Memorandum from the Department of Health
1. The Department of Health
is pleased to have this opportunity to provide a Memorandum to
the Defence Select Committee and to reaffirm our commitment to
ensuring that the Armed Forces, veterans, and their families have
access to high quality health services.
2. For clarity, this Memorandum
relates to the Department of Health and the NHS in England only.
NHS services in Scotland, Wales and Northern Ireland are the responsibility
of the Devolved Administrations.
3. This Memorandum covers:
— NHS responsibilities for the
Armed Forces, reservists, veterans and their families;
— working together to provide
modern and effective clinical support;
— Department of Health/Ministry
of Defence (MoD) working relationship; and
— working together in practice.
NHS RESPONSIBILITIES
FOR THE
ARMED FORCES,
VETERANS AND
THEIR FAMILIES
4. The NHS provides a universal
health service for all, based on clinical need, and centred on
the needs of the patient. The NHS provides primary, secondary
and tertiary services, through NHS Trusts, new NHS Foundation
Trusts and other providers such as GPs and dentists. The NHS is
responsible for healthcare for service families (although there
are special additional arrangements for families abroad) and for
veterans, and works in partnership with the Defence Medical Services
(DMS) to provide health services for the armed forces.
5. Much healthcare for the
Armed Forces, including primary healthcare and healthcare during
operations, is provided through the DMS, as detailed by the Memorandum
provided by the MoD. Upon mobilisation, reservists become the
responsibility of the MoD and go through the same pathways as
regular service personnel. When they are demobilised, they again
become the responsibility of the NHS.
Healthcare for the armed forces
6. Health Service Guidance
covers the treatment of service personnel in NHS hospitals and
the continuing medical care of service personnel on retirement
or discharge from the Armed Forces. The same Guidance also covers
the use of DMS personnel in NHS Trusts.
7. The Guidance sets out a
series of underpinning principles. These are that:
— the treatment of service personnel
should, as far as is appropriate, align with NHS arrangements
for the treatment of civilian;
— MoD is able to secure higher
levels of access where required for operational reasons from any
NHS Trust or other provider as appropriate, in return for enhanced
payments;
— NHS improved performance will
also benefit healthcare for service personnel, and hence operational
effectiveness;
— DMS personnel working at Medical
Defence Hospital Units (MDHUs) or other NHS Trusts should be fully
integrated into the host NHS Trust; and
— host NHS Trusts should not
be financially disadvantaged as a result of hosting employment
of DMS personnel or of provision of treatment.
8. Responsibilities are as
follows. In primary care, members of the armed forces should be
removed from GP practice lists when they enlist (as required by
NHS Regulations), and should not be able to register whilst they
are serving. During this time, the MoD is responsible for their
primary medical services through the DMS. However, where a member
of the armed forces does not have ready access to DMS (eg when
on leave), they can join the list of a local GP practice as a
temporary resident.
9. In relation to secondary
care, members of the armed forces based in the UK are entitled
to the full use of NHS facilities on the same basis as civilians
if appropriate military healthcare provision is not available.
Equally, members of the armed forces serving overseas are also
entitled to full use of NHS secondary care facilities without
charge, should they return to England for their treatment. Primary
Care Trusts (PCTs) are responsible for securing the provision
of secondary care treatment for such personnel in the UK, ie they
must make sure that services are available for them if they are
not accessing military healthcare provision. The MoD is responsible
for the provision and/or commissioning of healthcare to entitled
personnel in the majority of places where service personnel are
stationed abroad.
10. In addition to normal
NHS responsibilities, the DMS contracts with the NHS to provide
secondary care facilities for forces based in the UK. It has specific
contracts with 6 NHS/NHS Foundation Trusts. MDHUs have been established
within the following:
— Plymouth Hospitals NHS Trust.
— Frimley Park Hospital NHS
Foundation Trust.
— Peterborough and Stamford
Hospitals NHS Foundation Trust.
— Portsmouth Hospitals NHS Turst.
— South Tees Hospitals NHS Trust.
— The Royal Centre for Defence
Medicine at the University Hospital Birmingham NHS Foundation
Trust—(UHBFT). UHBFT is often referred to as Selly Oak Hospital.
This is one of the hospitals in the UHBFT and the location of
the main poly trauma ward where the majority of those service
personnel medically evacuated back to the UK from Iraq and Afghanistan
are located.
11. At the MDHUs, the MoD
have agreements with the NHS Trusts to provide accelerated access
for elective referrals of service personnel to meet operational
requirements. There are also single contracts between the DMS
and particular Trusts when needed. More details are given in the
Memorandum provided by the MoD.
12. There were unfortunate
media stories of alleged ill treatment received by military patients
at Selly Oak Hospital, Birmingham earlier this year. As a high
performing NHS Foundation Trust, UHBFT has publicly denied many
of the allegations and has addressed these with the Committee
in its written and oral evidence. The Department of Health shares
the view of the Committee in recognising the important work that
is done at Selly Oak. The Department is proud of the high quality
of clinical care provided by the staff working at the hospital
and wishes to extend its thanks to the clinical and management
teams involved. The Department also recognises and endorses the
move to establish a military-managed ward at Selly Oak, to provide
an environment that is appropriate and welcomed by service personnel,
with high quality clinical support on hand.
Continuing medical care of service personnel on
retirement, demobilisation (in the case of reserves) or discharge
from the Armed Forces
13. The NHS is responsible
for the medical care of service personnel on leaving the Armed
Forces provided the individual is entitled to residency in the
UK. It is the responsibility of the individual to register with
a general medical practice. The vast majority of personnel leave
the Services fully fit or with minor ailments only. For the small
number of service personnel who leave the forces with a serious
illness, any outstanding or on-going care will usually have been
arranged prior to discharge. For the small group of service personnel
who have a significant and debilitating illness or condition at
the time of medical discharge, the aim is to reach agreement on
future care pathways prior to the discharge from the armed services.
This is enabled through early contact between the MoD and the
PCT of future residence. We recognise that we need to keep working
closely with the MoD to ensure that these "best practice"
arrangements are operating well in practice.
14. Guidance also covers Priority
Treatment for War Pensioners (HSG (97)31). These guidelines state
that NHS hospitals should give priority to war pensioners, both
as out-patients and in-patients, for examination or treatment
which relates to the condition or conditions for which they receive
a pension or received a gratuity (unless there is an emergency
case or another case demands clinical priority). These priority
treatment guidelines do not apply for unrelated conditions. The
Department takes regular opportunities to bring these guidelines
to the attention of the NHS. The Chief Medical Officer is planning
to provide an update for GPs shortly.
15. War pensioners and veterans
in receipt of armed forces compensation are also entitled to other
benefits, if they are related to the relevant disability. These
include free NHS prescriptions, NHS wigs and fabric supports at
the point of treatment and the ability to claim money back for
dental treatment, costs of travelling for clinical care, sight
tests, glasses or contact lenses.
16. War pensioners can use
the NHS complaints system to resolve any alleged breakdowns in
the arrangements for priority treatment. This includes ultimately
asking the Health Services Commissioner to investigate their case.
The families of service personnel
17. The families of UK armed
forces members can—and would normally—remain registered
with GP practices although they are able to access primary care
from the DMS when overseas. They will access all NHS services
on the same basis as any other UK citizen.
18. The particular pressures
placed on families who may move around the UK on a more frequent
basis than the general population are recognised. These should
not, though, create any disadvantage in terms of access to NHS
services. Usual arrangements are explained here. Again, this is
an area where the Department of Health works closely with MoD
to ensure that these arrangements work well in practice.
19. For primary care services,
families access local services in the same way as anyone else
and, in particular, register with local GPs.
20. Particular concern has
been expressed about access to primary care dentistry by service
families. Action is under way to improve access to dental services
in England generally, following major reforms introduced from
April 2006 and significant increases in investment in NHS dental
services. Since 2003/04, the Government has increased annual investment
by around £400 million (before taking into account annual
pay increases). Overall expenditure in 2005/06 (including revenue
from patient charges) was around £2.1 billion. At present,
around 56% of the population of England receive NHS dental care
at least once within a 24-month period—this compares with
an historic peak of around 60% registration levels at a time when
there were no significant reported problems of access to services.
21. New legislation (Primary
Care Trust Dental Services Directions 2006) places a duty on PCTs
for the first time to provide or commission primary care dental
services to meet reasonable needs in their area. Most PCTs now
have helplines to direct patients to practices with capacity to
take on new NHS patients in their area. These helplines are well-placed
to help service families to find NHS services in any particular
area. It would also be possible for the MoD to make contact with
the PCTs to discuss arrangements for providing dental and other
care in preparation for service family moves.
22. There has also been some
concern expressed about frequent moves making it more difficult
to access secondary care services. Access to secondary care services
has been improving for the whole population. Since 1997, the number
of patients waiting more than 6 months for hospital treatment
has fallen from over 283,000 to 312 at the end of June 2007. The
number waiting over 3 months has fallen from over 570,000 to under
100,000. Waiting times have been reduced. Outpatient appointments—including
those for fertility problems—are covered by NHS targets.
The wait between a GP referral and the appointment should not
exceed 13 weeks.
23. The Department of Health
recognises that any NHS patient may have to move during courses
of treatment. The Department recommends as good practice that
when the original hospital sends patients to another hospital
for treatment, both Trusts communicate with each other regarding
the patient transfer. This enables the receiving hospital to take
into account the length of time the patient had already waited
at the original hospital. This would of course apply to service
families.
24. This general approach
would apply to fertility/IVF patients who move while they are
on a waiting list or during treatment. Department of Health advice
is that there should be discussion between clinicians and PCTs,
so that an appropriate arrangement can be made for a patient who
is moving. For service personnel or their family, the transfer
should be agreed in advance between the two Trusts involved, the
waiting time should not be reset and there should be no penalty.
NHS local funding and commissioning arrangements
25. Funding arrangements and
guidance on commissioning services for local populations provide
the framework for PCTs to meet the needs of service personnel
and their families.
26. In England, PCTs are responsible
for funding the healthcare provision of all patients registered
with GPs in practices forming the PCT. PCTs are also responsible
for residents within their geographical boundaries who are not
registered with a GP.
27. The Department of Health
provides funding to PCTs to meet these responsibilities. Revenue
allocations are made to PCTs on the basis of the relative needs
of their populations, to enable them to commission similar levels
of health services for populations in similar need. A weighted
capitation formula is used to determine each PCT's target share
of available resources. The components of this formula include
the size of the population for which PCTs are responsible, their
relative need (age and additional need) for healthcare, and unavoidable
geographical differences in the cost of providing healthcare (known
as the market forces factor).
28. With regard to the armed
forces, service personnel are included in the secondary care elements
and PCT revenue allocations, and excluded from the primary care
elements, as these services are provided by the DMS. UK Armed
Forces" dependents and former service personnel are included
in all elements of PCT revenue allocations, as of course the PCT
is responsible for their healthcare.
29. From April 2008, it is
expected that legislation and underpinning guidance will put in
place strengthened mechanisms for the needs of service populations
to be fully considered and taken into account in planning at local
level. New legislation (the Local Government and Public Involvement
in Health Bill 2007) clarifies the duty on NHS bodies, including
NHS Trusts (including PCTs) and NHS Foundation Trusts, to involve
and consult local populations on the planning of provision of
services and the development and consideration of significant
proposals for change. In areas with service populations, the Armed
Forces community would be able to become involved in these consultation
exercises to ensure that their concerns and needs were recognised.
Further, a new duty is also placed on NHS Trusts and NHS Foundations
Trusts to work with Local Authorities in determining local improvement
priorities. These will be determined through Joint Strategic Needs
Assessments. The needs of specific groups, such as service populations,
which are relevant in particular local areas should be taken into
account through this process. It is hoped that this Bill will
receive Royal Assent in October 2007. We believe that this is
important legislation which could be beneficial in providing new
routes for the needs of the community to be recognised and addressed.
WORKING TOGETHER
TO PROVIDE
MODERN AND
EFFECTIVE CLINICAL
SUPPORT
30. The NHS is fully committed
to playing its part in supporting the UK's Armed Forces by working
in partnership to ensure that the Armed Forces has a well-trained
and deployable operational healthcare capability.
31. The NHS does this through
a number of means:
— putting in place arrangements
within NHS organisations, both those which host MHDUs and others,
to ensure that DMS personnel have access to training opportunities
and to maintain and improve their clinical skills through working
in NHS organisations, while being able to be released to support
deployed operations and exercises when required;
— encouraging civilian healthcare
personnel to join the Volunteer Reserve Force (VRF)—for
example, East Midlands Strategic Health Authority (SHA) is encouraging
their healthcare graduates to include the Armed Forces in their
career options and is promoting this idea with the other SHAs—or
to support defence medical requirements in other ways, providing
important additional operational capability for the DMS; and
— loan and secondment arrangements
to the DMS of NHS personnel to fill civilian medical management
appointments in the DMS.
32. These are mutually beneficial
arrangements. The NHS benefits from this through enriching professional
and personal development opportunities for the NHS workforce;
making good use of the skills of DMS clinicians to meet NHS requirements
when not on deployed operations and exercises; and working closely
with the DMS to share expertise in relevant clinical areas, for
example trauma and rehabilitation. Experience in the VRF is seen
as a good opportunity for professional development.
33. Department of Health officials
are discussing with MoD ways in which NHS staff can be encouraged
to join the VRF. These discussions will also include consideration
of whether there is scope for cooperation over improving career
options for healthcare graduates.
WORKING RELATIONSHIP
BETWEEN DEPARTMENT
OF HEALTH/MOD
Department of Health and MoD Concordat
34. A Concordat between the
Department of Health and the MoD has been in place since 2002.
This sets out how the DMS, the Department of Health 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. The Concordat is an enabling document. It is designed
to leave the detailed decisions about service delivery to be made
locally by those who know and understand the delivery of local
healthcare services, and those who understand the needs and best
interests of the Armed Forces and their families. The Concordat
sets out a partnership approach, which enables the DMS to work
together with their colleagues in the Department of Health and
the NHS in planning and organising the delivery of defence medical
goals.
Partnership Board
35. The MoD/Department of
Health Partnership Board meets three times a year to discuss at
a strategic level areas of mutual interest and to identify areas
for future co-operation. The Board is co-chaired by senior officials
in Department of Health and MoD and its membership includes officials
from the MoD, the Department of Health (including a Regional Director
for Public Health), the Health Departments of Scotland, Wales
and Northern Ireland, two NHS Foundation Trusts and a PCT. Its
work is supported within the Department of Health and MoD at official
level through an Executive Team that is charged with ensuring
that operational and other issues are progressed as appropriate
and to ensure the progress of Partnership board projects in between
Partnership Board meetings.
36. Over the past year, the
Board has discussed and agreed ways ahead on a number of key issues
impacting on treatment of military personnel, their families and
veterans, for example on full connectivity between the National
Programme for Information Technology (NPfIT) and the DMS systems
and on access to dental services for the dependants of armed forces
personnel in the UK. It has also agreed a range of specific developments,
for example, the introduction of shadowing between the DMS and
Strategic Health Authorities and the NHS and the introduction
of an awards scheme for those caring for armed forces personnel.
The Board is in the process of developing a further joint strategy
supported by a detailed work programme.
WORKING TOGETHER
IN PRACTICE
37. The formal guidance issued
and governance procedures operated by the Department of Health
and the MoD ensure good joint working and the ability to tackle
problems as they arise and to take forward work programmes on
areas of joint concern. What matters though is what happens in
practice and we wish to take this opportunity to highlight some
areas where the Department of Health and MoD have worked together.
Mental health programmes
38. Mental health is an issue
of concern for service personnel, veterans and reservists. The
Department of Health and MoD are working together, and with Combat
Stress, to ensure that good quality and appropriate services are
available for those who need them. The aim is to bring Combat
Stress services into alignment with current best practice and
to achieve greater integration with the NHS services to allow
appropriate and speedy referral for those who need it.
39. As part of this process,
and linked to a wider project to improve NHS capacity to deal
with significant levels of civilian trauma, we are jointly developing
pilots based in NHS Trusts. These will provide an enhanced mental
health service to veterans by providing dedicated staff time both
to provide specialist assessment and intervention to individuals
and advice and support to primary care practitioners. The MoD
has provided some pump priming resource to move this forward and
two pilots are almost ready to go live with another two being
developed.
Healthcare Commission
40. The Healthcare Commission
does not currently have a role in relation to the DMS. In order
for the DMS to benefit from the type of assessments carried out
by the Commission, the Department of Health, MoD and the Commission
are currently considering the options for a one-off review of
the DMS.
Smoking cessation and legislation
41. At policy level, joint
working arrangements have resulted in programmes to reduce the
effects of smoking in the armed forces. The Department of Health
and MoD have worked closely over many years on ensuring smoking
cessation programmes are provided to service personnel. The issue
of second-hand smoke has also been taken seriously, and the MoD
have comprehensive smoke-free policies in place that replicate
the protection provided to the wider population through the smoke-free
provisions in the Health Act 2006 (in England) and in smoke-free
legislation that is in place in other parts of the United Kingdom.
Sharing Expertise
42. There is also significant
sharing of expertise. For example, recently, the Associate Chief
Medical Officer at the Department of Health accompanied the Surgeon
General to Afghanistan to advise on the improvement of the Afghan
Healthcare system.
MOVING FORWARD
43. The Department of Health
is committed to building on the current good working relationship
to continue to improve support to the Armed Forces, in terms of
ensuring the availability of a well-trained clinical workforce
and ensuring that service personnel, veterans and their families
receive the services they need.
14 September 2007
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