctors are more aware of mental health problems. I believe that doctors are now much more aware that there are different types of stress, but it is important to make sure that they can get to the expertise. We cannot expect the GP to do it all himself. If greater emphasis needs to be placed on different types of treatment, we must make sure that patients can be transferred quickly. Somebody who is not used to dealing with the outside world and whose treatment is delayed can be lost. It happens. If the transition is swifter and smoother, without form-filling or dozens of interviews, people will get to the right help quickly. I could carry on for a great deal of time on the transition phase, but I will just say that preparation for that transition will allow us to get the best out of what we are doing. That is surely the first step.

I ask my noble friend whether we have been able to identify the major bumps in the process. Where does the process break down when people do not get the best health and support? Have ways to avoid those problems been identified? Greater awareness is one and greater intervention would be another. Have we found out where they are most needed? We talked about pinch-points in defence recruitment and retention. Where are the pinch-points for services afterwards?

I shall curtail my remarks. I could have talked at considerable length about those who have lost limbs and the ongoing processes. Possibly, they will get a slightly better deal as they are more visible, because of their injuries, than those who have minor problems that manifest themselves later on. Can we have an assurance that we will keep this under review and that the Government will encourage all those who are involved in the political class to ensure regular reviews? This will go on beyond the life of this Parliament, and possibly the next two or three.

My Lords, I thank the noble Lord, Lord King, for tabling today’s debate and for giving us the opportunity to discuss the serious issues involved.

First, I declare an interest. I am the aunt of a young TA soldier who was 18 years old when he was seriously injured in Iraq in 2007. I know that it was the treatment that he received in the American military hospital in Basra, in Selly Oak Hospital in Birmingham and in the rehabilitation offered at Headley Court that gave him the life that he has today, as is the case for many others. I pay tribute to those working so valiantly to help the wounded and disabled, including the British Limbless Ex-Service Men’s Association, Help for Heroes and the British Legion.

The Report of the Task Force on the Military Covenant states that there needs to be a coherent national approach to trauma research to develop new technologies, particularly in,

“acute trauma, repair, reconstruction and long-term rehabilitation”.

That is important, but equally important is the issue of mental health, on which all previous speakers have focused. I am talking about the mental health of veterans returning from conflict zones, whether or not they have been injured.

Provision for the care of veterans with mental health problems is fragmented and patchy. There have been various initiatives. In November 2006, the MoD launched the reserves mental health programme, but by 2008 84 per cent of GPs were unaware of its existence. It is of limited application and does not address all the needs. There are particular problems for the early service leavers who are discharged, for whatever reason, and who may carry the mental scars consequential on or consequent to their military experience into their civilian life. Those scars may have catastrophic consequences.

The Murrison report recommends an increase in the number of mental health professionals to one per two mental health trusts. Their role is only to identify cases and to refer them to veterans’ organisations and other professionals. There is no evidence that such identification has been carried out effectively and we do not know the extent to which veterans who are identified as suffering from mental health problems actually receive the care that they need. They are a forgotten and, possibly in some people’s minds, less important group. They do not carry the scars in the same way as those young men and women like my nephew, but the consequences can be equally life-limiting.

The maximum level of compensation for mental health disorders appears to be fixed under the review of Armed Forces compensation at £2,888. That is not a large sum for someone who may be incapable of permanent employment for the rest of their live. The report acknowledges the fact that mental health services do not always fully address the needs of veterans. Pilot schemes have been established, but there is simply neither the level nor the quality of mental health provision that is needed.

These issues have been thought about at length. There is clearly some recognition of the problems faced by veterans with mental health needs, but they come low down the list of priorities in general health service delivery. Of course, there may be a reluctance among veterans, particularly men, to identify themselves as suffering from service-related mental health problems. The DoH’s New Horizons mental health strategy states that the prevalence of mental disorders in serving personnel and veterans is broadly similar to that of the general population, yet the research done by the Mental Health Foundation found that the risk of suicide in men aged 24 years and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age group in the general and serving populations—and the risk for this age group is high. Research also shows that reservists who served in Iraq were almost twice as likely to have mental health problems as those who have not served in Iraq—26 per cent compared to 16 per cent. Reservists who served in Iraq are twice as likely to have PTSD as those who have not served in Iraq. I am sure that there will be similar figures for Afghanistan.

We know that there are high levels of alcoholism, suicide and mental health problems. This is not unique to the UK, but it is a fact of military life. Post-traumatic stress disorder is not uncommon among those who have been affected in any way by conflict. The triggers can vary and the symptoms are now well identified. The triggers can be very simple. I think of the young man I know who was part of a patrol sent to search a village. Passing children playing on the road, they threw a bottle of water to a little girl of five who was waving to them. They accomplished their task and were driving home when they saw her little body hanging from a tree, her throat cut, a warning to others not to collaborate with the troops. I think of others who have seen their colleagues blown to bits or who have tried to carry out immediate first aid on colleagues who are suffering from major traumatic injuries and who have died. I think of those who should have been in the patrol that never came back but for some reason were not and who suffer survivors’ guilt. I think of those who survived explosions, only to face the flashbacks, night terrors, sleeplessness and fear of crowds et cetera that are so symptomatic of trauma. Research also shows that subsequent traumatic experiences can cause flashbacks to the original experience, thus compounding the suffering.

PTSD and the various mental illnesses consequential on involvement in armed conflict are well identified. However, the reality on the ground is that people are naturally reluctant to present with mental health problems and may well delay until the condition becomes too serious. When they do present, the services are not as accessible or as available as they should be. It is not enough in many cases to take people in for a week’s group and individual therapy and send them home. There is a well identified and serious risk that exposure to brief therapy can retraumatise the traumatised, leaving them to face their terrors alone.

What happens in reality is that people go into a lottery of available mental health care. People can often end up in psychiatric hospitals, heavily medicated to keep them compliant and hence unable to make any journey towards recovery from their trauma. There are limited services offering cognitive behavioural therapy or therapy for PTSD and they are often located at too great a distance for those incapable of individual travel. I think of one young man I know who cannot travel alone but faces a four-hour journey for one hour’s therapy and a four-hour journey back.

My questions for the Government are: can we find out the extent and geographical incidence of mental ill health consequential on armed service? Can some more attention be paid to the difficulties faced by those with serious mental health problems in accessing treatment and to the fact that such treatment is so scarce?

One of the things about trauma is that it can lie dormant for 25 or 30 years and then manifest itself suddenly. As the noble Lord, Lord King, said, we are talking not just about Iraq and Afghanistan, but about Korea, Northern Ireland and all the other conflicts. The reality is that many of these people end up in prison. Veterans are disproportionately represented in the prison population. We do not need more research to tell us that there is a problem; we need more planning for a future in which those who are currently struggling can keep going. Many of those who will be afflicted by PTSD in the future will need care. Those who have served in locations as diverse as Northern Ireland, Iraq, Afghanistan and Korea and who subsequently suffer the trauma of mental ill health in its various manifestations deserve our care.

My Lords, I, too, thank the noble Lord, Lord King of Bridgwater, for having secured this important debate. I reiterate the important points that he made about the success that is currently achieved in the acute management of injured service personnel in the battlefield and their successful early rehabilitation, which has resulted in saving these complex-injured casualties.

I shall focus on two issues. The first is how we should go about commissioning the longer-term care of injured service personnel once they are discharged from the services and the second is how we can organise long-term prospective research cohorts for research studies to allow us to understand the long-term physical and mental health needs of these veterans.

Veterans leaving the services represent a broad spectrum of complexity in their healthcare needs, from the complex-injured multiple amputee, where some of the early needs after discharge are very obvious, to those with more subtle injuries and the very large number of veterans who are apparently healthy at the time that they are discharged from the services but who are at risk of deteriorating health in the years and decades that follow their discharge.

The provision of medical care for veterans after discharge is, at best, haphazard. The majority of NHS civilian personnel have no military experience. As the noble Lord identified, some NHS personnel have military experience, but they are quite few. Therefore, the majority of doctors and clinical staff who will take responsibility for the care of discharged veterans will have little insight into the experience of that patient population. Under those circumstances, they may not always be in the best position to understand these specific patients or to provide the care that is necessary.

There are also important concerns about the transfer of medical information from Defence Medical Services to the NHS. This is a serious problem. At the moment, a final medical examination occurs prior to discharge and an FMed 133 form, which provides, at best, rudimentary medical information, is completed to provide civilian medical practitioners in the NHS with any pertinent medical history during service in the armed services. At best, this information is rudimentary and very frequently it does not reach the NHS general practitioner. In these circumstances, early arrangements for medical care are going to be poor and, importantly, as time progresses, whatever information was available that might be pertinent to the long-term healthcare needs will be lost. Service personnel may not be able to recall all that information, putting themselves at a great disadvantage in their longer-term medical care. Is any work taking place on trying to understand how better the transfer of medical information can occur between Defence Medical Services and the NHS, with particular reference to the establishment of the electronic patient record to transfer as much information as possible to ensure that the medium-term and long-term care of veterans after discharge from the services can be best secured?

There is an important opportunity to improve the training for civilian NHS staff on some of the information skills and knowledge that they will need to deal with quite important numbers of veterans who will present with physical or mental health needs. At the moment, some 24,000 military personnel leave the services every year, and 10,000 of them have recent combat experience. There are about 32,000 GPs, which means that on average a general practitioner will see one new veteran every 16 months. GPs are not going to have a large volume of patients, so the training and experience that they need to develop have to be specifically tailored.

I turn to how we should commission services in future. The Health and Social Care Bill was presented last week and will begin its passage through the other place shortly. It recognises the need to change all commissioning services, with greater emphasis on primary care commissioning of the majority of services by general practitioners. It also recognises that there are certain patient populations with very complex needs, for which there should be more central commissioning of services—so-called specialist commissioning. Does the Minister agree that complex-injured veterans discharged from the services represent a population of patients with complex, long-term, ongoing healthcare needs that could be considered to fall into a specialist commissioning group where either the NHS board commissions services specifically for this population of veterans, based on advice that it receives from Defence Medical Services, or commissioning responsibility is transferred to Defence Medical Services so that the services can be provided in centres that have the opportunity to provide all the specialist requirements in a holistic fashion to achieve the best possible clinical outcomes?

I believe that there is also a need to initiate a programme of research to address four important questions with regard to the health of veterans. The first is to look at what the long-term, ongoing physical and mental health needs are. As has been identified in this debate, our ability to provide acute medical care ensures that many more service personnel are surviving horrific injuries, but we have little knowledge about what the long-term needs will be in the years and decades hence. This research needs to be conducted on a prospective basis. Secondly, we need to understand how to provide rehabilitation to achieve the best healthcare outcomes for these personnel. Thirdly, we need to understand how to adopt new technology and innovation that will be available in the years to come to achieve the best quality of life. Fourthly, we need to be certain that we can assess what resources need to be provided over time to ensure that some of the potentially most vulnerable of our citizens, who are those to whom we owe the greatest debt, have healthcare services provided for them that they justifiably have a right to expect.

My Lords, I, too, am most grateful to my noble friend Lord King for raising this important issue. I certainly join with all those who pay tribute not only to the fortitude of those who are so grievously injured on operations but to their families, friends and the professionals who have the difficult task of supporting them on their return. I have various interests to declare. I was a member of the National Employer Advisory Board for the reserves of Britain’s Armed Forces for 14 years, for seven of which I was its chairman. I have been honorary colonel of a Territorial Army hospital support medical regiment for 10 years and for six years, concurrently, I have been honorary air commodore of a Royal Auxiliary Air Force medical unit. These specialist medical units regularly provide individuals—or even many individuals—to reinforce, and to provide specialists for, both regular and reserve medical units that are deployed.

As I have had substantial contact with many doctors, nurses and others, such as from the professions allied to medicine, who have the initial and subsequent care of servicemen with profound physical and mental trauma as a result of operations, I should like to concentrate my remarks on the reserves, particularly the medical reserves. From what I know, it is clear that many people deployed on operations in the medical field are seeing the most dreadful trauma that only a couple of years ago would not have been survivable. They often witness what was described to me yesterday as the “ultimate” in terms of trauma that they will ever see. They see perhaps the most awful experiences of their professional lives. The degree of preparation that the United Kingdom armed services gives all those who are due to deploy might be a major factor in helping the rate of post-traumatic stress disorder remain at a low level. However, we cannot afford to be complacent and we cannot be sure when repeated deployments will begin to take their toll and very real long-term issues of mental illness, requiring long-term rehabilitation, will become evident.

So far as the Defence Medical Services are concerned, a large number of their strength is made up of reservists. Some of these reservists, largely from the TA, deploy as formed units—perhaps as a field hospital taking over the manning and the operation of the medical facilities at Kandahar, Camp Bastion or in forward locations. These medical staff are almost the only formed reserve units to be deployed nowadays on operations. However, they also rely heavily on the additional expertise of specialists from national units, such as my own represents.

Many of these staff, with wide experience in the NHS and the private health sector, are used to dealing with fairly horrific scenes—whether in an A&E department of a hospital or in the subsequent treatment of the sort of trauma that I described earlier—but, however professional or inured to witnessing the most distressing scenes these people are, there must be a real risk that the effect on the individual clinician might become cumulative. These clinicians are supremely professional, but they are human beings who are prone to the same emotions as any of us. One has to wonder whether there will come a time when continued regular exposure to the extreme horrors of war could lead to a substantial cumulative effect on the individuals, with worrying consequences for the future. Even the most experienced, hardened doctors who have been deployed many times often say that it takes a good three months to recover and to come to terms with what they have seen, and it takes much longer for those who are not so experienced. Can my noble friend say what steps are being taken within the MoD to be alert to this possibility? What steps might be taken to deal with that outcome should it occur?

The trauma facilities in Camp Bastion are absolutely first class—I saw them two years ago and I should like to see them again—and they have probably improved hugely since I last saw them. As the noble Lord, Lord Kakkar, said, what is being achieved there in terms of the ability to treat trauma is quite astounding and, indeed, humbling. However, one cannot ignore the fact that, although the need to preserve life is a pre-eminent role of clinicians, there are huge, complex ethical issues involved, which can take their toll on even the most stoical and professional of clinicians. While our doctors and nurses are treating our own injured servicemen whom they know will have the very best clinical attention on their repatriation to the United Kingdom, they are also treating very seriously injured Afghan civilians and Afghan servicemen. In treating those people and saving their lives—however horrific their injuries and however limited might be their subsequent quality of life—one can all too readily understand that the clinicians face awful ethical and moral dilemma, because those people will not go back to the same sort of facilities that we have.

The British serviceman—man or woman—is an extraordinarily resilient being. One hears amazing stories of their sense of humour, their determination to overcome quite shocking injuries and their success in doing so. For those who can remain within the services while fulfilling other tasks, all is made easier by the sense of camaraderie that always prevails within the unit. I hope that the Government will accept that those who treat our servicemen may at some point also need special care and attention because of the effect of what they have had to deal with.

As my noble friend Lord King clearly stated, for reserve medical staff returning to their civilian places of work, however supportive and understanding senior management may be of their experience on operational tours, that is not always the case with junior civilian colleagues. The latter may not easily have the same depth of understanding of what clinicians have gone through and have witnessed in the theatre of war. Those clinicians, however robust and resilient, can talk among themselves as a sort of safety valve when they are with their military unit colleagues. I urge my noble friend the Minister to impress upon his Ministry of Defence colleagues that they should be alert to the possibility of traumatic reaction requiring a degree of mental rehabilitation over time for these individuals in the future.

The reserves of all three services make up a crucial element of the deployable Defence Medical Services. I would go so far as to say that operational deployment of any sort would be impossible without them. We must be alert to the risks of continued deployment which these very well meaning and extraordinarily professional clinicians face.

My Lords, I congratulate the noble Lord, Lord King, on his choice of this topic. Much has changed and is still changing in the support and needs of military veterans. As I will describe, their expectations of support have changed greatly over the years. When I was commissioned into the Royal Air Force 60 years ago, the strength of the three Armed Forces was approaching 700,000—almost 10 times what we shall have as a result of the recent defence review—and the medical and dental services were scaled to match those numbers. In the 1950s, with many service hospitals in this country and overseas, it was normal for most of the clinical needs of veterans and their families to be met by the medical branches of the services. The NHS was in its infancy. The veterans—largely from the First and Second World Wars—would on average have been in their fifties or in their thirties, so few of that large number of veterans were yet senior citizens, with the illnesses and disabilities more associated with old age.

By the 1970s, with the end of national service and the much reduced size of the three services, a major review of the clinical support required for the Armed Forces led to the closure of a number of service hospitals and much reduced staffing of the medical branches. It was no longer feasible, except in overseas locations, to provide medical and dental care for families or any veterans, many of whom felt very let down as a result. However, the National Health Service, by then well established, was there to provide medical care to veterans and their families, so it was wrong for the Armed Forces medical branches, at a cost to the defence vote, to double up on what could be provided by the NHS.

By the 1990s, most of the veterans of World War One had died and the age of the majority of veterans had risen to the sixties and seventies. Life expectancy was greater than before, with more likelihood of illness due to increasing years. To the World War Two number could be added those who had done national service or who had been involved in the many insurgencies and other conflicts of the latter half of that century. More recently, we have had the casualties and veterans of conflicts in the Falklands, the Gulf, Iraq and Afghanistan. Advances in medical care have seen the lives of many casualties of these most recent conflicts saved, but many will need continuous support for the rest of their lives.

A number of government responses have been made to these developments, such as: numerous ministerial Statements about the need to do more; the previous Government’s Command Paper The National Commitment: Cross-Government Support to our Armed Forces, their Families and Veterans; the introduction of a Minister in the MoD with specific responsibility for veterans; the setting up of a dedicated veterans agency; and improvements in the immediate medical support and care of veterans who had been injured and have not yet left their service at Birmingham Queen Elizabeth Hospital near Selly Oak, Headley Court and elsewhere.

Backing up these efforts have been the activities and commitment of the service charities—I declare an interest as an officeholder in a number of these charities, as in my declaration of interests—which have, as always, been very proactive in the interests of veterans. Noble Lords should be aware of the Confederation of British Service and Ex-Service Organisations, whose membership consists of about 180 service and ex-service organisations, including 65 regimental associations. I should like to pay tribute to the able leadership of COBSEO’s current chairman, Air Vice-Marshal Tony Stables, who has done much to motivate and co-ordinate the work of the organisation’s membership in their help and support for veterans. He has been instrumental in winning lottery funding support for the Forces in Mind programme.

However, healthcare provision is but one of the potential needs of veterans, and poor psychiatric health is often associated with other problems of housing, welfare and finance. Important though the support and generosity of the service charities is, it is wrong for the Government to be overreliant on this sector. All should agree that the support of veterans—particularly those who have been injured physically or mentally in the course of their service for the Crown—is primarily the duty of Government. The current arrangements, while an improvement on what went before, still need further restructuring. The MoD, of course, has responsibility for the care and support of servicemen and women who are still on the active list, but with their transition to retired veterans, the link between them and the MoD is weakened and, with the passage of time, can be broken.

In the United States—admittedly with a much larger corps of veterans—a distinct and separate state department bears responsibility for veterans’ affairs and is not an adjunct of the Department of Defense. Inevitably, inside our MoD there are bound to be conflicting pressures for resources and the needs of veterans, whether in pensions, compensation, health or other support, cannot be given the priority that is necessary to care for them properly. Building on the structure of Cm 7424 and its external reference group chaired by the Cabinet Office, could we not have a Minister for Senior Veterans, with the appropriate support and budget within the Cabinet Office? I fear that it is all too clear that the present MoD’s Minister with responsibility for veterans—this is not a personal criticism—is dismissive and given to writing bleak letters of blank refusal to any and every suggestion from members of COBSEO. Of course the financial situation does not make matters easy, but surely this is a transitory problem so far as veterans and their interests are concerned. Some indication that, as the economy recovers, there will be a proactive approach by Government to meeting the long-term support requirements of veterans would be welcome.

With the average length of life increasing, the skills of modern medicine and surgery and the recognition that there will be some without physical signs of disablement who are nevertheless afflicted with mental illness arising from their experiences in operations, there are going to be veterans spread across the length and breadth of the country who will need ongoing medical and other attention. If the Government are serious in their stated intention to do better for veterans—the ones who fought at risk to their lives, but lived through the conflicts—a new approach at senior ministerial level with the right proactive support for veterans’ needs should be found.

My Lords, I, too, congratulate the noble Lord, Lord King, on obtaining this important debate. I agree with a great deal of what he said, including his mention of Alabaré and other organisations, his question about the implementation of the Armed Forces compensation scheme and his mention of homelessness. He will remember that during the Options for Change exercise—when he was the Secretary of State and I was the Adjutant-General for the Army, responsible for planning and conducting the reduction in its size by a third over three years—the issue of homelessness came up. Looking back, I think we can say that we did better for families than for single people, and we would not be the only ones who would have to admit that. He will also remember the discussions on resettlement, which the noble Lord, Lord Addington, mentioned.

I declare two interests, one as the vice-president of the Centre for Mental Health, which in October last year produced a document entitled Across the Wire: Veterans, Mental Health and Vulnerability. I commend it to all those who have not seen it because it reflects a wealth of experience in the professional mental health community. I am also president of the Veterans in Prison Association, which I will come to in a moment.

I fully accept that later today we are to have a debate, sponsored by the right reverend Prelate the Bishop of Wakefield, on the Armed Forces covenant, but I make no apology for starting from the covenant, particularly from the point made by my noble and gallant friend Lord Craig about the post and position of a Minister for Veterans’ Affairs. I have mentioned several times in this House that I do not think that the MoD is the right place for a Minister for Veterans’ Affairs because all the veteran affairs with which he is meant to be dealing are conducted not by the MoD but by the other Ministries involved, such as the Department for Work and Pensions, the Department of Health, local government and so on. Unless he or she has outreach to those, the ministerial diktat will not reach to them. Bearing in mind how this Government approach the issues of the big society, I believe that veterans’ affairs ought to be lifted firmly into the big society agenda.

I therefore recommend most strongly that the responsible Minister should not be a separate Minister in the Cabinet Office but that the veterans’ portfolio should be added to that of the Minister for Civil Society, who already has cross-government responsibilities in this area. He or she would be supported by civil servants in the department. However, as has been recommended on more than one occasion, there should be a commissioner for veterans’ affairs who is an independent, active participant in what is going on—an observer or ombudsman, if you like—and who has responsibility for overseeing the 24/7 operations in support of veterans and their families throughout the country. That job cannot be done by civil servants or by ministerial diktat. Unless someone is responsible and accountable for doing it, nothing will happen.

Other noble Lords have mentioned that many good things are happening. I have just seen a marvellous report, produced by the North East Joint Health Overview and Scrutiny Committee, which has conducted a regional review in the north-east of the health of the ex-service community. Fourteen local councils came together to produce 47 recommendations. When you look through a list of those people who are involved in implementing those recommendations, you find local authorities, housing federations, homes and communities agencies, social landlords, Jobcentre Plus, career transition partnerships, masses of voluntary sector organisations—both military and otherwise, NHS commissioning boards, public health observatories, mental health bodies, primary care organisations, GP consortia and so on. The fact that these things are being thought about, with it being realised how many people must be brought together, is very useful for government, provided that they can pick it up and run with it. For example, the Avon and Wiltshire Mental Health Partnership has drawn up very sensible recommendations for the implementation of the findings of the Murrison report, mention of which has been made today. If you go into that, you will find an enormous number of organisations that are required to do work.

Good things are happening—we have mentioned the physical and mental health problems that are being dealt with on the battlefield and immediately afterwards—but it is long-term, lifelong support that is needed. I am very glad that 12 mobile personal recovery units are now going round and helping to supervise people’s recovery. There will be four personnel recovery centres—one in Edinburgh, one in Catterick, one in Colchester and one in Tidworth—which will provide one-stop welfare shops for ex-service people and their families. There will be welfare support, a prosthetic support clinic—which I mentioned in the House the other day—physical and psychological support and family support. That is fine; this is being funded by organisations such as Help for Heroes as well as by government, but if these things, which provide an admirable framework for all that we recognise is needed, are really to happen, they must by driven by someone who sees that they are done.

I mentioned my involvement with prison. It is sad to find the increasing number of ex-military personnel who end up in the hands of the criminal justice system. When you go into the reasons for that, you see that they are complex. Many of the people concerned have unwillingly returned to their original background, yet the support mechanism is not in place to help them. Much mention has been made of PTSD, but if you look at their problems, you see that three things stand out: alcohol, depression and anxiety. The anxiety is linked with an inability to cope. All this says to me that not only must treatment for post-traumatic stress and post-battle disorders be provided but treatment must be provided that is provided normally throughout the community, with the supplements that form the Armed Forces covenant and are given because the individuals concerned have been members of the services.

My Lords, I thank my noble friend Lord King of Bridgwater for securing this important debate. The state in which a number of our veterans find themselves on leaving service should fill us all with concern. These men and women demonstrate unparalleled bravery in their defence of our country. We should therefore put provisions in place that give our veterans who suffer from a physical injury or a mental health illness all the support that they require for their rehabilitation.

My contribution will focus mainly on the mental health challenges facing a number of our veterans. A recent report by the King's Centre for Military Health Research reveals that almost 25 per cent of Iraq war veterans are suffering from mental health-related illnesses. The King's Centre is of the view that of the 180,000 service men and women who have served or are serving in Iraq and Afghanistan, 48,000 veterans may suffer from an illness of this nature. The research states that 9,000 service personnel are at risk of developing post-traumatic stress disorder. This condition can lie dormant for a long period, yet its effects are terrible for those who suffer it. I welcome the Government's announcement to improve mental health services for veterans through the provision of 24-hour counselling, a support helpline and the introduction of 30 mental health nurses. Greater resources might be needed in areas that have a moderate-to-high percentage of veterans, as failure to do so might place a strain on local services. The coalition Government have doubled the operational service allowance, while amending the policy on rest and recuperation for service personnel deployed on operations. This, too, is welcome, as it will go towards addressing the impact of combat-related stress on our Armed Forces.

I fully support the provisions in the Armed Forces Bill that pertain to ensuring that the military covenant is honoured by government as a statutory duty. The Bill will also make it incumbent on the Secretary of State for Defence to report every year on steps that the Government are taking to support servicemen, veterans and their families. I look forward to debating the Bill when it reaches this House.

A more common mental health complaint among those who have served in the Armed Forces is depression. It has been found that those diagnosed with depression are more likely to be of lower rank or persons who are divorced or separated. One reason given for the prevalence of depression among veterans is a fear of not being able to secure a job on returning to civilian life, which in turn leads to a sense of despair. An unfortunate stigma is attached to mental health issues in our society. Regrettably, this is even worse among the Armed Forces.

It has been widely reported that many veterans who are suffering from mental health difficulties tend to hide their suffering. A number of service men and women have attributed this to the fact that they view acknowledgment of a mental health illness as a sign of weakness. In making the noble commitment to defend our nation, many of these brave men and women perhaps feel as though they are burdening their families and friends by sharing their mental trauma. I would be grateful if the Minister could inform your Lordships' House about any plans or campaigns that the Government will embark on to address this issue. Perhaps I may add that alcohol abuse among ex-members of the Armed Forces is double that among the British civilian population.

I was particularly heartened by the pledge in the SDSR to support ex-service personnel to enter tertiary education. This will provide those who have contributed so much to our national security with greater career choices on leaving the Army. I also take the opportunity to praise the decision to award scholarships to the children of service personnel who have lost their lives in active service since 1990. It will go towards expressing our gratitude to the children whose parents have made the ultimate sacrifice when defending our country.

I pay tribute to the excellent work undertaken by Combat Stress, the veterans’ mental health charity, which provides veterans suffering from a mental health illness such as post-traumatic stress disorder with specialist care.

I praise the Big Lottery Fund for launching the Forces in Mind programme. This laudable initiative is aimed at supporting the psychological welfare of service personnel and ensuring that veterans are given all the required assistance in making the transition to civilian life.

I refer to a report produced by Dr Andrew Murrison MP, a man with strong credentials in medicine and in the Armed Forces. His report is entitled Fighting Fit, and has generated four principal recommendations. I ask the Minister to update your Lordships' House on the implementation of the recommendations suggested in that report. I understand that Dr Murrison is undertaking a review of prosthetic limbs, as it is important that a supply of limbs for those who need them is often inadequate in quantity and quality.

Our Armed Forces have played an important role in bringing stability to many regions around the world. Our servicemen perform a unique, challenging and selfless duty in protecting the civilians and citizens of this country who are supporting the Government’s wider foreign policy objectives. The sacrifices of our Armed Forces, which are made to provide us with safety, entitle them to specialist treatment. We have a moral and civil duty to ensure that we make necessary provision so that our veterans return to civilian life in good mental health.

Finally, I take this opportunity to thank the Ministry of Defence for establishing the Armed Forces Muslim Association. General Sir David Richards is the patron of the association, and I have rendered support to the association.

My Lords, I thank the noble Lord, Lord King of Bridgwater, for a timely and pertinent debate. I am pleased to follow the noble Lord, Lord Sheikh, who does much for recruiting what we call the ethnic minorities. As I move among them myself a lot, I tell a British Muslim, a British Hindu or a British Sikh that it is payback time—and that it is time that more of them joined the Reserve Forces and the Regular Forces.

I worked almost monthly with at least four Ministers for Veterans from the previous Administration, and I pay tribute to them because they did a tremendous job. They woke up, as the noble Lord, Lord Addington, said, rather late—but when they woke up, great work was done. I particularly commend the veterans’ badge which they instituted. I agree with the two noble and gallant Lords that the Minister for Veterans is in the wrong place; I have always felt this. I have also found that the weakness is in local government. I suggested to the previous Administration—and I nudge the Minister now—that although Governments do not like interfering with local government, one councillor should be deputised in each local government to take on veterans’ affairs, particularly care of the wounded, both physically and mentally.

The Government talk about injury all the time, but when an overpaid soccer player gets a hack on the shins and rolls around as if he is in his last throes, he is injured. A serviceman is wounded. That word should be used more in the statistics and outpourings that our Government give. To be wounded is not much fun. However, it is a very proud thing for the individual to be wounded for his country. He is not given enough recognition today, as the noble Lord, Lord King, said, in our thinking and our daily workings. For those who are wounded, whether mentally or physically, a man or woman who takes a couple of bullets and a bunch of shrapnel or is blown up by an IED or wounded by a bit of cold steel when the fighting gets close, that is the most patriotic thing. I know that the word patriotism has not been a happy word lately in British jargon, but short of giving your life it is the next most patriotic action that you can take. We should look after these men and women.

I so agree with the two noble and gallant Lords that we need an organisation and a system—a fast track—to look after our veterans, and our wounded veterans in particular, as well as our widows. No one has mentioned widows today. I have 18,000 widows in the Burma Star Association, some of whom do not need any help but some of whom need a great deal. I understand—if I am wrong the Minister can put me right—that the Prime Minister said that he wants to look at the whole business of the military covenant and maybe write a new one or add to the one that is already there. The covenant must encapsulate the fact that we should look after a soldier, a sailor or an airman from the day he joins to the day he dies. The covenant should show an enduring responsibility for looking after the veteran.

Overall, I agree with the noble and gallant Lords that great work is being done, but we need a system and an organisation. The two words are communication—because we must be able to order and run it—and organisation. We could go on talking, but I feel that enough has been said. I do not think that we give our wounded service men and women the honour that they deserve, and I believe that something should be done about it. I am rather encouraged by what has been said today.

My Lords, I, too, thank the noble Lord, Lord King of Bridgwater, for securing this debate. I particularly thank him for his opening tribute to the previous Labour Government, which set the right tone for the debate. He had some thoughtful words about the covenant, particularly on mental health. While we have known about the problems of mental health in combat for many years, only now do we understand the depths of the problem.

The previous Government had a good record on the military covenant. We published the service personnel command paper—a first in government strategy—and made substantial investment in facilities such as Headley Court, including a new cognitive and mental health unit. We started community-based mental health pilots to provide veterans with expert assessment led by a community veterans’ mental health therapist. We started a number of initiatives on mental health, particularly with New Horizons: A Shared Vision for Mental Health, published at the end of 2009, which contained seven action points for the MoD and the Department of Health, particularly to look after support for veterans.

We also made commitments during our election campaign to continue with those strategies, particularly on developing pilots to deal with combat stress, which we signed up to in January 2010. They would improve veterans’ access to mental health facilities. If successful—and I hope they will be—we would have carried them forward. I hope that this Government will do so.

I move now to what the present Government are doing. There was an important commitment in the SDSR to:

“A dedicated 24-hour support line for veterans … and … 30 additional mental health nurses in Mental Health Trusts”.

That commitment was made as a result of the Fighting Fit report by Andrew Murrison. I should like to know from the Minister just how much progress has been made in securing those resources.

The interesting Fighting Fit report built upon New Horizons in its opening section and made 13 recommendations, of which only a couple have been clearly signposted and committed to. Perhaps we saw some progress today from Dr Liam Fox when writing in the Sun. He said he would be,

“working to implement them to provide much better and wider mental health support”.

That is good news. I hope that the Minister can report on progress. The Secretary of State also committed to changes in compensation. He said:

“Changes will be put into law next month to increase payment. They will nearly treble the maximum compensation for those suffering the severest mental health problems, and increase the amounts they are paid for life on leaving the forces”.

I hope that the Minister can give us more detail on what that commitment in the Sun from Dr Liam Fox actually means and to whom it will apply. Can the noble Lord confirm that the provisions will be introduced next month, how much it will cost the MoD, how many people will receive these higher payments, and what the exact scheme payments are that are being increased?

Looking further into the report, there are two particular recommendations on which, so far, there seems to have been no progress. They are a,

“Trial of an online early intervention service for serving personnel and veterans”,


“Incorporation of a structured mental health system inquiry into existing medical examinations performed while serving”.

I hope that we can have some indication that these recommendations, together with the other recommendations in the report, are about to be implemented.

This has been an important debate and the areas in which improvement is necessary are understood. The Government have made some commitments to make these improvements, but I really need to know what the pace and future commitments are. My knowledge might have been illuminated by an article in the News of the World, which I would like the Minister to confirm or not. Not everyone will have reached as far as page 36 of last Sunday’s edition, but there was an interview with Mr Nicholas Clegg, the Deputy Prime Minister, by the paper’s chief political editor. He reported:

“Nick Clegg is to spearhead a huge drive to give better care for troops traumatised by war. The Deputy PM will soon unveil a ‘health for heroes’ service … Under the scheme, millions of pounds of extra money will be pumped into the NHS to fight battlefield stress. A new screening programme will identify victims … family doctors will get special training while an army of therapists will be drafted into hospitals to spot post-traumatic stress disorders”.

If all this is true, it is to be welcomed. However, it does not seem to relate to the more incremental and steady progress reported elsewhere. It has not been mentioned in Parliament and does not seem to accord with the plan in Fighting Fit. It is news to us and to the forces’ charities. If the Minister is aware of the details of this programme, perhaps he could give us some indication of what extra money there is, where the millions of pounds will be spent, the timescale for implementation, and why it is to be announced by the Deputy Prime Minister, not the Secretary of State for Defence.

My Lords, we have had a very good debate and I thank my noble friend Lord King of Bridgwater for raising the important subject of the physical and mental rehabilitation of military veterans.

I always listen to and greatly value my noble friend’s informed views on all aspects of defence policy. While he was Northern Ireland Secretary and then Defence Secretary, our Armed Forces were deployed in Northern Ireland and the Gulf where, as my noble friend said, combat operations to liberate Kuwait from occupation by the forces of Saddam Hussein began 20 years ago last week. Then, as today in Afghanistan, we witnessed the professionalism, dedication and courage of our servicemen and women. We should be justifiably proud of what they do on our behalf.

During these past two decades, our Armed Forces have been deployed in the most demanding areas of conflict. They have always risen to the challenges they faced, and done their duty unflinchingly. For those who have made the ultimate sacrifice, our condolences and sympathies are with those families and friends left behind. However, as my noble friends Lord King and Lord Glenarthur, and the noble Lord, Lord Kakkar, said, injuries that were once fatal can now be survived, which is testament to the skill of our medical services. Indeed, the expertise honed on the battlefield is now subject to research at Queen Elizabeth Hospital Birmingham to determine how best that expertise can be used in the healthcare of civilian society. Just last week, we opened a brand new, ground-breaking surgical reconstruction and microbiology research centre in Birmingham.

However, today’s soldiers, sailors, airmen and women will one day become veterans. They will look at how the previous generation is being cared for and supported. If we are found to be wanting, it will be a question not only of moral failure, but of paying the price in recruitment and retention in our future Armed Forces. For some personnel who have been injured, a lifetime of care and treatment will be needed. As the noble and gallant Lord, Lord Craig, pointed out, as a nation and a Government we have a moral responsibility to ensure that such injured personnel receive the care they deserve. As a Government we are committed to ensuring that they do. I reassure the noble Viscount, Lord Slim, that we will be honouring the covenant between the Armed Forces and the nation.

The Government share the concerns that have been expressed regarding the mental well-being of our former service personnel. We acknowledge that it can take many years for a psychological problem to manifest itself. In the most serious cases—and these are the minority—experiences on operations can result in post-traumatic stress disorder. We continue to work with Combat Stress in the fight against that most debilitating condition.

For other veterans, their mental health needs will continue to be met by the National Health Service, which should remain the main provider of healthcare for former service personnel. The NHS is working hard to develop the best models of care and support for the few with mental health problems. The MoD has contributed £500,000 towards six community-based NHS mental health pilot schemes for veterans in Stafford, Camden and Islington, Cardiff, Bishop Auckland, Plymouth and Edinburgh. They aim to make it easier for former service personnel to access help. I hope that that addresses the question asked by the noble Lord, Lord Kakkar.

On 20 December, my right honourable friend, the Minister for Defence Personnel, Welfare and Veterans, announced the publication of an independent evaluation into these pilot schemes, conducted by the University of Sheffield's Centre for Psychological Services Research. The report identifies key components of successful services and makes a number of recommendations about the future planning of NHS mental healthcare services for veterans. I would also like to highlight the Medical Assessment Programme at St Thomas's Hospital, which continues to provide specialist mental health assessment of former service men and women with mental health problems who have undertaken operational service since 1982.

The coalition agreement set out our intention to provide extra support for former members of the Armed Forces with mental health needs, including PTSD. As part of that undertaking, Dr Andrew Murrison MP, who served as a medical doctor in the Royal Navy, was asked by the Prime Minister to conduct a study into the health of both serving and ex-service personnel to see what more can be done to assess and meet these needs. In the light of that work, on 6 October, the Defence Secretary announced that there would be funding for a 24-hour helpline for veterans and for 30 extra mental health nurses in mental health trusts. To answer the question asked by the noble Baroness, Lady Warwick, my noble friend Lord Sheikh and the noble Lord, Lord Tunnicliffe, we will continue to work closely with the Department of Health and others to work towards implementing all Dr Murrison's recommendations, as well as those produced in the evaluation of the pilot schemes, to consider how they can be taken forward to provide the best possible mental healthcare for former service personnel.

In terms of general welfare provision, there is a range of services that former Armed Forces personnel may need to call on during the course of their lives, provided by many different agencies. I assure my noble friend Lord Addington that these will be constantly reviewed. Some have argued that it would be more cost effective to provide services for veterans if these were brought together in a single administration. We do not agree. Where a service is already provided by one department for the majority of the population, there needs to be a very strong case to set up a separate organisation to do the same thing for any special interest group—even one held in such high regard as veterans who have served the nation so well. Former service personnel live among us; they are not separate from the community that they have served to protect. For the most part, their needs—whether healthcare, housing or benefits—are the same as those of their fellow citizens.

We must also recognise that some of the support for veterans comes not from government, but from the voluntary and community sector. I mentioned Combat Stress earlier and the noble Baroness, Lady O’Loan, in a well-researched speech, mentioned Help for Heroes. Sometimes, the service charities are described as filling in for what the Government should be doing. That does them a great disservice. It is not the place of the state to do everything. All of us have social responsibilities. The service charities are one of the best examples of the big society in action and I pay tribute to the vital role that they play in our national life.

The noble Lord, Lord Ramsbotham, and the noble Viscount, Lord Slim, made important points about the position of the Minister for Veterans. Several formulae have been suggested over the years to strengthen the focus on veterans' issues. They range from the full-blown, US-style, Veterans Department, to more modest changes to government machinery. Some give a greater role to the Ministry of Defence, others look to central government departments to take on that responsibility. The creation of a Minister for Veterans was partly a response to that desire. The MoD's responsibility is finite. It can act as an advocate, or as an interlocutor, for ex-service personnel. But we do not want to tell the Department of Health and its devolved equivalents how best to deliver healthcare. Rather we want to see ex-service men and women treated correctly across government.

I want to mention briefly the role of the Medical Assessment Programme at St Thomas's Hospital. This is part of the MoD and provides free and confidential advice on a wide range of issues. This can be provided in the home of a veteran, or by telephone, and is given by trained welfare managers. The Veterans Welfare service undertakes some 12,000 visits to former service personnel each year and 95 per cent declare themselves to be very satisfied. The welfare managers work closely with service charities and other voluntary organisations, local authorities and the Department for Work and Pensions.

I will try to answer as many questions as possible. If I do not answer them all, I assure noble Lords that I will write. My noble friend Lord King mentioned a possible figure of 180,000 veterans of Iraq and Afghanistan campaigns. That is an old figure. The most recent figure, as at April 2010, is 236,000 service personnel who have served in Iraq, Afghanistan or both at least once.

The noble Baroness, Lady Warwick, paid tribute to the Armed Forces parliamentary scheme and I also admire enormously the excellent work that Sir Neil Thorne and that organisation carries out. The noble Baroness and my noble friend Lord Addington made some important points about the reorganisation of the National Health Service. We continue to work closely with the NHS. As for the transfer of medical records from the MoD to the NHS, a summary of each medical history while in the Armed Forces, including the results of the discharge medical, is recorded and given to the individual to pass on to their GP. The form also includes information on how the GP can gain access to the individual’s complete service medical records if required. We are working to simplify the process and, where it is possible to do so, to enable medical records to be available to GPs electronically.

My noble friend Lord Glenarthur made some very important points about medical reserves. He raised concerns about the cumulative effects of continual exposure to really stressful situations. We are very alert to this, and the cutting-edge medical care that our service men and women receive in the front line is constantly being upgraded.

To answer my noble friend’s question, in November 2006 the MoD launched a new initiative, the Reserves Mental Health Programme. Under the programme, we liaise with the individual’s GP and offer a mental health assessment. If they are diagnosed to have a combat-related condition, we offer the out-patient treatment via one of the MoD’s 15 departments of community and mental health. The reserve forces continue to make a vital contribution to the ongoing success of military operations. In return, we have a duty of care to them, and this programme is an important enhancement of the medical services that we provide.

My noble friend Lord King asked about the review of the AFCS every five years. At this time we do not feel it necessary to conduct further reviews, but future changes will be considered by the Central Advisory Committee on Pensions and Compensation if the need arises.

I opened my speech by paying tribute to our Armed Forces. We ask them to do things on our behalf, and they do that willingly. We have a responsibility, not only as a Government but as a nation, to look after them. I hope that, by our explaining the Government’s position on the important subjects of welfare and physical and mental care, noble Lords will accept that we take this responsibility very seriously.

My Lords, I thank all noble Lords who have taken part in this debate. I thank the Minister for, as ever, his most conscientious and scrupulous attention to the debate and for his reply. This debate has been of real quality. People who are really interested in the subject have contributed to it from their different backgrounds and experience. In our present difficult times, this is the sort of the debate that this House can do extremely well and which makes a valuable contribution.

Without wishing to single anyone out, I thought that the speech of the noble Lord, Lord Kakkar, was impressive, drawing on his wide medical experience that is of such great interest. The speech of the noble Lord, Lord Glenarthur, drew attention to the debt that we owe to the clinicians themselves who are facing appalling trauma situations and are willing to serve. Against that background, I am most grateful to all those who have taken part.

If there was one slightly contentious note that emerged among Members here today, it was this: we have made some progress in having a Veterans Minister, which we never had before, but now the issue is whether he is in the right place. I see the arguments about whether the Ministry of Defence is absolutely the right place. The only thing that I want to say is that plenty of people have got lost in the Cabinet Office before now, and putting a Minister of perhaps not the most senior rank in there might mean that they were never seen again. Whoever he is, and unless he is of Cabinet rank, he will need a sponsoring Cabinet Minister of some authority, and until someone can think of a better one, this is the answer. We have a Veterans Minister who has been a serving officer, which is a good start. I think that Andrew Robathan has plenty of energy, and now we must make sure that that energy is applied with plenty of forcefulness. He knows his way around. He is a Deputy Chief Whip so he knows where some of the bodies are buried. That was an unfortunate phrase to use and I withdraw it, but that is a phrase often applied to Whips. He has considerable influence, and I hope that he will use it.

I shall add one point. Not every aspect has been covered, obviously, because of time reasons. There was one thing that did not come out in any speech. We use the word “veterans” as though they are all old men or women. A lot of so-called veterans now are extremely young, and one of the things that worries me, and I know that it worries the whole House, is the difficulty of employment opportunities for young people at this time. I know that my noble friend the Minister was not able to cover this in his speech, but I know the initiatives that are being made. I emphasise that giving these people self-respect is the best chance to recover from the difficulties and challenges that they may have faced, and opportunities of worthwhile employment are very high on that list.

I ended my earlier contribution by saying that many of us stand on Remembrance Day at war memorials up and down the country, and we say, “We will remember them”. We say that we will remember the dead. The purpose of this debate was that we will remember the living as well, along with our duties and obligations to them. I am most grateful to all who have taken part. I beg leave to withdraw the Motion.

Motion withdrawn.