House of Commons - Defence

Select Committee on Defence Seventh Report

4 Cooperation with the NHS

Ministry of Defence Hospital Units: secondary care and training

55. Following the closure of the military hospitals in the 1990s, the decision was taken to establish a number of military units within NHS facilities, both to provide a degree of secondary care for Armed Forces personnel, and to allow for the training and skills maintenance of military medical staff. There are currently five of these Ministry of Defence Hospital Units:

MDHU Portsmouth (Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust)
MDHU Derriford (Derriford Hospital, Plymouth Hospitals NHS Trust)
MDHU Frimley Park (Frimley Park Hospital NHS Foundation Trust)
MDHU Northallerton (Friarage Hospital, South Tees Hospitals NHS Trust)
MDHU Peterborough (Peterborough and Stamford Hospitals NHS Foundation Trust)

The MDHUs assumed most of the twin burdens of clinical care and training because there were insufficient numbers of patients and too small a range of cases to allow military medical personnel to develop and maintain the required skills.

56. MDHUs are not stand-alone units or wards. Rather, their purpose is "to provide administrative, business and training functionality", leaving clinical staff to concentrate on their medical work. Service medical personnel in MDHUs are integrated throughout the host NHS Trusts, thereby providing a double benefit: the volume and range of cases which pass through the NHS facilities allow them to develop and maintain their skills, which means that they are at full readiness for deployment when necessary. They also contribute to overall NHS capacity and capability.[34] MDHUs employ a substantial number of Reserve personnel. We examine this issue in more detail in Chapter 7.

57. A key role of MDHUs is to provide a pool of deployable personnel, and there are certain challenges in managing this. Terence Lewis, the Medical Director of Plymouth Hospitals NHS Trust, told us: "We have 260 Regular staff in our organisation, 250 of whom departed to Iraq with virtually no notice".[35] These were people who were "absolutely crucial to the organisation […] [and] losing those in an organisation such as ours has a very major effect".[36] The Health Minister told us that, while workforce planning was the responsibility of individual trusts under the guidance of their Strategic Health Authorities, the increase in the number of clinical personnel being trained would inevitably ease any problems caused by the deployment of personnel.[37] Andrew Cash, Co-Chair of the DH/MoD Partnership Board, added that workforce planning was one of the three key areas which his Board was currently examining, and it was acutely aware of the need for cooperating to manage the deployment of medical personnel.[38] We are satisfied that the MoD and the Department of Health are aware of the management problems which the deployment of personnel from MDHUs poses for the Trusts in which they are based and that they are working in a coordinated way to minimise these problems.

58. The General Medical Council (GMC) attested that the training provided in MDHUs was as good as that in the NHS. It explained that the training posts "are fully integrated into foundation training, carry full educational approval and deliver the required competencies of the Foundation Training Programme".[39]

59. While the training role which MDHUs play is important, they also provide considerable clinical care for the Armed Forces. The Health Minister told us that around 65% of Service personnel received elective treatment in MDHUs as opposed to in mainstream NHS facilities. However, we heard concerns that, while MDHUs offer swift access to high-quality care for Service personnel, some had to travel considerable distances to receive that treatment.[40] The Surgeon-General told us that the MoD attempted to balance clinical need against local access to healthcare.[41]

60. The Department of Health's memorandum explained that, where appropriate military healthcare was not available, Service personnel based in the UK were entitled to the full use of NHS facilities on the same basis as civilians, while personnel based abroad were similarly entitled to NHS secondary care if they returned for treatment. The provision of this care was the responsibility of Primary Care Trusts.[42]

61. The principle which underlies MDHUs is a sound one. We believe that embedding DMS personnel in NHS trusts to work side by side with civilian clinicians is the best way to develop and maintain their skills, as well as providing an opportunity for Servicemen and women to be treated in a semi-military environment. We were impressed by the MDHUs which we visited and are satisfied that they deliver high-quality care to military and civilian patients.

62. One of the aims of integrating Service medical personnel was said to be the exchange of skills and best practice between military and civilian clinicians.[43] However, when we visited the headquarters of 2 Medical Brigade at Strensall in Yorkshire, we were told that some of the trauma care which Service medical personnel provide in operational theatres was far in advance of that which the NHS could offer. In particular, we were told that the time from point of trauma to treatment was very much shorter in Afghanistan and Iraq than was the norm in the NHS. This suggested that there was more work to be done in terms of sharing best practice. The Health Minister, Ben Bradshaw, admitted that best practice was "not as widespread as it should be". He added that the Department of Health was considering putting more explicit advice in the annual operating framework about the need to encourage Reservists, which would assist the "cross-fertilisation of cultures".[44] The MoD and the Department of Health should address the sharing of best practice as a matter of urgency. More structured exchange of skills and techniques is in the interests of the NHS and Service personnel. We also consider it probable that the MoD, when working alongside forces from other countries, will learn lessons from differing approaches adopted by those other countries which could usefully be shared with the NHS. We expect the response to this report to explain in detail what steps will be taken to encourage this.

63. Some of us visited four of the five MDHUs. One striking characteristic of some of the units we visited was a strong single Service ethos, despite the notional tri-Service nature of MDHUs. Indeed, they were on one occasion described to us in explicitly single-Service terms: Derriford and Portsmouth being Royal Navy, Frimley Park and Northallerton being Army and Peterborough being RAF. The Deputy Chief of the Defence Staff (Health) explained that this was due to historic connections with specific Service communities.[45] We appreciate the strength of Service loyalties and the power of traditional connections, but we suggest that more needs to be done to ensure that MDHUs are representative of a genuinely tri-Service DMS.

'Fast track' treatment in the NHS

64. The MoD told us that there was a distinction between 'fast track programming' and 'accelerated access'. The latter refers to the treatment which Service personnel receive in MDHUs, for which the MoD pays the host trusts. However, there is also a system of 'fast track programming', under which Service personnel can receive fast access to treatment (generally for musculo-skeletal disorders) over and above the arrangements with MDHUs. This treatment can be in the MDHU host Trusts, in other NHS Trusts or in the independent sector.[46] This distinction between 'fast track programming' and 'accelerated access' was not at first explained clearly and it took prolonged examination to discover the full details. The priority in the treatment of injured Service personnel must be to return them as quickly as possible to operational effectiveness, so it is sensible for the DMS to use whatever mechanism delivers this objective most efficiently. The MoD should express more clearly the arrangements for 'fast track programming', and we are concerned that they are not fully or properly understood by all parties involved.

The devolved administrations

65. The MoD has responsibility for Service personnel across the UK but must cooperate with a number of jurisdictions to access civilian medical services. While the relationship between the MoD and the Department of Health seems to be a good one, the situation in Scotland seems to be less satisfactory, judging by the evidence we took from officials from the Scottish Executive in October 2007. Health ministers from the devolved administrations signed up to the concordat between the MoD and the Department of Health, and, as there is no MDHU in Scotland, the MoD deals with individual health boards when it is necessary for Service personnel to receive clinical care.[47]

66. The structure of the NHS in Scotland differs substantially from that in England. Since April 2004, healthcare provision has been the responsibility of 14 geographically-based NHS Boards and a number of Special Health Boards. Hospitals not managed by Special Health Boards are managed by, and GPs contracted in by, the local NHS Board. Provision of community health care and most mental health care is also the responsibility of local Boards.

67. We asked officials from the Scottish Executive about cooperation with the MoD on a variety of issues: giving help to Service families returning from overseas postings, the provision of mental health care for veterans, the transfer of medical records for those leaving the Armed Forces, the employment and conditions of Reserve personnel. On too many of these issues, the response was one of confusion, incomprehension or ignorance. On the subject of Service families returning from overseas and registering with a GP, for example, an official said:

Any family coming into a community has an entitlement to register with a general practice in their area, so there is no difference there. I suppose it is the local intelligence of knowing where to go, if you like, when the family gets back.[48]

On the subject of dentists, she added:

There is an obligation on the health boards to provide a general medical practitioner for every citizen whereas there is not for an NHS dentist. I have no knowledge of whether Service families have particular difficulties over and above the rest of the population.[49]

68. Overall, there was too much reliance on guidance issues to health Boards, and when we pressed officials on monitoring the implementation of this guidance, we were told:

We have not got a measure that would enable us to do that. I guess our major measure of these kinds of issues would be are we getting a lot of complaints about them, and we are not […] it is impossible to monitor how every bit of guidance that goes out is implemented […] some of this is about the actual clinical interaction between a GP or a practice nurse or a frontline clinician and a veteran, and unless you are sitting on top of that interaction it is an extremely difficult thing to measure.[50]

69. Our visit to Scotland left us deeply concerned. It is unreasonable to expect any administration, whether in Whitehall or one of the devolved assemblies, to micromanage the agencies which execute its policies. But depending on guidance and taking a laissez faire approach to making sure that such guidance is implemented is totally inadequate, and reinforces our view that the issues confronting Service personnel and their families are not sufficiently high up the list of priorities for the Scottish Executive.

70. We accept that plurality is an inevitable outcome of the devolution settlement. However, we are concerned that the provision of some aspects of healthcare in Scotland, for Service personnel and their families, is not always given the priority it deserves because of poor cooperation and communication. The MoD must review the structures through which it engages with other departments and administrations, and explain how it intends to improve the situation. We also expect the Scottish Executive to review its arrangements in response to our report.

34 Ev 96 Back

35 Q 175 Back

36 Q 189 Back

37 Q 475 (Mr Bradshaw) Back

38 Q 475 (Mr Cash) Back

39 Ev 105 Back

40 Q 56 Back

41 Q 428 Back

42 Ev 135 Back

43 For example, Ev 85-86 Back

44 Q 438 Back

45 Q 425 (Lieutenant-General Baxter) Back