Select Committee on Defence Third Report


137. Previous Defence Committees have reported on the Defence Medical Services (DMS) on a number of occasions[196] and expressed deep concerns about the reductions in the DMS, particularly the closure of the Service hospitals. In its Seventh Report of Session 1998-99, our predecessors concluded that the Government's vision for the DMS—'a fully trained, equipped, resourced and capable organisation with high morale, capable of providing timely and high quality medical care to the Armed Force on operations and in peacetime'—would certainly not be realised for some years into the future, and it was possible that it would not be achievable. While it acknowledged the various initiatives in hand, our predecessors questioned whether the DMS could survive for long enough for the measures to have effect. It called for the DMS and the NHS to work actively together to ensure that the potential collapse of the former did not become a reality.

138. The SDR recognised a particular weakness in the amount of medical support which could be provided for substantial combat operations overseas and identified a number of changes to address this—these included an increase in the regular element of the DMS and the use of compulsory call-ups of medical reservists to augment regular field hospitals.


139. First Reflections reports that:

It also reports that 'the scale of effort was only possible by the use of almost all medical Volunteer Reserves, most of whom worked in the NHS'.[198]

140. MoD provided us with information[199] on the manning shortfalls in DMS—these were most severe in key clinical specialties such as surgeons and anaesthetists. Medical reservists were called out to ensure that appropriate medical support was available for UK forces. Compulsory call-out was used to ensure that the appropriate numbers of the correct clinical specialties could be deployed to theatre. Following the main conflict phase, the Chairman of the British Medical Association's (BMA's) Armed Forces Committee[200], said that the conflict in Iraq had highlighted the chronic under-manning in the DMS and that there still remained acute shortages in specialties such as anaesthetics and general surgery as well as accident and emergency. He noted that the volunteer reserves were 50 per cent under strength and that the lack of resources to reinforce or rotate individuals placed greater stress on the DMS and had a detrimental effect on the NHS.

141. We asked MoD about the impact of the under-manning on the planning for the operation. Lieutenant General Kevin O'Donoghue, Deputy Chief of the Defence Staff (Health), told us that 'the medical plan proved to us that we could support CJO's operational plan in manpower terms, just, but we would be required to spend a lot of money on equipment. With that message the operational planning went ahead'.[201] In terms of how difficult it was for the DMS to get to a position of being fully manned for the operation, he told us:

    There were some specialties where we mobilised all that we could and deployed them. We deployed in all about one third of the Defence Medical Services if you add together regulars and reserves but in some specialties surgeons, anaesthetists, intensive care nurses, and so on, we deployed just about all that we could.[202]

    We cross-deployed, there were RAF and Navy in the field hospitals, one of the field hospitals was all regular, one was all reserve and one was half regular and half reserve. We took most of the specialisms out from the reserve and deployed them… There is a process that we went through and we got there and it worked. It was very, very close, yes, in certain areas.[203]

142. The Surgeon General, Vice Admiral Ian Jenkins added:

    we were fully manned for the medical support operation. If you asked me whether we could match it again tomorrow I could not put my hand on my heart and say yes. We have used all our resources… We have emptied the box to a large extent, that is a slight exaggeration, but in general terms in the major specialities for war requirement we have emptied the boxes. That then, of course, raises another question and that is that of course we are sustaining other mature operations, the Falklands, Northern Ireland, Sierra Leone and the Balkans of course and we are having to re-invite reservists to contemplate supporting some of those operations. We are obviously using our regular people again in our rotations and that is adding to the over-stretched disharmony and everything else which encourages them to consider whether they are going to stay or not.[204]

143. We find it worrying that some five years after the Strategic Defence Review the problems in the DMS, in particular the problem of under manning, appear to be as bad as they ever have been. We were alarmed to learn that for the major specialties for war MoD had 'emptied the boxes' for Operation Telic. Further deployments in the near future are only likely to exacerbate the problems.

144. We asked whether DMS was meeting any of its targets in addressing the problems it faced. General O'Donoghue told us:

    we are failing on manpower… Recruiting is buoyant, the retention… is stable but we need to look for other ways to attract people to stay in beyond their three year point. We need to look at other ways to give greater predictability of deployment for our TA specialists.[205]

The Surgeon General told us that 'we have to look for new solutions…. we are trying to identify better methods of pay and non-pay options to encourage more people into the military and to retain the people that we have'[206] He referred to initiatives in hand such as 'a pilot with the Birmingham Hospital Trust whereby a team, a surgeon, an anaesthetist, an operating theatre sister and an operating department practitioner, went as a formed unit to the Balkans as a trial last year and that was outstandingly successful'.[207] We acknowledge that the manning issue is not an easy one to address quickly, but we look to MoD, the Department of Health, the NHS and the medical profession to support the DMS in its efforts to find new and innovative solutions.

145. In terms of the constraints in deploying medical consultants, MoD told us[208] that, in the case of consultants, clinical governance guidelines limit the amount of time they can spend on operations. The time limit is primarily in place to ensure they do not lose clinical currency or suffer skill fade. On routine low tempo operations the DMS aims to deploy any consultant for no more than three months in any twelve month period. Due to operational commitments, this may not always be possible, although the DMS seeks to avoid deploying them for more than six months at any one time, hence the need to deploy reservist consultants.

146. We asked about the growing trend in the NHS towards greater specialism amongst surgeons and the consequences of this for the DMS. The Surgeon General told us that 'we are really addressing this because it is a very, very major issue… and we have commissioned a study to see how we can address this'.[209] This is an area of real concern for the future. Fewer NHS consultants will have the range of surgical skills required for military deployment, and at the same time the greater focus on specialisation in the NHS risks making a period of regular service in the DMS a still less attractive prospect for anyone who expects their long term career to be in the NHS. Again, we recommend that MoD bring together the Department of Health, the NHS and the medical profession with the DMS in order urgently to identify solutions to this problem.

147. A number of press articles had reported that medical reservists returning from deployment on Operation Telic had resigned. General O'Donoghue told us that he understood that, from the Army, 17 medical reservists had put their papers in since Operation Telic. In his view 'that is not very many. After any conflict one would expect a number to put their papers in'.[210] He did not know how many medical reservists from the Royal Navy and RAF had resigned, but was not aware of any problem. MoD subsequently provided us with information (as at November 2003) on the number of medical reservists who had resigned following Operation Telic. This showed: 19 from the Royal Navy; 14 from the Army; and 14 from the RAF. For the Army, the figure provided by MoD related to the number of personnel who had left from Field Hospital Units - MoD was aware that a number of medical reservists had also left from other TA medical units.[211] We are most concerned to learn that 47 medical reservists have resigned on returning from Operation Telic, and that MoD is aware of further resignations from Army medical reservists. The number of resignations represents some six per cent of the 760 medical reservists deployed. We expect MoD to monitor this issue closely, to identify the reasons behind the resignations, and to take account of these in its recruitment and retention efforts.

Impact on the NHS

148. In terms of the impact on the NHS, the Surgeon General told us:

149. This was the first operation where all the medical personnel deployed came almost exclusively from the NHS and it appears that the arrangements, such as the liaison between MoD, the Department of Health, and NHS Trusts worked well. However, thankfully, the number of casualties was low and the arrangements for treating casualties in NHS hospitals were not fully tested.

Medical equipment and supplies

150. Lessons for the Future reports that 'because of the lead-time for the supply of some key items of medical equipment, some modules arrived in theatre incomplete… There were also shortfalls in some medical stocks, including ComboPens (self-injection antidotes for nerve agent poisoning) prior to deployment'.[213] General O'Donoghue told us, 'we spent £35 million on UORs'[214] (Urgent Operational Requirements) but he said that some of the 'modules were not necessarily complete but where they offered an operational capability… they were dispatched and the bits that were missing were sent later'. [215] He was 'not aware… that any equipment that was critical was not in place on time'. [216]

151. The Chief of Defence Logistics told us that no UORs were prosecuted if they could not be delivered at the six month point (31 March 2003) and we asked whether there was any medical equipment or supplies which were not ordered because they would not be delivered within the timescale. General O'Donoghue told us that there were not, but added that 'we had to procure too much equipment by UOR, we need to have more on the shelf.'[217]

152. We are pleased to learn that lessons about the need to have more medical supplies on the shelves rather than over-relying on UORs have been recognised. We expect MoD to identify the appropriate balance between holding items and relying on UORs. We also expect MoD to review any cases from Operation Telic where inadequate or insufficient equipment may have disadvantaged clinical outcomes and, if any such cases are identified, to take appropriate action to avoid such situations occurring in the future.

196   Fifth Report 1994-95; Third Report 1996-97; Seventh Report 1998-99. Back

197   Ministry of Defence, Operations in Iraq-First Reflections (July 2003), para 5.7. Back

198   Ministry of Defence, Operations in Iraq-First Reflections (July 2003), p 31. Back

199   Ev 407 Back

200   Speech by Dr John Ferguson, Chairman of the British Medical Association's (BMA's) Armed Forces Committee, July 2003. Back

201   Q 1177 Back

202   Q 1195 Back

203   Q 1196 Back

204   Q 1197 Back

205   Q 1229 Back

206   Q 1198 Back

207   Q 1198 Back

208   Ev 407 Back

209   Q 1194 Back

210   Q 1207 Back

211   Ev 418 Back

212   Q 1181 Back

213   Ministry of Defence, Operations in Iraq-Lessons for the Future (December 2003), para 9.41. Back

214   Q 1211 Back

215   Q 1211 Back

216   Q 1211 Back

217   Q 1212 Back

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Prepared 16 March 2004