Further supplementary memorandum from
the Ministry of Defence
In the course of the Committee's visits
last month to HQ 2 Med Bde at Strensall and Redford Barracks a
number of issues were raised on which the Committee requested
further clarification. These were:
— Information on the pilot scheme
being undertaken by the Army looking at occupational health services
for the TA;
— An explanation of how primary
and secondary healthcare for the Armed Forces is funded (including
the division of responsibility between MoD and NHS);
— An explanation of the provision
of "accelerated access" to treatment from NHS trusts
hosting Ministry of Defence Hospital Units (MDHUs), and the fast
track programme to deal with musculo-skeletal injuries.
— An explanation, including
anonymous case studies, on how medical discharges, both on physical
and mental health grounds, are handled and how care is transferred
from the Defence Medical Services (DMS) to NHS;
I also thought that you might find it
useful to have a copy of the slides used during the oral briefing
on in-Service mental healthcare that you received at Redford Barracks
and some information on the processes for transferring medical
records from DMS to NHS.
OCCUPATIONAL HEALTH
SERVICES PILOT
SCHEME FOR
THE TERRITORIAL
ARMY
Currently the provision of an Occupational
Health support service to TA personnel has been delivered in an
ad hoc fashion. This has been for a number of reasons: TA personnel
have limited time; they are geographically widely dispersed; and
there are often differences in Occupational Health assessments
due to the differing Occupational Health requirements for civilian
and military employment. It was agreed that a pilot scheme should
be conducted in the Headquarters 2nd Division area (Scotland and
the North of England) to allow an opportunity to demonstrate how
the most important elements of an Occupational Health Service
(OHS) could be delivered to the TA. The objectives of the scheme
were to deliver OHS to the TA, maintain best clinical practice
and deliver efficient management of the service. It is envisaged
this would be provided by a commercial in-Service provider and
would offer an opportunity to determine the projected overall
costs of providing OHS to the TA.
The pilot scheme was initiated in July
2007 and was fully up and running by September. It will run until
April 2008 when it will be evaluated by a panel including the
Army Consultant Adviser in Occupational Medicine. It is too early
at this stage to draw any conclusions.
FUNDING OF
PRIMARY AND
SECONDARY HEALTHCARE
FOR SERVICE
PERSONNEL
In the UK:
(a) Primary Care
1. Service Personnel: The
MoD funds primary care for Service personnel. However, Service
personnel are able to access NHS primary care on an emergency
or immediate care basis. In addition, Service personnel can register
as a temporary resident with a NHS GP for up to three months should
the individual be unable to use a reasonably accessible military
facility.
2. Dependants: In the UK,
Service dependants are entitled to NHS provision of primary care
and the majority are registered with NHS GPs. In a few locations,
military GP practices in the UK register families so that the
practice can meet the criteria required of a GP training practice
(so that military GPs can attain the appropriate qualifications)
or because the military practice has spare capacity. No funding
flows from the local PCT to MoD in such cases.
(b) Secondary Care and Community Services
1. Service Personnel: All
Service personnel are entitled to access NHS secondary care and
community services. The allocation to PCTs is based on the National
Census and the MoD informs the DH if there is likely to be a significant
reduction (such as a base closure) or increase in the local Service
population. The military population is included when the calculations
take place for funding allocation from the Department of Health
to PCTs. In addition, the MoD purchases accelerated access from
certain NHS providers at additional cost in order to meet operational
requirements. Secondary care is also purchased from the independent
sector.
2. Dependants: All dependant
secondary care and community services in the UK are obtained from
the NHS. The MoD provides no funding for this care.
The funding arrangements at the MDHUs
and RCDM were determined when the initial units were established
in the mid-1990s in parallel with the closure of Service hospitals.
To avoid complex PES transfers, it was decided that the MoD would
pay for all military patients treated at the MDHU Host Trusts.
This includes both emergency and elective care, the latter being
subject to additional premiums to obtain the accelerated access
described above (and described in more detail below). .
Overseas:
MoD is responsible for providing primary,
secondary and community services to dependants and entitled civilians
as well as Service personnel.
SECONDARY CARE
"ACCELERATED ACCESS"
AND "FAST
TRACK PROGRAMME"
As a matter of definition, these two
labels are attached to two separate schemes for serving personnel.
In addition they should not be confused with the "priority
treatment" to which veterans who are War Pensioners with
qualifying conditions are entitled.
Fast Track Programme
The most common medical condition in
military patients is a musculo-skeletal disorder. Since April
2004, for patients with these conditions, we have arranged rapid
access to diagnosis and—for the minority who are then found
to need it—surgery in NHS facilities. Typically we achieve
a decision as to which path the patient will follow (either to
surgery or physio/rehab) within 10-20 days of referral to a specialist
multidisciplinary team (MIAC clinic).
Those needing only physiotherapy/ rehabilitation
treatment (the majority) are treated in MoD's own Regional Rehabilitation
Units (RRUs)—so no NHS waiting list issue arises. Typically,
these patients will start physiotherapy within 4-6 weeks of the
decision on their treatment path. If surgery is necessary (for
the minority of cases) we can and do arrange fast access to surgery
in the MDHU Host Trusts or other NHS Trusts (and in the past from
the independent sector) within 6 weeks of the decision on their
treatment path.
Accelerated Access
MoD pays the MDHU Host Trusts an additional
premium to gain accelerated access for the assessment and treatment
of Service personnel, with conditions other than musculo-skeletal
conditions, in a faster timescale than NHS standard target times.
MoD does this to meet operational requirements and maximise fitness
for task when this is clinically deliverable. The MoD's targets—aiming
for full delivery of these targets by April 2009—are 100%
to be seen as an outpatient within 4 weeks and with 100% receiving
elective treatment within a further 6 weeks if that is clinically
appropriate. Many of the MDHU Host Trusts are already delivering
a good percentage of their activity in line with these targets
as a result of our contract incentivisation programme. These targets
compare very favourably with the current NHS targets of 13 weeks
for outpatient assessment and 6 months for elective surgery, although
these figures are constantly being updated as the NHS aims for
an 18 week total package by December 2008.
How much does MoD pay for "fast-track"
and accelerated access?
In financial year 2006-07 the Ministry
of Defence paid just under £30 million for activity (outpatient
and inpatient care) from the five NHS trusts hosting MDHUs and
from University Hospital Birmingham NHS Foundation Trust (UHBFT)
which hosts RCDM. Approximately £6.5 million of this was
for emergency care. This care by definition is delivered under
NHS emergency access standards. The remainder (some £23.5
million) was used to commission care commencing sooner than current
NHS waiting times. This includes both "fast track" treatment
for those with musculo-skeletal conditions, and "accelerated
access" for those with other conditions where this is deemed
appropriate to meet the operational tempo and where it is clinically
deliverable.
We also spend just over £1 million
annually for other fast track access (for those with musculo-skeletal
conditions) outside our MDHU Host Trusts. For example,this enables
rapid access to MRI scans for the 13 Regional Rehabilitation Units
(RRUs) in the UK to enable early diagnoses.
TRANSITIONAL ARRANGEMENT
FOR SERIOUSLY
ILL SERVICE
PERSONNEL MEDICALLY
DISCHARGED FROM
THE ARMED
FORCES
The key to successful transition of the
small group of complex patients who are medically discharged from
the Armed Forces with significant illness is an individually tailored
care plan that integrates both the ongoing clinical and welfare
needs of the patient. Early engagement with the relevant civilian
services is essential.
Physically Injured
There is a social work department at
DMRC Headley Court for those that are medically discharged from
DMRC. They work closely with the single Service welfare services
and the appropriate ex-Service charities to help to ensure a seamless
transition to civilian life. We have placed a contract with the
Brain Injury Rehabilitation Trust (BIRT) which has improved the
transition for those with acquired brain injury as they provide
regional centres around the UK to continue neuro-rehabilitation
and importantly are always seeking to maximise the eventual independence
of the patient. For those that are not capable of being managed
at DMRC, the DMRC consultants have the responsibility to assess
each patient and determine the most clinically appropriate facility
for the continuation of care. The Healthcare Directorate then
attempts to place individuals in facilities as close to their
homes as possible. In all cases discussions are commenced with
the local PCT and Social Services so that they are aware of the
needs of the patient and their responsibilities once the individual
is medically discharged from the Armed Forces. Joint planning
is crucial and every attempt is made to facilitate this.
Mentally Ill
The Mental Health Social Workers (MHSWs)
play a key role in ensuring a smooth transfer of the patient from
the Armed Forces to civilian life. Once it appears likely that
an individual will require medical discharge for mental health
reasons, one of the MHSWs will be assigned to the case and work
with the patient. The MHSWs are community-based in the military
Departments of Community Mental Health.
The MHSWs provide an all-encompassing
service for vulnerable patients in their transition to civilian
life. Their responsibilities include:.
— One to one support to patients
in preparation for and understanding of Medical Boards.
— Support and advocacy regarding
local authority/private accommodation, post service.
— Information, advocacy and
support regarding the resettlement process.
— Advice and advocacy regarding
Pensions and Veterans Agency processes and decisions.
— Support and explanation to
dependants of patients regarding mental health issues.
— Visiting and social work support
to mental health in-patient, at NHS and independent service provider
locations.
— Written legal reports and
liaison for Mental Health Review Tribunals (Mart's), for detained
military patients under the Mental Health Act.
— Briefing and advocacy for
patients needing State Benefits, such as Incapacity Benefit and
Disability Living Allowance.
— Ensuring GP and NHS support
is available ongoing after the patients' discharge.
They work with the DMS consultant psychiatrists
and mental health nurses to achieve this transition.
PROVISION OF
DEFENCE MENTAL
HEALTH SERVICES
IN UK
A copy of the slides used during the
presentation the Committee received on mental health services
are attached.
TRANSFER OF
MEDICAL RECORDS
FROM DMS TO
NHS
Following routine discharge
When a member of the Armed Forces is
discharged from the Services a summary of the individual's medical
record is sent to the relevant Service manning agency. The individual
is provided with the address of the agency which they should then
give to their new civilian GP when they register for the first
time. The GP may then write to the Service manning agency, either
directly or through NHS Central Register (NHSCR), to request a
copy of the individual's medical summary. A copy of the entire
Service medical record may be obtained on application supported
by the patient's written consent.
Following medical discharge
The same procedure applies as that following
routine discharge. In addition however, the specific DMS health
team who have been caring for the individual to be medically discharged
will liaise with appropriate civilian healthcare providers (eg
General Practitioner/PCT/civil mental health team/NHS Trust) to
ensure that the transfer of care and patient history takes place.
Additionally we have specialist health social workers who manage
the individual's wider resettlement issues, liaising with relevant
civil agencies such as local housing authorities, financial authorities,
service welfare and charitable organisations; again to endeavour
that the individual's transfer into the civilian environment is
as smooth and as seamless as possible.
22 November 2007
| 
