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
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 (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 (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 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).
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
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.
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.
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
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.
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
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.
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
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
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.
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
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 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
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 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
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
|Army Medical Services||2,848
|Royal Air Force Medical Services||1,144
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.
| Surgeon General's Department||42
Notes: (1) The higher number of staff compared with the
other two Services reflects DGAMS(RAF)'s wider Command and professional
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)
||86||46 (incl 2 Med
|Professions Allied to Medicine||4
|Military Support Orderlies||146
||810||393 (incl 40 medical
|Professions Allied to Medicine||394
|Combat Medical Technicians||1,592
|Professions Allied to Medicine||18
The units manned by the Volunteer Reserves are as follows:
|Royal Naval Reserve||
||Primary Casualty Receiving Ship|
||201, 202, 203, 204, 205, 207, 208, 212, 243 and 256 Field|
|306 Independent Field Hospital (V)
|Ambulance Train Group (V)
|381 Field Medical Equipment Depot (V)
|Royal Auxiliary Air Force||
|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
The cost of the DMS for the years 1989-90 to 1997-98, where
available, and estimated expenditure for 1998-99 are as follows:
A breakdown of expenditure is only possible for the following
units for the years 1996-97 to 1998-99:
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
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
(inc Regimental HQ and Museum)
(inc CAM, RAF MB, IoH,
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
|Plymouth Hospitals NHS Trust
|Devon PL6 8DH
|Principal Commissioning Authority:
|South and West Devon Health Authority
|Dartington TQ9 6JE
|Name of MDHU||
||Ministry of Defence Hospital Unit Peterborough
||Peterborough Hospitals NHS Trust|
|Cambridgeshire PE3 6DA
|Principal Commissioning Authority
|North West Anglia Health Authority
|Peterborough PE3 6JG
|(from 1 April 1999 it will change to Cambridgeshire Health Authority.)
|Name of MDHU||
||Ministry of Defence Hospital Unit Frimley Park
||Frimley Park Hospital NHS Trust|
|Surrey GU16 5UJ
|Principal Commissioning Authority:
|South East and North East Hampshire Health Authority
|Surrey GU16 5UJ
From 1 July 1999, following closure of the Duchess of Kent's
|Name of MHDU||
||Ministry of Defence Hospital Unit Northallerton
|North Yorkshire DL6 1JG
|Principal Commissioning Authority:
|North Yorkshire Health Authority
|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)
|MDHU Frimley Park||253
MDHU CIVILIAN STRENGTH (as at 22 Feb 1999)
Lieu of Military
|MDHU Frimley Park||9
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 MDHUa Service hospital unit within
a larger NHS hospitalwas 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
personnelthe cost the Trust bears if appointing civilian
staff in place of the Service personnel posted to its hospital
by the DMSis 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
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
1. This letter gives details of revised financial arrangements
between the NHS and Defence Medical Services.
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.
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
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.
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
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.
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
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
Implications for GPFH Budget Setting
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.
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
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