Government response
The Government welcomes the House of Commons Defence
Committee's report on Medical care for the Armed Forces. We note
that the report pays tribute to Defence Medical Services (DMS)
personnel, and their NHS colleagues, who together provide world-class
care, and that the Committee concludes that the clinical care
provided for Servicemen and women seriously injured on operations
is second to none.
We welcome the Committee's recognition of the excellent
work carried out by DMS and NHS staff at Selly Oak Hospital, and
that rehabilitation services, especially at Headley Court, are
recognised as exceptional, making an enormous contribution to
the welfare of injured Service personnel. The Government echoes
the HCDC's condemnation of the irresponsible reporting of the
treatment provided to our injured Service personnel at the University
Hospital Birmingham Foundation Trust.
We are pleased that the Committee commends the MOD's
sound decision to base its secondary care around units embedded
in NHS Trusts, allowing military clinicians to maintain and develop
their skills, with a case load and mix that could not be matched
by stand-alone military hospitals. We hope that this will close
the debate on Service hospitals and the future of Royal Hospital
Haslar.
The Government's response to the Committee's conclusions
and recommendations as set out on pages 35-39 of the report are
as follows:
1. (Recommendation 1) We find the arguments in
favour of the closure of the stand-alone Service hospitals irresistible.
We accept that the reduction in numbers of personnel which took
place in the Armed Forces after the end of the Cold War meant
that there was insufficient patient volume to make the military
hospitals viable in the long term (Paragraph 14)
2. (Recommendation 2) The principle behind the
decision to move from stand-alone military hospitals to facilities
which co-operate with the NHS was the right one, from a clinical,
administrative and financial point of view, and we see no evidence
that the care offered to military personnel has suffered as a
result. Indeed, we believe that Armed Forces clinicians now have
experience of a much broader range of cases, which benefits their
training. We also support the decision by the MoD to disengage
from the Haslar site. (Paragraph 14)
3. (Recommendation 3) It seems clear that there
has been much inaccurate and irresponsible reporting surrounding
care for injured Service personnel at Birmingham, and that some
stories were printed without being verified or, in some cases,
after the Trust had said that they were untrue. We condemn this
completely. Editors have a responsibility to ensure that their
newspapers report on the basis of verified fact, not assumption
or hearsay. The effect of such misrepresentation on the morale
of clinical staff and Service personnel and families was considerable.
We consider the publication of such misleading stories as reprehensible.
(Paragraph 29)
4. (Recommendation 4) We acknowledge the progress
which has been made at Selly Oak in terms of creating a military
environment, to take advantage of the healing process of being
surrounded by those who have been through similar experiences,
to make patients feel comfortable and give them familiar surroundings.
The MoD has made substantial efforts in this regard, and we look
forward to hearing of further progress in the response to this
report. The MoD must make sure that the issues of welfare for
patients and families are central to its planning in developing
its medical facilities in and around Birmingham. (Paragraph 34)
We are pleased that HCDC has recognised our achievements,
working with UHBFT, in developing a military managed ward at Selly
Oak Hospital. We shall be building on those achievements when
we take this concept forward in the Trust's new hospital. We shall
of course continue to keep the HCDC informed of progress.
We attach a high priority to the welfare of military
patients and their families. Current patient family accommodation
is contracted for until 2011. Officials are now working on plans
for the family accommodation that will be required when the Clinical
elements of the Royal Centre for Defence Medicine move to the
Birmingham New Hospital. This planning phase will also consider
the means of provision of welfare facilities, for which there
are several options. We are most grateful to SSAFA-FH for their
generosity in offering to provide a "home from home"
in the area, for patients' families.
5. (Recommendation 5) We also welcome the improvements
in welfare provision and pay tribute to the work of welfare and
charitable organisations. We consider that there is nothing intrinsically
wrong in welfare and charitable organisations contributing to
the support of our injured Service personnel. Indeed, quite the
reverse is the case, since it builds on a proud tradition in the
United Kingdom of linking the community with the Service personnel
who have been injured fighting on their behalf. The MoD and the
voluntary sector should engage openly with the debate about which
services are more appropriately provided by the Government and
which by charities and voluntary groups. (Paragraph
35)
The Government shares the Committee's view on the
improvements in welfare provision, and takes this opportunity
to place on record its own appreciation for the work of welfare
and charitable organisations. It is entirely appropriate for the
continuing generous support of charities to sit alongside the
provision of facilities from public funds, as is the practice
in many walks of life. Charitable assistance is a welcome and
tangible demonstration of public support for the armed forces.
The Government welcomes an open debate about the respective roles
played by the Government and by charities and voluntary groups.
The forthcoming Service Personnel Command Paper will be an important
part of that debate.
6. (Recommendation 6) However, we also underline
the fact that many of the improvements set out above are relatively
recent, and there has been a great deal of change over the past
18 months. The MoD should not be complacent: they have had to
learn important lessons and it is clear that the picture at Selly
Oak was not always so positive. Nor should progress now stop,
but the MoD should continue to learn lessons from its experiences
in treating injured Service personnel at Selly Oak. (Paragraph
36)
The Government agrees that improvements should continue
to be made as part of an ongoing lessons learned process. We continue
to address lessons to be learned in all aspects of the patient
care pathway for injured service personnel, through in particular
the work that was initiated by the appointment of a Standing Joint
Commander (Medical), to which the Committee referred in its report.
Ministers are advised regularly by the Deputy Chief of the Defence
Staff (Health) and the Surgeon General on the progress of that
work, and aspects of it have been reviewed as necessary by the
Chiefs of Staff and the Service Personnel Board. There is also
regular liaison and review with NHS staff through the University
Hospitals Birmingham NHS Trust Clinical Governance Committee.
[1]
7. (Recommendation 7) We acknowledge the case
for concentrating the main clinical and training assets of the
DMS and DMETA on one cluster of sites. While Birmingham may not
be close to a major Service community, we accept that it is suitable
in terms of transport links and proximity to a university, both
of which are important factors. However, the MoD needs to make
its case for the Birmingham-Lichfield 'dumb-bell' more explicitly,
and we expect the Government response to our report to set out
in detail the plans and progress on this. The MoD and, where appropriate,
the voluntary sector should also make sure that there are adequate
travel and accommodation arrangements for families visiting patients
in Birmingham, and, as important, that these are easily understood
and accessible. (Paragraph 43)
The Government welcomes the HCDC's endorsement of
our plans to develop the Defence Medical presence in the Midlands.
It remains the intention of the Midland Medical Accommodation
project to co-locate key elements of the Defence Medical Services
at Whittington Barracks, Lichfield. These elements are expected
to include the HQ of the new Joint Medical Command (currently
located at Fort Blockhouse, Gosport) and the new Strategic Medical
HQ that is being developed.
The project is still in the Assessment phase, but
we hope to reach a decision on the next steps before the summer.
We shall provide the Committee with details of our plans when
they are decided.
Lest there should be any misunderstanding, it should
be noted that there never has been any intention to establish
MoD secondary care facilities or accommodation for patients or
their families at Lichfield. However, we are considering plans
for accommodation for families of military patients being treated
at Birmingham, as explained in our response to paragraph 4.
8. (Recommendation 8) The UHBFT/RCDM services
are delivered at Selly Oak in buildings which are in many cases
ageing. Delivery of the PFI development is scheduled to bring
new, state-of-the-art buildings and facilities by 2012. We expect
the MoD, as part of its annual reporting process, to state whether
delivery on the Birmingham New Hospitals project is on target.
(Paragraph 44)
The new hospital project of the University Hospital
Birmingham NHS Foundation Trust will deliver a range of new facilities,
including for the Royal Centre for Defence Medicine (RCDM), from
2010 onwards and is making excellent progress towards completion
by 2012. The RCDM is in discussion with the Trust about the MOD's
detailed requirements and the timetable for the occupation of
the proposed military areas of the new hospital. We shall advise
the Committee once conclusions have been reached and provide subsequent
up-dates as necessary.
9. (Recommendation 9) We were very impressed by
the services at the Regional Rehabilitation Unit we visited in
Edinburgh and commend the staff for their excellent work. The
MoD's approach to musculo-skeletal injuries is forward-looking
and sensible, and we are persuaded that it has been of significant
benefit to Service personnel as patients, and to the efficiency
and effectiveness of their units. (Paragraph 47)
10. (Recommendation 10) We readily acknowledge
the extraordinary work which is carried out at Headley Court and
have nothing but praise for the staff, who have had to cope with
an increased tempo of operations and treat patients with injuries
which, only a few years ago, would have been fatal. We regard
this as a good example of the Government and charities cooperating
to provide those services which they can most appropriately deliver.
We were astonished by the ability of some gravely-injured Service
personnel to be successfully treated, and to return to active
military duty. However, we are concerned by reports of problems
with the local community in terms both of developing the facilities
at Headley Court and of using local authority amenities. If it
is true that some local residents objected to the presence of
Service personnel, we find that attitude disgraceful. The Government
should make the outcome of the current review into the facilities
at Headley Court fully available, and should explain what planning
it has done to account for the increased operational tempo and
its implications for Headley Court. (Paragraph 54)
The Government welcomes the Committee's recognition
of the achievements of the staff and patients at Headley Court.
We are in the process of reviewing what our future requirements
for rehabilitation are likely to be. This involves not only the
Defence Medical Rehabilitation Centre (DMRC) at Headley Court,
but also our Regional Rehabilitation Units (RRUs). We expect the
review to be completed shortly and will make the outcomes available
to the HCDC.
Capacity at the Defence Medical Rehabilitation Centre
at Headley Court was increased by the opening of a 30-bed ward
annex last May and will be further enhanced later this year, by
the building of a new staff and patient accommodation block.
We expect to continue to invest in Headley Court
for the foreseeable future and our current review will encompass
how we might best target additional investment. In addition to
public investment, we welcome all offers of charitable support
for our wounded Service personnel. The MOD works together with
a number of charities in this field. We consider this to give
the public a good opportunity to show their support for the Armed
Forces.
11. (Recommendation 11) We are satisfied that
the MoD and the Department of Health are aware of the management
problems which the deployment of personnel from MDHUs poses for
the Trusts in which they are based and that they are working in
a coordinated way to minimise these problems. (Paragraph 57)
12. (Recommendation 12) The principle which underlies
MDHUs is a sound one. We believe that embedding DMS personnel
in NHS trusts to work side by side with civilian clinicians is
the best way to develop and maintain their skills, as well as
providing an opportunity for Medical care for the Armed Forces
Servicemen and women to be treated in a semi-military environment.
We were impressed by the MDHUs which we visited and are satisfied
that they deliver high quality care to military and civilian patients.
(Paragraph 61)
13. (Recommendation 13) The MoD and the Department
of Health should address the sharing of best practice as a matter
of urgency. More structured exchange of skills and techniques
is in the interests of the NHS and Service personnel. We also
consider it probable that the MoD, when working alongside forces
from other countries, will learn lessons from differing approaches
adopted by those other countries which could usefully be shared
with the NHS. We expect the response to this report to explain
in detail what steps will be taken to encourage this. (Paragraph
62)
This is an area which the Government had already
identified as a priority, and which it is committed to developing
further, for example through regular meetings between MOD and
Health Ministers, the MOD/Departments of Health Partnership Board
and the Medical Research Council. The MoD already has a number
of processes in place to ensure that best practice is shared between
the Defence Medical Services and the NHS.
When not deployed overseas, DMS medical personnel
who work in secondary care maintain their clinical skills in the
NHS, ensuring cross-pollination of the skills they develop while
on deployment and NHS best practice. Similarly, NHS reservists
bring the clinical and crisis management skills they learn on
operations back into the NHS.
The MOD also shares the results of defence medical
research. DMS personnel undertaking research publish their papers
in the wider scientific press, and deliver presentations at both
national and international civilian clinical conferences. An expert
symposium comprising international experts (including from MOD)
was convened in London last year to produce best evidence guidance
on clinical practice following a blast incident. From this, best
practice guidance was issued to the NHS in December 2007.
Advances in military emergency medicine have influenced
recommendations from the Joint Royal Colleges Ambulance Liaison
Committee. Also, DMS' Royal Centre of Defence Medicine is hosted
at University Hospital Birmingham Foundation Trust, a centre of
excellence for polytrauma medicine, and the closest cross-fertilisation
exists between them, and with field hospitals in theatre.
DMS also shares best practice with the Medical Research
Council, for example to increase awareness of our recent enhancements
in battlefield medicine that may have wider A&E applicability.
The MOD has also engaged with Dame Carol Black's review of health
in the workplace, where our rehabilitation programmes are seen
as leading the field in getting severely injured people back to
work. Such work is taken forward within an overall framework that
is overseen by the cross-Government MOD/UK Health Departments
Partnership Board.
14. (Recommendation 14) We appreciate the strength
of Service loyalties and the power of traditional connections,
but we suggest that more needs to be done to ensure that MDHUs
are representative of a genuinely tri-Service DMS.
(Paragraph 63)
The MOD indeed aspires to have a "genuinely
tri-Service DMS" and the recent creation of the new Joint
Medical Command, which has wider responsibilities than the former
Defence Medical Education and Training Agency, is an important
step towards such a goal. In addition, secondary healthcare DMS
personnel are frequently deployed and gain considerable experience
on operations on a tri-service basis. We are also looking at how
to make MDHUs more tri-service. We are, for example, planning
to open up more senior posts within the MDHUs to all three Services
and the Joint Medical Command is reviewing the arrangements made
for military medical placements with the NHS and examining the
assumptions behind the current structures of the MDHUs. However,
it is important to recognise the practicalities imposed by the
geographical presence of the single Services in the vicinity of
the MDHUs, and the fact that most DMS personnel will spend the
majority of their career based with their parent Service. This
means that it is inevitable and by no means undesirable that the
DMS personnel at an MDHU will be drawn more from one Service than
the others, just as the military patient population using that
MDHU will be predominantly from the same Service. This does not
represent any reduction in capability.
15. (Recommendation 15) The priority in the treatment
of injured Service personnel must be to return them as quickly
as possible to operational effectiveness, so it is sensible for
the DMS to use whatever mechanism delivers this objective most
efficiently. The MoD should express more clearly the arrangements
for 'fast track programming', and we are concerned that they are
not fully or properly understood by all parties involved. (Paragraph
64)
There are three separate schemes for obtaining faster
than normal access to treatment for Service personnel or veterans.
To clarify, the arrangements are:
Accelerated access for
Service personnel—Service personnel are of course entitled
to access local NHS secondary care by referral from local (military
or civilian) GPs. In addition, the MOD will in some circumstances
purchase accelerated access from a small number of NHS providers
at additional cost, for any medical condition, in order to meet
operational requirements. These providers are the NHS Trusts hosting
Ministry of Defence Hospital Units[2]
(MDHUs) and University Hospital of Birmingham Foundation Trust
(UHBFT).
Orthopaedic "fast track"
programme for Service personnel—The MOD has also developed
a specific orthopaedic fast track programme to meet the relatively
high incidence of musculo-skeletal cases within the military population.
For Service patients with these conditions the MOD arranges rapid
access to diagnosis and— for the minority who are then found
to need it - surgery in NHS facilities. Those needing only physiotherapy/
rehabilitation treatment (the majority) are treated in MOD's own
Regional Rehabilitation Units (RRUs). 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) the MOD arranges fast access to surgery from the MDHU
Host Trusts, other NHS Trusts and in the past from the independent
sector within 6 weeks of the decision on their treatment path.
Priority treatment for
war pensioners and veterans—Where a veteran in England,
Wales and Scotland has a disorder accepted as due to service under
either the War Pensions or Armed Forces Compensation Schemes,
there is entitlement to priority treatment—including assessment,
treatment, aids and appliances for accepted conditions. Priority
is decided by the clinician in charge based on clinical need.
NHS priority treatment has recently been extended to all veterans
in England and Scotland, whose injuries or ill-health are suspected
of being due to their service, and will be extended to veterans
in Wales on the same basis soon.
16. (Recommendation 16) Our visit to Scotland
left us deeply concerned. It is unreasonable to expect any administration,
whether in Whitehall or one of the devolved assemblies, to micromanage
the agencies which execute its policies. But depending on guidance
and taking a laissez faire approach to making sure that such guidance
is implemented is totally inadequate, and reinforces our view
that the issues confronting Service personnel and their families
are not sufficiently high up the list of priorities for the Scottish
Executive. (Paragraph 69)
17. (Recommendation 17) We accept that plurality
is an inevitable outcome of the devolution settlement. However,
we are concerned that the provision of some aspects of healthcare
in Scotland, for Service personnel and their families, is not
always given the priority it deserves because of poor cooperation
and communication. The MoD must review the structures through
which it engages with other departments and administrations, and
explain how it intends to improve the situation. We also expect
the Scottish Executive to review its arrangements in response
to our report. (Paragraph 70)
The MOD maintains regular contact at both working
level and the highest official levels with counterparts in the
health departments of the Devolved Administrations to ensure that
health issues affecting Serving personnel, their families and
veterans are given the consideration they deserve.
The Under Secretary of State for Defence chairs the
Veterans Forum where he meets regularly with officials from the
Devolved Administrations to discuss and address issues of concern
to the veterans' community. He also meets Ministerial counterparts
where issues of concern justify engagement at this level; he most
recently met with the Scottish Government Minister with lead responsibility
for veterans, Stewart Maxwell MSP, on 3 December 2007.
The MOD/UK Departments of Health Partnership Board,
chaired at senior official level, typically meets 3 times a year
and is a forum designed to strengthen further the working relationship
between the Department of Health, the Devolved Administrations,
NHS and MOD. The Partnership Board has established 3 working Groups
with representation from the devolved administrations to take
individual workstreams forward between Partnership Board meetings.
The focus of the forward work programme is on tackling key strategic
issues in order to produce real improvements in the quality of
health and healthcare provision for Service personnel, their dependants
and veterans and in the delivery of deployable operational capability.
There are also numerous contacts at working level
between officials in MOD, the Scottish Executive and with the
Welsh and Northern Ireland administrations on various issues
of concern to Service personnel, their families and veterans.
There has for example been close discussion of the arrangements
for meeting the mental health needs of veterans.
The Government understands that the Scottish Executive
has provided a separate response to the Committee. We welcome
the fact that Scotland has extended NHS priority treatment to
all veterans for conditions which are likely to be related to
their service. This came into effect on 29 February 2008
18. (Recommendation 18) We welcome the Government's
extension of the priority access available to veterans in England.
However, the MoD must explain clearly what it is doing in conjunction
with the devolved administrations to ensure that this entitlement
extends across the UK. It should also give a clear definition
of who qualifies as a veteran and is therefore entitled to this
treatment. (Paragraph 75)
For the purposes of establishing eligibility for
priority NHS medical treatment a veteran is anyone who has served
for at least one day in HM Armed Forces (Regular or Reserve) or
the Merchant Navy Seafarers and Fishermen who served in a vessel
at a time when it was operated to facilitate military operations
by HM Armed Forces.
The Department of Health, which is responsible for
meeting the health needs of veterans in England, consulted with
the Devolved Administrations before the Secretary of State for
Health announced his decision to extend priority treatment for
veterans in England. Both the Scottish Executive and Welsh Assembly
Government have also announced the extension of NHS priority treatment
for war pensioners to all veterans in Scotland and Wales, on the
basis of clinical need for health conditions related to their
service. This came into effect in Scotland on 29 February 2008.
Priority treatment for war pensioners was not introduced
in Northern Ireland because historically, Northern Ireland retained
a dedicated hospital for war pensioners. We have been informed
by the Northern Ireland Government that it is committed to providing
excellent public services for all its citizens.
19. (Recommendation 19) We also acknowledge that
the implementation of the policy will present some challenges
in terms of privacy. However, the MoD and the Department of Health
need to do much more to make sure that the entitlement to priority
access is widely understood and taken up by those who need it.
We do not believe that there is currently a sufficiently robust
system for tracking veterans in the NHS, and we expect the MoD's
response to this report will set out the Government's thinking
on how this could be improved. Simply to rely on the individual
to bring his or her status as a veteran to the attention of a
clinician, given some of the conditions which are common among
ex-Service personnel, is inadequate and an abdication of responsibility.
We believe that an automatic tracking system with an 'opt-out'
provision would balance the need for robustness with the protection
of individuals' privacy. (Paragraph 76)
Having extended NHS priority treatment to all veterans
in England, the Government is aware that it needs to raise awareness
of the provisions. Steps have already been taken: for example,
the new guidance on priority treatment for veterans was sent to
all NHS Trusts, foundation trusts and GPs in England and the forthcoming
Chief Medical Officer Update includes an item on priority treatment;
in Scotland a generic leaflet on entitlement to NHS priority treatment
is to be distributed to all current members of veterans associations
in Scotland, citizens advice bureaux, general practitioners and
NHS hospital outpatient clinics. The Welsh Assembly Government
will also be issuing guidance to remind clinicians about the extension
of priority treatment for war veterans.
MoD has also asked the various veterans' agencies
to publicise the provisions through their communications with
veterans. The Department of Health, the Scottish Government and
the Welsh Assembly are all considering further means of raising
awareness and will keep this issue under review.
We have considered carefully the Committee's proposals
around tracking of veterans in the NHS.
The Government believes that that there could be
significant issues from a security viewpoint in flagging the medical
records of veterans. The fact that someone was a member of the
armed forces is sensitive personal information. It would be cumbersome
under current arrangements to flag up a veteran's status to a
GP while giving that personal information sufficient protection.
In addition, we would need to respect that some individuals may
not wish it to be known, for whatever reason, that they have previous
Service experience.
Moreover, because of the large numbers of veterans
in the UK a retrospective solution would not be viable.
In the Government's view, however, the introduction
of the English NHS National Programme for IT (NPfIT) through the
Connecting for Health initiative—and the Defence Medical
Services' connectivity with the NPfIT—should allow greater
integration between the NHS in England and MoD, improving the
provision of care to Armed Forces personnel with the protection
of strong security measures. Work is also in hand with the devolved
administrations to allow a similar level of integration in the
future.
20. (Recommendation 20) We remain concerned that
medical records do not transfer as seamlessly from the Armed Forces
to civilian life as they could. Too much is left to the initiative
of the patient, and on our visits we heard that the existing system
often works imperfectly. We recommend that the MoD re-examine
its procedures with regard to medical records and examine ways
in which there could be an automatic transfer of records and a
more effective safety net for those who, for whatever reason,
do not take the initiative in transferring or requesting records.
We also ask the MoD to give us an update on the progress of its
IT system, the compatibility with the NHS National Programme for
IT, and its anticipated schedule for implementation of the new
system. (Paragraph 79)
All individuals leaving the Armed Forces are given
a summary of their medical records, which they are advised to
give to their new civilian GP when they register. If the GP wishes,
they can request a copy of the full medical record from the appropriate
single Service.
For medical discharges that require an ongoing medical
care plan to be put in place, the military consultant in charge
of medical care arranges the handover of care to his civilian
counterpart, much in the same way as a handover of care is arranged
for civilians moving from one primary care trust to another. The
transfer of medical records forms an integral part of the process.
MOD's new IT system for the Defence Medical Services,
the Defence Medical Information Capability Programme (DMICP),
will allow the sharing and transfer of medical records electronically
in future. The programme is being introduced incrementally and
is now in use at 140 medical centres in the Army and the Royal
Air Force in the UK. It will continue to be introduced at Royal
Navy shore locations, the Defence Dental Service and to all our
Armed Forces in permanent bases overseas, such as those in Germany,
Cyprus and Gibraltar, throughout 2008 and should be complete by
early 2009. The system will also be deployed to our Armed Forces
on overseas operations and to HM ships beginning later in 2008.
The system is compatible with the English NHS National
Programme for IT (NPfIT). Work to effect an interface between
DMICP and the NPfIT has been approved by the MOD and the Department
of Health and has already begun. It is due to be completed in
2010. There is a need to protect patient confidentiality,
including their military history, and to comply with each
patient's decision on whether or not their medical record could
be shared. Subject to this it is intended that detailed records
could be transferred electronically to their new GP when Armed
Forces personnel retire and that a summary record could be made
available to the NHS during service. It is also intended that
the Defence Medical Services will be able to use the NHS Choose
and Book system for their patients in England. Defence Medical
Services are also actively engaged with the devolved administrations
to establish a similar electronic exchange of information in the
future.
21. (Recommendation 21) We believe that providing
first-class healthcare for veterans, and making sure that people
have confidence that they will be able to access and will receive
such treatment, is an integral part of the debt which society
owes to those who serve in the Armed Forces, and, as such, has
an impact on recruitment and retention. (Paragraph 80)
The Government entirely accepts this conclusion.
The Department of Health has continued to make progress in terms
of health care for the armed forces, their families and veterans.
Last November the Department of Health announced the extension
of priority treatment to veterans for conditions related to their
military service, and the establishment of a number of pilots
to look at the best way of meeting the needs of veterans with
mental health problems. In December 2007 the Operating Framework
for the NHS in England for 2008/09—the document which sets
the NHS's key priorities—was published, which included:
making sure that the NHS provides the right services to meet the
needs of armed forces and their dependants who move frequently;
reminders that the NHS should support staff who want to be volunteers
in the Reserve Forces; and reminding the NHS about the priority
treatment provisions and their extension to all veterans.
The Scottish Executive has also extended priority
treatment to all veterans in Scotland, on the basis of clinical
need for health conditions related to their service, with effect
from 29 February 2008 and is working with the MOD on the establishment
in Scotland of a community-based pilot to examine the best way
to address the particular mental health needs of veterans. Each
NHS Board in Scotland has been asked to appoint a senior member
of staff to have overall responsibility in ensuring the implementation
and monitoring of the extension of priority treatment for veterans.
The Scottish Executive intends to hold a workshop for those individuals,
representatives from the veterans' organisations in Scotland and
representatives from Citizens Advice Scotland to establish and
promote a general understanding of what is meant by NHS priority
treatment.
The Government accepts that support for veterans
and the families of Service personnel plays an important part
in the retention of Service personnel and works hard to ensure
that support from all relevant departments in the UK works as
well as possible. In particular, work on medical and health support
is undertaken between MOD and the UK health departments through
the Partnership Board and its supporting working groups.
22. (Recommendation 22) We acknowledge that Service
families posted overseas generally receive very good healthcare
through sensible partnership arrangements. We are glad that the
MoD accepts that its spending has lagged behind that of the NHS.
It is essential that medical care for our Service personnel posted
overseas should keep pace in every way with the NHS, so that they
are not penalised for joining the Armed Forces. (Paragraph 83)
The Government agrees with the Committee that Service
Personnel and dependants are entitled to high-quality medical
services to NHS best practice standards where practicable. It
is important that policy and resource initiatives to improve the
health of the UK population are also extended to Service Personnel
and their families in the same way. The MOD and Department of
Health have agreed to work closely together, and with HM Treasury,
on this issue in the run up to future Spending Reviews.
23. (Recommendation 23) We doubt if the establishments
in Cyprus and Gibraltar are clinically or financially viable in
the long term. The MoD should make clear how it intends to address
this problem and what options are being explored for maintaining
healthcare provision for Service communities in a more effective
and efficient manner. It should also set out a timetable for tackling
this issue. (Paragraph 85)
The Ministry of Defence will be reviewing the provision
of Secondary Health Care (SHC) in its Permanent Joint Operating
Bases (PJOBs) in Cyprus and Gibraltar to Service personnel and
their dependents. The project team, involving all key stakeholders,
will consider a range of options, including the use of local health
providers and the development of partnerships with UK health trusts
to ensure that the MOD continues to meet its obligation to provide
appropriate care to its personnel. This will be a challenging
undertaking, and sufficient time must be allowed to ensure that
we deliver the right outcome. We will need to investigate the
most effective relationships between ourselves, health providers
and other stakeholders. This will also need to address quality
assurance and capacity. We will, of course, ensure that our personnel
in Cyprus and Gibraltar are kept fully informed about the future
provision of SHC in these locations
24. (Recommendation 24) We acknowledge that the
healthcare of Service families in the UK is the responsibility
of the NHS. However, the MoD has a part to play, and should be
doing more to support Service families during the transition from
overseas postings to reliance on NHS healthcare. There should
be better cooperation between the MoD and health departments across
the UK. The Scottish Executive also has a responsibility to improve
its procedures in this regard. Providing this sort of support
is a vital part of maintaining morale among Service personnel
themselves and their families, which has such a profound effect
on the retention of experienced Servicemen and women. (Paragraph
89)
The Government accepts that support for the families
of Service personnel plays an important part in both the delivery
of operational capability and retention of Service personnel.
This is a fundamental aspect of the Service Personnel Command
Paper, which in itself demonstrates the commitment for cross-Government
efforts to ensure support from all Departments works as well as
possible. But work is already undertaken on these issues between
MOD and the UK health departments through the Partnership Board
and its supporting working groups. This has proved an effective
mechanism for cooperation and has led to important work on, for
example, specific guidance on support for Service families in
the NHS Operating Framework and identification of best practice
through primary care trusts that serve significant Service communities
in England and Wales.
The MOD also provides a range of support for families
that are relocating, including the HIVE Information Service. With
about 165 HIVE offices worldwide in every significant Service
location plus a remote web-based service, every Service family
can access relocation support specific to their circumstances.
This includes healthcare, with detailed information on the options
for GP and dentist registration at the future location. The Relocation
Guide—available through HIVE, online and via Families Federations—and
specific pages in the Service Community area of MODWeb provide
information and guidance on a range of issues, from transfer of
current care to the necessary contacts for any follow up with
key organisations, particularly if facing any difficulties. Nevertheless,
the MOD will look for further ways in which the advice, guidance
and specialist support available can be better communicated to
the Service community.
25. (Recommendation 25) We consider that the MoD
provides adequate mental healthcare for serving members of the
Armed Forces. We have been told on visits that there is a culture
of individuals 'bottling things up' inherent in the Services,
but we note with approval the steps which have been taken to attempt
to prevent problems through 'decompression'. This should be an
integral part of the procedures for all personnel returning from
operational tours. It is also important that the problems which
can arise are recognised throughout the Services, so that early
warning signs can be spotted and dealt with before problems get
worse. We believe it is sensible to approach mental healthcare
from community-based provision, delivered in conjunction with
local military units, in-patient treatment being a last resort.
The MoD should also review its contract with the Priory Group
to assess its effectiveness. (Paragraph 97)
"Decompression" is part of the package
of operational stress management that is delivered to Service
personnel before, during and after their operational deployment.
It is our policy that mental health issues should be properly
recognised and appropriately handled and that every effort should
be made to reduce the stigma associated with them. The Ministry
of Defence recognises mental illness as a potentially serious
and disabling condition, but one that can be treated. Diagnosis
and treatment of mental illness in the Armed Forces is performed
by fully trained and accredited mental health personnel.
Our mental health services are configured to provide
community-based mental health care in line with the guidelines
and standards set by the National Institute for Health and Clinical
Excellence and the National Service Frameworks.
We do this by providing outpatient assessment and
treatment at our military regional Departments of Community Mental
Health (DCMH) centres sited in military bases with care provided
by either military mental health care professionals or civilians
employed by the MOD. This means that serving personnel usually
remain with their units and receive outpatient care in a military
environment.
In-patient care, when necessary, is provided regionally
in specialised psychiatric units under a contract with the Priory
Group.
Close liaison is maintained between local DCMHs and
the Priory Group to ensure that all Service elements relating
to in-patient care and management are addressed. This has worked
very successfully, with appointed Service Liaison Officers regularly
attending Priory facilities where Service patients are admitted.
They attend consultant ward rounds and influence the care plan
of these patients. The aim is to stabilise and return the individual
to the community for onward management. This has helped limit
the length of stay for the majority of patients.
The Priory Group won a competitive bidding process
as its bid best met our requirements for access to high quality
care without delay, providing regional care within easy reach
of unit, base or home. The contract with the Priory Group was
extended for two years under the provisions of the original contract,
but is due to expire at the end of November 2008. In line with
commercial practice a competitive tendering exercise is now being
conducted to place a new contract.
26. (Recommendation 26) We welcome this additional
funding, and pay tribute to the work which Combat Stress is doing.
The MoD is right to engage with private organisations such as
Combat Stress where that is appropriate, but it must continue
to ensure that the organisation is adequately funded and has the
clinical capability to deal with the patients who are referred
to it. The MoD should also think more strategically about, and
explain in their response to this report, their relationship with
private and charitable organisations, and the extent to which
they should provide services on behalf of the Government. (Paragraph
104)
The MOD is the single biggest contributor to Combat
Stress. Last financial year we paid them £2.5 million in
fees for the care of individual veterans with a mental health
condition accepted under the War Pension Scheme as due to service.
On 4 October 2007, the Minister for Veterans announced a further
increase of 45 per cent to be phased over the year to reflect
the build up of staff to deliver the enhanced capability required
to treat war pensioners. This substantial increase represents
a significant boost to the charity's finances and demonstrates
the Government's continuing commitment to help Combat Stress play
an appropriate part in treating veterans with mental health problems,
and we will work with them to ensure that the model of care is
the most appropriate. We are working closely with Combat Stress
on the pilot schemes that are currently being undertaken in six
locations across UK which will assist in determining the best
model of care.
As we explained above in our response to the Committee's
Recommendation 5, the Government welcomes an open debate about
the respective roles played by the Government and by charities
and voluntary groups. The forthcoming Service Personnel Command
Paper will further inform that debate.
27. (Recommendation 27) We are concerned that
the identification and treatment of veterans with mental health
needs relies as much on good intentions and good luck as on robust
tracking and detailed understanding of their problems. If the
NHS does not have a reliable way of identifying those who have
been in the Armed Forces, then it already has one hand behind
its back when it comes to providing appropriate clinical care.
We repeat our belief that there must be a robust system for tracking
veterans in the NHS, and this should feed into enhanced facilities
for addressing their specific needs. (Paragraph 110)
The Government is committed to ensuring that those
who have served in our Armed Forces receive the most appropriate
mental health care. In particular, we need to ensure that NHS
mental health services are better able to recognise the link between
service and later mental ill-health. We also need to ensure that
veterans themselves are encouraged to come forward in the confidence
that their concerns and background will be understood. The current
piloting of a new expert veterans service within the NHS, with
funding support from the MoD, should teach us a great deal about
how to improve access and take-up. Once there has been an opportunity
to evaluate these pilots, the other NHS Mental Health Trusts will
be encouraged to develop their own plans to meet these needs,
building on this model.
In addition, the Department of Health's current work
to improve the response of NHS services to mental health problems
resulting from trauma of all kinds, as well as the increased availability
of the skills necessary to deliver these services through the
Improving Access to Psychological Treatment Programme, will better
equip NHS Mental Health Trusts to respond to the needs of veterans.
On the former, the Department of Health is currently
taking the lead in working with the World Health Organisation
to establish an agreed framework for the management of those affected
by trauma and the best way of ensuring the resilience of all emergency
services to traumatic events. When agreed, expected to be early
summer of this year, the Department of Health will develop a regional
plan for enacting this framework and, as well as implementing
this in the English Regions, will make the work available to the
devolved administrations.
On the latter, on top of the significant investment
in mental health services over the past decade, the Government
has made available an additional, initial, investment rising to
£173 million by 2011 to improve the provision of evidence-based
psychological treatment in the NHS. This provision will be for
people with common mental health problems such as depression and
anxiety disorders, conditions often experienced by veterans.
There is an ongoing debate about the efficacy of
screening Service personnel for psychological problems. Current
MOD policy is to conduct health surveillance of Armed Forces personnel
returning from deployment so that any signs of psychological distress
are detected and treated appropriately. However, research published
by the King's Centre for Military Health Research (KCMHR) has
found inconclusive evidence that screening personnel for possible
future mental health problems is helpful, and there is evidence
that it can cause problems due to the number of false positives
and stigma associated with a diagnosis. We have commissioned the
KCMHR to carry out a continuing major cohort study of physiological
and psychological health of UK Service personnel who were deployed
to the Iraq in 2003 compared to personnel who were not deployed.
This study looks at Regular and Reserve personnel. Many of their
findings have already been published. The MOD has recently commissioned
an extension to the study to look at the health consequences further
down the line, and following deployment in Afghanistan and other
theatres.
28. (Recommendation 28) We understand and appreciate
the vital role which Reservists play in delivering the Armed Forces'
healthcare capabilities, and believe that they are an integral
component of the DMS. We have seen ample evidence of excellent
cooperation between Regular and Reserve forces, and believe that
Reservists bring important skills to the Armed Forces. We also
think that operational deployment gives members of the Reserve
forces the opportunity to make use of their training when back
in the UK. (Paragraph 118)
We are pleased to note that the Committee recognises
the major contribution that Reservists make to the requirement
for medical personnel. The MoD recognises that Reservists provide
both additional manpower and specialist expertise using skills
gained in their civilian employment and they provide personnel
across a wide range of medical care specialisations. The NHS in
particular provides a talent pool of qualified specialists. The
military training they receive and involvement on operations provide
the environment to gain skills not necessarily found in civilian
life and these skills and experiences can usefully be used in
their civilian employment.
29. (Recommendation 29) The MoD must not take
the integral involvement of Reservists for granted. It must make
sure that recruitment remains buoyant and that retention is sufficient
to guard against any degradation of capability. It must also ensure
that members of the Reserve forces receive proper support, both
from their civilian employers, and from the Armed Forces when
they return from operational deployments. The public should recognise
the contribution which the Reserve forces make to the military
and to society as a whole. (Paragraph 119)
The MoD is not complacent and strives for better
integration of its reserves not only on operations but throughout
Reservists' careers. The responsibility for recruitment and retention
is managed by the single Services and the front line Commands
responsible for force generation now attempt whenever possible
to integrate Reservists' pre-deployment activity with that of
Regulars at the earliest opportunity. Employer supportiveness
is an important retention component for the Volunteer Reserves.
SaBRE (Supporting Britain's Reservists and Employers) is a MOD
campaign that provides support by providing information and advice
to Reservists and their employers. Through a national marketing
programme and a network of regional representatives SaBRE explains
to employers the benefits, rights and obligations associated with
employing a member of the Reserve Forces. The MoD recognises its
obligations to mitigate the disruption caused to employers if
an employee is mobilised and above all understands that the only
sustainable approach is one which balances the requirements of
the Government, the Reservists and the employer.
The NHS is a supportive employer of Reservists, and
the MOD actively engages with the NHS to further encourage and
support NHS reserves. The Chief Executive of the NHS in England
visited Afghanistan recently, where he saw for himself the contribution
that NHS reserves make to the DMS medical support to operations.
There are a number of initiatives being taken forward
by the MoD/UK Health Department Partnership Boards and key areas
include encouraging reserve service and developing the Sponsored
Reserves concept. The MoD recognises the support the NHS could
provide in specialist clinical areas and that developing the sponsored
reserves concept could enhance the manning option available. The
Sponsored Reserves concept is already being successfully used
in other non-medical military cadres and a supporting legal and
employment framework is already in place. Under the Defence Career
Partnering (DCP) concept there is a proposal to develop a collaborative
relationship between DMS and the NHS. Conceptually DCP is an arrangement
between the individual, selected employers and the MoD, in which
the parties co-operate to mutual advantage to enable continuous
service in the Defence community, and which allows for a two-way
flow of individuals between military service and civilian employment.
When Reservists terminate service they are entitled
to the services provided by the Service Personnel and Veterans
Agency. In addition, the MOD recognises that it has expertise
to offer in certain specific circumstances, and in November 2006,
it launched, in partnership with the NHS, the Reserves Mental
Health Programme (RMHP). Under RMHP, the process of self-referral
can be initiated by the Reservist or the individual's GP and an
offer of assessment follows. If diagnosed to have a combat-related
mental health condition, the MOD offers out-patient treatment
via one of the 15 UK DCMHs. If more acute cases present, the DMS
will assist access to NHS in-patient treatment. The MOD is working
with the UK health authorities to ensure that GPs across the UK
are aware of this initiative.
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