A military medico-legal medley

Introduction

When considering what to talk to you about this evening, and reflecting on the role of President, I started by looking at the disparate topics of previous presidential addresses for inspiration. What struck me most is that the Society has benefited from a hugely diverse range of Presidents and approaches to the role over the last 123 years. The language has of course changed over time from the first presidential address by Sir William Collins, on 3 November 1902, but perhaps less so, the sentiments. It will do no harm to pick up on a few of their comments.

When His Honour Paul Layton, incoming President, addressed the Society in 1983, [Medico-Legal Journal, Vol. 52, Issue 1, p.9] he said that he was in severe shock: “It was a shock which if anything increased as the realisation became clearer of what a distinguished line of Presidents I was joining and I knew that my own qualities hardly lived up to those of my predecessors.” I think that is precisely how I feel at this moment as I contemplate the heavy weight of the honour bestowed upon me by our members.

The Journal Editor, in introducing the first woman President, Dame Louise McIlroy, to the presidency in 1949, noted, “The Society has for long been honoured to number among its members distinguished ladies of the medical and legal professions. Papers have been read and discussions enlivened by their grace and wit and this has culminated in the overdue election of our most distinguished lady member to the Presidential chair.” [Medico-Legal Journal, Vol. 17, Issue 4, p.1] From what I have read women seem to have been fully accepted and respected in the society during the 1930s and 1940s, at a time when there were still many bars within professional life both in medicine and the law, something for the Society to be proud of.

Finally, an insight from the 1908 Presidential address is perhaps the most relevant to our situation today. The new president, Mr Justice Walton, picked up on the theme of communication in medicine and law: “In these days of telephones and motor cars and record ocean passages of marvellous rapidity, when obstacles of time and space appear to be most annihilated, it sometimes seems as if there were no room left in the transactions of mankind for thought, or at all events for deliberation. Logic has become a despised study.” [Medico-Legal Society Transactions, Vol. 6, Issue 1, p.1.] If we remove the reference to cars, phones and boats, and replace with digital communications, the obstacles of time and space do indeed appear to be annihilated. Mr Justice Walton’s comments are as pertinent today as they were 116 years ago.

My interest in medico-legal matters, and in the military, were sparked in tandem at the beginning of the 1980s, when as an undergraduate I joined Cambridge University Officers’ Training Corps (CUOTC) and took an undergraduate medicine option in medical law and ethics. Since then, my career has danced to the music of time in a rather random manner, and certainly unplanned, between medicine, the military and the law. All three requiring precise and accurate communication to avoid disaster. I joined the Royal Signals wing of the OTC, and although I didn’t realise it at the time, whilst providing radio support on the banks of the river Cam for the May bumps rowing, communications are absolutely key to the three professions of medicine, the law and the military. I was commissioned as a Royal Signals officer in the army reserves during my student clinical years in London, prior to joining the regular army. I was an RAMC doctor for ten fascinating years, serving in the UK, Germany, Northern Ireland and the Persian Gulf for the first Gulf War.

I am going to talk about a small selection of military medico-legal themes from the mid-1980s to the present. This is all in the public domain. The world was, of course, a very different place in the mid-1980s. it was coming to the end of the first, I fear we have now entered a second, cold war. The British Army on the Rhine (BAOR) had a standing army of approximately 55,000 service personnel. At that time there was a network of service hospitals in the UK and Germany covering specialities ranging from Obstetrics to Paediatrics and Surgery. There was little litigation, not least because Crown immunity prevented common law legal claims by service personnel until May 1987 (although families had the same rights as civilians).

Repeal of Crown immunity

Many of you will be aware that it was not possible to bring tort claims against the state until the late 1940s. In 1947 that changed: s 2 [Section 2: Subject to the provisions of this Act, the Crown shall be subject to all those liabilities in tort to which if it were a private person of full age and capacity it would be subject] of the Crown Proceedings Act 1947 made the Crown liable to tort negligence claims in the same way as a private individual. However, s 10 of the 1947 Act excluded service personnel from these new legal rights. This had the effect of preventing legal action by members of the services who were injured, including employer or clinical negligence. This was the case, provided that the Secretary of State issued a certificate stating that the death or injury was attributable to service for the purposes of entitlement to a War Pension. This had the effect of disadvantaging service personnel compared with the civilian population.

This disparity remained for the next 20 years, although as society changed there were legal challenges, particularly in relation to medical negligence. [Bell v Secretary of State for Defence [1986] 1 QB (CA) 323.] Finally, in May 1987, s 10 of the 1947 Act was repealed by the Crown Proceedings (Armed Forces) Act 1987, giving service personnel the same rights as civilians, except whilst engaging with the enemy – so called “combat immunity”.

However, there was an important provision in the 1987 Act: s 2 of that Act empowers the Secretary of State for Defence to make an order reviving s 10 immunity either when there is “imminent national danger or of any great emergency” or if any other operations which are “warlike operations in any part of the world outside the UK or if any other operations which are or are to be carried out in connection with the warlike activity of any persons in any part of the world”. Section 2 has a broad meaning so that whenever there is a hint of operational danger the Secretary of State could easily re-enact s 10 immunity. There is even greater flexibility in the legislation in that he can make an order to “make different provision for different cases, circumstances or persons”.

The provision provided to the Secretary of State has never been used, and it is doubtful it would now ever be politically acceptable to do so.

First Gulf War: Anti biological warfare vaccinations

The 1990/1991 first Gulf War was a war with very few allied casualties. However, prior to deployment intelligence raised the threat of chemical and biological weapons use. You will have heard of Saddam Hussein’s “SCUD” missiles that were expected to be used to deliver battlefield chemical and biological weapons. This was a very real threat at the time and health was at the forefront in trying to provide our troops with the maximum protection possible. The aspect of that initiative I shall pick up is the use of vaccinations to counter the biological warfare threat.

There is provision within service law to discipline any soldier malingering who “does or fails to do anything … whereby he produces, or prolongs or aggravates any sickness or disability”. [Army Act 1955, s 42(1)(d), (2); Amended Armed Forces Act 1971, s 14; Amended Armed Forces Act 2006, s 16.] I refer to this only in order to exclude it from our consideration. Whilst technically this provision could be used to discipline a soldier who refused consent to vaccination it has never and would never be used.

It has been the case during living memory that service personnel have the right to refuse vaccination. Indeed, even in 1954 there was a parliamentary debate concerning servicemen in France and Germany who were prevented from going on leave by their Commanding Officers on the grounds that they had refused routine vaccinations. The Secretary of State for War’s comments, recorded in Hansard, [Parliamentary Debates (Official Reports) 1954–5 537 Feb 14 to Mar 4 w67] made it abundantly clear that vaccination is voluntary. The Commanding Officers had exceeded their authority and soldiers must not be coerced into receiving them.

The military imperative is to be able to continue operations under a biological warfare threat. If the vaccination take-up rate dropped, on the basis of voluntary informed consent, there could be operational compromise. A situation in which there is conflict between an individual serviceman’s rights and the group as a whole.

If an individual refuses vaccinations offered and, as a direct result succumbs to a biological warfare agent, then he affects not only himself, but also the operational capability of his unit, with his own incapacity and also because others are required to look after him. However, the principle of informed consent remains. MOD policy for all vaccinations has always been to explain the personal and community benefits, much in the same way as one would discuss childhood vaccinations for infectious diseases.

The vaccines used to protect troops against the biological warfare threat in the first Gulf War were anthrax, pertussis and plague. Military intelligence indicated that there were high risks of anthrax and plague being weaponised as biological warfare agents on the battlefield. The licensing issues at the time were complex. Anthrax vaccine had been produced at Porton Down since the mid-fifties and was licensed in the UK to protect against cutaneous anthrax in veterinary, tannery and laboratory workers. [Medicines Control Agency Product Licence 1511/0037.] It was not clear whether it would provide significant protection to the aerosol challenge of inhaled anthrax spores in a weaponised battlefield scenario. However, the decision was made to use it “off licence”. MOD’s official position was: “in each case the decision to use an unlicensed product reflected the need to protect British troops against a specific threat in the absence of an appropriate UK licensed alternative”. [Background to the Use of Medical Countermeasures to Protect British Forces during the Gulf War, MOD report, 28 October 1997, www.mod.uk/gulf.]

Pertussis was used as an adjuvant to the anthrax vaccine; there was evidence that it may improve the efficacy of the anthrax vaccine after one or two doses in the tight timescale of the deployment. The risk of delivery of weaponised plague, Yersinia pestis, was also assessed as high. The vaccine decided upon for plague, a dead cell vaccine, was licensed in the USA [Cutter biological licensed by US Food and Drug Administration (FDA)] and FDA “release” letters were provided for the batches used.

Vaccines were completely voluntary on the basis of informed consent with all information made available to troops before being vaccinated. The approach, as with other routine vaccinations, was to explain the personal and community benefits without any coercion. Attendance at the vaccination parade to read that information was a duty.

What in practice happened on the ground? I was a Regimental Medical Officer in BAOR at the time of preparation for the deployment and was responsible for organising the vaccination of about a thousand soldiers. Such was the rapidity of the deployment that first doses were given prior to deploying and we administered second doses in theatre. My recollection from that time is that although some service personnel had pertinent questions to ask about the anti biological warfare vaccinations, to a man and woman they were vaccinated. The risk–benefit ratio concentrates the mind wonderfully when faced with a biological and chemical weapons threat in a war fighting scenario. Indeed, booster doses in theatre during the conflict were, in my experience, unanimously gratefully received. Anecdotally, all of us deploying were keen to accept any protection available as the biological warfare assessed threat was very high.

In the case of chemical weapons, personal protection was twofold, the personal protective equipment (NBC suit and gas mask) and the NAPS (Nerve Agent Pre Treatment Set) [Pyridostygmine tablets] tablets in the case of high risk of nerve agent attack. I am not going to discuss that aspect further.

I left the army in early 1994, armed with a bizarre triad of an HGV driving licence, a certificate saying I was qualified to escape from helicopters underwater and a newish husband. Only the latter proved to be of any use to me. I briefly joined an NHS GP practice partnership before studying medical law and moving to MOD employment in a medico-legal role.

Around this time allegations of “Gulf War Syndrome” had just started. Having served in the northern desert of Saudi Arabia in a field hospital it was of particular interest to me. There were thousands of so-called “Gulf War Illness” potential claims received by MOD. Although there was disclosure of medical records, with a paucity of evidence for a defined condition, proceedings were never served.

However, very recently a firm of solicitors has indicated they wish to revisit Gulf War allegations and specifically allege that there was a lack of informed consent to vaccination. In particular they allege anthrax vaccine led to the same constellation of symptoms, including chronic fatigue, joint pain, breathing problems, headaches, insomnia, mood swings and memory loss. All common symptoms in the general population, especially as we age; I was vaccinated against anthrax and have all those symptoms on occasion. Association or causation? I won’t say more as this new potential litigation is ongoing and at an early stage.

PTSD group action 2003

In 2003 the biggest group claim concerning PTSD[Multiple Claimants v the Ministry of Defence [2003] EWHC 1134 (QB)] led to MOD facing a group action that resulted in a full six-month hearing in the High Court. Robert Jay KC acted for MOD and the judge was Mr Justice Owen. The principal MOD-instructed psychiatric expert advising on generic issues was Sir Simon Wessely. This was a group action brought by more than 2000 service personnel who had served in a number of major operations prior to 1996 (the period under consideration), including the Falklands, Northern Ireland, the first Gulf War and the Balkans. There were 16 lead cases, selected as broadly representing the spectrum of allegations. I can only pick up on a few of the most important issues raised; these remain as pertinent today as 20 years ago.

Mr Justice Owen ruled that many of these cases, prior to the repeal of s 10 on 15 May 1987, were debarred by Crown immunity, as we have already discussed.

The services, by the nature of their work, frequently put personnel in harm’s way: it goes with the territory of being a soldier. MOD didn’t argue against the premise that war can cause psychiatric injury, indeed evidence shows that war is bad for you. MOD accepted that it had a duty of care to look after those who suffered such injury. The range of allegations brought against MOD covered a variety of themes, illustrated in detail by the lead cases.

The claimants’ lawyers argued that MOD had the knowledge available to prevent or ameliorate any detrimental effects on the mental health of service personnel, a proposition roundly rejected by the court. They argued military culture mitigated against seeking help; a proposition rejected by the judge who concluded attitudes to mental health problems had softened over the index period and that MOD acted reasonably.

It was argued that potential service personnel should have been screened for any personal or family psychiatric illness, personality problems or low IQ. Screening had been tried during WW2; the predictors were too weak to be of any practical use. Expert evidence from the UK and US concluded such screening was unreliable. Part of the evidence by US experts set out how the US had abandoned their screening programme in 1944 after excluding two million people from military service because of psychiatric vulnerability; many of those later enlisted. The judge ruled for MOD in that such screening was unreliable on all the evidence.

One of the main aspects of the claim concerned briefing and debriefing. Allegations were that MOD had a duty to brief all personnel on the effects of stress prior to combat; the claimants argued MOD was negligent in failure to train all its service personnel on the psychiatric consequences of combat – so-called “fear training”. Experts instructed by both the claimants and MOD agreed that there was no empirical evidence for the benefit of fear training. The judge held MOD was not negligent if it failed to brief individual soldiers on fear, it was reasonable to leave the decision to commanders on the ground. There is a misconception that emotional ventilation of traumatic events, debriefing, is always beneficial. In his judgment Justice Owen noted the assembled experts had agreed there was no empirical evidence supporting the efficacy of psychological debriefing. Indeed, there was some evidence to the contrary, in that those who received debriefing were at a significantly increased risk of developing PTSD.

The key question for the lead cases then became one of detection and treatment. Detection of PTSD relies on either the individual seeking medical assistance, normally by making a GP appointment, or a referral by a commander to the medical centre. The claimants’ team alleged MOD erred in failure to adequately implement a “battleshock” directive. They also claimed that medical records should be flagged for soldiers taking part in combat. These arguments were rejected by the court. There was a duty for commanders to “know their men” but the evidence heard didn’t amount to any systemic failure.

With regard to treatment, it was held that the evidence base for Cognitive Behavioural Therapy (CBT) wasn’t fully formulated until at least the mid-1990s. Before that a variety of treatments were used on the basis of clinical judgment and MOD had not erred systemically.

There were some individual cases where there were failures to detect combat-related stress disorders; MOD had already conceded those.

The scrutiny of these cases by experts and the detailed judgment resulted in what was arguably the most comprehensive review ever of the PTSD literature. The case set the bar for subsequent cases. Currently there is a more recent group action of PTSD in an early stage of litigation.

Child A and legal liability in German designated provider hospitals

Until the mid-1990s MOD had a network of hospitals, on the model of the District General Hospital at the time, providing most specialist care to service personnel and families posted in BAOR. With the end of the cold war and gradual reduction of service personnel numbers in northern Germany, this was no longer a feasible model and formal alternative arrangements needed to be made for secondary care. The number of military hospitals in Germany had reduced to two and it became the government’s general policy to market test for better facilities.

The market testing process aimed to arrange secondary medical care, as far as possible, British in style and equivalent to the NHS. MOD didn’t set out to directly arrange for provision of secondary healthcare. Instead, it entered into a contract with Guys and St Thomas’ NHS Trust in 1996 for the procurement of elective secondary health care in five German hospitals, known as Designated German Provider hospitals (DGPs).

The Child A case concerned a baby born in one of those contracted hospitals, the Gilead, in 1998. The baby was born prematurely by ventouse extraction and sustained brain damage during the delivery. In Germany the procedure for establishing clinical negligence is by an expert commission, the “Gutachterkommission”, to investigate the facts. Although it was eventually conceded that there was obstetric negligence, the parents wished to pursue the claim under UK law against MOD based on the premise that, analogous to the NHS using non-NHS facilities, there was a “non-delegable duty of care” for the provision of secondary healthcare in Germany by German hospitals contracted to MOD.

After an initial hearing in the High Court, which found for MOD, the Court of Appeal, under the Master of the Rolls, heard the case in 2004. [Child A v MOD [2004] EWCA Civ 641.] The claimant’s lawyers pursued the argument of a “non-delegable duty of care” – however, the NHS analogy failed. In the NHS cases the hospital had already accepted the patient for secondary healthcare and, having done so, could not discharge that duty by sending patients abroad. MOD’s case was that it discharged its duty by exercising reasonable care in the selection and appointment of Guys and St Thomas’ Trust.

The Master of the Rolls in judgment concurred that MOD was no longer in the business of treating patients in hospital in Germany, its sole role being to arrange such treatment provided by others. The Court of Appeal declined to extend the boundaries of the non-delegable duty principle and dismissed the claim against MOD. The MR stated that Germany was the appropriate forum for the litigation and the Gilead Krankenhaus the correct defendant. He concluded, “I can see no justification for imposing a non-delegable duty of care on MOD to ensure that due skill and care is exercised in those hospitals. It seems to me that Germany is the appropriate forum for this litigation and the Gilead Krankenhaus is the appropriate defendant.”

Not directly relevant to the legal case, but interesting for medical members, MOD instructed an expert obstetrician who was German trained and had later worked in the UK as a Consultant; he was hence cognisant with both systems. He advised that whilst there were some differences in practice approach, clinical outcomes were broadly similar.

Over the following decade BAOR further reduced the number of personnel until total withdrawal in 2020, in line with the 2010 strategic defence review.

Other themes

There have been other themes over the last few years in personal injury and continue to be so in areas that I have been less involved, particularly Non Freezing Cold Injury (NFCI), heat injury and Noise Induced Hearing Loss (NIHL).

You may have read about the Snatch Land Rover and Challenger tank [Smith and Others v The Ministry of Defence; Ellis v The Ministry of Defence; Allbutt and Others v The Ministry of Defence [2013] UKSC 41] cases which challenged the breadth of interpretation of the doctrine of combat immunity. The Lariam, anti-malarial, litigation I shall follow with interest. I can’t say much about that as it is ongoing, save to say that allegations against MOD concern informed consent to prescribing of antimalarials, and choice of antimalarials. A new round of PTSD for the 21st century also beckons.

Personal injury anecdote

Finally, on a lighter note, a case that reminds me how much I have loved working with soldiers, both in uniform and later as a civilian: I read the Particulars of Claim in a personal injury case concerning a Royal Artillery Gunner who was seconded to the Royal Artillery motor cycle display team for a show. He was, at short notice, ordered to participate in an interval entertainment programme. The Particulars of Claim made amusing reading: “The claimant was asked to take part in a stunt known as the ‘Escaped Monkey’ stunt (hereafter ‘the stunt’)”. The stunt involved the claimant riding a miniature 50 cc motorcycle whilst dressed as a zookeeper. The particulars read:

“The stunt involved the claimant chasing a colleague, who was dressed in a monkey costume, hereafter the Monkey, whilst riding a 50 cc motorcycle and wearing a zookeeper’s costume. As part of the stunt the Monkey was to pretend to hit the Claimant about the head with a scaffolding plank and the Claimant was to feign injury and fall from the moving motorcycle whereupon the Monkey was to ride off on it. … The said scaffolding plank measured approximately 5 feet in length 6 inches in width and 2 inches in depth.”

An important detail.

What could possibly go wrong?

The claimant, aka the zookeeper, had not previously performed the stunt and had not received any instruction or training and didn’t feel competent to perform it.

“Whilst performing the stunt as ordered, the Claimant was riding the said miniature 50 cc motorcycle towards the Monkey, when the Monkey so negligently swung the scaffolding plank in the direction of the Claimant and the motorcycle as it moved towards him that he caused the same to strike the Claimant’s jaw with such force that the Claimant was knocked from the motorcycle …”

Inevitably, the long list of allegations in the Particulars of Claim against the Monkey, whom MOD was vicariously liable for, included that the monkey was negligent in failing to swing the scaffolding plank in such a manner that it passed above the claimant’s head, MOD failed to train the monkey and the zookeeper (aka the claimant) adequately, and multiple allegations impugned the general competence of the monkey and the training of the zookeeper.

Conclusion

As I look back I often muse how the next generation will face new medico-legal challenges in the 21st century as Mr Justice Walton speculated about the 20th century in 1908. The impact of artificial intelligence, data mining and quantum computing will change out of all recognition the current medical and legal complex. Recently MOD has been trialling its own version of Chat GPT known as MOD-GPT as a way forward to improve the speed, quality and efficiency of our work. As well as document drafting, summarising and analysis it is being looked at for more specialised tasks such as strategising future concepts. We really have no idea what the future may hold. Suffice it to say accurate communication will continue to be central to medicine, law and the military.

Thank you for indulging me, and once again thank you for placing your confidence in me as your next President. Whilst I cannot offer you the academically erudite personae of my 56 Presidential forbears, I promise you that I shall approach my role for the next two years to the best of my ability with humility, good humour, diligence and fortitude. I shall work hard on the grace and wit described of Dame McIlroy.

Discussion

Dr Andrew Johns (Forensic Psychiatrist): What was the outcome of the monkey case?

The President: It was settled. MOD was vicariously liable for the monkey and the zookeeper; they hadn’t trained them properly.

Dr Mark Tarn (Psychiatrist): In terms of promoting a multinational deployment zone, the British military is deployed to provide that foreign country with support and that the other country is providing services for, if there is query negligence happening in a foreign country also provided by a foreign power, who is liable?

The President: That’s a really good question because after the Child A case there had then been a series of cases concerning treatments at civilian hospitals in various disparate places including Brunei. Whilst there have been attempts to use the Child A judgment in certain places, in other places we have simply taken the position that we’re not legally liable, but I think one or two cases have just been settled, they haven’t gone to court. No case has gone to court so there’s been no precedent or challenge.

Dr Mark Tarn: What if it’s a country where the medical team are visiting as well, say Afghanistan, and a German hospital is providing treatment to British soldiers in a third country?

The President: If it was in a British medical facility we would be liable.

Dr Mark Tarn: But if it’s in a German facility in a third country.

The President: Are you talking about a German civilian facility?

Dr Mark Tarn: No, I’m talking about a German military facility providing care for British soldiers in a third country like Afghanistan.

The President: I think it would depend on the facts of the case. It would be argued out by those clever lawyers!

Dr Mark Tarn: The reason why I raise it is because most interventions that happen in deployment are routine, so there’s not the pressure, but who is liable?

The President: Where people have received treatment/operations by multinational teams, for example in Afghanistan where they have joined teams with the Americans, Dutch and so on, then because in a way MOD is holding itself out to provide medical care we accept liability.

Dr Mark Tarn: How does MOD validate that the support provided, say, by a Czech hospital is equivalent to what they would receive?

The President: That’s a very good question again because that’s problematic. An example that I can give is, as you know, Mark, there was a service hospital in Cyprus until about ten years ago and, since then, local Cypriot facilities have been used. There’s not a formal contract for local Cypriot facilities, they can be used on an ad hoc basis; they still provide primary care in Cyprus. When the Akrotiri Hospital was closed, there were attempts by, for example, MOD’s Consultant Adviser in Obstetrics to visit the Cypriot facilities for exactly that, to quality assure, but of course they basically just said “sod off” in a nutshell, “We’re not going to engage. You want it or you don’t want it.”

Can I pick up a couple of the Zoom attendees?

Dr Jonathan Leach (General Practitioner): Many congratulations on your appointment and I’m sorry I can’t be with you in the room. As you will be aware, I’m ex-military as well and so I understand a lot of the context in which you were discussing. One of the issues is that when we deploy and when we have deployed, the range of facilities that are supplied by a military deployed hospital are significantly less than would be in the DGH. So you sometimes get, for example, a general surgeon having to do more specialist things which in the civilian setting would only be done by somebody who was very specially trained in that. What do you consider to be the major medico-legal risks regarding that? There would be clinical risks with that but what do you consider to be the medico-legal risks where, for example, you might have, as I say, a general surgeon needing to do a hysterectomy?

The President: It would be interesting, Jonathan, to turn that on its head. I haven’t been in the military for many years but I’m married to someone who was and, as a general surgeon, did a number of Afghan tours and the trauma surgery standards in Camp Bastion Afghanistan, for example, were well recognised by the NHS to be far in excess of what one would receive within the National Health Service and the message that came from the audits afterwards said that there were huge numbers of unexpected survivors. What you are describing where, for example, someone had to undergo and did you say a hysterectomy or a caesarean section? What did you say?

Dr Jonathan Leach: Either. It’s where you have normally something which would be done by a specialist in this country where you have to have somebody who would be less trained but almost because there’s no other option.

The President: Sure, but the point is that our people are trained not just in their civilian role which may well be a sub-specialty but they’re also trained as trauma surgeons and now with fast CASEVAC you’re not talking about having somebody staying for weeks. All that I can say, Jonathan, is that I’m not aware of any clinical negligence claims to date from the scenario that you’re describing. Indeed, in terms of the Afghan theatre, I don’t even recall receiving a clinical negligence claim.

Mr Rizwan Baig (Medical Student): I often take the volume and nature of litigation in the context as a litmus test for the underlying trust in the organisation. Did you ever find what were essentially legal fights between the people on the ground and the institution damaging to the British Army?

The President: Individual cases, as with individual cases within the National Health Service, clearly there’s also an element of bitterness as well as everything else, but I’m not really aware of what you’re describing. Certainly in primary care there’s superlatively better access than within the National Health Service at the moment. I think there is sometimes resentment where particularly older service people have been used to a situation where they’d be referred to service hospitals and now they’re referred into the NHS and they may well linger on a waiting list and they don’t quite appreciate that. They may be on the waiting list the same as everybody else. That’s all I can say.

Dr Yogesh Patel (General Practitioner): Being a GP, I think you said that PTSD did not need to be flagged on GP records and I find that a bit confusing.

The President: I was parroting the High Court case and it wasn’t if they were diagnosed with PTSD, it was more if there were vulnerabilities prior. If they’re diagnosed they get medically downgraded, so they either wouldn’t deploy again or they’d have to be reviewed before. There is very, very close occupational health because, in the services, which you don’t have in the NHS, the primary care doctor provides occupational medicine as well and there’s a very close inter-relationship with them. So if somebody is diagnosed with a particular condition and is functionally disabled by it, they’ll be medically downgraded which prevents them doing all kinds of things from picking up a weapon to whatever.

Dr Yogesh Patel: I now understand. Thank you.

The President: Thank you very much. (Applause)