Examination of Witnesses (Questions
21 JUNE 2007
Q180 Mr Jones: What are you doing
differently? I know the James Cook very well because most of my
constituents go there for heart specialism. I think you are saying
that personnel trainers have different specialisms but what prevents
you, Mr Lewis, from allowing them to get experience in terms of
trauma, which you are obviously a good centre of in the South
Mr Lewis: Nothing at all. I am
not here to rubbish anybody else, not Birmingham, not any other
healthcare organisation, I am here to state the situation as we
perceive it in Plymouth.
Q181 Mr Jones: What stops you from
using those people you are training to get expertise in trauma
areas and other expertise?
Mr Lewis: We do not need the expertise,
we have got every regional specialty that is provided except paediatric
cardiac transplantation and liver transplantation.
Q182 Mr Jones: You are training people,
are they getting experience in trauma medicine in your Trust?
Mr Lewis: They are getting a lot
of experience in civilian trauma but there is a difference between
civilian trauma and battle trauma.
Q183 Mr Jones: That is what I am
trying to get at.
Mr Lewis: Our civilian consultants,
and we have 80 doctors who work, the rest of the 260 or something
are nursing staff, technical staff and the rest of it, our doctors
are deprived from battle wound experience but they see an enormous
amount of general trauma.
Chairman: We are falling behind quite
badly now. Kevan Jones, can you move on, please?
Q184 Mr Jones: In terms of the requirements
for Service medicine, can I ask you what are the challenges that
Service populations put to you and what do you do to cater for
them differently possibly than the ordinary civilian population?
Mr Morris: I think the key challenge
is accessing treatment. Most people in the Services want to get
back to the job they are doing, so there is enormous pressure
on us to fast track soldiers so they can go back to their barracks
and Service. The contract is structured such that there is a significant
incentive for us to provide faster access to outpatient services
and treatment services. A lot of us are hitting points where 75
per cent of people are seen within four weeks and 90 or 100 per
cent are treated within 13 weeks if they need surgery, and I think
that is the key concern along with welfare support and access
to our sites. If you come into Frimley for an arthroscopy for
a day, a knee procedure, and you are stationed in Maidstone, having
the ability to stop overnight in Aldershot and just come down
the road the following morning for your day procedure is quite
important. That is where we work closely with colleagues in the
MoD to make that pathway as smooth as possible. We do the procedure
on a day case basis, it is cheaper for the MoD and the soldier
is housed in an MoD environment before coming to Frimley if he
has got difficulty in getting to Frimley.
Q185 Mr Havard: Given the time, we
would have liked to have asked you a lot more questions but what
is clear from what you have said is there are lots of questions
about the benefits as well as the problems organisationally and
the connections between the MoD and NHS, but that is a developing
agenda. Can I ask you whether or not your Trusts, which are particular
because of your relationship with the MoD, have considered becoming
involved in the provision of healthcare overseas, Germany, wherever,
because we have got people in a number of locations? You have
Mr Permain: No, we have not.
Mr Morris: No.
Mr Lewis: You mean providing to
civilian overseas patients?
Q186 Mr Havard: Yes essentially at
the first level.
Mr Lewis: Increasingly we now
get patients from all over the South of England and abroad in
terms of our cardiac surgical outfit which has got amazing results.
We are running businesses now and our businesses have got to deliver
a surplus in order to reinvest in our organisations. We would
be very short-sighted in terms of marketing not to work out what
our opportunities are. The opportunities for us in the South West
are fairly considerable due to where we are and access to it.
We would have no problems at all, particularly for our tertiary
services. Secondary services are different, we have to concentrate
and realise the core responsibility for us is to provide secondary
services for the 450,000, 470,000 patients of the immediate Plymouth
environment and for the 1.7 million patients in Devon and Cornwall.
For tertiary and specialist services, which we have a complete
range of, we must look wider where we have the spare capacity
but not where we do not.
Mr Havard: Can I ask you a question about
overseas in a different way. We are going to take some evidence
from the BMA in a little while who are going to tell us there
are all sorts of shortages in terms of the right sorts of people
in the right place and so on, and we have TA personnel and there
is a reliance on Reservists within the medical service. People
get engaged in that process, we have got consultants flying on
helicopters in Helmand going out and doing things, so people do
get experience in all sorts of different ways for different reasons.
The suggestion is that in some way or another if you get involved
in this there are disincentives and you could be discriminated
against or in some way be seen to be disadvantaged in terms of
your medical career. What is your experience of trying to engage,
because you have a lot of people involved in this way, presumably?
What is your direct experience? Is that true?
Q187 Chairman: I wonder if we could
ask Mrs Wilkinson to start off with that because we have been
keeping you too quiet.
Mrs Wilkinson: Thank you. I think
you are asking about military medical consultants.
Q188 Mr Havard: Yes, nurses and people
going in formed units or whatever.
Mrs Wilkinson: The way we work
with the MDHU in Peterborough is we work towards as full integration
as we can so the opportunities that are available to our military
colleagues are the same as those available to our NHS colleagues.
We work very closely in all of the decision-making policy boards
and so on, so I do not see disadvantage for opportunity within
the NHS spectrum of experiences for my military colleagues.
Q189 Chairman: Would anybody like
to add anything to that? Mr Lewis?
Mr Lewis: I do not want to be
seen to be hogging this, I am sorry. I think there is a real threat
there particularly in terms of the Reservist side of things. We
are increasingly running ourselves as businesses and chief executives
and medical directors, next or after next, are likely to be much
more hard-nosed about the thing. Personally, in terms of a business
I would not appoint a whole raft of Reservists if I knew they
were more and more likely to disappear from our organisation.
When we lost 250not lost, but when they disappearedinto
Iraq with zero notice, we have to bear in mind what these people
were and they were absolutely crucial to the organisation: they
were surgeons, anaesthetists, intensivists, high technology technicians,
they are in A&E, they were in orthopaedics. Losing those in
an organisation such as ours has a very major effect. In addition,
if you are going to bleed your Reservists as well I think that
is a real danger to their appointment and you could find them
being negatively considered in years to come. Not now, we are
absolutely committed to the whole manoeuvre, but I want to make
sure that the critical mass of the military within my organisation
is correct. It has stayed the same now for nine years and we have
tripled in size, so it is becoming
Q190 Mr Jones: Mr Lewis, what is
the solution to that?
Mr Lewis: The solution is making
a larger critical mass of military and spreading it through a
smaller number of hospitals, particularly the extremely complex
high-tech ones because that is the way that medicine is going
to go. That does not mean to say that secondary care needs to
be directed in the same direction. It would help as a financial
carrot to trusts to carry on being involved in the military, but
people need to be under no illusions as to how difficult is to
have a very large military medical presence in a hospital because
they do disappear all the time.
Q191 Mr Havard: Would you see that
map of five, seven, or however many it is, coterminous with the
future super garrison sort of map?
Mr Lewis: I do not see why not,
it works perfectly well. That would allow long-term care of those
patients as well. A lot of the R&D in terms of military medical
care is not just about the acute episode, it is about what happens
to these people in the middle and long-term. We have a very large
population of such problems and we need to be in it at the beginning,
the middle and the end.
Q192 Linda Gilroy: Do any of you
have observations about how we can address the reported shortages,
particularly in areas like anaesthetics?
Mr Permain: No specifics other
than to link it to the last point. The practical difficulties
in a hospital that you have heard from Birmingham as well of a
large military contingent are about deployments and variability
in staffing levels, but we have learned to adapt with that. It
does legislate against whole units or predominant units covered
by military staff, but maybe for anaesthetics certainly we would
be able to take more military personnel and to a marginal degree
in other areas as well. Because we are increasingly using James
Cook as well as Northallerton we probably could take on more staff
and help to develop and train those people. Not on a wholesale
basis but a marginal increase is possible. There are more opportunities
in the existing MDHUs to take people if there is a shortage of
specialties, fine. We react to that: to ophthalmology recently
we have had two requests and I think we have had two requests
to anaesthetics as well and we have taken those people on board
at consultant level and integrated them into the service that
we provide. There are opportunities there.
Chairman: Thank you very much indeed
to all of you for coming to Birmingham to see us and help us with
our inquiry, it has been extremely helpful and also very interesting.
Thank you very much.
Witness: Dr Brendan
McKeating, Chairman, Armed Forces Committee,
British Medical Association, gave evidence.
Q193 Chairman: Dr McKeating, could you
tell us what your role is and why you do it?
21 JUNE 2007 DR
Dr McKeating: Good afternoon.
It is actually a voluntary role. My name is Dr Brendan McKeating.
I am Chairman of the British Medical Association's Armed Forces
Committee. Just to give you a little bit of background on myself,
I served for 16 years as a Regular in the Royal Navy as a medical
officer, both at sea and ashore, both in the UK and overseas,
and both in secondary and primary care both in the NHS side and
military hospital side of the work as well. I am a Gulf War veteran.
I have now served for the last seven years as a Reservist in the
Naval Reserve and recently commanded my local Royal Naval Reserve
unit. I am an NHS GP full-time and a GP trainer. I am Chair of
this thing called the Armed Forces Committee of the BMA. We represent
the views of members of the BMA who serve in the Armed Forces,
be they uniformed, Reservists or civilians as well working as
CMPs, civilian medical practitioners, both GPs and consultants
for the MoD. We represent their views both within the BMA itself
and obviously to external bodies. Most of our work is based around
providing evidence to the Armed Forces Pay Review Body and that
is a lot of what we do throughout the year, but obviously we get
involved in other work such as this as well.
Q194 Chairman: Thank you, that is
helpful, Dr McKeating. You have given us a list of a number of
shortfalls in DMSD manning levels in a number of medical specialties.
For example, there is a shortfall of, I think, 32 per cent in
orthopaedic surgeons, 69 per cent in pathologists and 100 per
cent in neurosurgery. Where do you get these figures from and
what is the evidence for your figures?
Dr McKeating: These figures are
provided to us by the MoD, by the Defence Medical Services, so
directly from the MoD themselves.
Q195 Chairman: What impact are the
shortfalls having on an operational basis?
Dr McKeating: In terms of the
operational basis, that is actually difficult to quantify. Certainly
the guys who deploy around the world with the Armed Forces will
give their all for their patients and they are part of the same
organisation. They will look after their people to the best of
their abilities, as I think we have heard. In terms of actual
patient care, we have no evidence of any detriment that we are
aware of to patient care on the frontline or coming back through
the casualty evacuation process, but obviously what does happen
is if you look at these shortfalls it is going to put a strain
on certain pinch point crucial areas, such as surgeons, GPs, anaesthetists,
because if you have got a small cadre of people who have been
repeatedly deployed, if you look at the numbers here for deployable
trained strength of general surgeons, we are looking at 12 and
that puts a very heavy strain on those individuals. For a number
of years we have been doing a cohort study looking at the attitudes
and views of people as they move through their career with the
Armed Forces and certainly this factor of turbulence and family
separation is something that comes through all the time when we
send out our questionnaires and I think that is where it is hitting
people. The problem is as the group gets smaller the burden on
these key groups who are going to repeatedly deploy gets heavier
and I think that is the problem. We are asking a lot of these
people. Not only do they have to meet all the requirements of
their civilian colleagues, they have to be trained as GPs and
consultants as per the NHS, they have to meet all the training
requirements of the Royal Colleges and keep up-to-date and keep
their standards going through appraisal just the same, and they
also then have to be able to do that job in a military environment
and they have to be safe and be able to function in the air, under
the sea, on the sea and on the ground. These people are quite
a national resource and the burden is falling on significant sub-groups
of them repeatedly to meet the operational tempo at the moment.
Q196 Chairman: I was talking to one
this morning who was regularly shot at, which is an additional
burden to bear, I dare say.
Dr McKeating: It certainly is.
As a Gulf War veteran a similar thing happened to me and it does
focus the mind.
Q197 Chairman: How do these shortfalls
compare with the National Health Service?
Dr McKeating: If the NHS was undermanned
by 55 per cent for trained GPs and consultants in terms of their
stated requirement it would be a very significant problem. Obviously
the military have to have some flex in there, they have people
doing staff jobs, people in training, various other posts, but
we are looking at a very, very significant shortfall in terms
of what goes on in the military. As far as I am aware, I do not
think the shortfall in the NHS is anywhere near that and if you
look at what has been going on recently in terms of the training
of junior doctors, certainly the situation in the military is
much more acute than in the NHS.
Q198 Linda Gilroy: Looking ahead,
some commentators suggest that there may well be almost a surplus,
unbelievably, of doctors in a few years' time, domestic overproduction,
so do you see this changing? Do you care to comment on the balance
between having generalists available for deployment rather than
Dr McKeating: I will take that
in two parts. First of all, yes, I understand that if you look
at the people leaving the Armed Forces' Medical Services, the
doctorsthese are MoD's own figures8.4 per cent was
the resignation rate in 2004-05 and 3.8 per cent in 2005-06 and
that is falling and we believe that may be lower this year. Why
is that? Well, it may be due to turbulence on the outside, it
may be that people are perhaps hedging their bets and waiting
until things settle down in the NHS with the changes in training
and structures within the NHS. In terms of the training pipeline,
the military have always done relatively well. They can recruit
people early on in their careers but traditionally their problem
is keeping the trained product, the trained accredited GP, GP
trainer and the trained accredited consultant, that has been the
problem. In terms of deploying generalists, you could argue that
all military surgeons have to be able to perform some general
surgery and if you look at what has gone on in recent operations
people are certainly extending their roles, but the way doctors
have been taught and the way they are being trained, people are
working in very specialist areas now. If we are going to continue
to provide the high level of care that we do to people, our forces
on the ground, then we are going to need to keep those specialists
within the military.
Q199 Chairman: Okay, so that is the
problem, what is the solution?
Dr McKeating: Certainly we see
that there are a number of issues relating to why people go. One
is turbulence and the problem is this becomes a vicious circle
because if the cadre gets smaller then the burden falls more and
more upon those who remain. That is one issue. Whenever we do
our studies looking at how people feel and what the factors are
that make them leave, it tends to come out that it is separation
from family and turbulence, and also turbulence in terms of how
it affects your clinical work as well being repeatedly deployed
away. Certainly most hospital specialists are working within an
NHS environment now, so they are working with their colleagues
just the same as any other cardiologist or surgeon would do and
that puts pressure on their workload. Pay is another issue. We
still feel there is a differential between what people are being
paid in the NHS and in the military. A few years ago we were not
far off parity when a new pay scheme was brought through to military
doctors, but hot on the heels of that came the new GP and NHS
consultant contracts which moved the goalposts for us. Certainly
in terms of the consultant cadre we feel that over a career they
are probably about four per cent behind their NHS colleagues looking
at introducing a system of quality rewards, such as the local
clinical excellence awards that NHS consultants get, and also
some sort of out-of-hours supplement that the NHS consultants
get, that will add another five per cent. In terms of the GPs,
overall career-wise we think there is a career earnings differential
of 4.8 per cent there, looking at our figures, but that differential
in the early years of when you accredit is greater. If you are
looking at the first one to 12 years you are looking at somewhere
between an 11 and 14 per cent pay differential between what you
would earn in the NHS and what you would do in the military. Pay
is not everything and people do not serve in the Armed Forces,
serve their country and put themselves through what they do when
they join the military for the pay, but when you approach that
time in your career and you are accredited as a GP or a consultant,
you may then have a partner, may have children, you are looking
for more stability in your life perhaps, if you then look and
you perceive there to be a pay gap as well then that is going
to have an effect. The third issue is around work issues, promotion,
flexibility, flexible careers, career breaks, part-time working
and that sort of thing. We know this is something that when we
have spoken to the Defence Medical Services Department and also
to the MoD about these issues they are looking at them, but these
things are crucial. If you look at who go into medical school
now, 50 per cent-plus and rising are female medical students.
As time goes by they will want perhaps to manage their careers
differently from the traditional role that the military have seen
doctors working through in the past. There may be times when they
want to take career breaks and may need flexibility in their working
patterns and the hours that they work. These are all issues, I
think, that come together to influence people to decide to go.
As I say, we know that the PVR (requests for premature voluntary
release from the Armed Forces) rates, the requests for premature
release, are slowing but that may be due to changes and the turbulence
in the NHS at the moment with what is happening with medicine
rather than what is going on in the MoD itself.