5 Care for veterans and Service families
Priority access for veterans
71. Medical care for ex-Service personnel is the
responsibility of the NHS. However, since 1948, there has been
an entitlement to priority access for war pensioners to treatment
for conditions relating to their service.[51]
On 23 November 2007, the Government announced that this priority
access would be extended to all veterans for conditions which
were believed to derive from service. This followed a pilot project
run by Hull Primary Care Trust, and the Health Minister estimated
that it would extend priority access from around 170,000 veterans
across the UK to a figure in the region of 5,000,000.[52]
72. Just as important as priority access to treatment
for veterans is ensuring that those who are eligible are aware
of their entitlement and how to benefit from it. Andrew Cash,
Co-Chair of the DH/MoD Partnership Board, said that this was a
two-part process: personnel would be informed of their entitlement
while in the Armed Forces, while the arrangements would also be
explained in the operating framework issued to PCTs and to general
practitioners.[53]
73. The new system will, therefore, rely on self-identification
by veterans, some of whom may be reluctant to make their status
known. This seems to present a fundamental problem. Even assuming
the seamless transfer of medical records (which we consider in
paragraphs 77-79 below), a clinician will not automatically have
any way of knowing that a patient has served in the Armed Forces,
let alone that his or her condition may be related to the period
of service. This is all the more problematic given that some conditions
can show symptoms months or years after the patient has left the
Armed Forces (particularly in relation to mental health, which
we consider in Chapter 6 below).
74. In response to these criticisms, the Surgeon-General
counselled caution. He told us that:
Not all veterans want it to be known that they are
veterans, so we just need to be careful about being too proactive
in some cases. An individual who has left the Armed Forces, in
some cases, not many but in some cases, may wish that severance
to be complete, and we need to be very careful about being too
proactive and overriding an individual's wish.[54]
75. We
welcome the Government's extension of the priority access available
to veterans in England. However, the MoD must explain clearly
what it is doing in conjunction with the devolved administrations
to ensure that this entitlement extends across the UK. It should
also give a clear definition of who qualifies as a veteran and
is therefore entitled to this treatment.
76. We also
acknowledge that the implementation of the policy will present
some challenges in terms of privacy. However, the MoD and the
Department of Health need to do much more to make sure that the
entitlement to priority access is widely understood and taken
up by those who need it. We do not believe that there is currently
a sufficiently robust system for tracking veterans in the NHS,
and we expect the MoD's response to this report will set out the
Government's thinking on how this could be improved. Simply to
rely on the individual to bring his or her status as a veteran
to the attention of a clinician, given some of the conditions
which are common among ex-Service personnel, is inadequate and
an abdication of responsibility. We believe that an automatic
tracking system with an 'opt-out' provision would balance the
need for robustness with the protection of individuals' privacy.
Transfer of records
77. An issue which goes hand in hand with priority
treatment for veterans is the transfer of medical records from
the military to the civilian clinician. The system as it was explained
to us is that those leaving the Armed Forces, after having a medical
examination, are given a summary of their medical history to present
to a civilian general practitioner upon registering. The GP can
then, if necessary, request the full medical records of his or
her patient from the MoD, relating to the period of service in
the Armed Forces.[55]
The Health Minister also claimed that the transfer of the summary
would become automatic under the NHS National Programme for IT
when the NHS and MoD computer systems were integrated.[56]
The Surgeon-General added that he did not think the system was
ineffective, as there was currently no backlog of requests from
GPs for military medical records.[57]
78. The system remains essentially reactive. It is
the responsibility of the individual veteran to present the GP
with a summary medical report, and the responsibility of the GP
to request the full records if necessary. We heard anecdotal evidence
from Service personnel that the procedures do not always operate
as they should, that records are not transferred, are not fully
disclosed, and are not always accepted by clinicians, for example
when needed for insurance policies. Commodore Elliott, Chief Executive
of Combat Stress, put the problem plainly:
The procedures for medical discharge involve handing
the patient across to the National Health Service, and the medical
records go with the patient into the NHS. All too frequently the
problem is that the Services do not know where that patient will
end up. He has nowhere to go. A lot of servicemen who are being
discharged will not contact their local GPs and all the services
that they should connect up to until they are in trouble, and
therein lies a huge problem.[58]
79. We
remain concerned that medical records do not transfer as seamlessly
from the Armed Forces to civilian life as they could. Too much
is left to the initiative of the patient, and on our visits we
heard that the existing system often works imperfectly. We recommend
that the MoD re-examine its procedures with regard to medical
records and examine ways in which there could be an automatic
transfer of records and a more effective safety net for those
who, for whatever reason, do not take the initiative in transferring
or requesting records. We also ask the MoD to give us an update
on the progress of its IT system, the compatibility with the NHS
National Programme for IT, and its anticipated schedule for implementation
of the new system.
Wider implications
80. The care of veterans is important not just in
terms of making sure that first-class healthcare is available
swiftly and easily to those who have served the country. It has
a wider impact on the perception of Service life, both in terms
of Service personnel and their families, and in terms of the community
at large. We have already expressed concern over the issue of
recruitment and retention of personnel by the Armed Forces.[59]
We believe
that providing first-class healthcare for veterans, and making
sure that people have confidence that they will be able to access
and will receive such treatment, is an integral part of the debt
which society owes to those who serve in the Armed Forces, and,
as such, has an impact on recruitment and retention.
Service families overseas
81. The MoD is responsible for the delivery of healthcare
to Service families posted abroad. It is provided in a number
of different ways. In Germany, British Forces Germany Healthcare
Services (BFGHS) is a partnership between the MoD, Guy's and St
Thomas' NHS Foundation Trust, the Defence Medical Welfare Service,
SSAFA Forces Help and the Defence Dental Service which provides
"seamless primary, community, secondary and tertiary care".
Hospital facilities are the responsibility of Guy's and St Thomas',
which subcontracts with five German provider hospitals. In the
Permanent Joint Operating Bases (PJOBs) at Cyprus and Gibraltar,
primary healthcare is provided by PJHQ, using primarily Service
personnel, while secondary care is provided by The Princess Mary
Hospital (Cyprus) and the Royal Naval Hospital (Gibraltar). There
are also contracts with some local healthcare providers and UK-based
NHS hospitals to provide access to services which MoD resources
cannot supply.[60]
82. SSAFA Forces Help, which is involved in providing
some healthcare services for families abroad, observed that the
standard of care offered was "generally very satisfactory
and indeed in most cases excellent". However, it warned that
the substantial increases in funding for the NHS had not been
matched by the MoD in terms of funding healthcare abroad: the
NHS budget had risen by 5% a year since 2002, while the MoD's
expenditure had risen by only 2%. Given that it was necessary
to pay military clinicians comparable salaries to those of civilian
staff, the funding gap was exacerbated.[61]
The Minister accepted that the MoD had not been able to match
the rate of increase in expenditure enjoyed by the NHS. He told
us in November that it was a subject of ongoing discussions with
the Treasury.[62]
83. We acknowledge
that Service families posted overseas generally receive very good
healthcare through sensible partnership arrangements. We are glad
that the MoD accepts that its spending has lagged behind that
of the NHS. It is essential that medical care for our Service
personnel posted overseas should keep pace in every way with the
NHS, so that they are not penalised for joining the Armed Forces.
84. Another issue which is under review is the continuing
existence of stand-alone hospitals for Service communities overseas
in Cyprus and Gibraltar. When we visited The Princess Mary Hospital
at RAF Akrotiri in November 2006, we saw a facility which was
clinically of a very high standard, but which was serving a population
of a size so small that the facility was underused and overstaffed.
However, it was not possible to outsource the provision of all
services to local providers. Equally, it was reliant on visiting
clinicians or locums from the UK for some services. This made
clinical continuity and the maintenance of skills difficult.
85. We doubt
if the establishments in Cyprus and Gibraltar are clinically or
financially viable in the long term. The MoD should make clear
how it intends to address this problem and what options are being
explored for maintaining healthcare provision for Service communities
in a more effective and efficient manner. It should also set out
a timetable for tackling this issue.
Service families in the UK
86. One of the major issues for Service personnel
and families returning from overseas postings is making the transition
from a situation in which the MoD provides healthcare, to a situation
in the UK in which families (though not Servicemen and women)
are entirely reliant on local NHS services. Particular concerns
have included the process of registration with NHS general practitioners
and dentists (pressure on the latter is particularly acute, as
has been reported widely in the media), and the management of
expectations when transferring from one regime to the other.
87. The problem of dentistry in particular was put
to us by Sammie Crane of the Army Families Federation. She identified
two aspects of this problem. The first was that Service families
move so regularly that it could be very difficult to get to the
top of a waiting list for an NHS dentist, while such lists are
non-transferable. The second, anecdotal, issue was that families
in which both parents are Service personnel, and whose dentistry
needs are taken care of by the MoD, often found that dental practices
would not register children unless one parent was also registered
with that practice.[63]
88. There appeared to be an acute lack of support
for families in Scotland making the transition from postings abroad
to those in the UK. The Scottish Executive told us that "these
are really matters for the MoD", and demonstrated no substantial
awareness of the problems which Service families faced.[64]
Asked whether more could be done to ease the transition, one official
responded, "I suppose they [the MoD] could give them an information
pack".[65] The impression
was created that Service families would have no more information
and support in getting access to healthcare after prolonged absence
overseas than any other sector of the population.
89. We acknowledge
that the healthcare of Service families in the UK is the responsibility
of the NHS. However, the MoD has a part to play, and should be
doing more to support Service families during the transition from
overseas postings to reliance on NHS healthcare. There should
be better cooperation between the MoD and health departments across
the UK. The Scottish Executive also has a responsibility to improve
its procedures in this regard. Providing this sort of support
is a vital part of maintaining morale among Service personnel
themselves and their families, which has such a profound effect
on the retention of experienced Servicemen and women.
51 Ev 95 Back
52
Q 373 Back
53
Q 385 Back
54
Q 390 Back
55
Q 389 Back
56
Q 387 Back
57
Q 390 Back
58
Q 85 Back
59
Defence Committee, Fifth Report of Session 2007-08, Ministry
of Defence Annual Report and Accounts 2006-07, HC 61 Back
60
Ev 95 Back
61
Ev 112 Back
62
Qq 467-69 Back
63
Q 57 Back
64
Q 312 Back
65
Q 311 Back
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