Memorandum from the British Medical Association
ABOUT THE
BMA AND THE
ARMED FORCES
COMMITTEE
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.
INTRODUCTION
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.
MANNING LEVELS
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.
TABLE 1
SHORTFALL OF REQUIREMENT VS TRAINED STRENGTH
FROM 1 APRIL 2005 THROUGH TO 1 APRIL 2007[28]
| Requirement* |
Trained strength | Shortfall
| Difference from previous year's trained strength
|
| 1 April 07 | 770 |
495** | 36% | +5
|
| 1 April 06 | 780 | 490
| 37% | +10 |
| 1 April 05 | 1,030 | 480
| 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.)
TABLE 2
MANNING AND REQUIREMENT FIGURES IN THE KEY OPERATIONAL
PINCH POINT SPECIALTIES AT 1 APRIL 2007[29]
| Specialty | Requirement
| Trained strength | Shortfall No.%
|
| Anaesthesia | 97 |
46 | 51 | 53 |
| General surgery | 40 | 20
| 20 | 50 |
| Emergency medicine | 30 |
16 | 14 | 47 |
| General medicine | 29 | 16
| 13 | 45 |
| Psychiatry | 28 | 13
| 15 | 54 |
| Rheumatology and rehabilitation | 12
| 5 | 7 | 58 |
| Neurosurgery | 3 | 0
| 3 | 100 |
| General medical practitioners | 321
| 257 | 64 | 20
|
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.
RETENTION
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.
PAY AND
CONDITIONS
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]
RESERVISTS
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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