Memorandum from the Ministry of Defence
1. This Memorandum aims to provide the House
of Commons Defence Committee (HCDC) with relevant background information
to aid their inquiry into medical care in the Armed Forces.
INTRODUCTION
2. The strategic intent of the Defence Medical
Services (DMS) is that every Serviceman and woman enjoys a level
of health that is appropriate for the tasks they are required
to perform by the Chain of Command. To that end, the DMS have
two key measurable outputs: the provision of medical support to
deployed operations (from theatre back to the UK); and the provision
of healthcare to the Armed Forces[1]
to ensure that the maximum numbers possible are "fit for
task". The DMS also provide advice to commanders to support
them in the discharge of their responsibility for the health of
their personnel. There have been many significant developments
in support of the DMS' outputs since the HCDC last reported on
the organisation in 1999. These are summarised within the sections
below.
3. The DMS are headed jointly by the Deputy
Chief of Defence Staff (Health) (DCDS(H)) and the Surgeon General
(SG). DCDS(H) is accountable for the overall outputs of the DMS,
and SG is the clinical head of the Department with responsibility
for the professional performance and development of military medicine.
They oversee the work of three separate organisations:
(a) Defence Medical Services Department (DMSD)—The
Head Office for the DMS, which provides strategic direction to
ensure coherent delivery of all medical outputs;
(b) Defence Medical Education and Training
Agency (DMETA)— A tri-service organisation that provides
secondary care personnel to meet requirements for operational
deployments. It also underpins medical support to the UK's Front
Line forces by educating and training medical personnel. The Agency
delivers annually over 300,000 man training days across 2,000
clinical courses to the single Services. DMETA has command and
control over:
(1) Ministry of Defence Hospital Units (MDHUs);
(2) The Royal Centre for Defence Medicine
(RCDM);
(3) The Defence Medical Rehabilitation Centre
(DMRC) at Headley Court;
(4) The Defence Medical Services Training
Centre (DMSTC) at Keogh Barracks;
(5) The Defence Medical Postgraduate Deanery;
and
(6) Retained military tasks at the Royal
Hospital Haslar, which is managed in partnership with Portsmouth
Hospitals NHS Trust (due to close in late 2009).
(c) Defence Dental Services (DDS)—a
tri-service organisation employing both Armed Forces and civilian
personnel, providing dental services in the UK at service establishments
and to personnel on operations.
5. DCDS(H) and SG also produce medical policy
for the three Single Services. The Royal Navy (RN), Army and Royal
Air Force (RAF) Medical Services are responsible for delivering
primary healthcare to their respective Service Commanders in Chief
and for providing the requisite medical support on operations;
PROVISION OF
MEDICAL SUPPORT
TO DEPLOYED
OPERATIONS
Meeting Operational Requirements
6. DMS personnel are currently deployed
on operations in Iraq (TELIC), Afghanistan (HERRICK) and Bosnia
and Kosovo (OCULUS), as well as supporting military training (eg
in Sierra Leone) and other standing commitments worldwide. For
example, the DMS provide uniformed personnel to meet some of the
medical manpower requirements of the medical services provided
by Commander Joint Operations (CJO) within the Permanent Joint
Operating Bases (PJOBs) (Cyprus, Gibraltar, The Falkland Islands
(FIs), Ascension Island (ASI) and the British Indian Ocean Territories
(BIOT)). The majority of the manpower requirement lies within
the PJOBs in Cyprus and Gibraltar, where both Primary and Secondary
medical care is provided, as well as primary Dental care, Environmental
Health and Community Mental Health services. Lesser requirements
exist in FIs, ASI and BIOT, where DMS services are predominantly
primary care based, utilising local Secondary Care facilities
as appropriate.
7. The DMS' medical manpower commitments
are met by utilising personnel from all three Services with RN,
Army and RAF personnel serving along-side each other. Reservists
continue to make a significant contribution to medical capability,
most importantly for deployed hospital care and in niche specialisations.
Close to 50% of the Army's deployed Secondary Care capability
has been found from the Territorial Army (TA). For example, four
TA Field Hospitals are covering a 12 month period (HERRICK 6 &
7) in Afghanistan starting in April 2007. Early indications are
that deployment as formed units is welcomed and strongly supported
by TA volunteers. In addition, early engagement with NHS employers
of TA volunteers has also had had a positive impact on the TA
deployment process.
8. To date, the DMS have met all the operational
requirements placed on them (although harmony guidelines[2]
have been broken for some cadres). In addition, whilst some manpower
shortfalls exist, the manning situation is improving and the standard
of medical care provided to Service personnel remains high. Further
details of the DMS manning situation can be found at Annex A.
Medical Operational Pathway
9. The DMS provision of medical support
on deployed operations covers treatment and casualty evacuation
from the deployed theatre back to the UK. This managed patient
care pathway ensures that patients are assessed and treated in
a timely fashion and that they receive high quality treatment
and rehabilitation, aimed at maximising functional outcome and
returning them to operational fitness, when this is clinically
possible.
10. Pre-Deployment Training. Comprehensive
military pre-deployment training of DMS personnel is conducted
prior to deployment. Pre-deployment collective medical training
is also essential as deployed field hospital manning is found
from a wide range of donor units. Mission rehearsal for hospitals
is conducted at the Army Medical Services Training Centre Strensall
(2 Med Brigade). Experience in field medical units is also provided
and personnel attend specific training courses, such as the Battlefield
Advance Trauma Life Support (BATLS) course. Secondary Care personnel,
both Regular and Reserve, are also routinely employed within the
NHS to ensure the currency of their clinical skills (further details
at paras 59-62).
11. Treatment in Theatre. The size of the
deployed force, specific mission and prevalent threats, determines
the capability and capacity of medical support provided in theatre.
In-theatre medical staff provide assessment and immediate treatment
for all casualties, whether as a result of hostile action or non-battle
illness or injury. The medical element of Incident Response Teams
(IRTs) provides the link between initial medical care and evacuation
to a hospital facility. Our Concept of Operations for delivering
the medical component of IRT is saving lives. For example, a recent
innovation on Op HERRICK has been to deploy a hospital-based consultant
forward on the IRT to recover severely injured casualties. This
hospital physician led team has become known as the Medical Emergency
Response Team (Enhanced) (MERT(E)), a step up from the Emergency
Medicine Nurse/Paramedic lead Medical Emergency Response Team
(MERT)).
12. Deployed Rehabilitation Teams also contribute
to force conservation by retaining and treating in Theatre those
who would otherwise have to be evacuated. For example, the fielding
of Deployed Rehabilitation Teams provides for the treatment and
return to duty of some patients with musculo-skeletal injuries.
The teams will also provide guidance on the most appropriate further
course of treatment, if required. Similarly, Deployed Mental Health
Teams will also treat in theatre and provide guidance on further
courses of treatment for patients with mental health conditions.
13. More detailed information on the medical
treatment facilities available to UK personnel on operations can
be found at Annex B and in the section below on mental health.
14. Evacuation of Casualties. Where casualties
have been seriously injured on operations, the usual care pathway
is for our deployed medical support to treat and stabilise the
patient's condition and then aeromedically evacuate them back
to the UK at an appropriate point in their treatment. UK strategic
Aeromedical Evacuation (AE), provided by the RAF, is widely regarded
as delivering an exceptional service. For example, the RAF are
able to transfer critically injured and ventilated patients by
using specialist teams capable of maintaining a patient's condition
when in transit. The UK has also agreed to provide strategic AE
to some coalition partners. This has been activated, when required,
as part of a multinational agreement.
15. Patients are evacuated on the basis
of clinical need. From 1 Jan 2006 to 15 April 2007, 367 UK personnel
from Afghanistan and 866 from Iraq were aeromedically evacuated
back to the UK on medical grounds (not just battle casualties).
Casualty statistics are updated regularly on the following MoD
webpages:
http://www.mod.uk/DefenceInternet/FactSheets/OperationsFactsheets/OperationsInAfghanistanBritishCasualties.htm
http://www.mod.uk/DefenceInternet/FactSheets/OperationsFactsheets/OperationsInIraqBritishCasualties.htm
16. Selly Oak Hospital. Since 2001, the
Royal Centre for Defence Medicine (RCDM), based at the University
Hospital Birmingham Foundation Trust (UHBFT), has been the main
receiving unit for military casualties evacuated from an operational
theatre. In the Birmingham area, military patients can benefit
from the concentration of five specialist hospitals (including
Selly Oak Hospital) to receive a very high standard of care. Indeed,
Selly Oak is at the leading edge in the medical care of the most
common types of injuries (eg polytrauma) our casualties sustain.
The medical needs of the Armed Forces are best served through
access to facilities and training in a busy acute care hospital
that is managing severe trauma on a daily basis. By contrast,
the last of our UK military hospitals, the Royal Hospital Haslar,
had for many years nothing like the range of medical facilities
and expertise that is found at a major trauma Trust hospital such
as Selly Oak. The clinical skills that our personnel need to deliver
excellent medical care on deployed operations would have suffered
if we had not taken steps to develop and maintain them in a busy
acute care environment. In addition, Selly Oak offers much better
links to the military airhead at Brize Norton, and a regional
civilian airport that can handle our largest aircraft within easy
reach of the receiving hospital. That is why Selly Oak Hospital
now acts as the primary receiver of our overseas casualties.
17. Wherever practicable, military patients
are allocated to one of the military consultants who work at RCDM.
However, by far the largest proportion of specialist care is provided
by NHS consultant staff, which reflects the range and capabilities
of the knowledge, skills and resources the NHS makes available
to our patients. We do, of course, appreciate the importance of
military casualties continuing to feel part of the military family,
where practical. They will obviously benefit from being treated,
where clinically feasible, in a predictable and understandable
environment, with care delivered by staff who can empathise with
patients. That is why at Selly Oak Hospital we have created a
Military Managed Ward (MMW), located within the main orthopaedic/trauma
ward at Selly Oak Hospital. The MMW reached Initial Operating
Capability just before Christmas 2006. A combined team of military
and civilian personnel provide care for military patients whose
clinical condition allows them to be nursed in this ward. Military
nursing managers work at all levels on the ward and military nursing
staff, including military nurses and military health care assistants,
are on duty on every shift. Full Operating Capability (FOC) for
the MMW will be declared once the military presence on the ward
has been assessed as having achieved sustainable increased staff
numbers, together with the skills and experience levels required
to take over fully the management of the ward from UHBFT and to
have a predominantly military nursing presence on the ward. A
works project also started on 14 May 2007 to change the layout
of the ward to produce a separate area for some military patients
whose condition allows them to be nursed together, utilising the
two bays and isolation rooms at the far end of the main orthopaedic/trauma
ward. FOC for the MMW will be achieved by summer 2007.[3]
18. The new MMW is one of several improvements
we have made to the treatment of military patients. Each military
patient in the Birmingham area now has a named military nurse
whom he or she can contact at any time on clinical and other issues.
Community psychiatric support has also increased, with two full
time Community Psychiatric Nurses now in post. A military nurse
team member visits every military patient being treated at a Birmingham
hospital three times a day. This is in addition to the welfare
support we receive under contract from the Defence Medical Welfare
Service (DMWS), which has four welfare officers based at UHBFT
who visit our patients regularly.[4]
19. Additional funding has been provided
to help meet the travel and accommodation costs of patients' families
who need to travel to Selly Oak. Accommodation available includes
seven flats, plus a number of family rooms. Some of the flats
have benefited from recent refurbishment funded by the Soldiers,
Sailors, Airmen and Families Association (SSAFA), which is helping
to provide a more suitable environment for the families of the
patients concerned. Additional transport for patients and families
is also being provided from public funds.
20. Military staff at Selly Oak hospital
are assisted by the staff of the Aeromedical Evacuation Cell,
the Military Patient Administration Cell and the Defence Medical
Welfare Services, which are all part of RCDM. The military chain
of command also works to maintain links between the individual
patient and their parent single Service unit.
21. Although Service patients are nursed
with other Service patients when this is clinically feasible,
the over-riding factor in the treatment of any patient must be
their clinical condition and need. The patient must be placed
in the most appropriate specialist environment, with associated
equipment and trained personnel who have the necessary skill sets.
22. Defence Medical Rehabilitation Centre
(DMRC) and Regional Rehabilitation Units (RRUs). MoD has made
considerable investment in rehabilitation in recent years and
now adopts a tiered approach. Selected primary care centres have
been reinforced by physiotherapists. When necessary, patients
are referred to one of 15 Regional Rehabilitation Units (RRUs)
which focus on the assessment and treatment of musculoskeletal
injuries and sports medicine and are staffed by specially trained
Doctors, Physiotherapists and Rehabilitation Instructors. Further
details on the benefits of RRUs can be found at Annex C.
23. Military patients requiring further
rehabilitation care may be referred to the Defence Medical Rehabilitation
Centre (DMRC) at Headley Court in Surrey, which is the principal
medical rehabilitation centre run by the Armed Forces. DMRC also
accepts direct admission from hospitals, and most combat casualties
are referred directly to DMRC from Selly Oak. DMRC provides both
physiotherapy and group rehabilitation for complex musculo-skeletal
injuries, plus neuro-rehabilitation for brain-injured patients.
The Complex Rehabilitation and Amputee Unit, based within DMRC,
provides high quality prosthetics and adaptations, manufactured
on site and individually tailored as necessary for the specific
patient. Priority is given to the provision of prosthetics to
enable Service personnel to resume service duties.
24. Deployed Rehabilitation Teams help to
determine the most appropriate location for a patient and, in
the UK, the Defence Rehabilitation Evaluation Coordination Cell
is improving the management of operational patients with musculo-skeletal
injuries or rehabilitation needs. This has led to improvements
in clinical outcomes and more effective return to fitness and
duty.
25. Mental Illness. It is our policy that
mental health issues should be properly recognised and appropriately
handled and that every effort should be made to reduce the stigma
associated with them. Diagnosis and treatment of mental illness
in the Armed Forces is performed by fully trained and accredited
mental health personnel. The MoD recognises mental illness as
a serious and disabling condition, but one that can be treated.
26. Measures are in place to increase awareness
of mental health at all levels and to mitigate the development
of operational stresses. These include pre-and post-deployment
briefing and the availability of support, assessment and (if required)
treatment, both during and after deployments. This is available
to all personnel, whether Regular or mobilised Reservists.
27. During a pre-deployment medical, whilst
deployed, or during the post- deployment normalisation period,
all personnel including reservists can identify themselves to
any Medical Officers or their chain of command if they believe
they are suffering from any mental health condition. The families
of returning personnel are also offered a presentation and issued
with leaflets to alert them to the possible after-effects of an
operational deployment.
28. In the deployed operational arena, commanders
and their medical staff can call upon mental health professionals
that can provide assessment and care in theatre. Theatres are
regularly visited by consultant psychiatrists who audit the service
provided by the in-theatre mental health professionals. If personnel
do need to leave the operational environment, then their care
continues either on an out or inpatient basis in the UK.
29. Following the Medical Quinquennial Review,
whose conclusions were published in 2002, our mental health services
have been re-configured in line with national best practice, meeting
the standards of the National Institute for Health and Clinical
Excellence, to provide community-based mental health care. We
do this primarily through our 15 military Departments of Community
Mental Health (DCMH) across the UK (plus satellite centres overseas),
which provide out-patient mental healthcare. The DCMH mental health
teams comprise psychiatrists, mental health nurses, clinical psychologists
and mental health social workers. The aim is to see referred individuals
at their unit medical centre and, with the patient's permission,
to engage with general practitioners and their chain of command
to help manage mental health problems identified in personnel.
A wide range of psychiatric and psychological treatments are available,
including psychological therapies, environmental adjustment and
medication, where appropriate. The Defence Mental Health Services
have particular expertise in psychological treatments for mental
health problems in general and psychological injury in particular.
30. In-patient care, when necessary, is
provided in psychiatric units belonging to the Priory Group of
Hospitals, through a central contract with MoD.[5]
Close liaison is maintained between local DCMHs and the Priory
units to ensure that all Service elements relating to inpatient
care and management are addressed. The arrangement with the Priory
Group means that the majority of patients can be treated much
closer to their parent units than was the case when we maintained
the last of our own psychiatric hospitals.
31. It should be noted that medical discharge
from the UK Armed Forces due to psychological illness is low.
As at Jan 2007, out of almost 180,000 Regular Service personnel
only about 150, or less than 0.1%, are discharged annually for
mental health reasons, whatever the cause. Of these, only 20-25
meet the criteria to be diagnosed with PTSD at discharge.
32. Reservists. Any mobilised serviceman
or woman injured when on operational deployment is entitled to
and will receive the same level of medical treatment and support,
irrespective of whether they are a member of the regular or reserve
forces. If a medical officer in-theatre assesses that a member
of the reserve forces requires treatment or rehabilitation back
in the UK, they will be treated in exactly the same way as regular
personnel. This may include treatment and rehabilitation at a
military RRU or the DMRC at Headley Court, Surrey, or—if
the problem is related to their mental health—treatment
at a military Department of Community Mental Health (DCMH) or
admission to the Priory Group.
33. When reserve personnel are demobilised,
they are given a medical assessment. During this process, if it
is identified that they are in need of hospital care they may
be referred to NHS hospitals hosting Ministry of Defence Hospital
Units (MDHUs) or the RCDM at Selly Oak Hospital. They will be
treated within military timeframes which can in some cases offer
faster access to treatment than is the case for NHS patients.
Reserve personnel will receive treatment for injuries sustained
on operation until they are deemed to have reached a steady state
of fitness. They are then demobilised, and taken through a transition
from military to NHS care, if they have continuing healthcare
needs. The patient may express a preference for treatment in a
hospital nearer to their home, which may be a non-MDHU hospital,
and some reservists opt for this route. In accordance with NHS
protocols, if they are referred on to a non-MDHU hospital, then
access to treatment is according to clinical priority.
34. Once demobilised, it is a long established
tradition that reserve forces' medical care becomes the responsibility
of their own local NHS primary care trust and the majority of
Veterans' physical and mental health needs are met by these provisions.
However, the MoD recognises that it has an expertise to offer
in certain specific circumstances, and in November 2006, it launched
a new initiative—the Reserves Mental Health Programme (RMHP).
35. The RMHP is open to any current or former
member of the UK Volunteer and Regular Reserves who has been demobilised
since 1 January 2003 following an overseas operational deployment
as a reservist, and who believes that the deployment may have
adversely affected their mental health. Under the RMHP, we liaise
with the individual's GP and offer a mental health assessment
at the Reserves Training and Mobilisation Centre in Chilwell,
Nottinghamshire. If diagnosed to have a combat-related mental
health condition, we then offer out-patient treatment via one
of the MoD's 15 DCMHs. If more acute cases present, the DMS will
assist access to NHS in-patient treatment. We are working with
the UK health authorities to ensure that GPs across the UK are
aware of the initiative. Full details of this programme, and how
to access it, are published on the following web site: www.army.mod.uk/rtmc/rmhp.htm.
36. For the wider veteran population, MoD
officials, the Health Departments, the NHS and the specialist
mental health charity Combat Stress have been working together
to develop a new community based mental health service for veterans.
Advised by national clinical experts, this service will reflect
NHS good practice and procedures and will be made up of clinical
networks. This will allow civilian and military experts from the
public and charitable sectors to work together, sharing experience
and expertise and delivering appropriate evidence-based interventions
in a culturally accessible and acceptable way. Plans are now well
advanced for the model to be piloted at sites across the UK, including
one each in Scotland and Wales. The pilots will run for two years
and will be fully evaluated ahead of wider roll out.
37. We also have work in hand to ensure
that Service leavers can recognise the signs of stress and know
where to go for help, using suitable magazine-style material.
In addition, the Government funds courses of care at Combat Stress
facilities for those veterans whose condition is due to service
and for whom this is an appropriate course. In 2005-06 this amounted
to some £2.9 million.
Further Developments in Support to Operations
38. Details of further key developments
in the provision of medical support to operations can be found
at Annex D.
PROVISION OF
HEALTHCARE TO
THE ARMED
FORCES—MAINTAINING
HEALTH
39. Members of the regular Royal Navy, Royal
Marines, Army and Royal Air Force have access to a wide range
of medical and dental services at all times when they are not
on operational deployment overseas. The range of services includes:
Primary Medical Care; Dental Services (including dental hygiene);
Secondary Medical Care in NHS hospitals; Overseas Healthcare;
Rehabilitation Services provided by DMRC and the 15 RRUs (see
paras 22-24 above) and Community and Inpatient Mental Health Services
(see paras 25-31 above).
Primary Medical Care
40. The MoD provides a range of Primary
Care Services including medical centres located throughout the
United Kingdom and Service base areas overseas. The size and "skill
mix" of each medical centre varies depending on factors such
as location and the size of the population served. The typical
medical centre provides access to General Practitioners, Practice
Nurses, Military Medical Assistants and Physiotherapists and Remedial
Instructors. Some of these personnel will be uniformed DMS personnel
and others will be civilian practitioners. The medical centres
provide medical diagnostic and treatment services similar to those
provided by a civilian medical practice, but they also provide
occupational medical services, which is a major component of their
activity. In the main, Service personnel have access to a medical
centre on their unit or barracks but in some areas where the serving
population is few in number, personnel will have access to the
medical centre of another military unit.
Dental Services including Dental Hygiene
41. The DMS provide unit- and regionally-based
dental centres in the UK and overseas base areas. These centres
operate under the command of the Defence Dental Service (DDS).
The DDS provides local access for serving personnel to Dentists,
Dental Nurses and Dental Hygienists. These specialists provide
routine diagnostic and treatment services, but also offer valuable
occupational screening services ensuring that serving members
of the Armed Forces are "dentally fit" to undertake
their role.
Secondary Medical Care in the UK
42. Service personnel are entitled to secondary
care from the NHS. In addition to local NHS access, the Ministry
of Defence provides access to secondary care services at the NHS
Trusts hosting MDHUs[6]
and at UHBFT where the RCDM is based. The MoD have agreements
with the NHS Trusts (referred to as "Host Trusts") in
these areas, to provide accelerated access for elective referrals
of Service personnel to meet operational requirements. The MDHUs
are situated in areas with dense military populations so the trusts
are ideally located to provide the required accelerated access.
43. The MoD has developed a specific musculo-skeletal
fast track programme to meet the relatively high incidence of
these disorders within the military environment. Unit-based General
Practitioners and Physiotherapists can refer personnel to Multi
Disciplinary Injury Assessment Clinics (MIAC) located at their
local RRU to seek specialist opinion and treatment of musulo-skeletal
injuries. This involves rapid access to assessment by multi-disciplinary
teams, investigations (specifically MRI scan) and treatment, which
includes physiotherapy, rehabilitation and orthopaedic surgery
when clinically indicated. The latter has been very successful,
enabling personnel to return speedily to operational fitness,
thus reducing the burden on fit personnel, and enabling the MoD
to meet its commitments. Further details on MDHUs are provided
at paras 59-62.
44. The MoD also has contracts with some
NHS Trusts and other organisations to provide specialist diagnostic,
treatment and screening services in areas such as Cardiology and
Cervical Cytology screening.
45. The Army is also responsible for the
Duke of Connaught Unit in Belfast, a diagnostic and treatment
facility providing access to secondary care services equivalent
to those at MDHUs in mainland Great Britain.
Overseas Healthcare
46. Germany and Isolated Detachments (ISODETS).
Medical support is provided by British Forces Germany Health Services
(BFGHS) which comprises a partnership between MoD; Guys and St
Thomas's; DMWS and SSAFA; and the Defence Dental Service (DDS)
who seek to provide seamless primary, community, secondary and
tertiary care. Those aspects of primary and community care currently
provided by SSAFA are in the process of being re-competed.
47. Hospital support is provided through
Guys and St Thomas's Hospital who subcontract with five German
provider hospitals. These hospitals provide a service tailored
to the requirements of UK patients and UK primary care (for example,
providing an outpatient service, an additional evening meal, enhanced
privacy and UK television). The Department of Health now funds
tertiary care in Germany, obviating the need to return patients
to the UK for this purpose.
48. BFG Health Services has also recently
assumed responsibility for medical support to ISODETS and is currently
scoping the local medical services being provided.
49. Permanent Joint Operating Bases (PJOBs).
The Permanent Joint Headquarters (PJHQ) oversees the provision
of primary, community, secondary and tertiary care for our Service
population and their families in the PJOBs.
50. Primary Healthcare in all of the PJOBs
is provided directly by PJHQ, using predominantly Service personnel.
51. Secondary Healthcare is provided locally,
by the Princess Mary's Hospital and the Royal Naval Hospital,
in Cyprus and Gibraltar respectively. A variety of local civilian
provider hospitals and UK- based NHS Hospitals are also used to
access services that cannot be provided through MoD resources.
The facilities are manned by a mixture of Service and civilian
staff, the latter generally under UKBC contracts or as part of
an arrangement with SSAFA. The DMWS also provides welfare support
to patients in Cyprus.
52. For the remaining PJOBs (FIs, ASI and
BIOT) there are no local MoD Secondary Healthcare facilities.
Secondary Healthcare is therefore provided exclusively through
either local civilian facilities or via UK-based NHS hospitals.
53. Land Overseas Bases.[7]
Primary and Secondary care is provided at LAND overseas bases
through a variety of routes, depending on the location and size
of the base. Primary care is provided by Medical Reception Stations,
Medical Centres or local GPs. Dental Services are also provided
for personnel locally. Secondary medical care is made available
by local government hospitals, private clinics/hospitals or through
referral overseas or back to the UK.
Veterans
54. When personnel leave military service
their healthcare becomes the responsibility of the NHS. That has
been the policy of successive governments since 1948.
55. War pensioners are entitled to priority
NHS treatment for accepted disablements. This arrangement has
been in place since 1953 when Ministry of Pensions hospitals were
transferred to the NHS. Priority is decided by the clinician in
charge and is based on clinical need. Regular reminders of the
provision are sent out by the NHS Executive to Trusts and clinicians.
56. War pensioners are also entitled to
free prescriptions for accepted conditions and are paid treatment
allowance (ie reimbursement of lost earnings) and travel expenses
for out-patient attendances in respect of accepted conditions.
In addition, where there are patient costs under the NHS (eg dentistry,
eye examinations or spectacles), war pensions funding is also
appropriate.
57. There remains in war pensions legislation
a discretion (Article 21of the Service Pensions Order 2006) whereby
any necessary expenses in respect of the medical surgical or rehabilitative
treatment of accepted conditions, aids and adaptations for disabled
living may be defrayed. However, no expenses can be defrayed where
treatment, aids or appliances are provided for under other legislation
of the UK. Essentially, this discretion does not therefore apply
to treatments which are the responsibility of the NHS. This power
to meet the individual costs of war pensioners undergoing "remedial
treatment" at homes run by Combat Stress is a long standing
arrangement and predates clarification of the NHS responsibility.
Medical Discharges
58. Once personnel are identified as potential
medical discharges, a comprehensive programme of resettlement
assistance is given. That resettlement assistance lasts for the
rest of the service leaver's lifetime. The programme includes
comprehensive advice on future employment and assistance in specific
training for future employment. Advice can also be obtained on
other regional matters such as schooling and housing
RELATIONSHIP WITH
THE NHS
Ministry of Defence Hospital Units (MDHUS)—Training
DMS Personnel
59. The MoD took the decision in the mid
1990s to close military hospitals and open Ministry of Defence
Hospital Units (MDHUs) within NHS hospitals after it had become
clear that our existing military hospitals did not have sufficient
patient volume or the range of military cases to develop and maintain
the skills of our medical personnel. On average, the total number
of military in-patients in hospitals across the UK is currently
only about 60-75 for all illnesses and injuries, however sustained.
Those kinds of numbers do not provide the kind of breadth of experience
that our military doctors and nurses need to stay on the cutting
edge of medical care. Neither does it make sense to bring together
in one place such a small number of patients from all across the
country.
60. At the MDHUs, Service medical personnel
are integrated throughout the host NHS Trust, enabling them to
maintain their clinical skills in an active, up-to-date environment,
while also contributing to the NHS clinical capacity. This ensures
that they retain their qualifications, allowing them to deploy
quickly to areas of conflict, providing the essential medical
support to frontline forces. Indeed, the vast majority of the
Reservist medical personnel whom we deploy to operations are NHS
employees. The training they gain in their NHS jobs is indispensable
for ensuring the quality of the frontline care they help to provide.
The role of the MDHU is to provide administrative, business and
training functionality and they enable clinical staff to concentrate
on honing their medical and military professional skills. It is
precisely because of the success of the adopted model for training
military medical personnel and providing care for our personnel
in NHS hospitals, that we can deliver our excellent levels of
medical care in the UK, overseas and on operations.
61. When the decision was taken to close
military hospitals, it was originally intended to retain the Royal
Hospital Haslar, primarily as a centre for training. But the required
number and range of cases did not occur, and in December 1998
the Government announced its decision to phase out Haslar and
consolidate training within the NHS, building on the establishment
of the MDHUs. Since then, Haslar has undoubtedly continued to
provide a first class service for the local community , but the
medical needs of the Armed Forces are best served through access
to facilities and training in a busy acute care hospital that
is managing severe trauma on a daily basis. And the fact is that
for many years Haslar has had nothing like the range of medical
facilities and expertise that are found at a major trauma Trust
hospital such as Selly Oak. In addition, Selly Oak offers much
better links to the military airhead at Brize Norton, and a regional
civilian airport that can handle our largest aircraft, within
easy reach of the receiving hospital. That is why Selly Oak Hospital
now acts as the primary receiver of overseas casualties.
62. Although it ceased to be a military
unit on March 31, the Royal Hospital Haslar continues to be owned
by the MoD and will continue to function, under a partnership
arrangement with the Portsmouth Hospitals NHS Trust, until late
2009 when clinical services, along with both NHS and some military
staff, will transfer to the redeveloped Queen Alexandra Hospital
in Cosham, Portsmouth. Other military tasks currently retained
at Haslar will be transferred to the RCDM and elsewhere. Until
the hospital's closure military doctors and nurses will continue
to serve at Haslar, many of them as part of the Portsmouth MDHU.
The MDHU will continue to play a major role for the foreseeable
future in providing training for our medical people, as well as
providing healthcare for both military and civilian patients.
There will, therefore, continue to be a strong military medical
presence in the Portsmouth area when Haslar eventually closes.
Royal Centre for Defence Medicine (RCDM)
63. RCDM opened in April 2001 as a centre
of military medical excellence, with academic, teaching and clinical
roles. RCDM, with its host UHBFT, provides a stimulating working
environment for the DMS staff and an opportunity to develop academic
ties with universities. Defence medical personnel gain valuable
work experience primarily at UHBFT's Queen Elizabeth and Selly
Oak sites (although other hospitals in the Birmingham area are
used for particular specialisms), and some work closely with the
Universities of Birmingham and Central England and with other
academic partners in research and teaching roles. Many of the
DMS Nurses and Allied Health Professionals gain their professional
qualifications through the academic courses provided at these
universities. The Defence School of Health Care Studies is a unit
of RCDM. RCDM's roles also include the provision of clinical feedback
to operational areas, the development of clinical doctrine and
the focus for curriculum design and development for clinical operational
preparedness.
64. The Surgeon General's vision for defence
medicine in the 21st Century is for RCDM to develop into an internationally
recognised centre of excellence for military medicine. This vision
is being principally implemented through the Midland Medical Accommodation
(MMA) project and the MoD's close involvement in the Birmingham
New Hospital Project.
65. The Midland Medical Accommodation (MMA)
project is currently planned to bring together on one site the
Headquarters of the Royal Centre for Defence Medicine (RCDM),
the Headquarters of the Defence Medical Education and Training
Agency (DMETA), the Defence Medical Services Training Centre,
and 33 Field Hospital. The site will also provide living accommodation
and facilities for military training and sports. Whittington Barracks,
Lichfield has been selected as the preferred option to meet the
requirement. The project is currently undergoing its Assessment
phase which should be concluded around the end of this year. A
"Main Gate" decision will then be taken on the major
capital investment that would be involved. Assuming that the Lichfield
site's suitability is confirmed, redevelopment could be completed
around the end of the decade.
66. The NHS Birmingham New Hospitals Project
will replace the existing Queen Elizabeth and Selly Oak Hospitals,
and will provide acute and mental health hospital services in
South Birmingham. It is Birmingham's first new hospital for nearly
70 years, and is scheduled for final completion in 2011. The main
partners in the project are UHBFT and Birmingham and Solihull
Mental Health Trust (BSMT). Central to the development will be
a 1,213-bed acute teaching hospital on the 50-acre Queen Elizabeth
site. There will be 30 operating theatres, as well as specialist
treatment units for angiography, CT scanners, ultrasound, MRI
scanners, and fluoroscopy. The patient care and training elements
of RCDM will form part of this main new hospital building under
long term arrangements that have been concluded between the MoD
and UHBFT. The new hospital will thus give the MoD access to some
of the best medical "state of the art" facilities in
Europe. We will take the Military Managed Ward (MMW) concept forward
in our discussions with UHBFT to confirm our footprint in Birmingham's
new hospital. Options will be examined to see how we might resource
an MMW of up to 32- bed capacity for the treatment of operational
casualties and elective patients, where these can be brought together
on clinical grounds. This would mean the ward would have military
ward managers, and patients on this ward would be nursed by predominantly
military personnel.
Partnership Board
67. The key outputs of the DMS are supported
by a close working relationship with the NHS, supported by the
MoD/Department of Health (DH) Partnership Board. A Concordat between
the DH and the MoD has been in place since 2002, which sets out
how the DMS and the NHS will work together to further their individual
and mutual aims of delivering high quality healthcare to both
the UK Armed Forces and NHS patients. The Concordat was extended
in March 2005 to include the Health Departments of Scotland, Wales
and Northern Ireland.
68. The MoD/DH Partnership Board meets three
times a year to monitor the effectiveness of the Concordat and
to explore mutual areas of co-operation. Its membership consists
of representatives from MoD, the DH, the Health Departments of
Scotland, Wales and Northern Ireland and NHS Trusts. Its work
is supported by desk level liaison on a day to day basis to ensure
the progress of Partnership board projects in between Partnership
Board meetings.
PROCESS/ORGANISATIONAL
IMPROVEMENT
The Defence Health Programme
69. The Defence Health Programme (DHP) is
the performance management tool that enables the DMS to deliver
the changes and improvements needed for it to continue to provide
Service personnel with the level of health care support necessary
to maintain their medical fitness for their operational role.
The following key strands of work are being undertaken under the
umbrella of the DHP:
(a) Director General Medical Operational
Capability (DG Med Op Cap) Project. The principal achievement
of the project to date has been the endorsement of the DMS regular
uniformed manpower baseline (see Annex A) together with a number
of recommendations for future work on manpower issues, including
the Reserves. Additionally, a project report has now been produced
which provides an assessment of the operational outputs (clinical,
organisational and equipment) required of the DMS and their associated
processes. During the same timeframe, a number of recommendations
to further improve our capability in medical logistics have been
identified.[8]
An integrated Implementation Programme is now in place to expedite
the findings and recommendations of the DG Med Op Cap project
and to take forward the recommendations of the uniformed medical
manpower requirement work and the Medical Logistic End-to-End
Review.
(b) Leadership, Management And Governance
Of The Defence Medical Services study. In parallel to the above
project, DG Med Op Cap has also been tasked with reviewing the
extent to which the DMS Top Structure is effective in delivering
the two pathways of Medical Operational Capability and Healthcare.
It has been decided that the Department will pursue the development
of a "Joint Medical Service" manned by people recruited
by the single Services to fill a joint medical manpower liability
that is globally managed. A short study (the DMS Leadership, Management
and Governance (LMG) study) is now taking place to determine how
this restructuring will be delivered. The study will recommend
the future functions, structure, leadership responsibilities and
outputs of a Joint Medical Service, which builds on the currently
agreed organisation of the DMS. The review is due to complete
in summer 2007.
(c) Managed Military Health System. The MMHS
Project was conceived within the Service Personnel plan to improve
pan-DMS management and delivery of health and healthcare (medical
and dental) to the Armed Forces and other entitled personnel.
The project was concluded in Jul 06 and follow-on work to further
develop the MMHS is now be undertaken as part of the Director
General Healthcare's routine work. The aims of the MMHS are to
maximise the number of Armed Forces personnel Fit for Task; contribute
to deployed Medical Operational Capability and improve morale
in the DMS. The MMHS scope is limited to UK non-deployed personnel.
However, many of the changes expected from it will beneficially
impact on Health and Healthcare provision across the MoD including
the overseas Commands. The project has already delivered a number
of significant improvements through the development of the Fast-Track
treatment regimes, rehabilitation and the provision of Mental
Health Services (see above). Further work is now underway to:
(1) Develop enhanced Primary Care services
(General Practitioners with Special Interests and (Advanced Nurse
Practitioners)
(2) Implement patient Care Pathway tracking
across Defence Primary Health Care
(3) Implement common processes and standards
(4) Develop Performance Management processes
and structures
(5) Expand our Healthcare capabilities and
capacities to meet need.
(6) Develop relationships with the Department
of Health and the NHS
(7) Implement connectivity between the MoD
and NHS ICT services
(8) Put in place the MoD response to the
Governments initiatives on Health.
(d) Defence Medical Information Capability
Programme (DMICP). DMICP is a major IS-enabled business change
programme. It will provide an integrated healthcare information
system across the DMS, and will also link to the NHS's major new
National Programme for IT. The roll-out of the system to pilot
UK sites started earlier this year. It should be available in
all fixed medical and dental centres in the UK and Germany by
mid-2008. DMICP will provide an integrated Health Record—including
both medical and dental data—for all members of the Armed
Forces. This will promote improved medical treatment by enabling
medical staff worldwide to have immediate access to a complete,
up to date Health Record at the point of treatment. The system
will also link electronically with the NHS from 2010, which will
bring benefits for Armed Forces patients receiving secondary care
in NHS hospitals. The programme will bring improvements to patient
management, enabling improved appointment booking for both primary
and secondary care. A deployed version of the system will be available
from late 2008 to medical staff on operations. The system will
also improve information handling, and provide a range of data
about health patterns in the Armed Forces, as well as health information
on forces about to deploy. The system has been designed with confidentiality
controls to ensure that only medical staff with a legitimate relationship
with the patient have access to a health record.
1 and other entitled personnel, eg MoD Civil Servants
serving overseas and dependents accompanying Service personnel
posted overseas. Back
2
Back
3
Military nursing staff allocated to the MMW at FOC will be: Back
4
DMWS staff also provide welfare support in Germany, Cyprus and
deployed field hospitals. Back
5
The Priory Group was awarded its current contract on 1 April
2004, when it won a competitive bidding process as its bid best
met our requirements for access to high quality, regional care. Back
6
Derriford, Frimley Park, Northallerton, Peterborough and Portsmouth. Back
7
Brunei, Nepal, Kenya, Canada and Belize. Back
8
Work carried out with Medical Stores Integrated Project Team
on Medical Logistics. Back
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