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Select Committee on Defence Written Evidence


Memorandum submitted to the Defence Committee by the Ministry of Defence responding to the Committee's Questions on the Defence Medical Services

Q1.   What is the current and proposed structure of the DMS? Could you provide a description of each element and their relationship, and the reporting and managerial line?

  The Surgeon General (SG) is the professional head of the Defence Medical Services (DMS) and is responsible for the provision of policy to ensure effective medical services for the Armed Forces. SG is the owner of, and responsible for the strategic direction of, the four medical agencies; the Defence Secondary Care Agency (DSCA), the Medical Supplies Agency (MSA), the Defence Dental Agency (DDA) and the Defence Medical Training Organisation (DMTO).

  The three single Service Medical Directors General (MDGs), while having functional and professional responsibilities to SG, report to their single Services and are responsible for implementing medical policy, standards, plans and personnel matters relating to their own Service.

  Under the future strategy for the DMS, announced in December 1998, the three MDGs will, in future, report to SG, thus giving him for the first time complete oversight over the DMS. The role of the MDGs will also be strengthened by bringing primary care in their Service under their budgetary control.

  The DMS comprise the Royal Naval Medical Service, the Army Medical Services and the Royal Air Force Medical Services. Personnel in the three Medical Services serve in the four medical agencies and in The Health Alliance in Germany. They also serve in ships, primary care centres, field ambulances and various other posts. Brief descriptions of the three Medical Services, the medical agencies and healthcare arrangements in Germany are given below.

THE ROYAL NAVAL MEDICAL SERVICE

  The Royal Naval Medical Service (RNMS) is headed by the Medical Director General (Naval) and a small support staff located in Portsmouth. Primary care services are provided in ships, to Naval bases which support and supply the Fleet to training establishments such as HMS Raleigh and the RM Commando Training Centre at Lympstone and to specialist training bases such as HM Ships Collingwood and Sultan. The Fleet Accommodation Centres at HM Ships Nelson and Drake also have major primary care centres. Secondary care is provided by naval medical personnel at the tri-Service Royal Hospital (RH) Haslar and the Ministry of Defence Hospital Units (MDHUs). The RNMS also includes the Institute of Naval Medicine situated at Alverstoke, Gosport.

  Dental services are provided by personnel of the Royal Naval Dental Service (RNDS) who are employed in the DDA; nursing services are provided by the Queen Alexandra's Royal Naval Nursing Service (QARNNS).

THE ARMY MEDICAL SERVICES

  The Army Medical Services (AMS) are headed by the Director General Army Medical Services (DGAMS), located in the Army Medical Directorate at Ash Vale, near Aldershot. The AMS comprise the Royal Army Medical Corps (RAMC), the Royal Army Veterinary Corps (RAVC), the Royal Army Dental Corps (RADC) and the Queen Alexandra's Royal Army Nursing Corps (QARANC). The Commander Medical LAND Command controls the medical units of the Field Army and primary healthcare.

THE ROYAL AIR FORCE MEDICAL SERVICES

  The Director General Medical Services (RAF) (DGMS (RAF)) is based at HQ Personnel and Training Command (HQ PTC) at Innsworth, Gloucester. He is supported by specialist medical personnel and the staff of the RAF Medical Directorate. The specialised RAF Medical Units for which DGMS(RAF) is responsible are; the Tactical Medical Wing located at RAF Lyneham; the Centre for Aviation Medicine (CAM) and the RAF Medical Board (RAF MB) both located at RAF Henlow; the RAF Institute of Health (IoH) and the Department of Post Graduate General Practice Education (DPGPE) both located at RAF Halton; and the Officer and Aircrew Selection Centre (OASC) Medical Board located at RAF Cranwell. Dental services are provided by personnel of the RAF Dental Branch employed in the DDA and nursing services are provided by the Princess Mary's Royal Air Force Nursing Service (PMRAFNS).

MEDICAL AGENCIES

The Defence Secondary Care Agency

  The DSCA was created in April 1996 following Defence Cost Study (DCS) 15 in 1994 and is responsible for secondary care of the Armed Forces in the UK and overseas in Gibraltar, Cyprus and the Falkland Islands. The headquarters of the agency is situated in London. Secondary care in the UK is provided at RH Haslar, near Gosport, the Duchess of Kent's Hospital, Catterick, and three MDHUs located in NHS District General Hospitals at Derriford in Plymouth, Frimley near Aldershot, and Peterborough and the Defence Services Medical Rehabilitation Centre (DSMRC) at Headley Court, Leatherhead.

The Defence Medical Training Organisation

  The DMTO was created in April 1996 following DCS 15 and became an agency in April 1997. The Organisation consists of a headquarters staff and the Royal Defence Medical College (RDMC) based in Gosport and the Defence Medical Services Training Centre (DMSTC) at Ash Vale, Aldershot.

The Defence Dental Agency

  The DDA was formed in March 1996 following DCS 15 and has its headquarters at RAF Halton, Aylesbury. The personnel of the Royal Naval Dental Service, the Royal Army Dental Corps and the Royal Air Force Dental Branch serve in the DDA.

The Medical Supplies Agency

  The MSA was formed in March 1996 following DCS 15 and comprises a headquarters at Ludgershall near Andover, Hampshire, the Medical Equipment Depot, the Blood Supply Depot, both also housed at Ludgershall, and 14 Medical Distribution Centres (MDC) in the UK and overseas.

HEALTHCARE IN GERMANY

  The Health Alliance runs facilities for UK Service personnel and their dependants within five German hospitals located close to Army units and RAF stations. LAND Command is responsible for The Health Alliance while policy guidance is given by SG. The Health Alliance comprises military medical personnel together with civilian staff from Guy's and St. Thomas's NHS Trust and the Soldier's, Sailors' and Airmen's Families Association, a charitable organisation which assists serving and ex-Service personnel and their families. The Health Alliance also provides primary care for the Army in Germany, but not for the RAF which continues to provide its own primary care.

Q2.   What are the functions of each of these elements (eg the Defence Secondary Care Agency, the Defence Medical Training Organisation, the Medical Supplies Agency, the Defence Dental Agency, the single Service structures, etc)?

  The functions of the three Medical Services are described below.

ROYAL NAVAL MEDICAL SERVICE

  The RNMS exists to provide medical support to operational commanders of the Royal Navy and Royal Marines. The provision of surgical teams is of principal importance and the current structure and skill mix required of its men and women is derived from this requirement. Surgical support teams consisting of surgeons, anaesthetists, technicians and nurses. These teams are deployed to major ships, such as aircraft carriers and to Primary Casualty Receiving Ships (PCRS) where they provide second and third line surgical support to the wounded.

  Primary care, occupational health and public health are provided to naval personnel in ships, units and establishments of the three principal naval commands of FLEET, FLEET Support and Naval Home Command. These services are provided by a wide range of personnel who include medical branch ratings, nurses and doctors. Medical Branch ratings provide the backbone of medical support to ships and submarines which do not necessarily carry doctors.

  Expert advice in specific areas of military medicines such as aviation, diving, submarines and radiation is available from specialist medical officers together with supporting scientific staff at the INM. The Commander in Chief FLEET is the principal beneficiary of this expertise which supports Air Stations, the Submarine Flotilla, and Mine Counter Measures Squadrons. The INM also provides training for Medical Service personnel in these and other Service specific subjects such as the effects of cold and immersion. Applied research in a wide range of disciplines is undertaken at INM addressing specific operational problems.

  Training is conducted to national standards, resulting in appropriate professional recognition. However, to maintain the right balance of skills it is essential that naval medical personnel are exposed to as wide a range of patients and procedures as possible. This is achieved by rotating personnel between the RH Haslar, the MDHUs attached to major NHS civilian hospitals and other hospitals where specialist training is undertaken.

  The QARNNS provides nursing services in support of the Armed Forces and dental services are provided by the Royal Naval Dental Services who are employed in the DDA.

ARMY MEDICAL SERVICES

  The function of the AMS is to promote effective and efficient medical health services for the Army at home and abroad and to provide a policy focus for individual medical training, doctrine and force development. The AMS are responsible for advising Commanders on the maintenance of health and prevention of disease in the Army, the collection, medical classification, evacuation and treatment of the sick and wounded in war. The AMS are made up of a number of component parts.

  The Royal Army Medical Corps (RAMC) provides the medical manpower to support the Field Army on the front line. It also provides medical personnel for secondary care at the hospitals at RH Haslar and Catterick, the three MDHUs and in Cyprus, Gibraltar and the Falkland Islands. The Field Army is organised with three 200 bed Field Hospitals, five Armoured Field Ambulances, two wheeled Field Ambulances, one Airmobile Field Ambulance and one parachute Field Ambulance. For operations at medium scale war fighting these require the additional support of the Territorial Army Medical Services. Members of the RAMC provide advice on medical matters, including occupational and public health, and contribute to the operational effectiveness of the Army by advice on the maintenance of health and hygiene. The RAMC provides specialist health professionals and is involved in the continuing training of clinical personnel, maintaining links with the Royal Colleges and other professional medical bodies.

  The Queen Alexandra's Royal Army Nursing Corps (QARANC) provides a nursing service in support of the Armed Forces at home and abroad. Members of the Corps are currently serving in secondary care Service hospitals and MDHUs, in primary care facilities and in Field Hospitals and Field Ambulances.

  The Royal Army Dental Corps (RADC) provides dental support to the Armed Forces. Delivery of primary dental care is under the control of the DDA which co-ordinates the provision of dental care across all three Services.

  The Royal Army Veterinary Corps (RAVC). The Veterinary and Remount Service provides Military Working Animals (MWA) and personnel for diverse animal related roles in support of military operations and training and the provision of veterinary care and treatment to all MWA's. The Veterinary and Remount Service also provides support in public health matters such as food hygiene, water quality and pest control; zoonoses (infections) of major human or animal significance; Biological Warfare defence, including monitoring of the Biological and Toxin Weapon convention; wider peace-keeping roles as in veterinary "hearts and minds" activity and civil affairs.

ROYAL AIR FORCE MEDICAL SERVICES

  DGMS(RAF) is responsible for Primary Health Services (PHS) which encompass primary healthcare, occupational and environmental health, public health, operational support and other specialist functions. HQ PTC has Lead Command responsibility for provision of PHS to all RAF Commands: responsibility for the management of personnel of the Medical, Medical Secretarial and Medical Technical Branches; the development and promulgation of medical, medical operational and other associated policies and standards. Strategic Planning lies with the Director of Medical Personnel, Policy and Plans on the staff of the DGMS(RAF). RAF PHS policy and standards interpret and supplement those promulgated by the SG. Implementation and audit of PHS policy and standards, and oversight of the day to day provision of service is the responsibility of the Director of PHS (DPHS) on the staff of the DMS(RAF). The RAF PHS is provided by medical centres located at RAF stations and by a number of specialist units which underpin PHS. The specialist units are:

  Tactical Medical Wing. The TMW at RAF Lyneham undertakes operational medical training, administrative control and logistic provision of the units of TMW which are only formed to support military operations and during exercises. As part of this function it oversees the manning of RAF aeromedical evacuation. Air Officer Commanding HQ 38 Group, embedded within HQ Strike Command, has Command and Control of TMW, but professional responsibility lies with DGMS(RAF).

  RAF Centre for Aviation Medicine. This unit is based at RAF Henlow and provides aviation medicine training for RAF aircrew, as well as other groups such as medical officers, parachutists, aeromedical personnel and cabin crew. CAM also provides aviation medical support to operations, research in support of Eurofighter aircraft on behalf of the Defence Evaluation and Research Agency and specialist medical input to aircraft accident investigation. Professional responsibility for the CAM lies with DGMS(RAF) and Command and Control passes from Strike Command to HQ PTC on 1 April 1999.

  RAF Institute of Health. This unit, based at RAF Halton, provides specialist occupational and environmental health advice as well as aviation pathology and toxicology services. The unit has a specialist noise and vibration division for advising on issues such as low flying aircraft. Functional control of IofH lies with DGMS(RAF), but Command and Control of the unit lies with the Air Officer Commanding Administered Units, HQ PTC.

  RAF Medical Board. The RAF MB at RAF Henlow assesses fitness for work in the light of illness and injury, awarding appropriate Medical Employment Standards as required. The Board also advises the executive on cases which may require medical discharge from the Service. DGMS(RAF) has Command and Control of the RAF MB.

  The Officer and Aircrew Selection Centre Medical Board. The OASC Board at RAF Cranwell is responsible for performing initial medical examination and boarding of applicants for commissions, aircrew duties, cadetships and flying scholarships. The Board also examines allied and foreign and some civilian contractor aircrew. Command and Control for the OASC Medical Board lies with the Deputy Director of Recruiting and Selection with professional oversight from DPHS.

  The Department of Post Graduate General Practice Education. This unit is located within the RAF IofH and reports directly to DPHS and advises on and supports the education and training of general medical practitioners within the RAF, it also oversees standards within training practices.

  The Princess Mary's Nursing Service provides nursing services in support of the Armed Forces and personnel of the Royal Air Force Dental Branch employed in the DDA provide dental services in support of the Armed Forces.

AGENCIES

The Defence Secondary Care Agency

  The key task of the DCSA is to provide Britain's front-line Armed Forces, wherever they are in action, with fully trained Service doctors, nurses and other medical staff. To achieve this, the Agency provides a peacetime organisation within which clinicians and other medical personnel develop their professional and military skills.

  The DSCA's units in the UK deliver peacetime healthcare to Service personnel and lcoal civilian NHS patients. Its overseas units treat only Service personnel, UK-based civilians and their dependants.

  The RH Haslar is the largest Service hospital and the core hospital of the Agency. Haslar is now a tri-Service teaching hospital, providing District General Hospital services to the Gosport community, and working closely with the Portsmouth and South East Hants Health Authority and NHS Trusts. Haslar has also achieved accreditation as a Cancer Unit linked to Portsmouth Hospitals Trust Cancer Centre. The future strategy for the DMS, announced in December 1998, entails the closure of Haslar and its replacement with an MDHU in the Portsmouth area. The hospital will not close until satisfactory alternative arrangements are in place and this is unlikely to be before 2002 at the earliest. The Portsmouth Health Authority and the DSCA are now taking forward work on the proposed MDHU in the Portsmouth area.

  The Duchess of Kent's Hospital at Catterick, Yorkshire, serves one of the largest military garrisons in Western Europe and a civilian population. However, the future services offered by the hospital have been in question for several years because of declining patient numbers and the effect of the reduced case-mix on the skills of doctors and nurses. It has therefore been decided that in-patient services at the Duchess of Kent's hospital will close; a new MDHU at the Northallerton Friarage hospital is planned to open in July 1999. A Minor Injuries Unit and a Medical Reception Station will be retained at Catterick and the Defence Services Psychiatric Centre is planned to stay there for the immediate future.

  The DSMRC, Headley Court, is a centre of excellence, the key aim of which is to rehabilitate Service personnel and return them to duty as quickly as possible. The specialties provided at Headley Court include the treatment of orthopaedic and sports injuries, hand and peripheral neurological injuries, spinal injuries, neurological rehabilitation and rheumatic disease.

  The Princess Mary's Hospital, Akrotiri, Cyprus, provides comprehensive secondary care to Service personnel and their dependants. Specialties include anaesthetics, general medicine, general surgery, orthopaedic surgery, obstetrics and gynaecology and oral maxillo-facial surgery.

  The Royal Naval Hospital, Gibraltar, serves the MOD community and visiting ships and submarines. The hospital provides a range of medical services, including accident and emergency, out-patient and a local ambulance service.

  MDHU Derriford is a fully integrated part of Derriford District Hospital near the Naval base at Devonport. The MDHU manages one general surgery ward. Within the range of treatments provided, Service specialties are ENT, general surgery, oral maxillo-facial surgery, orthopaedics and radiology.

  MDHU Frimley Park is an integral part of Frimley Park NHS Hospital Trust near the major garrison at Aldershot. The MDHU manages a general medical ward and a general surgery ward within the host Trust and provides 26 per cent of the hospital consultants. Service specialties include accident and emergency, ENT, dermatology, general medicine, general surgery, gynaecology, maternity, oral maxillo-facial surgery, ophthalmology, orthopaedics and urology.

  MDHU Peterborough is integrated within the Peterborough Hospitals Trust, serving large Service populations across East Anglia and Central England, as well as NHS patients from Peterborough. The MDHU manages both a general medical ward and a surgical/orthopaedic ward. Service specialties at the hospital include ENT, general medicine, general surgery, orthopaedics, ophthalmology, oral surgery, rheumatology and gynaecology.

THE DEFENCE MEDICAL TRAINING ORGANISATION

  The objectives of the DMTO are to deliver personnel, trained to the specified standard, as required by the agency's customers; to maintain and utilise the required training capability and capacity cost-effectively; to develop training in response to changes in doctrine, medical practice, Research and Development, and equipment being introduced into service, so as to teach best practice appropriate to the military environment; to develop and maintain a joint Service culture within the DMTO staff and to develop both a joint Service understanding and single Service culture within the trainees; to ensure the provision of a Defence Medical Library Service and a Defence Entomology Service to support medical services and to meet the needs of the DMTO's customers.

  The DMTO consists of a small headquarters to manage the agency based at Fort Blockhouse, Gosport, under the Director General Medical Training (DGMT) who is also the Chief Executive. The RDMC is also situated at Fort Blockhouse and is reponsible for the training of all medical officers, nurses, and medical technicians other than Pharmacy and Environmental Health (EH) Technicians. It also co-ordinates Physiotherapy and Radiographer training. The Commandant of the College is also the Defence Postgraduate Medical Dean, responsible for the supervision of higher professional training of medical officers. The DMSTC at Keogh Barracks, Ash Vale, Aldershot, is responsible for medical military, and career development training for the majority of other ranks in all three Medical Services. It is also responsible for the training of Pharmacy and EH technicians, elements of career and military training for officers of the Army Medical Services and for the medical, first aid and environmental health training of nominated non-medical Service personnel.

THE DEFENCE DENTAL AGENCY

  The aim of the DDA is to contribute to the operational effectiveness of the Armed Forces by achieving and maintaining, in the most cost-effective way, their dental fitness in war, operational situations other than war, and peace.

  The DDA comprises the Royal Naval Dental Service, the Royal Army Dental Corps, the Royal Air Force Dental Branch and civilian contingent and is responsible to the SG for the provision of primary dental care for approximately 225,000 Service personnel at 180 locations. The agency also provides primary dental care to entitled civilians and dependants outside the UK.

  The DDA has a world-wide commitment to serve the UK military community, with clinics in the UK, Germany, SHAPE, Naples, Brunei, Canada, Gibraltar, Falkland Islands, and Belize, some of which are permanently manned, and some of which are visited. In addition, capital ships of the Royal Navy have permanent surgeries, whilst others are regularly visited by mobile dental teams with portable equipment. The DDA also provides trained dental staff to The Health Alliance in Germany, and mobile fully equipped dental teams for operational deployments.

  Policy setting, budgets and high level management is provided by the DDA Headquarters but the day to day administration of dental care is devolved to 19 regions world-wide, each with a Principal Dental Officer, usually at Colonel level, responsible for the delivery of dental care in his region. As a result of the tri-Service nature of the DDA, Principal Dental Officers will have managerial responsibility for dental personnel of the other Services within their region.

  Recruits are inspected and most are made dentally fit to reduce morbidity and minimise the loss of fighting effectiveness due to dental problems. The target is for 75 per cent dental fitness overall, and 90 per cent in priority groups. In addition, the DDA provides professionally and militarily trained personnel at specified readiness for deployment to meet operational deployments.

  The dental service provided is consultant led with both restorative and orthodontic consultants visiting the Regions and taking outpatient clinics. The DSCA is responsible for oral maxillo-facial surgery care which is hospital based but dental consultants also make regular visits to the major dental centres to provide Forward Outpatient Clinics, where diagnostic and minor procedures are undertaken.

  Professional dental training is provided by two tri-Service units: a Postgraduate Dental Institute (PGI) and a DDA Training Establishment for ancillary personnel, the latter providing formal qualifications with civilian equivalence for all staff. The PGI provides courses for dental officers to enable them to achieve further qualifications, and to fulfil and update their educational needs. Vocational training is provided for all newly qualified dental officers on entry and the DDA supports dental officers going forward to examinations for the Royal Colleges which are seen as positive career milestones.

THE MEDICAL SUPPLIES AGENCY

  The function of the MSA is to ensure cost-effective and timely provision of medical, dental and veterinary materiel, blood and blood products, technical and logistic support and trained people to the UK Armed Forces world-wide in war and peace. The MSA's mission is to be the preferred supplier of medical materiel and associated services to the MoD. Its outputs and objectives are: the provision of trained personnel to support commitments defined by Permanent Joint Headquarters (PJHQ) at Northwood and the single Service Commands; provision of peace and war entitled scales of modularised materiel and other medical materiel that may be authorised by higher command; provision of advice and information in support of policy formulation.

  The MSA comprises a headquarters organisation at Ludgershall, the Medical Equipment Depot and the MSA Blood Supply Depot, also at Ludgershall, and 14 Medical Distribution Centres (MDCs) in the UK and overseas. On operations, the MSA forms the nucleus of a field medical equipment depot (84 FMED) and provides supply detachments to deployable medical units of all three Services.

Q3.   What are the establishments of each of these elements? What are the planned increases or reductions for each element?

  The current requirement for each of the three Medical Services, including SDR enhancements, compared with the DCS 15 requirement is as follows:


DCS 15 Requirement
Post SDR Requirement

Royal Naval Medical Service
653
1,598
Army Medical Services
2,848
4,345
Royal Air Force Medical Services
1,144
1,718


  Military medical establishments for the SG's Department, MDGs and medical agencies at 1 April 1999 are shown below. Civilian staff is also employed in these areas. The figure for SG's Department includes the new two star Chief of Staff and one star Director of Personnel, Training and Policy posts recommended in the future strategy for the DMS and additional staff under the one star Director of Personnel, Training and Policy. Additional staff, military or civilian, may be required by the MDGs as a result of their new budgetary responsibilities for primary care, but the requirement cannot be quantified at this stage. The figure for the MSA will also change to reflect the manning of the SG's Information Strategy. Likewise, the anticipated increase in manpower in the DMTO as a result of the SDR and implementation of the future strategy for the DMS has yet to be finalised.

  Remaining DMS personnel are employed in primary care and various other posts.


Requirement

Surgeon General's Department
42
MDG(N)
9
DGAMS
33
DGMS(RAF)
45(1)
DSCA
1,819
DMTO
162
DDA
733
MSA
46


  Notes:  (1) The higher number of staff compared with the other two Services reflects DGAMS(RAF)'s wider Command and professional responsibilities.

Q4.   What is the current Reservist contribution to the DMS? What changes are planned?

  It was announced in SDR that the Volunteer Reserves will play an increasingly important role in the DMS. Part of the additional funding made available under the Review will be used for a major recruiting campaign for the Volunteer Reserves. In addition, SDR recommended making more and better use of Reserves including extra Territorial Army, personnel assigned to support roles in the AMS, or retrained as Combat Medical Technicians. The tables below for the three individual Reserve Services show both the pre- and post-SDR establishment together with the current trained strength.

MEDICAL RESERVES (as at 12 February 1999)

ROYAL NAVAL RESERVE


Pre SDR
establishment
Post SDR
establishment
Current  trained
strength

Doctors
74
86
46 (incl 2 Med
Students)
Nurses
125
144
54
Dentists
0
0
0
Professions Allied to Medicine
4
4
1
Military Support Orderlies
146
168
154
Dvrs/Clerks/Chefs etc
0
0
0
Totals
349
402
255


TERRITORIAL ARMY


Pre SDR
establishment
Post SDR
establishment
Current trained
strength

Doctors
588
810
393 (incl 40 medical
students)
Nurses
997
2,348
800
Dentists
109
183
63
Professions Allied to Medicine
394
595
285
Combat Medical Technicians
1,592
1,552
1,442
Dvrs/Clerks/Chefs etc
1,963
1,396
1,231
Totals
5,643
6,884
4,214


ROYAL AUXILIARY AIR FORCE


Pre SDR
establishment
Post SDR
establishment
Current trained
strength

Doctors
31
31
21
Nurses
57
57
46
Dentists
4
4
0
Professions Allied to Medicine
18
18
10
Medical Assistants
61
61
60
Dvrs/Clerks/Chefs etc
77
77
52
Totals
248
248
189


The units manned by the Volunteer Reserves are as follows:


Royal Naval Reserve
Primary Casualty Receiving Ship
Territorial Army
201, 202, 203, 204, 205, 207, 208, 212, 243 and 256 Field
Hospital (V)
306 Independent Field Hospital (V)
Ambulance Train Group (V)
381 Field Medical Equipment Depot (V)
Royal Auxiliary Air Force
4626 Squadron
Air Transportable Surgical Support Team


  Individual Reserves and Volunteer Reserves are also used to fill posts in other units.

Q5.   What has been the budget for each element of the Structure described above for each of the last 10 years (or as many as are available up to 10), and what is it projected to be for the next three years?

  The cost of the DMS for the years 1989-90 to 1997-98, where available, and estimated expenditure for 1998-99 are as follows:


89-90
90-91
91-92
92-93
93-94
94-95
95-96
96-97
97-98
98-99
281.0
290.0
310.0
N/A
N/A
414.1
414.1
257.7
273.5
291.5


  A breakdown of expenditure is only possible for the following units for the years 1996-97 to 1998-99:


96-97
97-98
98-99

SG's Department
3.3
3.5
5.3
MDG(N)
7.7
6.1
4.6
DGAMS
3.8
4.2
4.7
DGMS (RAF)
5.8
5.3
6.7
DSCA
100.6
106.1
115.1
MSA
38.9
41.2
43.1
DDA
26.0
29.7
33.7
DMTO
11.6
15.4
16.7
Germany
60.0
62.0
61.6


  Notes:

  1.  Figures for 1989-90 to 1991-92 are taken from the Statement on the Defence Estimates 1991, Volume 2. Their precise composition is not known but they are not thought to include primary care costs since these were embedded in each unit's costs.

  2.  Expenditure for 1992-93 and 1993-94 cannot be provided since figures ceased to be published in the Statement on the Defence Estimates after 1991 when budgets were disaggregated and contemporary records are no longer available.

  3.  Figures for 1994-95 and 1995-96 are the costs of the DMS estimated by DCS 15 and cannot be broken down by unit. However, these figures do include primary care costs, estimated at £83.5 million for 1994-95 and £81.1 million for 1995-96.

  4.  Figures for 1996-97 to 1998-99 exclude primary care costs, other than those for Germany, and various other posts filled by DMS personnel. The figures for Germany represent both the cost of Army primary care and Army and RAF secondary care provided under contractual arrangements with The Health Alliance.

  5.  Figures for 1998-99 represent the latest forecast of expenditure.

  6.  All figures in £ million.

  Plans for future Defence spending reflect the annual Long Term Costing (LTC) of the Defence programme. The LTC represents projections and assumptions, which inform internal advice to Ministers on the affordability of particular elements of the Defence programme. It is MoD practice that detailed information on such provision is withheld under Exemption 2 of the Code of Practice on Access to Government Information. Subject to this policy, however, broad indications are provided wherever possible; total estimated expenditure on the DMS for the next three years, 1999-00 to 2001-02, is shown below. The figures exclude devolved primary care costs, other than those for Germany, and various other posts filled by DMS personnel. The figures for Germany represent both the cost of Army primary care and Army and RAF secondary care provided under contractual arrangements with The Health Alliance.

1999-00 to 2001-02

SG's Department
30
MDG(N)
(inc INM)
15
DGAMS
(inc Regimental HQ and Museum)
20
DGMS(RAF)
(inc CAM, RAF MB, IoH,
DPGPE)
50
DSCA
360
MSA
120
DDA
110
DMTO
65
Germany
160


Q6.   Could you list each of the existing Ministry of Defence Hospital Units (MDHUs), giving the NHS Trust within which they are located, their principal commissioning authority and the addresses in each case.


Name of MDHU
Ministry of Defence Hospital Unit Derriford
Host Trust
Derrriford Hospital
Plymouth Hospitals NHS Trust
Plymouth
Devon PL6 8DH
Principal Commissioning Authority:
South and West Devon Health Authority
Lesceze Offices
Shinners Bridge
Dartington TQ9 6JE
Name of MDHU
Ministry of Defence Hospital Unit Peterborough
Host Trust
Peterborough Hospitals NHS Trust
Eastlea
Thorpe Road
Peterborough
Cambridgeshire PE3 6DA
Principal Commissioning Authority
North West Anglia Health Authority
St. John's
Thorpe Road
Peterborough PE3 6JG
(from 1 April 1999 it will change to Cambridgeshire Health Authority.)
Name of MDHU
Ministry of Defence Hospital Unit Frimley Park
Host Trust
Frimley Park Hospital NHS Trust
Portsmouth Road
Frimley
Camberley
Surrey GU16 5UJ
Principal Commissioning Authority:
South East and North East Hampshire Health Authority
Portsmouth Road
Frimley
Surrey GU16 5UJ


  From 1 July 1999, following closure of the Duchess of Kent's Hospital:

Name of MHDU
Ministry of Defence Hospital Unit Northallerton
Host Trust
Friarage Hospital
Northallerton
North Yorkshire DL6 1JG
Principal Commissioning Authority:
North Yorkshire Health Authority
Sovereign House
Kettlestring Lane
Clifton Moor
York YO3 4XF


Q7.   Could you list for each MDHU the numbers of medical and nursing staff contracted to provide MoD service?

  MoD military personnel are integrated fully with their NHS colleagues at each of the MDHUs.

  There are five military-run wards in the three existing MDHUs; one general surgery ward at Derriford, a general medical ward and a general surgery ward at Frimley Park and a general medical and a surgical/orthopaedic ward at Peterborough.

MDHU MILITARY ESTABLISHMENTS/STRENGTHS (as at 1 Dec 98)


Estab
Strength

MDHU Frimley Park
253
203
MDHU Peterborough
164
123
MDHU Derriford
161
137
TOTAL
578
463


MDHU CIVILIAN STRENGTH (as at 22 Feb 1999)


Strength
Civilian in
Lieu of Military
Vacancies

MDHU Peterborough
10
0
2
MDHU Frimley Park
9
0
0
MDHU Derriford
9
0
2
TOTAL
28
0
4


Q8.   Could you explain the nature of the contractual arrangements between the MOD/MDHUs/NHS for the provision of NHS services, the nature of any local variations in these arrangements, and what the balance between NHS/MOD work is? Could you detail the changes proposed in these arrangements?

  The concept of an MDHU—a Service hospital unit within a larger NHS hospital—was first mooted in the 1992 review of secondary care in the Armed Forces, and formalised in the 1994 restructuring of the DMS. The first unit was created in 1995 within Plymouth Hospital NHS Trust (Derriford) with the closure of the Royal Naval Hospital at Stonehouse; the contract with the Trust was predicated on the wholesale transfer of the historical activity of the RNH and the staff of the naval hospital.

  Similar assumptions were made with the creation of the second MDHU at Frimley Park Hospital in Surrey which followed the closure of the Cambridge Military Hospital in Aldershot; the third MDHU, at Peterborough, was consequent on the closure of RAF Wroughton, near Swindon, a few years earlier, and was designed to ensure an even spread of catchment for Service personnel across the country. The MDHU concept integrates Service medical personnel into the clinical directorates, duty rotas and training systems of the hosptial. Although each unit is tri-Service in principle, agreements with the single Services mean that in practice the RAF provides the greater share of management and patients at Peterborough, the Royal Navy at Derriford, and the Army at Frimley Park.

  Financial arrangements in the Service Level Agreements (SLAs) with the NHS with respect to MDHUs were outlined in the NHSE FDL(95)45 (copy attached), which set out a formula whereby the proportion of the NHS value of the Scheme of Complement (NVSOC) for Service personnel—the cost the Trust bears if appointing civilian staff in place of the Service personnel posted to its hospital by the DMS—is set as a rebate against the treatment costs of Service personnel. A further rebate is paid by the Trust to its local health authority(ies) to compensate for the fact that the Service staff are treating civilian patients. This rebate is intended to compensate for the so-called "free good" which the NHS is receiving from the MOD in the form of free treatment for civilian patients via the military doctors and nurses, and the abatement to the MOD reflects the proportion of Service as opposed to civilian activity carried out by Service personnel. Both rebates can be discounted to fund the so-called "risk premium"; ie compensation for the Trust for:

    (a)  the temporary withdrawl of DMS staff for military operations or exercises;

    (b)  turbulence of Service staff being posted or drafted into and out of an MDHU and potential ward closures when military operations require large-scale deployments;

    (c)  absence of Service staff from duty for adventurous training, group training etc;

    (d)  differential standards for Service patients; operational priority targets ("fittest quickest").

  The SLAs were reviewed and renegotiated during 1998-99. The initial agreements have been clinically successful, but contractually more problematic. These difficulties relate largely to the fact that Service activity in the three Units has not approached the levels built into the contract assumptions of the initial five-year SLAs. This reduced the value of the annual contract significantly and made capacity and financial planning difficult for the host Trusts. The absence of Service personnel on deployment and for other military reasons is also greater than the Trusts felt were covered by internal NHS financial mechanisms around the "free good". Following detailed discussions with the NHS at local, regional and national levels during 1997 and 1998, the principles of a new SLA have been developed to form a revised contract from 1999-2000. These principles are:

    —  the separation of the "host" from the treatment contract;

    —  host contract: the direct payment to MOD for its staff, abated by agreed assessments of staffing "turbulence";

    —  treatment contract: payment by MOD to the host Trust directly for agreed treatments for military patients;

    —  audited assessments of staffing "turbulence" (eg the extent to which military staff are absent for MOD reasons);

    —  payment of a price premuim on the treatment contract for achievement of the MOD's operational priority key targets;

    —  a transfer of funds from MOD to NHS to compensate affected Health Authorities for the loss of the free provision of Service staff, and thus to enable the DSCA to negotiate directly with the relevant NHS Trusts. This effectively means that the end of the so-called "free-good".

  Revised contracts based on these principles are presently being negotiated locally, and will be in place for 1999-2000 at the three original MDHUs, and at the new MDHU at Northallerton. This model will also form the basis for all future MOD contract relationships with the NHS for hosting staff or providing treatment. The new contract, by making more explicit the military requirement and the culture this implies, should underpin a new era in understanding and clinical relationship between the MOD and NHS.

  Local variations to these arrangements are in detail and have been agreed corporately between the MOD and the NHS. Staffing varies according to availability and posting of appropriate military personnel and the treatment contract because of the availability within the Trust of specific sub-specialty treatments and the traditional throughput volumes of Service patients.

  Service nurses in the MDHUs rotate through all clinical areas in the hospital, but also manage either one or two wards to develop managerial and teamwork skills. They inevitably nurse more civilian than military patients because of the balance of work within the Trust. The balance of military/civilian patients within the caseload of military consultants is dictated by the requirement to achieve an appropriate casemix of work to sustain professional interest, skills and professional accreditation for the post. This balance varies from specialty to specialty.

DEFENCE MEDICAL SERVICES: FINANCIAL ARRANGEMENTS

INTRODUCTION

  1.  This letter gives details of revised financial arrangements between the NHS and Defence Medical Services.

BACKGROUND

  2.  Since the NHS was formed in 1948 the Ministry of Defence (MOD) has provided hospital treatment free of charge for NHS patients. The prime purpose of the Defence Medical Services (DMS) is to provide treatment and healthcare for service personnel in war and operations. In peacetime, DMS personnel need to acquire training and education, including appropriate Royal College accreditation in order to deliver their operational role. Because in normal peacetime circumstances there are insufficient service patients to provide this, the DMS need to treat NHS patients as well and this has been done in service hospitals at no cost to the NHS.

DMS REVIEW

  3.  A review of future requirements for secondary care in the Armed Forces was completed in February 1993 and it concluded that around 1,500 beds were required in the UK to help meet the operational role and for Service medical training purposes. Of these beds, 1,000 to 1,200 would be needed in Service hospitals and the remainder could be provided in Ministry of Defence Hospital Units (MDHUs) in NHS hospitals. There would then be no further requirement for three of the seven service hospitals in the UK.

  4.  In July 1994 the Secretary of State for Defence announced a series of measures under "Front Line First" aimed at reducing support costs for the armed forces including restructuring of the Defence Medical Services (DMS). Following a period of consultation, Ministry of Defence (MOD) Ministers announced their final plans in December 1994.

  5.  As a result of these changes nearly all DMS hospitals are to close with RN Haslar in Portsmouth expanding to become the main tri-service teaching hospital in the UK. This hospital will be supported by a continuing presence at the Duchess of Kent Military Hospital at Catterick. In addition there are to be three Ministry of Defence Hospital Units (MDHUs):

    —  Plymouth Hospitals NHS Trust (Derriford Hospital).

    —  Frimley Park Hospital NHS Trust.

    —  Peterborough Hospitals NHS Trust (Peterborough District Hospital).

  6.  The first of these is nearing establishment and the other two are still to be set up. MDHUs will integrate with their host hospitals where they will treat civilians as well as military personnel. These arrangements will allow DMS doctors and nurses to treat the necessary range and number of patients as part of their training in order to equip them for their primary MoD role as well as assisting them to gain relevant professional qualifications.

FINANCIAL ARRANGEMENTS

Ministry of Defence Hospital Units (MDHUs)

  7.  The decision to develop MDHUs within the NHS has meant that a new financial arrangement has had to be agreed with the MoD. Agreement has now been reached and the new financial arrangements for the treatment of civilian and service patients in MDHUs are set out in Annex A.

Defence Medical Services (DMS) Hospitals

  8.  The NHS-MoD financial arrangements for DMS hospitals have been reconsidered but, at the request of MoD, will not be formally reviewed until the DMS Agency has been established later in the year. This therefore means that existing financial arrangements (as originally described in FDL(94)114) remain unchanged. These have been updated where appropriate and can be found at Annex B.

Implications for Weighted Capitation

  9.  The NHS funding and contracting policies which have been developed to handle the implications of these financial arrangements are set out below.

MDHUS

  10.  For MDHUs the NHS value of the DMS staff treating civilian patients usually constitutes a "free good" to the Trust. Subject to a discount to be retained, the Trust will be expected to pay this to all DHAs which purchase a material level of activity from the Trust, ie more than 20 per cent of the free good, or have the value deducted from the DHA contract. These DHAs will thereby benefit from the "free good". This will be taken into account in the NHS funding policy, by being added to the DHAs allocation for purposes of determining the "Distance from Capitation target" (an illustration of the effect on capitation position is given at Annex C).

  11.  The discount to the value of the "free good" to be paid to the host DHA will take into account the responsibilities of the Trust and the risks it faces; for example, in the temporary withdrawal of some of the DMS staff. Each year the NHS Executive will undertake an exercise to calculate the value of the "free good".

DMS HOSPITALS

  12.  An agreed number of NHS patients are treated free of charge in Service Hospitals. This level of patient activity is known as the "training baseline". The cost which would have been incurred by the NHS in treating these patients is regarded as a "free good" benefitting the districts of residence of the patients treated in the Service Hospitals. Benefitting DHAs will have the value of the "free good" net of any discount added to their allocation for purposes of determining the "Distance from Capitation target" (an illustration of the effect on capitation position is given at Annex C).

Implications for GPFH Budget Setting

MDHUS

  13.  The value of the "free good" is added to HA allocations (outside of weighted capitation) and therefore normal arrangements will apply for GPFH budget setting.

DMS HOSPITALS

  14.  The budget setting process for GPFHs benefitting from the "free good" will take account of the value of the "free good". Further details will be included in the GPFH Budget Setting Guidance for 1996-97 due to be issued shortly.

ENQUIRIES

  15.  If you have any queries on the content of this letter, please contact: Liz Eccles, FPB RAFT B, Room 1N10 Tel: (0113) 254 5323, Julie Ross, FPB RAFT B, Room 1N33C Tel: (0113) 2545325.

Colin L Reeves

Director of Finance


 
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Prepared 3 November 1999