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
- MDHU Portsmouth (Queen Alexandra
Hospital, Portsmouth Hospitals NHS Trust)
- MDHU Derriford (Derriford Hospital, Plymouth
Hospitals NHS Trust)
- MDHU Frimley Park (Frimley Park Hospital NHS
- 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.
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".
These were people who were "absolutely crucial to the organisation
] [and] losing those in an organisation such as ours has
a very major effect".
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.
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.
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".
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.
The Surgeon-General told us that the MoD attempted to balance
clinical need against local access to healthcare.
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.
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.
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".
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.
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.
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
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.
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
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.
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.
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
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
Q 175 Back
Q 189 Back
Q 475 (Mr Bradshaw) Back
Q 475 (Mr Cash) Back
Ev 105 Back
Q 56 Back
Q 428 Back
Ev 135 Back
For example, Ev 85-86 Back
Q 438 Back
Q 425 (Lieutenant-General Baxter) Back
Ev 144 Back
Qq 265-68, Qq 280-81 Back
Q 308 Back
Q 309 Back
Qq 296, 298 Back