|
UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 655-ii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE DEFENCE COMMITTEE
MEDICAL CARE FOR THE ARMED FORCES
Committee Room C, Council House Extension, Birmingham
Thursday 21 June 2007 MS JULIE MOORE and DR DAVID ROSSER MR TERENCE LEWIS, MR ANDREW MORRIS, MR NEIL PERMAIN and MRS CHRIS WILKINSON
DR BRENDAN McKEATING Evidence heard in Public Questions 105 - 210
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Defence Committee on Thursday 21 June 2007 Members present Mr James Arbuthnot, in the Chair Mr David Crausby Linda Gilroy Mr Dai Havard Mr Brian Jenkins Mr Kevan Jones ________________ Memorandum submitted by Birmingham NHS Foundation Trust Examination of Witnesses Witnesses: Ms Julie Moore, Chief Executive, and Dr David Rosser, Medical Director, University Hospital Birmingham NHS Foundation Trust, gave evidence. Q105 Chairman: Welcome to the evidence session here in Birmingham on the medical care that is given to the Armed Forces of our country. Welcome to Julie Moore and Dr Rosser. Thank you for showing us round Selly Oak this morning. As we take evidence from you this afternoon I would ask you, please, to remember that the microphone in front of you needs to be activated when you speak. It would be helpful, probably in order to avoid feedback and all that sort of stuff, if you could switch it off when you stop speaking. Could I ask you, please, to introduce yourselves and say what your role is. Julie Moore, would you like to begin? Ms Moore: My name is Julie Moore, I am Chief Executive of University Hospital Birmingham which covers the Queen Elizabeth and Selly Oak Hospitals. Dr Rosser: Dave Rosser, I am currently a consultant in intensive care at University Hospital but I am also the Medical Director. Q106 Chairman: Can I ask that people switch your phones off otherwise it will cause all sorts of problems. Can I begin with a rather important issue. Do you think the decision to site the Royal Centre for Defence Medicine, the Centre for Defence Medicine as it was then, at a large National Health Service teaching hospital was the right one when it was taken? That is a sort of yes or no question. Do you think it is the right way for it to be run now? Ms Moore: Thank you, Chairman. Thank you for inviting us today to talk about this. I think it was the right decision. Healthcare has evolved greatly now and increasing sub-specialisation in medicine means you do need a large acute teaching trust to have available all the specialties required to treat what are pretty complex injuries. Some of the soldiers we have had coming back from abroad have had upwards of ten, 11, specialties working on them at one time and I think only an acute teaching trust can provide that complex level of care. How it is run at the moment, I think it is the right way to do it, we are integrating military and NHS and both sides learn from each other. I think we are providing an excellent standard of care. Q107 Chairman: Dr Rosser, do you have anything to add? Dr Rosser: I would just like to emphasise the training role at the RCDM. One of the key functions is not just about looking after the military patients when they are evacuated to us, it is about making sure that staff who need to go out to the frontline and provide clinical care in theatre are adequately trained. As Julie says, if you are going to acquire and keep those skills up-to-date you need a significant workload and there is compelling evidence across a whole range of clinical specialties that people who do more of the procedure get better results. If you look at the workload, the complex surgery that comes purely from the military, there simply is not enough work to train and keep skilled a range of specialists. Q108 Chairman: You have both given very medically-based answers. We will come on to the military ethos questions that all of this raises in a few minutes. Thank you for those answers. Why Birmingham? What makes Birmingham the right place, if it is the right place? Is it the right place? Ms Moore: Birmingham is one of seven major trauma centres throughout the country but in terms of its central location, located near to a big airport and its good road networks, I think that was one of the major factors in choosing it so that patients can be easily transported when they are aeromedically evacuated back to Birmingham. In addition, it has got very strong partnerships with local universities, again feeding the training environment at the Royal Centre for Defence Medicine. Q109 Chairman: By the way, you do not have to add anything if you do not want to. Dr Rosser: I was just weighing up whether it adds value and I think it probably does. The other thing is the range of clinical specialties we have is very extensive. The only major specialties we do not provide are paediatrics and obstetrics and gynaecology. If one is injured in any form of major trauma any part of the body can be affected and we have surgical specialists particularly skilled in dealing with virtually every part of the body. Q110 Chairman: Can you tell us, please, how you are funded? Ms Moore: We are funded on a very similar basis to the NHS in that we get paid per patient that we treat. In addition, there are some overhead costs put in to support the aeromedical evacuation service based at the Trust. Chairman: Moving on to the treatment of casualties, David Crausby, the Vice-Chairman. Q111 Mr Crausby: Thank you, Chairman. Could you explain to us first of all, briefly, the patient pathway for casualties from the frontline? Dr Rosser: It depends on the severity of the injury and the nature of the injury to an extent. Essentially the evacuation is organised by aeromed, which is closely allied to the RCDM, so from a clinical perspective we receive a phone call from aeromed saying, "We have a casualty or a number of casualties" and a description of the injuries. Together with the aeromed team we make a judgment on whether they need to come to critical care or should go straight to a ward and which specialist ward they should go to. Aeromed decide which is the most appropriate airport, they are flown to that airport, brought to us by land ambulance and managed by the relevant clinical teams when they hit our institution. Q112 Mr Crausby: Could you tell us what arrangements you have for the treatment of service patients with mental health issues? Dr Rosser: We do not provide mental health care specifically. On the Queen Elizabeth site there is the mental health trust but that is an entirely separate trust, so we are not involved in the care of people with purely psychiatric problems. Q113 Mr Havard: But the co-ordination of all of that is done through you, is it not, or done at your site? Dr Rosser: If a patient comes back with physical injuries and psychological problems then we will import the relevant psychiatric and psychological support, usually via the RCDM because, as you are aware, they are quite specialist and not necessarily able to be dealt with by civilian psychiatric services. Chairman: I do think you need to use the microphone for recording purposes. Q114 Mr Havard: Technology and children, never work with either! The question is you are assessing that individual in the round, are you not, you are not just mending their broken leg or wound they have had from a bullet? That assessment is done at your location, is it not, and then that is the centre of the process? Ms Moore: That is right. Q115 Mr Havard: That gives the pathway for the individual, is that not right? If it is not right then it should be. Dr Rosser: Yes, it is right. Q116 Mr Jones: Some of the patients we saw this morning had some very severe and traumatic injuries but, in terms of their rehabilitation, what is the pathway when possibly they leave Selly Oak and perhaps go into the NHS, especially those people who are perhaps leaving the Armed Forces because of their injuries? What is the pathway for them to ensure that the care that you give is continued on, possibly from their local GP or local primary care trust? Ms Moore: The RCDM have put in place a senior officer who is responsible for the whole pathway. Once a patient is fit to be discharged from our organisation, he will take over co-ordinating that care, whether it is to another hospital, to the military, to the GP or back to the unit to make sure that is as seamless as possible. That is all co-ordinated by a senior officer. Q117 Mr Jones: That is on a case-by-case basis? Ms Moore: Yes. Q118 Mr Jenkins: Can I take you back six years because originally when the Government set this system up it was set up merely to be a contract with the MoD, so you treat it like that: twisted ankles playing football, dislocated shoulders, maybe some medical conditions amongst the personnel of the Armed Forces. It was never set up to expect you as a single unit to take the war casualties. In fact, there are arrangements in place with other hospitals which were funded with equipment so that we could put these war casualties across a wide range. You have ended up with a role that you did not envisage to start with. What impact has this had on the ability to run the hospital normally? Ms Moore: You are absolutely right in what you say but what happened was with training the doctors and nurses to go out to the frontline and the degree of expertise and knowledge of the situation at Selly Oak and the frontline, that led to casualties increasingly being sent back to Selly Oak by the doctors on the frontline. At the same time, at Selly Oak we started developing a degree of expertise in trauma injuries that had not been seen in this country for decades. There was a sense of pride in the staff that what we were doing was really quite groundbreaking in some of the surgeries and things we were doing to preserve life, preserve limb and the results coming back that the military have had show that the clinical results are excellent and better than would be expected. What we have done to make sure that there is no impact on our local population is gear up to meet that. We have put in additional facilities and expanded our services to do that. I am pleased to say that our waiting times for NHS patients are still amongst the lowest in the country. We have still delivered all our targets for all our commissioners; we have still got very high Healthcare Commission ratings, and have done so for the past four or five years. Q119 Mr Jenkins: Thank you. I expect you to say the hospital is quite good, and I expect you to say it is improving and it is the centre of excellence, but would you agree - I am sure you will but I want to put this on the record - that the reason they are sent back to Birmingham is because the medical doctors in Afghanistan and Iraq recognise this as the place they want to send their patients, they are quite happy with it, in fact they are more than happy, so they see that as the centre of excellence. It is through their recommendation rather than your recommendation, and I tell you now I would rather take their recommendation about the state of the hospital rather than yours because you are paid to say how good you are and they are not, they are there to look after the interests of our Service personnel. Given that, their recommendation raises your status, I am quite pleased to say, but the Reception Arrangements of Military Personnel have been ignored basically in as far as we are not sending them to any other hospitals, just yours. Do you think we have to rethink that procedure or do you think that procedure should still be in place because how many casualties can you accept and when do you have to start sending them to other reception centres? Ms Moore: We are planning with the MoD how we take forward the contract for the future because we have seen an escalation in the number of casualties coming back and at the moment I am very proud to pay tribute to our staff who have come in on days off and who have worked tirelessly to make sure we have always accommodated casualties. The last time casualties were diverted was in 2003 and that was the only time. Since then we have always managed to accommodate any military casualties being aeromedically evacuated. What would be helpful for the Trust would be to have certainty as to whether we are to continue doing this for the future or, indeed, if the national plan is to be brought into place. We are having discussions at the moment about that. Chairman: There are several of us who want to come in on this question, so if you can stick to this question. Q120 Mr Jenkins: I am going to stick to this question. I would like to know, do I send a message to the Taliban asking them just how big and ferocious their attacks are going to be in Afghanistan because then we would have a degree of certainty. I asked you the simple question of what is the cut-off point where you would have to say, "We can handle no more, they must be diverted somewhere else". Have you worked out or thought of a number? Ms Moore: If we know with certainty what the number is we can plan for that. If we were told that the numbers are going to continuously go up, can we continue, yes, if they were to increase 20 per cent, 50 per cent, yes, but what I do not know is whether that is the plan to continue, that we will be the sole receiving hospital at the moment. If we were told, "You are going to be it", then we would like to build in capacity to flex up and down which, indeed, we are doing at the moment. We could take, and have taken, anything we have been asked to take by the military and the MoD and we will continue to do so. A degree of certainty that they are going to continue to do that would just be helpful. Q121 Chairman: Would you expect there to be any change in these arrangements when super garrisons come on-stream? For example, if there were large numbers of personnel based around Colchester, and hospitals are therefore used to dealing with military personnel there, would you expect any change in these arrangements as a result of that? Ms Moore: Not in aeromedically evacuated patients. Prior to the recent conflicts we were seeing very, very small numbers of inpatients, sometimes none and the maximum we ever got up to was about four, six or eight before that, so very small numbers in a 1,200 bedded hospital. The real difference that has been made is soldiers posted overseas in conflict. Q122 Mr Jones: Can I ask a question of Dr Rosser. We were in Afghanistan two months ago and we met the medical personnel at Kandahar and were very impressed by not only their dedication but also the change of emphasis in putting doctors on the frontline, for example, rather than after med evacuation. What feedback or professional contact do you actually have with the people on the frontline who are treating these young Servicemen as they are actually wounded? Is there an exchange of professional expertise or any lessons you could learn or vice versa? Dr Rosser: A number of the people who go out are actually based with us so the contact we have with them is great because they are colleagues when they are back in the UK. We have learned a number of lessons about communication essentially and how important it is that there is personal conversation between doctors on the frontline, particularly for the major injuries, particularly chest, head and neck injuries that surgically are very complicated. We have done quite a lot of work with General Lillywhite and have arranged a number of different communication channels and regular telephone conferences to discuss issues in principle: maybe we are not using the right dressings, maybe we should approach something slightly differently. The surgery at the front end is about saving life, as I sure you know, really stopgap surgery, and reconstructive surgery is what we do when people get back here but clearly you cannot entirely separate those. There has been a lot of communication really fine tuning that interaction: "Perhaps if you did it a little bit differently the reconstruction results would be better". We have also done a lot of work on opening up communication channels so there can be direct communication about individual patients on the way back because theoretically one should be able to put the necessary details on a handover sheet. To quote one of my surgical colleagues, "If you are going to have to put both hands inside somebody's chest it is very reassuring to know exactly what your predecessor did and found". We have recognised the importance of that and opened up better channels. Ms Moore: The Army are looking at putting digital links in so that images are being fed directly back to our consultants for views as well, and also to have web cams to look at wounds. That is something that 24 hours a day will give access to surgeons that they have not got on the frontline. Chairman: We saw something pretty similar to that in the Shaibah base in Iraq last year. Q123 Mr Havard: As I understand it, that process is going to be extended further in the new hospital arrangements that are coming along. Ms Moore: That is right. Q124 Mr Havard: Therefore, a lot of this stuff is being planned to be developed in that. This comes back to a point that you made earlier about certainty and planning and the question that we asked about financing and contract arrangements and so on and the certainty of something remaining here and developing here. As I understand it, you, the NHS Trust, contract with the MoD to provide certain things. That is presumably, what, a 12 monthly process. Can you explain to us whether or not there is a 12 monthly contract between you and the MoD that deals with the current process as is described and running, and how the contracting arrangement is being negotiated about future development and your point about certainty and planning? Ms Moore: The contract is negotiated 12 monthly. At the moment there are two processes going on, there is a routine 12 month contract and there are two contracts, one for treatment and one for the training and personnel placement and, secondly, we are having discussions with the MoD about what facilities they want exactly in the new build. We have got capacity to expand the military presence in there but we do need to know about that fairly soon. With a PFI build there is a timescale you have to meet, so the deadline that I have asked for is that they will let us know by August about what they want in the new hospital. Q125 Mr Havard: So the new hospital is a PFI build. Ms Moore: Yes. Q126 Mr Havard: And you are in the process of contract negotiations now? Ms Moore: Yes. Q127 Mr Havard: So when you say the near future, are we talking about 18 months, 12 months, six months? Ms Moore: No, six weeks. Q128 Chairman: The new hospital is to be finished in 2011? Ms Moore: We start moving in in 2010 and we finish the whole process in 2012. We have got an 18 month moving in process so you were right, somewhere in the middle. Q129 Mr Jenkins: If I can take you back once again, because I like to learn from our mistakes if possible. There was a time when we first started out when we did have some problems in the treatment of injured personnel, and I think you would accept that as a justified criticism. As you put it, there were some "inevitable teething problems". Did you log those teething problems? Did you in any way keep a profile of how you overcame those teething problems? If we need it I want to be sure that we can pass that on to another trust so we do not undergo the same problems in the future. Did you do that? Ms Moore: We did do that. We have regular meetings with the military where we go over issues that are learning points. Some of those have been clinical issues because some of the injuries we have not seen and people have not been trained in for some time and a lot of that expertise has been shared. Others were some organisational issues but they were minor compared to some of the clinical elements at play. Q130 Mr Jenkins: It is the clinical side that I am interested in. I think anyone who has spent any time looking at this problem will realise that there are men and women now alive today because they have come to Selly Oak. It would have been extremely challenging for our military medical teams to have shown the same degree and level of skill. Will you take it from me back to your staff and say thank you for all the work you have done, all of the hardships you have overcome, all of the teething problems you have overcome and everything else to provide that service. Ms Moore: I will be very glad to do so. Thank you. Q131 Mr Jones: Would you recognise one of our witnesses last week described the situation in Selly Oak in the early days as - the actual words used were - "confused and shameful"? Do you recognise that as a fair criticism? Ms Moore: No, I would not. The focus has always been on providing the utmost clinical care. I think those words may have been applied to some other aspect but certainly not to the clinical care that was given then. I would be on record as saying that the staff of the Trust take a very, very high degree of pride in the care that they provide to the military. They are distressing injuries, the staff have a degree of empathy with the military casualties coming back, and I have no problem at all when we have an aeroplane landing that has got six coming into critical care that staff will come in at a moment's notice on their day off to look after the soldiers. Around clinical issues, no, I would not recognise that at all. Q132 Chairman: Clinically, clearly, you are quite excellent, and if I may take this opportunity, on behalf of the Committee, I would like to thank you for that because I think the care that you give is outstanding. Ms Moore: Thank you. Q133 Chairman: I suspect we all think that. When you say that around clinical issues you would not recognise that phrase, would you recognise it about any other aspect of the care which was provided by Selly Oak in the early stages? We have clearly moved on now but in the early stages would you recognise that? Ms Moore: I think in the early stages where casualties were coming back people were not so used to casualties arriving back in the middle of the night or whenever and there may have been some organisational issues. There was never anything that we investigated from the Trust's perspective that gave great cause for concern as far as we are aware. There were some complaints that came through about some of the follow-on care afterwards once people had gone. Q134 Mr Jones: I just have a follow-up to that in terms of complaints, either about medical care or the way people dealt with it. How many complaints have you received from Armed Forces personnel who have been through Selly Oak, or their families in, say, the last 12 months? What type of complaints have they been? Ms Moore: Since we have had the military there we have treated nearly 40,000 patients and we have had seven complaints; two last year and there have been five this year. Q135 Mr Jenkins: What was the nature of those complaints? Were they about medical care or welfare care? Ms Moore: There were a variety of issues. One issue we could say was about clinical care but the rest of the issues were more peripheral issues, if you like. The one medical issue Dave is familiar with so I will ask him to answer that. Dr Rosser: The one which you could say is a half clinical thing which we picked up in one of the complaints was around a drug error when a short acting version of a painkiller was given instead of a long acting painkiller. That in itself poses no major risk but clearly it is not acceptable for drug errors to happen. Having said that, to put it in context, we administer 147,000 drug administration events per week in our organisations, so realistically, however hard you try and however hard your policies are for dealing with drug errors they will happen, when you are dealing with that many events it is inevitable. Q136 Chairman: Do you know how those sorts of statistics compare to other NHS trusts in the United Kingdom? Dr Rosser: The complaints statistics or drug error statistics? Q137 Chairman: The complaints statistics I was asking about, but the drug error statistics as well. Dr Rosser: The drug error statistics I do not really know how it relates because we are running a very advanced electronic prescribing administration system in our organisation which is unique to us. I can trot out those figures because I get weekly reports from that system, I suspect most of my medical director colleagues around the country would not have those figures. I think Julie knows the figures on complaints better than I do. Ms Moore: In terms of general NHS complaints 0.1 per cent of patients in the NHS complain, the statistics for the military is 0.02 per cent, so five times lower. Q138 Chairman: A final question on this and then I will turn over to Kevan Jones again. If this system is so good at administering drugs, why is it unique to you? Dr Rosser: It was developed by us in partnership with the university and it has not spread throughout the NHS largely, I guess, because the NHS is waiting for similar products to be devolved through Connecting for Health. Ms Moore: We will be looking to sell it in the near future! Q139 Mr Jones: One of the debates, certainly in Parliament, has been about the idea, and one of the arguments is, we should have separate hospitals altogether for military personnel. Obviously even the Opposition have now conceded that is not clinically advisable. The emphasis now is on the creation of military-managed wards and we saw this morning when we visited it is perhaps the best way of treating military, not just in terms of the care but also people being together with a military ethos. Where are we at with that at Selly Oak and also what challenges does it set you as the Trust in terms of managing the military unit with all the other responsibilities clearly for the provision of care for the people of Birmingham? Ms Moore: I think you are right, it provides the best of both worlds. We have got the skilled NHS staff who are able to teach the military staff and it also provides a high degree of military staffing for the wards so that the soldiers are nursed by large numbers of military nurses on the ward, which you saw this morning. The challenges it presents are that military nurses are not trained in running NHS wards so they have to get familiar with whole new jargon and I think the NHS have to get used to whole new jargon from the military as well. Both sides use acronyms like there is no tomorrow. In bringing the teams together there has been a positive benefit for both sides to learn from each other. There are not great challenges in that there are problems with it, they are all nurses, they are all doctors and they are all looking after very sick patients. We do recognise that the military environment is a different environment and having military people looking after you is good. Q140 Mr Jones: So as a Trust you welcome it? Ms Moore: We have always welcomed it. We did have a military-managed ward up until the deployment at first conflict. The problem with that was in times of conflict the military clinical staff are needed so they were deployed and we were given 24 hours' notice of the ward staff being removed. We have to be quite careful, we have got contingency plans because obviously when there is conflict the military clinical staff are busy elsewhere rather than in Britain. Q141 Mr Jones: That gives you flexibility, does it, in terms of if staff are then deployed on operations you can still cover a military-managed ward with your NHS staff? Ms Moore: We make sure we have a core of NHS staff on the ward as well, yes. Q142 Chairman: This issue has been put very strongly in certain quarters, so strongly, in fact, that some people say it is a breach of the military covenant to have a young man just serving in the military next to an elderly lady who has just had a stroke. How do you answer those criticisms that this is going on and that it is a breach of the military covenant? Ms Moore: I would say the overriding factor that is most important is getting the soldiers to be in the most clinically appropriate place with staff who are skilled at saving lives and saving limbs. Occasionally soldiers have been nursed alongside patients of the same sex - we do not mix patients of different sex inside the bays, we have entirely single sex bays - in other bays. I do not believe that is the most important factor, I believe the most important in all of this is the skilled care given by the doctors and nurses who are skilled to look after those patients. Whenever possible we put military patients together but if you have a head injury you want a neurosurgeon looking after you and if you have got a chest injury you want a cardiothoracic surgeon. Those injuries are very, very few in number, so we are not ever going to have enough to fill a ward or even a bay with single patients on there. Q143 Mr Havard: My understanding of this is the Military Services Department have said that they would like to have a situation where a trauma ward could be established. From the business of managing it, it would appear there are not military nurses with the relevant qualifications to actually manage a ward and the idea is to get up to 70 per cent military nurses as the component in such a ward. We have not got to that situation yet. As I understand it, there are training activities and plans to try to get to that position, that is the idea. Currently, the situation is presumably managed by one of your NHS, I do not know what they are --- Ms Moore: Ward sisters. Mr Havard: This is England and I come from Wales, so there is a different set of problems down here. Q144 Chairman: You would never have been able to tell! Dr Rosser: I had not noticed, no. Q145 Mr Havard: It is that Grand Slam tie you have got on! It is 2005, by the way. How do we get to that situation? Is that what you are trying to move towards? I am concerned about the contractual arrangements from the point of view of knowing what the timetable is to advance this programme if this is what the programme is going to be. Is that where we are going to get to? As I understand it, you are not going to be in that position next month and next month was the original target date. Where are we? Ms Moore: The military did have some ward managers but, as I explained before, a lot of them have been deployed and it does take time to skill somebody up for that. We do have a military nurse as part of the leadership team on the ward. There is a senior sister and there are junior sisters on the ward. There is a senior military nursing presence on the ward and that has been proved to be beneficial both to the casualties and the rest of the nursing team. The military nurses do require training up to be able to take full control of the ward. Some of them have been outside the NHS environment for a long time, have been out in the frontline in Afghanistan and Iraq, and they do take time to pick up their skills. I do not believe that the lack of that is causing any detriment to the people on the wards whatsoever. Q146 Mr Havard: I was not suggesting that at all. Ms Moore: No. Mr Havard: I was asking if these are the parameters we are trying to get to, where are we getting in terms of progress towards it. Q147 Mr Jenkins: With regard to our military ward and the military nurses because of deployment, and when they are on a six month deployment they are entitled to so much leave, they do not come back for a while, what difficulty is there in being able to rotate your staff to a level where they can get their training? You have to mix these with your NHS nurses but what problems have you had to overcome? I know it is necessary to train them because they have to go out to theatre and then come back home but have there been any major problems in these rotas for nurses? Ms Moore: We are very fortunate to have some very skilled nurse managers who are used to managing rotas that you could only describe as 3-D rotas at times. I would pay tribute to the head of nursing in the division of the senior nurses who has done an absolutely fantastic job in managing the nursing situation. Chairman: Moving on to welfare issues, David Crausby, the Vice-Chairman. Q148 Mr Crausby: Thank you, Chairman. In our evidence session last week with representatives of families, there was a general acceptance about clinical excellence and the British Legion, for instance, said: "at the moment healthcare is extremely good". One of the criticisms which the British Legion made to us was that you were better at looking after patients' clinical needs than dealing with wider welfare issues. They made the point that charities are having to step in to provide basic essentials like clothes and toiletries when people are separated from their possessions. How do you respond to that? Is it appropriate that Service personnel and their families in these circumstances should depend on a charitable organisation? Ms Moore: I am very glad of that comment because we are aiming to be excellent clinically and the comment did say that. The welfare of the military patients is purely provided for by the military but I would say I thought the comment was referring more to visitors than to patients. We have a full range of toiletries, pyjamas, slippers, towels, anything anybody might want when they come into hospital, because it does not just apply to the military who arrive without their things. Q149 Mr Crausby: She said there were essential things like toiletries and clothing for people who have been separated from their possessions. I think it was aimed more at families but, even so, is it appropriate in these circumstances that charities should deliver this need? After all, people are sometimes quite proud about having to make appeals to charities. In circumstances like this should they be put under even more stress by having to ask for assistance with travel, for example? Dr Rosser: We would answer no, it is not appropriate. We have very clear responsibilities as part of providing a high quality of clinical care to ensure that families understand what is happening clinically with their loved ones. The provision of welfare, travel, support and accommodation is not provided through us as the NHS, it is provided through the RCDM, so it would be unfair of me to comment too deeply on how that is provided. Q150 Mr Jones: This morning we visited some of the flats that are made available for families to stay on site when they are visiting very seriously ill relatives. Can you just talk us through what actual support is given on site for relatives and also what the interface is? You say it is the military but one of the key things is what is the interface between yourselves as the clinicians and the actual next of kin? This morning we saw some very difficult examples where there were divided families and other things and who do you deal with as the next of kin, so I can accept it is not easy in some cases. Can you talk us through what is the impact and interface with the next of kin and what support is given to them? Dr Rosser: As I said, from our perspective the interface with the next of kin is around communicating clinical progress, prognosis, making sure people are aware of what the plans are, trying to keep people up to speed as clinical plans change because in difficult complex injuries clinical plans do change as things evolve. As I said, provision of accommodation and the other aspects of welfare are not provided through us. That accommodation is on our site but it is provided by the RCDM. Q151 Mr Havard: As I understand it, that is then partly delivered by the Defence Medical Welfare Service - another set of initials! Dr Rosser: Yes. Q152 Mr Havard: They are contracted to the MoD to do that. Dr Rosser: Correct. Q153 Mr Havard: So it is not just the charitable sector that gets involved in that activity. Dr Rosser: No. Q154 Mr Crausby: As Kevan said, we saw some good facilities this morning, we did not see them all of course, but the real issue is, is there more you could do or more you would like to do? Ms Moore: I think Selly Oak is two pints in a one pint pot and there is very limited life left in the site and in three years' time we will not be using it any more. In order to make sure that there is suitable accommodation nearby the RCDM have taken over some local flats to rent for relatives coming in. It is sub-optimal; we would like people to be on site, but in trying to make sure that there is accommodation available they have really tried hard to get accommodation nearby. Chairman: I want to move on now to media coverage of the issues that we have been discussing. Q155 Linda Gilroy: In your memorandum you are very critical of the effect of negative media coverage, and I will ask you in a moment about the effects of that. First of all, can you say how you think it came about? Ms Moore: I am afraid I have thought long and hard about that and I do not know why the negative stories were picked up in the way that they were. We have given very good news stories that some of the media have run with and we have done some world first type surgery at the hospital and we were very proud to publicise that but it was not picked up so much as some of the stories that did do the rounds. Q156 Linda Gilroy: We have your written evidence, of course, but for the purpose of this evidence session can you tell us what effect the media coverage has had and how you and the hospital as a whole, but particularly the staff involved in the wards, have been affected by it and reacted? Ms Moore: Perhaps if I tell you a comment from one of the nurses on the ward who looks after the military casualties. She said: "I don't like coming to work on Sunday morning any more because I never know what I might be going to read" as they are looking after the soldiers and what the soldiers might open up in the newspapers. We went through a period when there were a lot of sudden stories that we had no warning were coming arising in the press that staff found quite puzzling because the work they were doing and the feedback they were getting from soldiers and their families was not reflected in the articles they were reading. Q157 Linda Gilroy: So it had an impact on the staff. It was quite a sustained period that it happened over. Have you had to offer support to the staff to try and cope with that? Ms Moore: We have offered support to staff. We have offered them additional support to go in and talk to them about their experiences and I am pleased to say that the staff are so dedicated and pleased that they are looking after the military that they are still there, they are still wishing to provide the high level of service, and are viewing it as a nasty period in their lives that now, hopefully, is over. I think they are glad today that we have got the opportunity to tell you and put on record the kind of care that they have been giving. Q158 Linda Gilroy: I think my colleague is going to come on to some of the urban myths in a moment but, before we move on to that, we have received a submission from the four Birmingham MPs expressing concern because they have had good contact with you over the period that the media coverage has led to measures being taken that were driven by motives other than clinical need. They are also concerned that the desire for a military-managed ward might override proper clinical considerations. How would you respond to their concerns? Ms Moore: The most important point is the last one and I think I would say that we retain clinical responsibility for that ward and would not let anything get in the way of providing excellence of care. Our main focus has solely been to provide clinical care that saves lives, saves limbs and rebuilds and preserves as much function as possible. Neither I nor Dave, as Medical Director, would let anything get in the way of that. The MPs have been exceptionally supportive, they have visited, they have been round the wards, talked to the casualties, they do know what is going on there and they have been as puzzled as we have - as MPs you probably deal a lot more with the press than we do anyway - as to why these things happen. Q159 Linda Gilroy: Before passing over to my colleague to deal with the myths issue, can I say that we are hardened as far as media flak is concerned. Finally, can you tell us the scale of activity you had to put in place to respond to what has emerged from the media interest? Even though we are battle-hardened to these things, I must admit I was quite shocked at what you described in your memorandum. Ms Moore: Some of the things that caused most concern were people posing as relatives, posing as visitors, taking photographs on phones, phoning the critical intensive care unit saying, "This is the on-call manager, just run down the military patients". The staff have had to have their senses heightened to be aware of what is going on. We have got additional security around the place, and I do not think I should go into all that we do at the moment, but we have had to become extra-vigilant to watch out for this. We have had some excellent reporting and some excellent news stories as well, and some people have reported extremely well. I must say it is a small minority and it is disproportionate in how the press has represented it in that way. The small stories, the urban myths, have spread whereas the good stories that have been well reported have not. Q160 Linda Gilroy: In terms of press time to cope with that and arranging the visits that have flowed from all of that coverage, what would you describe that as? Ms Moore: The time taken to deal with this has been quite considerable. The senior nurse in charge of the ward at one time said she felt she was doing organised visits round the ward instead of looking after patients, and that cannot be right. Linda Gilroy: Absolutely scandalous. Q161 Mr Jones: Can I just put some specific examples to you and I would value your comments. One is from last year and two from this year in national newspapers. The first one is the Daily Telegraph, 2 October 2006, headline, "Muslim accosts injured Para in hospital". From this year, the Daily Star, 5 March, "Hero squaddie told by British hospital to strip uniform as offensive to Muslims". The last one, quite recently, Mail on Sunday, 10 June 2007, "Muslim women abuse soldiers at troops' hospital". Can you just tell us what the background to any of these stories is and what you have done to look into what actually happened? Ms Moore: I certainly can. The first one, the Muslim nurse, we looked into this and the RCDM interviewed every soldier who was a patient at the time and we looked at the nurses, we have no Muslim nurses on that ward, we have no Muslim nurses on that wing. No soldier said anything had happened to him at all in that time. The RCDM could find nothing and we could find nothing. The second one, soldier told to remove uniform because it was offensive, the soldier may have been told to remove his uniform but it is not unheard of for people in hospital to be asked to get out of their clothes and get into bed. As you will have seen from going round the hospital today, we have lots of staff in full military uniform, not just clinical uniform but full combat uniform, big boots, the lot. We have never told anyone to get out of their uniform because it is offensive, they are all over the place. On the last one, my understanding of this from talking to the soldiers is that the person concerned entered into some banter with three Asian people in the street, did not report it, somebody else saw and raised it. When the individual was asked about it himself he did not want to make an issue of this. I am told amongst young people, and it is a long time since I can remember this, that quite often banter will take place in the street between people. A lot of the soldiers say wherever they are, or the sailors in Plymouth, wherever, quite often young people will say something and most people thought it was meant in that vein. Q162 Mr Jones: Clearly, as my colleague referred to, these are urban myths but we have even had Members of Parliament standing up repeating these as though this is the reason why we should have military-only wards, for example. Have you received any direct complaints to the Trust either from patients or member of families about any of the incidents that have been highlighted in those three examples of national newspaper stories I have got here? Ms Moore: No. Dr Rosser: No. Q163 Mr Jones: None at all? Ms Moore: No. Q164 Mr Jones: Have the national newspapers contacted you to actually ask you before they print these? Ms Moore: For those that were printed, no. For one of the stories one of the newspapers did contact us, we told them it was not true and they did not run it. Another newspaper, despite being told so, continued to run it. When we have been asked for comments we have strongly denied them. In relation to some of the stories I wrote letters to the editors and they were quite long and they published a paragraph or two. In most instances we were not asked to comment. Chairman: We expect, therefore, on the front pages of these newspapers no doubt the headlines will be, "Julie Moore debunks urban myths". Linda Gilroy: Scandal! Mr Havard: Do not hold your breath! Q165 Chairman: May I say to both of you thank you very much indeed for coming to give us evidence, it has been most helpful. Once again from the Committee, representing a broad range of opinion across the country, thank you enormously for the work that you and your staff do. We would be grateful if you could pass on our thanks. Ms Moore: We would be very pleased to do so. Thank you all. Chairman: Thank you. Memoranda submitted by South Tees Hospitals NHS Trust, Peterborough and Stamford Hospitals NHS Foundation Trust and Plymouth Hospitals NHS Trust
Examination of Witnesses Witnesses: Mr Terence Lewis, Medical Director, Plymouth Hospitals NHS Trust, Mr Andrew Morris, Chief Executive, Frimley Park Hospital NHS Foundation Trust, Mr Neil Permain, Director of Operational Services, South Tees Hospitals NHS Trust, and Mrs Chris Wilkinson, Director of Nursing, Peterborough and Stamford Hospitals NHS Foundation Trust, gave evidence. Q166 Chairman: Gentlemen, and lady, welcome. If I may begin by asking you to introduce yourselves and say where you are from and what you do. Mr Lewis: My name is Terence Lewis. I am a consultant cardiothoracic surgeon and I am Medical Director of Plymouth Hospitals. I am here representing, I suppose, the opinion of Plymouth Hospitals. I separately submitted written evidence in my own right because I am a civilian consultant adviser and I sit on ASCAB. I have been involved with military medicine for a very long time. Mr Morris: Andrew Morris, Chief Exec, Frimley Park Hospital. Frimley is about five miles from Aldershot, just in case you are not familiar with the geography. Q167 Chairman: And you gave some very good care to my own family recently. Mr Morris: Thank you. Mr Permain: I am Neil Permain. I am the Operational Services Director for South Tees Trust, which is the James Cook University Hospital in Middlesbrough but also the Friarage Hospital in Northallerton. The Friarage Hospital is very close to Catterick Garrison. My responsibility in terms of military healthcare is the senior board lead for the contract with the military both on treatment and hosting of personnel. Mrs Wilkinson: Mrs Chris Wilkinson, Director of Nursing from Peterborough and Stamford Hospitals. Q168 Chairman: I wonder if you could explain briefly what sort of services you provide to Forces personnel. You do not all have to come in on this because you probably provide fairly similar services. Mr Morris: Frimley Park Hospital provides a broad range of what I would call district general hospital services to MoD personnel. We treat around 14,000 outpatient attendances for Service personnel and around 2,500 inpatients and day cases. It could be a dermatological problem, it could be someone needing a hernia operation or an orthopaedic procedure. It is a broad range of activities that you would expect to find in that group of population. Mr Permain: Similarly, district general hospitals, marginal orthopaedics, general surgery, around 1,800 inpatients and day cases during the year, and 8,000 outpatient episodes during the year. Predominantly that is from the Garrison in Catterick but also we have an orthopaedic service that takes patients from a much wider geographical area through referral from the Regional Rehabilitation Unit run by the military, so we do have a reach up to Scotland and sometimes down into the Midlands, patients in orthopaedics on the so-called fast track service particularly. Mr Lewis: We are a somewhat different organisation and, therefore, we are in a position to provide a very different kind of support for services than actually we do at the moment. We are a major tertiary service provider, one of the biggest hospitals in Western Europe under one roof, and one of only two or three trauma one units in the UK. We do not provide any trauma infrastructure to military personnel despite the fact that we are in the middle of a very considerable provider of personnel serving in the Armed Forces. We regard that as being a great pity. We provide every single service that is required for a trauma one unit under one roof. We have a helipad 50 yards from our A&E and trauma resus area and we have a fixed wing airport only half a mile away. It is particularly inappropriate that we should be having our military personnel, for instance we have a personnel from 42 Commando at the moment who is being looked after up here when actually he should be looked after by us because we have the facilities to do it, we have a very large military staff able to do that but we are not part of that side of the organisation, which I think is a great pity. Q169 Chairman: That is very interesting. Mrs Wilkinson, would you like to add anything? Mrs Wilkinson: We provide district general hospital services similar to that of my colleagues. Q170 Mr Jenkins: Mr Permain, you mentioned a "fast track service". Last week one of our witnesses made the claim that we have thousands of Servicemen languishing on NHS waiting lists, yet when we followed this up we found it not to be the case. Can you explain what you mean by a "fast track service"? Mr Permain: If I could talk about the fast track service but also the waiting time issue in general because I think it is maybe of some interest. This is a service by referral within musculoskeletal services where there is a defined period of time within which a referral would be expected and further treatment. Predominantly two military consultants in orthopaedics deal with these patients. To be honest, I would not want to be quoted on exactly what the timescales are but they are pretty short run-through timescales to be referred and then to be treated as an inpatient. There is also a system within the contract of financial recognition for accelerated treatment for Service personnel across all of the different specialties, so we track and monitor waiting times for access to first outpatient appointment and also subsequent inpatient appointment. It is a particular part of the contract that we try to accelerate that treatment as fast as possible and our times are improving. Q171 Mr Jenkins: Would you recognise what we were given as a waiting time of ten days? Mr Permain: Would I recognise that as a waiting time of ten days for inpatients or outpatients? Q172 Mr Jenkins: Inpatients. Mr Permain: I think that would not be usual. The military would like us to aim for referral within 42 days and subsequent treatment within the same time period as an inpatient. Some patients will access within ten days but that would not be the norm, no. I would say at the moment the waiting times are probably slightly shorter than NHS waiting times, although they are reducing all the time as well. Q173 Mr Jones: Can you explain what the procedure is for people accessing that service? How does that actually work in terms of the connection between the military and yourself in terms of, say, a squaddie at Catterick who needs an orthopaedic operation, for example? How does it work? Mr Permain: Service personnel will be seen by military GPs within Catterick, there is a primary care centre there, and, as I mentioned, on a wider geographical patch there are the Regional Rehabilitation Units which are run by the military. It would be a referral from a military doctor from either of those two sources. There is an administration centre run by military personnel on site at Friarage Hospital in Northallerton who will then make the administrative arrangements directly into our booking and outpatient services and inpatient services to agree a date and communicate that to Service personnel to inform them of the date and subsequent communications from the hospital in the normal way about their clinical care. Q174 Mr Jones: Is that dealt with separately from, for example, someone living in Northallerton who went to a GP? Is it a separate track or Chain of Command that it goes through? Are they dealt with differently? Mr Permain: It is separate up until the point where your appointment is made within an outpatient department and then the system is essentially through our staff within the outpatient department to when they see the patient and then subsequent inpatient correspondence will eventually fit into the same system. The initial referral and dealing with that referral and some of the administration has a dedicated service for military personnel. Q175 Chairman: Mr Lewis, can I pursue a point that you raised about somebody being inappropriately treated here when you have the speciality and the skills where you are to treat him in your MDHU. What happens if you ask Selly Oak for your patient back, as it were, and that patient asks, "Can I go to be treated by Mr Lewis, please?" and his family asks? Does any of that sort of communication take place? Mr Lewis: We do get involved in the longer term care of our local Service personnel who have been repatriated back home and have got continuing problems, and that is completely appropriate. If we were to be approached by people wanting to be transferred to us then that would be fine, we would have absolutely no problem with that. The problem is that we have a relationship now developing between the military whereby the contracting basis for work is completely separate from the business of educating and training military doctors. We have 260 Regular staff in our organisation, 250 of whom departed to Iraq with virtually no notice. If you read the Ministry of Defence briefing document that has been released today for the first time it does not even mention the fact that Plymouth exists, which is entirely inappropriate. It does not mean that our staff within the organisation, who are highly trained and very senior and carry considerable roles and responsibility within military defence services, are not exposed to any of the trauma battlefield training at all and in the long-term it will become a real difficulty for them keeping their skills alive, and it is not necessary. The way that the NHS is developing - the NHS is changing very fast - I believe that we will end up with a small number of complex multi-specialists in very large organisations and a series of district general hospitals, some of which will do surgery and have A&E departments and some of which will not. The kinds of things that trauma patients need, and we do an awful lot of trauma as the tertiary services centre for the South West Peninsula, will have to more and more be concentrated in large organisations. My feeling is that the large organisations are suitable for the care of military trauma patients and that the expertise needs to be gained by the military staff who are being trained by those organisations. Pari passu with that, I think it is inappropriate for the routine work, which is the incentive, the carrot, for organisations such as my own to want to carry on training military personnel, the work should and must go with them. In the past there has been a penalty in terms of funding but now with tariff and PDR that is not necessary, it should not be a financial risk to the Armed Forces and there needs to be concentration on Armed Forces' medicine within a smaller number of organisations which by and large are at the complex end of things. That does not mean to say that I think all services should be there. If, in fact, certain services can be entirely military as a proper critical mass in terms of people's careers and critical mass throughput, such as rehabilitation, mental health services, counselling, that kind of thing, I have no problem with that at all, but most of it is increasingly complex, it increasingly depends on interdigitating specialities and I think that services need to be rethought and fundamentally rethought. Q176 Chairman: Should there then be a smaller number of MDHUs? Mr Lewis: In my opinion, yes. I think that the MDHUs need to be concentrated, wherever possible, where there is an ethos of care and involvement in the military and where they are close to conurbations which provide those kind of people. Mr Permain: Just to give the context because the debate is moving that way, I think it is worth pointing out that at South Tees Hospitals, which includes the James Cook as a major site, we have a cardiothoracic centre and a neurosciences centre and vascular services which are provided to the sub-regions, so as a hospital equally we have very high level complex services. In terms of the relationship the military have with the centre, we do have the services. When you asked me which services we provide, at the moment we are not a direct referral centre for the military for those complex needs but we do have that capability. I thought it was worth emphasising that. Particularly on the hosting side of staff as well, that does give opportunities for staff who are working within the unit to get experience in all of those specialties. Although the general services are provided to the personnel, staff are working in all areas. In fact, in our relationship with the MDHU staff locally we have continued to increase their presence in Accident & Emergency, in ITU and in other specialist services. I just wanted to emphasise that rather than just focus on where treatment is focused at the moment in our hospital, which is in the more general areas. Q177 Chairman: Mr Morris, do you want to add anything? Mr Morris: Nothing, apart from the fact that typically 95 per cent of the referrals are all looked after within the organisation, so very few people have to go on elsewhere to get a service. Clearly there is a balance to strike between proximity of MoD personnel and where people need to go for specialist care. The majority of Service personnel around Aldershot would look to Frimley for a service, and that is literally just down the road. Q178 Chairman: Mrs Wilkinson, do you agree with Mr Lewis? Mrs Wilkinson: I think that the specialist care is very important to go wherever the clinical outcomes are going to be the best for the patients. There are different issues around where MDHUs should be hosted for the training requirements of the staff who are going to go to places of conflict. Q179 Mr Havard: Heaven forefend that I should interfere with this competition process in the health service, which I did not vote for! This is an interesting argument though because, as I understand it, in 1999 there was a competition held to have the host for the medical centre and this organisation - Birmingham - won that competition and that is why it is where it is. You seem to be suggesting in slightly different ways that that question about where the training is all concentrated in relation to this might be something that needs some form of re-evaluation and then the provision is perhaps a different level of discussion because people can be physically transferred after original assessment, as it were. What was said to us previously, as I understand it, was that Birmingham wants to be the reception centre and effectively has become that, by default or design that is what is happening, so they start by arriving in Birmingham. Mr Lewis, you seemed to be suggesting that some of them ought to arrive in Plymouth. There is a difference of opinion there, presumably, about the strategy of having the reception all in one place and the training in one place. Do I understand that correctly or are you just making a bid that you did not make in 1999? Mr Lewis: No, this is not a fashion parade at all. We have got a very large civilian following in Plymouth and we have to respond to that. We are expected to do so and we are delighted to do so as part of our ethos. We want to look after our troops, many of whom come from that part of the world, particularly the Marines and the Navy, and we expect to be part of their long-term care as well and that is one of the advantages of being looked after from the very beginning to the very end in that the acute episode is just that, an acute episode, but too many of these episodes have very long-term follow-up requirements and we would want to be part of that. Where I am coming from, having been involved with the provision of Armed Forces' medicine for a very long time, is that there needs to be a radical rethink of the relationship between the Armed Forces' medicine and the NHS. The NHS is changing dramatically fast, it is not the same as it was before. My own organisation is not the same as it was in 1999. Our consultant numbers have gone up from 98 to 315 in seven years and we have become a tertiary services engine for the South West; we were not in 1999. Things are changing very rapidly. We need to play our role within Armed Forces' healthcare and we think that our role should be changed and different from what it has become, which is at the moment a trainer of a large number of Regular military forces and a provider of lots of Reservists who come and go with increasing regularity. We get contract work in terms of orthopaedics and various things like that in relatively large numbers, although I cannot give them to you, but we are not involved in the major trauma side of things, which is an absolutely key part of what we provide to our local population. We are a very major trauma centre and we need to, and feel that we ought to, be part of that as well as just a trainer of Regular forces. Q180 Mr Jones: What are you doing differently? I know the James Cook very well because most of my constituents go there for heart specialism. I think you are saying that personnel trainers have different specialisms but what prevents you, Mr Lewis, from allowing them to get experience in terms of trauma, which you are obviously a good centre of in the South West? Mr Lewis: Nothing at all. I am not here to rubbish anybody else, not Birmingham, not any other healthcare organisation, I am here to state the situation as we perceive it in Plymouth. Q181 Mr Jones: What stops you from using those people you are training to get expertise in trauma areas and other expertise? Mr Lewis: We do not need the expertise, we have got every regional specialty that is provided except paediatric cardiac transplantation and liver transplantation. Q182 Mr Jones: You are training people, are they getting experience in trauma medicine in your Trust? Mr Lewis: They are getting a lot of experience in civilian trauma but there is a difference between civilian trauma and battle trauma. Q183 Mr Jones: That is what I am trying to get at. Mr Lewis: Our civilian consultants, and we have 80 doctors who work, the rest of the 260 or something are nursing staff, technical staff and the rest of it, our doctors are deprived from battle wound experience but they see an enormous amount of general trauma. Chairman: We are falling behind quite badly now. Kevan Jones, can you move on, please? Q184 Mr Jones: In terms of the requirements for Service medicine, can I ask you what are the challenges that Service populations put to you and what do you do to cater for them differently possibly than the ordinary civilian population? Mr Morris: I think the key challenge is accessing treatment. Most people in the Services want to get back to the job they are doing, so there is enormous pressure on us to fast track soldiers so they can go back to their barracks and Service. The contract is structured such that there is a significant incentive for us to provide faster access to outpatient services and treatment services. A lot of us are hitting points where 75 per cent of people are seen within four weeks and 90 or 100 per cent are treated within 13 weeks if they need surgery, and I think that is the key concern along with welfare support and access to our sites. If you come into Frimley for an arthroscopy for a day, a knee procedure, and you are stationed in Maidstone, having the ability to stop overnight in Aldershot and just come down the road the following morning for your day procedure is quite important. That is where we work closely with colleagues in the MoD to make that pathway as smooth as possible. We do the procedure on a day case basis, it is cheaper for the MoD and the soldier is housed in an MoD environment before coming to Frimley if he has got difficulty in getting to Frimley. Q185 Mr Havard: Given the time, we would have liked to have asked you a lot more questions but what is clear from what you have said is there are lots of questions about the benefits as well as the problems organisationally and the connections between the MoD and NHS, but that is a developing agenda. Can I ask you whether or not your Trusts, which are particular because of your relationship with the MoD, have considered becoming involved in the provision of healthcare overseas, Germany, wherever, because we have got people in a number of locations? You have not? Mr Permain: No, we have not. Mr Morris: No. Mr Lewis: You mean providing to civilian overseas patients? Q186 Mr Havard: Yes essentially at the first level. Mr Lewis: Increasingly we now get patients from all over the South of England and abroad in terms of our cardiac surgical outfit which has got amazing results. We are running businesses now and our businesses have got to deliver a surplus in order to reinvest in our organisations. We would be very short-sighted in terms of marketing not to work out what our opportunities are. The opportunities for us in the South West are fairly considerable due to where we are and access to it. We would have no problems at all, particularly for our tertiary services. Secondary services are different, we have to concentrate and realise the core responsibility for us is to provide secondary services for the 450,000, 470,000 patients of the immediate Plymouth environment and for the 1.7 million patients in Devon and Cornwall. For tertiary and specialist services, which we have a complete range of, we must look wider where we have the spare capacity but not where we do not. Mr Havard: Can I ask you a question about overseas in a different way. We are going to take some evidence from the BMA in a little while who are going to tell us there are all sorts of shortages in terms of the right sorts of people in the right place and so on, and we have TA personnel and there is a reliance on Reservists within the medical service. People get engaged in that process, we have got consultants flying on helicopters in Helmand going out and doing things, so people do get experience in all sorts of different ways for different reasons. The suggestion is that in some way or another if you get involved in this there are disincentives and you could be discriminated against or in some way be seen to be disadvantaged in terms of your medical career. What is your experience of trying to engage, because you have a lot of people involved in this way, presumably? What is your direct experience? Is that true? Q187 Chairman: I wonder if we could ask Mrs Wilkinson to start off with that because we have been keeping you too quiet. Mrs Wilkinson: Thank you. I think you are asking about military medical consultants. Q188 Mr Havard: Yes, nurses and people going in formed units or whatever. Mrs Wilkinson: The way we work with the MDHU in Peterborough is we work towards as full integration as we can so the opportunities that are available to our military colleagues are the same as those available to our NHS colleagues. We work very closely in all of the decision-making policy boards and so on, so I do not see disadvantage for opportunity within the NHS spectrum of experiences for my military colleagues. Q189 Chairman: Would anybody like to add anything to that? Mr Lewis? Mr Lewis: I do not want to be seen to be hogging this, I am sorry. I think there is a real threat there particularly in terms of the Reservist side of things. We are increasingly running ourselves as businesses and chief executives and medical directors, next or after next, are likely to be much more hard-nosed about the thing. Personally, in terms of a business I would not appoint a whole raft of Reservists if I knew they were more and more likely to disappear from our organisation. When we lost 250 - not lost, but when they disappeared - into Iraq with zero notice, we have to bear in mind what these people were and they were absolutely crucial to the organisation: they were surgeons, anaesthetists, intensivists, high technology technicians, they are in A&E, they were in orthopaedics. Losing those in an organisation such as ours has a very major effect. In addition, if you are going to bleed your Reservists as well I think that is a real danger to their appointment and you could find them being negatively considered in years to come. Not now, we are absolutely committed to the whole manoeuvre, but I want to make sure that the critical mass of the military within my organisation is correct. It has stayed the same now for nine years and we have tripled in size, so it is becoming --- Q190 Mr Jones: Mr Lewis, what is the solution to that? Mr Lewis: The solution is making a larger critical mass of military and spreading it through a smaller number of hospitals, particularly the extremely complex high-tech ones because that is the way that medicine is going to go. That does not mean to say that secondary care needs to be directed in the same direction. It would help as a financial carrot to trusts to carry on being involved in the military, but people need to be under no illusions as to how difficult is to have a very large military medical presence in a hospital because they do disappear all the time. Q191 Mr Havard: Would you see that map of five, seven, or however many it is, coterminous with the future super garrison sort of map? Mr Lewis: I do not see why not, it works perfectly well. That would allow long-term care of those patients as well. A lot of the R&D in terms of military medical care is not just about the acute episode, it is about what happens to these people in the middle and long-term. We have a very large population of such problems and we need to be in it at the beginning, the middle and the end. Q192 Linda Gilroy: Do any of you have observations about how we can address the reported shortages, particularly in areas like anaesthetics? Mr Permain: No specifics other than to link it to the last point. The practical difficulties in a hospital that you have heard from Birmingham as well of a large military contingent are about deployments and variability in staffing levels, but we have learned to adapt with that. It does legislate against whole units or predominant units covered by military staff, but maybe for anaesthetics certainly we would be able to take more military personnel and to a marginal degree in other areas as well. Because we are increasingly using James Cook as well as Northallerton we probably could take on more staff and help to develop and train those people. Not on a wholesale basis but a marginal increase is possible. There are more opportunities in the existing MDHUs to take people if there is a shortage of specialties, fine. We react to that: to ophthalmology recently we have had two requests and I think we have had two requests to anaesthetics as well and we have taken those people on board at consultant level and integrated them into the service that we provide. There are opportunities there. Chairman: Thank you very much indeed to all of you for coming to Birmingham to see us and help us with our inquiry, it has been extremely helpful and also very interesting. Thank you very much. Memorandum submitted by British Medical Association Examination of Witness Witness: Dr Brendan McKeating, Chairman, Armed Forces Committee, British Medical Association, gave evidence. Q193 Chairman: Dr McKeating, could you tell us what your role is and why you do it? Dr McKeating: That is a good question! Q194 Mr Havard: I bet there is money involved! Dr McKeating: Good afternoon. It is actually a voluntary role. My name is Dr Brendan McKeating. I am Chairman of the British Medical Association's Armed Forces Committee. Just to give you a little bit of background on myself, I served for 16 years as a Regular in the Royal Navy as a medical officer, both at sea and ashore, both in the UK and overseas, and both in secondary and primary care both in the NHS side and military hospital side of the work as well. I am a Gulf War veteran. I have now served for the last seven years as a Reservist in the Naval Reserve and recently commanded my local Royal Naval Reserve unit. I am an NHS GP full-time and a GP trainer. I am Chair of this thing called the Armed Forces Committee of the BMA. We represent the views of members of the BMA who serve in the Armed Forces, be they uniformed, Reservists or civilians as well working as CMPs, civilian medical practitioners, both GPs and consultants for the MoD. We represent their views both within the BMA itself and obviously to external bodies. Most of our work is based around providing evidence to the Armed Forces Pay Review Body and that is a lot of what we do throughout the year, but obviously we get involved in other work such as this as well. Q195 Chairman: Thank you, that is helpful, Dr McKeating. You have given us a list of a number of shortfalls in DMSD manning levels in a number of medical specialties. For example, there is a shortfall of, I think, 32 per cent in orthopaedic surgeons, 69 per cent in pathologists and 100 per cent in neurosurgery. Where do you get these figures from and what is the evidence for your figures? Dr McKeating: These figures are provided to us by the MoD, by the Defence Medical Services, so directly from the MoD themselves. Q196 Chairman: What impact are the shortfalls having on an operational basis? Dr McKeating: In terms of the operational basis, that is actually difficult to quantify. Certainly the guys who deploy around the world with the Armed Forces will give their all for their patients and they are part of the same organisation. They will look after their people to the best of their abilities, as I think we have heard. In terms of actual patient care, we have no evidence of any detriment that we are aware of to patient care on the frontline or coming back through the casualty evacuation process, but obviously what does happen is if you look at these shortfalls it is going to put a strain on certain pinch point crucial areas, such as surgeons, GPs, anaesthetists, because if you have got a small cadre of people who have been repeatedly deployed, if you look at the numbers here for deployable trained strength of general surgeons, we are looking at 12 and that puts a very heavy strain on those individuals. For a number of years we have been doing a cohort study looking at the attitudes and views of people as they move through their career with the Armed Forces and certainly this factor of turbulence and family separation is something that comes through all the time when we send out our questionnaires and I think that is where it is hitting people. The problem is as the group gets smaller the burden on these key groups who are going to repeatedly deploy gets heavier and I think that is the problem. We are asking a lot of these people. Not only do they have to meet all the requirements of their civilian colleagues, they have to be trained as GPs and consultants as per the NHS, they have to meet all the training requirements of the Royal Colleges and keep up-to-date and keep their standards going through appraisal just the same, and they also then have to be able to do that job in a military environment and they have to be safe and be able to function in the air, under the sea, on the sea and on the ground. These people are quite a national resource and the burden is falling on significant sub-groups of them repeatedly to meet the operational tempo at the moment. Q197 Chairman: I was talking to one this morning who was regularly shot at, which is an additional burden to bear, I dare say. Dr McKeating: It certainly is. As a Gulf War veteran a similar thing happened to me and it does focus the mind. Q198 Chairman: How do these shortfalls compare with the National Health Service? Dr McKeating: If the NHS was undermanned by 55 per cent for trained GPs and consultants in terms of their stated requirement it would be a very significant problem. Obviously the military have to have some flex in there, they have people doing staff jobs, people in training, various other posts, but we are looking at a very, very significant shortfall in terms of what goes on in the military. As far as I am aware, I do not think the shortfall in the NHS is anywhere near that and if you look at what has been going on recently in terms of the training of junior doctors, certainly the situation in the military is much more acute than in the NHS. Q199 Linda Gilroy: Looking ahead, some commentators suggest that there may well be almost a surplus, unbelievably, of doctors in a few years' time, domestic overproduction, so do you see this changing? Do you care to comment on the balance between having generalists available for deployment rather than specialists? Dr McKeating: I will take that in two parts. First of all, yes, I understand that if you look at the people leaving the Armed Forces' Medical Services, the doctors - these are MoD's own figures - 8.4 per cent was the resignation rate in 2004-05 and 3.8 per cent in 2005-06 and that is falling and we believe that may be lower this year. Why is that? Well, it may be due to turbulence on the outside, it may be that people are perhaps hedging their bets and waiting until things settle down in the NHS with the changes in training and structures within the NHS. In terms of the training pipeline, the military have always done relatively well. They can recruit people early on in their careers but traditionally their problem is keeping the trained product, the trained accredited GP, GP trainer and the trained accredited consultant, that has been the problem. In terms of deploying generalists, you could argue that all military surgeons have to be able to perform some general surgery and if you look at what has gone on in recent operations people are certainly extending their roles, but the way doctors have been taught and the way they are being trained, people are working in very specialist areas now. If we are going to continue to provide the high level of care that we do to people, our forces on the ground, then we are going to need to keep those specialists within the military. Q200 Chairman: Okay, so that is the problem, what is the solution? Dr McKeating: Certainly we see that there are a number of issues relating to why people go. One is turbulence and the problem is this becomes a vicious circle because if the cadre gets smaller then the burden falls more and more upon those who remain. That is one issue. Whenever we do our studies looking at how people feel and what the factors are that make them leave, it tends to come out that it is separation from family and turbulence, and also turbulence in terms of how it affects your clinical work as well being repeatedly deployed away. Certainly most hospital specialists are working within an NHS environment now, so they are working with their colleagues just the same as any other cardiologist or surgeon would do and that puts pressure on their workload. Pay is another issue. We still feel there is a differential between what people are being paid in the NHS and in the military. A few years ago we were not far off parity when a new pay scheme was brought through to military doctors, but hot on the heels of that came the new GP and NHS consultant contracts which moved the goalposts for us. Certainly in terms of the consultant cadre we feel that over a career they are probably about four per cent behind their NHS colleagues looking at introducing a system of quality rewards, such as the local clinical excellence awards that NHS consultants get, and also some sort of out-of-hours supplement that the NHS consultants get, that will add another five per cent. In terms of the GPs, overall career-wise we think there is a career earnings differential of 4.8 per cent there, looking at our figures, but that differential in the early years of when you accredit is greater. If you are looking at the first one to 12 years you are looking at somewhere between an 11 and 14 per cent pay differential between what you would earn in the NHS and what you would do in the military. Pay is not everything and people do not serve in the Armed Forces, serve their country and put themselves through what they do when they join the military for the pay, but when you approach that time in your career and you are accredited as a GP or a consultant, you may then have a partner, may have children, you are looking for more stability in your life perhaps, if you then look and you perceive there to be a pay gap as well then that is going to have an effect. The third issue is around work issues, promotion, flexibility, flexible careers, career breaks, part-time working and that sort of thing. We know this is something that when we have spoken to the Defence Medical Services Department and also to the MoD about these issues they are looking at them, but these things are crucial. If you look at who go into medical school now, 50 per cent-plus and rising are female medical students. As time goes by they will want perhaps to manage their careers differently from the traditional role that the military have seen doctors working through in the past. There may be times when they want to take career breaks and may need flexibility in their working patterns and the hours that they work. These are all issues, I think, that come together to influence people to decide to go. As I say, we know that the PDR rates, the requests for premature release, are slowing but that may be due to changes and the turbulence in the NHS at the moment with what is happening with medicine rather than what is going on in the MoD itself. Q201 Chairman: In relation to the pay thing that you have just raised, when we were in Iraq last we met a doctor who said if he left the following day he would be paid double what he was being paid in Iraq, with all the difficulties and danger there, if he went into the NHS. Is that about right? We put that figure to the Minister of State and he thought he recognised that. Dr McKeating: There are certain instances where you could do that. If you were a newly accredited GP, for instance, depending on what practice you went into, you could go out and earn a lot more. To be quite honest, military doctors are quite a marketable commodity: they are well trained, they are going to turn up on time, do the job, do what they have to do. They are a very marketable commodity. You could envisage a situation where somebody could go outside, more so in secondary care perhaps with the inclusion of private practice. Q202 Linda Gilroy: I think since that remark you have been successful in getting a reasonable settlement. It does not address everything but since a year ago there has been some improvement, even though it does not meet the whole gap. Dr McKeating: Yes, certainly we managed to narrow the gap last year but, unfortunately, this year we got the standard public sector two per cent which effectively starts to chisel back the progress we made the previous year. Those figures I quoted initially are the differentials that we believe we are still looking at after the admittedly good pay rise that the Defence Medical Services achieved last year. Q203 Mr Jenkins: They may have received a good pay rise but nothing like the GPs in the NHS got, did they, so how is a young GP going to explain to his family that he is prepared to go away and serve with the military and earn 40,000 or 50,000, but as a GP in the NHS he could bring home £120,000 a year? If you have done all the figures, can you tell us what the bill is to make sure that these people are compatible with the NHS because I would love to know so that we can pursue the MoD to see if we can bring them in line? Dr McKeating: I am sorry, I do not quite understand. Do you mean the overall costing of such a pay rise? Q204 Mr Jenkins: The bill that would bring them into line. Dr McKeating: No, we do not produce such figures for the Government. We leave it up to the Government to do that. Q205 Mr Havard: I find what you say very interesting. I was a trade union official for a number of years so I understand exactly what you are doing, you put all the factors in and you are bidding up the price, which is fair enough, that is part of your activity, and it is part of the difficulty as well as part of the solution. In the limited time I have got available, in the evidence that you have given there are two elements, this question about terms and conditions issues, as it were, and whether or not people are discriminated against in their careers, either by the fact that their training fades or they cannot do the specialism they want to do and that side of it, discrimination in the sense of over-use of them in a particular way, but also direct discrimination, particularly in relation to Reservists. You seemed to suggest, and some of the trusts were suggesting earlier on, that because of more commercial arrangements within the NHS, if you like, it was said directly, "I would not employ them because they are a drag", that sort of pressure. That was not directly what they said, I do not want to misrepresent their argument. Are people directly discriminated against and where is the evidence for that, or is the discrimination much more related to this complex complexion of different elements relating to training, pay, usage and so on? It is important. Is there a difference as well between the full-time personnel who you say are wanting to leave and the Reservists who increasingly are having to be retained and recruited to fill in the difference because of the gap? Dr McKeating: In terms of Reservists, the figure we had to April 2006 was 770 and they got 380 doctors, so they are 50 per cent undermanned in the Reserved Medical Services. If you look at the people leaving the Armed Forces it is very interesting that the study that we did showed that only one in ten who were leaving the Regulars would consider joining the Reserve Forces. They will have some Reserve commitment on leaving the Regulars but in terms of joining the Reserve Forces and volunteering for Reserve Service, in other words joining the Royal Naval Reserve or the TA or the Royal Auxiliary Air Force, only one in ten said they would do that. Q206 Mr Havard: But, as I understand your study, that was much more related to their family issues than it was any of these other issues about pay or training. Dr McKeating: Coming on to the Reservists themselves, we are getting some evidence, and certainly I know of one senior Reservist Medical Officer who feels he was very much disadvantaged by the Reserve Forces in terms of every day that he took away to do his Reserve commitment he lost time out for his pension and towards seniority and towards clinical excellence awards while he was doing that. When we were coming up to TELIC 1, the invasion of Iraq, he was spending a lot of time being involved and feels he was very much penalised by his trust for that. Q207 Chairman: Does that system remain the case? Dr McKeating: It depends on the trust. Certainly from my own experience with my own Naval Reserve unit, we have one trust locally that is very supportive of Reservists and they effectively get two weeks' paid leave a year to go and do their training to keep themselves in-date for their Reserve commitment, but we know other trusts are much less supportive. It was very interesting to hear the gentleman from Plymouth's comments. These trusts are becoming much more commercially savvy and orientated and having a Reserve commitment in the future could become something that might go against you when competing for a job. Q208 Mr Havard: So is the solution to bid up the price for the individual or is it to give a countervailing amount of money to the employer in order to avoid that problem? Dr McKeating: If you are going to have Reserve Forces you need to look after the employer as well, especially if you are going to use them. You have to make it so that first of all the individual does not lose out by volunteering to serve their country and do these things. Certainly Reservists do not do it for the money but what they do not want to do is to lose out and when people approach them and say, "I have looked at the Naval Reserve" and then find out they may have to use their holiday to meet their training commitment or lose out financially or may find they are being disadvantaged in some way, we have to look after the employer as well and make sure the employer is on board. Trusts are like different employers: some employers are very supportive and other employers are not, unfortunately. Q209 Linda Gilroy: We have heard some evidence from Service families that there can be difficulties with registering on coming back from overseas. From the point of view of your members, have you come across that at all? Dr McKeating: Do you mean registering with an NHS GP? Q210 Linda Gilroy: Yes. Dr McKeating: That is something outwith our terms of reference, so I have no information on that. I have done it myself and not had a problem, but that is anecdotal. Chairman: Dr McKeating, thank you very much indeed. Your session, as well as everybody else's session, has been fascinating and very helpful indeed. Thank you very much. |