Select Committee on Defence Written Evidence

Memorandum from the British Medical Association


  The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 139,000.

  The Armed Forces Committee was established by the BMA "To consider matters relating to the medical branches of the armed forces and the medical branches of the reserve armed forces and so far as possible to ensure that medical officers serving in the medical branches of the armed forces are not disadvantaged in relation to their civilian counterparts". The main focus of its work has traditionally been the production of evidence to the Armed Forces Pay Review Body. The Committee also represents civilian doctors working for the Defence Medical Services.


  1.  The Armed Forces Committee of the BMA very much welcomed the publication of the Defence Committee's report Medical care for the Armed Forces in February 2008 and would like to thank the Committee for its support and the acknowledgement of the high standard and quality of clinical care afforded to military personnel by doctors in the Defence Medical Services (DMS) both on the frontline and in the UK.

  2.  We also welcome this inquiry into recruitment and retention as we are concerned that the undermanning of fully trained consultants and GPs in the DMS deserves further consideration. Medical care for the Armed Forces acknowledged the effect of increased operational tempo on DMS activity as well as the need for an adequate pool of deployable personnel. Further to the evidence we submitted to the Committee in May 2007:

    —  There remains a shortfall of 47% in fully trained, deployable doctors. The deficits in trained strength are felt most in crucial specialties such as surgery (50% shortfall), general medicine (45% shortfall), psychiatry (55% shortfall) and rehabilitation medicine (58% shortfall).

    —  Fully trained doctors are needed for deployment. Retention problems occur largely at the stage when doctors have completed their training and have fulfilled any return of service required. Thus, although the training pipelines are full this will not necessarily address the problem of retention, one cause of which is repeated deployment.

    —  Studies undertaken by the BMA in 2008[26] and the National Audit Office in 2006[27] show that the effects of increased deployment such as overstretch, turbulence, separation from family and the ability to plan a life outside work are all key drivers in decisions about whether to leave the service.

    —  Immediate consideration needs to be given to incentives to retain DMS doctors, such as better pay that matches the recent benefits brought about by the new NHS GP and consultant contracts and better and more flexible working conditions.

    —  Employer support for reservists is also vital at this time if we are to maintain a pool of deployable personnel ready to relieve and support the DMS on operations.


  3.  DMS manning levels remain significantly below requirements at a time of exceptional high operational activity. There is a shortfall of 36% against the total requirement for trained medical officers, with a 47% shortfall of deployable trained doctors.


Requirement* Trained strengthShortfall Difference from previous year's trained strength
1 April 07770 495**36%+5
1 April 06780490 37%+10
1 April 051,030480 53%

*Baseline requirement—manning training margin (MTM) not included **Shows numbers of qualified doctors available. Not all will be deployable in their specialty as they may be medically downgraded, working out of specialty or in Command and Staff. The number of officers who, as of 1 April 07 were able to deploy in specialty is 407 with a shortfall, thus of 47%.

  4.  There are serious shortages in the deployable specialties crucial to the service, such as general surgery, general medicine, psychiatry and rehabilitation medicine. (Table 2 shows the shortfall for key shortage specialties across the three services at April 2007.)


SpecialtyRequirement Trained strengthShortfall No.%
Anaesthesia97 465153
General surgery4020 2050
Emergency medicine30 161447
General medicine2916 1345
Psychiatry2813 1554
Rheumatology and rehabilitation12 5758
Neurosurgery30 3100
General medical practitioners321 2576420

  5.  The Army in the UK alone spent £4.7 million on locums in 2006-07.[30] This does not include any overseas or operational commitments or locum costs incurred by the other two services. We believe this reliance on civilian locums to cover the manpower deficit is a false economy and that long-term investment is needed to redress the personnel shortfall. We also believe the dependence on civilian locums raises clinical governance issues around the specialised care of military personnel.

  6.  While the Defence Committee in its report Medical care for the Armed Forces found the quality of medical care of armed service personnel to be of the highest quality and second to none, the undermanning of DMS doctors is a risk and a concern.


  7.  Retention of DMS doctors is key to redressing its problem of undermanning. Doctors who have completed their training are needed for deployment. Increasing the numbers of doctors in training is not the sole solution as many doctors leave once they have completed their training and fulfilled any return of service required in order to pursue attractive careers outside the DMS.

  8.  In 2008, the BMA's Health Policy and Economic Research Unit undertook a survey which shows that almost two thirds of respondents planned to leave the DMS in the next five years.[31] Among those respondents who are not retiring at the end of a full commission, the main reasons for leaving the DMS included family commitments and operational turbulence. 20-30% were dissatisfied with their degree of separation from their families and the impact of this on family life and 25-28% had considered or would consider leaving the services because of family and operational commitment/turbulence factors. DMS doctors are involved in a high level of active service with respondents spending an average of 34 days on deployment during the past year but with a range from 21 days for junior doctors to 51 days for GPs. The average number of days spent on military activities other than deployment was around 36 days in 2007. As many as 48% of respondents report that they were unable to take their full annual leave entitlement over the past year.

  9.  The 2006 National Audit Office (NAO) study also found that separation from family and the impact of a career in the services on family life and the ability to plan life outside of work were key drivers in the decision to leave the services.[32] Where the operational pinch-points were concerned there was "little or insufficient trained strength to perform operational tasks while enabling guideline levels on the amount of time away from home to be met". While a degree of separation from home and family life is expected in the services, substantial numbers of personnel have exceeded "harmony guidelines" within their respective service on the maximum time personnel should spend away from home in order to sustain a reasonable balance between time away and time at home.

  10.  The continued overstretch and increased operational tempo means that DMS medical officers in specialties experiencing shortages will continue to face a high rate of deployment. This will, in turn, impact on the retention of medical officers in these specialties.

  11.  While the undermanning of DMS personnel has not affected military medical care, the problems it causes at this time of increased operational tempo can be seen to have an effect on morale and motivation and thus on retention. Urgent consideration of how to break this vicious circle therefore needs to be given.


  12.  Better pay, benefits and working conditions would clearly be incentives for doctors to remain in the DMS. Our survey shows that 35-41% of respondents believed that pay and conditions are better in the NHS, the private sector or an alternative career. A DMS GP, for instance, stands to earn an average of 9.6% less than an NHS GP over the course of a career.[33]

  13.  43% of respondents to the BMA 2008 survey were dissatisfied with the career development and career prospects within the DMS. Fully trained DMS doctors are also an attractive prospect for NHS and other employers.

  14.  Work/life balance is a key factor in retention and morale and better flexible and part-time working opportunities are needed. The increasing feminisation of the medical profession means that the ability to balance professional and domestic commitments are significant factors in morale and motivation.[34] Doctors generally are also increasingly choosing career paths which allow greater flexibility and part-time working and the ability to combine varied professional as well as domestic commitments and such opportunities are more readily available in the NHS and outside the DMS.[35]


  15.  As the Defence Committee found in Medical care for the Armed Forces, reservists provide a vital role and remain a fundamental element of operational planning, particularly at this time of increased operational tempo. The deficit of deployable doctors makes the DMS ever more dependent on the contribution made by reservists in the provision of care on the frontline as well as a relief for DMS doctors on deployment.

  16.  The reservist pool is finite and existing manpower shortages among the reserves will contribute to overstretch in DMS support. The availability of reservists to fulfil their intended roles depends on successful recruitment and consistent commitment to training.

  17.  There are two elements impacting on the morale and retention of reservists: the impact of active service and the attitude of employers both in terms of operational deployment and the need for reservists to meet their annual training requirement.

  18.  As we stated in our previous evidence to the Defence Committee, in the current climate of the NHS economic and service delivery considerations are likely to influence employers' views of doctors' professional commitments. Consultants who are reservists may thus be perceived as an encumbrance and a less preferable employment prospect than a consultant with no reserve liability. Non-reservist NHS GPs are also likely to be preferable to employ unless existing partners are sympathetic to the concept of reserve liability. NHS GP partnership agreements generally mention reserve liability and, for the practice, the need to cover the absence of deployed colleagues can represent a major financial commitment. Reserve liability may be considered a handicap and a disincentive to recruit. These situations are driven again by the medical workforce shortage coupled with the severe lack of contingency capacity in most NHS organisations and general practices.

  19.  The Department of Health (DH) reported to the Defence Committee that there had been no reports of specific employer discrimination against reservists. Apart from a few isolated cases, we have found it difficult to encourage those experiencing problems to come forward and therefore believe they would be reluctant to access employment grievance procedures as suggested by the DH. We are concerned that doctors may thus be more inclined to leave the reserve forces than to pursue formal complaints procedures against their permanent employers.

  20.  We were pleased with the Defence Committee's recommendation of raising awareness of the contribution made by the reserve forces to the military and to society as a whole and believe that this should be emphasised to employers. Employers should be encouraged to appreciate the benefits and added value that can be gained from the additional skills and experience of doctors who have trained and been on active deployment on operations in the reserves. For example, in hospital foyers in the USA, photographs of staff who have served in the armed forces can be found on display. In the UK a change is needed in the culture and attitude of UK employers from one of reluctance to one of celebration of their staff who volunteer to train in order to provide medical care on the frontline. We would be happy to work together with the MoD, the Department of Health and NHS Employers towards fostering a culture among employers of support for reservists.

3 April 2008

26   Health Policy and Economic Research Unit, 2008, Survey of Defence Medical Services doctors-report- January. BMA:London. Back

27   National Audit Office, 2006, Recruitment and Retention in the Armed Forces. London: The Stationery Office, p 23. Back

28   Data supplied by MoD. Manning figures as at 1 April 2007. Back

29   Data supplied by MoD. Manning figures as at 1 April 2007. Back

30   Cited in: A Joint Paper by DG Healthcare and DGCP. Proposals for a competency-based career structure for civilian medical practitioners. 14 December 2007. Back

31   Health Policy and Economic Research Unit, 2008, Survey of Defence Medical Services doctors-report- January. BMA:London. Back

32   National Audit Office, 2006, Recruitment and Retention in the Armed Forces. London: The Stationery Office, p 23. Back

33   British Medical Association and British Dental Association. Memorandum of evidence to the Armed Forces Pay Review Body. January 2008. Back

34   Health Policy and Economic Research Unit, BMA Cohort Study of 1995 Medical Graduates, Tenth Report, June 2005. BMA; London. Back

35   Health Policy and Economic Research Unit, BMA Tripartite Cohort Study of Doctors in the DMS, 2006, BMA: London. Back

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