Memorandum from the British Armed Forces
1. This Memorandum is submitted
on behalf of the British Armed Forces Federation, an independent,
representative staff association formed in December 2006 for serving
members of the armed forces. Former members of the forces may
also join. Members are drawn from all three services, including
the reserves, with no restrictions as to rank.
2. BAFF's membership includes
serving and retired Defence Medical Services staff, and at least
one member who has experienced the casualty evacuation chain from
operations in Afghanistan.
3. Recent media stories about
alleged deficiencies in forces medical care have been deplored
as "bad for morale". We agree, but real deficiencies
could be worse. Confidence is not increased by denying deficiencies
when they are first raised in the media, only for remedial action
to be announced much later, rendering the original criticisms
"out of date". A case in point is that of helicopter
availability for battlefield casualty evacuation in Afghanistan.
4. We therefore warmly welcome
the opportunity afforded by the Defence Committee's Inquiry to
establish the facts in an impartial cross-party setting. We have
played our part in helping to publicise the Inquiry and to encourage
individuals to participate in the Committee's online forum.
5. BAFF seeks not to turn
the clock back to the previous network of Military Hospitals,
but argues that the present system requires more attention and
investment before it fully comes up to the claims made for it.
Anything less than world-class medical services for our country's
armed forces will damage recruitment, retention and operational
efficiency. We welcome improvements which have been made. We also
draw attention to a number of concerns relating to the after-care
of discharged personnel, especially in the area of mental health.
6. It is, of course, the norm
for advanced countries to maintain dedicated military hospitals
for their armed forces. The former Naval Hospitals, British Military
Hospitals, and RAF Hospitals had much to commend them, and criticisms
of them by those seeking to justify the present arrangements have
sometimes been exaggerated. An updated, streamlined system of
military hospitals is theoretically feasible, although the investment
required for a fresh start would be daunting.
7. Some military hospitals
were able to treat non-military patients from service families
or, in some places, from the local community. This widened the
clinical experience of staff as well as, arguably, increasing
value for money for the taxpayer. It has been suggested that a
restored system of military hospitals could treat ex-service people
("veterans") as well as serving members of the armed
forces. We do not, however, consider that there is a realistic
case for our UK veterans to be treated separately from other non-serving
patients, with the exception of treatment for service-related
psychiatric disorders, discussed further in this Memorandum.
8. We recognise the premise
underlying the present arrangements that the more patients who
are treated in any particular clinical specialisation, the better
the average outcome is likely to be. In any type of hospital whether
military, NHS or private there will always be some sub-optimal
patient outcomes, for whatever reason. While we have no figures,
we suggest that the standard of treatment provided to UK military
patients is high, and that many of the reported problems relate
to inadequate patient management rather than to clinical deficiencies.
Nevertheless, poor management of a patient can have a very harmful
effect on the psychological outcome of their physical injury.
9. The need for a strong military
presence within, or dedicated to liaison with, the NHS is paramount.
This is achieved at the MDHUs, and to an extent at RCDM, but is
more difficult in non-MDHU NHS facilities.
10. The Military Administrative
Officer (Civil Hospitals) ["MAO(CH)"] concept is good,
but is severely under-resourced. These individuals have to track
all Service personnel in NHS hospitals across the UK, and in addition
need to engage with Primary Health Care trusts to track Service
personnel under non-military GP care. Without a properly co-ordinated
and mutually understood system in this area, any military input
to (or even knowledge of) after-care is impossible. Again, the
essential occupational aspect of the Service patient is missed,
as civilian GPs (and indeed hospital practitioners) are unaware
of the specific stresses placed on Service personnel.
11. The NHS is not an occupational
service. It is not interested in getting people back to work,
but in getting them out of hospital beds. For Service personnel
this has a particular disadvantage. Civilian patients are discharged
to the care of their NHS GP, and to their home environment. The
Service patient may be a single individual living in barrack accommodation,
and his "family" (including in some instances his Service
GP) may be away on an operational tourso there may be no
real supervision of this individual.
12. Military medical records
remain a problem area. Part of the problem relates to the need
for records for Service personnel on posting to be transferred
manually at present; speeding up the introduction of DMICP (Defence
Medical Information Capability Programme) will undoubtedly assist
in this. However, the complexities involved in this should suggest
avoiding too rapid an approach, lest the technical necessities
are overtaken by user unfamiliarity. Continuity of care may also
be challenged by the frequent move of Service personnel, including,
of course, the medical personnel who look after them, and the
requirement for medical personnel to be removed from their "peacetime"
locations for operational tours. Too great a reliance on civilian
medical staff (either employed by the MoD or contracted to the
NHS) removes the essential occupational medicine input to the
militaryan input which is needed to maintain their individual
health and the operational effectiveness of the Defence Forces.
13. There must be no repetition
of the widespread "disappearance" of inoculation dose
records for personnel who served on Operation Granby (Gulf 1990-91),
which remains a source of understandable concern to both serving
and retired personnel.
14. Albeit from a small sample,
BAFF has received favourable reports of the standard of medical
care provided in operational theatres. In-theatre and strategic
casualty evacuation should be reviewed. Our comments here concentrate
on the after-care of operational casualties.
15. In addition to the after-care
of sick and injured who are returned from operations but are still
members of the Forces, we also attach importance to the continuing
after-care of those who have left the Service whether voluntarily,
16. In respect of physical
injuries, the Defence interest in post-discharge after-care is
transitional. For example, a patient who leaves the Service while
on the waiting list for an operation, and returns to his or her
home area, may well find themselves back at the bottom of the
waiting list. There are also record-transfer issues.
17. From a purely medical
perspective, the treatment and support of an amputee may be little
different whether the injury occurred on the battlefield, or in
a motorcycle accident. Service-related psychiatric disorders such
as PTSD demand a more tailored approach, however.
18. The crucial point is the
properly worked out, contractually agreed and mutually workable
interface with the NHS. The limitations of the existing contractual
arrangements (under the "Concordat") need to be recognised,
and managed for the future. The NHS may not be equipped to deal
with specific problems of military service, such as PTSD.
19. The MAO(CH) system is
not only under-resourced, it is single-service. The recent introduction
of Sickness Absence Management has helped, but there remains a
need for a tri-service system. In many cases lines of communication
and protocols between hospitals and patients' units are insufficiently
defined, leading to duplication of effort. A combination of charities,
senior officers' wives and unit personnel may descend upon the
patient and however welcome they may be, confusion can sometimes
20. Whilst we understand that
PTSD may typically present within six months of the traumatic
event, this may not be the case with service patients, for two
reasons. Firstly, the military PTSD-sufferer may have experienced
repeated events, having a cumulative effect which may not be apparent
until some further event brings the problems to the surface much
later. Secondly, serving members of the armed forces are supported
by feelings of comradeship and esprit de corps, and may succeed
in coping with their trauma while still in uniform; they may,
indeed, successfully conceal their problems for a time for reasons
of machismo and, even, the real fear of damaging or losing their
21. We welcomed the MoD announcement
on 11 June, 2007 to extend the Medical Assessment Programme (MAP)
to allow more former Service personnel to seek "professional
advice" on mental illnesses which they feel are linked to
their time in the Armed Forces. Apparently the "advice"
will, however, only comprise screening. So as not to deter eligible
individuals from seeking screening under the MAP, we would welcome
an assurance that the results may not be used in relation to any
pension or compensation issue without the consent of the patient.
22. We are also awareas
many NHS practitioners clearly are notof the tri-Service
Reserves Mental Health Programme (RHMP) established at Chilwell.
This facility needs to be publicised much more effectively.
23. Eligibility under the
RHMP is currently restricted to those reservists who have been
demobilised from an operational theatre since January 2003. Eligibility
under the MAP is restricted to those veterans who have served
since 1982. Both of these date restrictions are arbitrary and
unjustifiable, and we would urge the MoD to remove them.
24. Whilst ex-forces sufferers
from mental health problems must not be directed away from the
NHS if that is the treatment they prefer, NHS psychiatric services
may not in some cases be the best source of treatment. Ex-forces
PTSD sufferers have, on occasion, been asked not to continue NHS
group therapy because their recounted experiences were upsetting
the other patients.
25. Every veteran suffering
from mental health issues linked to their past service should
be eligible for whatever treatment they need either directly under
Defence arrangements, or from Combat Stress (Ex-Services Mental
Welfare Society) with adequate MoD funding.
26. We note the comprehensive
arrangements in Canada for treatment of "Operational Stress
Injury" both for serving personnel, and for veterans. British
personnel and their families are given helpful information sheets
on issues which might arise after an operational tour, but these
sheets may be easily lost or discarded. In Canada, the information
remains readily available to veterans and their families by various
means, including the internet.
PRIORITY NHS TREATMENT
27. War pensioners and equivalent
are supposed to be entitled to "priority NHS treatment"
for the condition for which their pension was awarded. There are
two problems with this provision. Firstly, many NHS staff are
unaware of it, and it seems likely that awareness will diminish
as time goes on. Secondly, priority "is a matter for clinical
judgement based on clinical need which means that the case with
the greatest clinical need will receive precedence" (MoD
2007). Since the prime criterion is clinical need, and NHS staff
are also required to apply numerous targets none of which include
"care for veterans", the priority entitlement appears
in reality to be virtually meaningless.
18 June 2007