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10.28 p.m.

Lord Williams of Elvel: My Lords, the House will be grateful to the noble Baroness for putting down her Question today and securing time for it at a rather late stage in the proceedings of this Parliament. I wish also to place on record our appreciation of those in the Defence Medical Services who are trying to adapt to what is obviously a rather difficult new system.

Unfortunately, we meet in rather sombre circumstances in that the House of Commons Select Committee has reported, as the noble Earl will be aware, in fairly dramatic terms. That was referred to by noble Lords who have spoken in the debate. I emphasise that this is not a party political issue; I am not trying to make party political points. I always value the contributions of the noble Baroness, Lady Strange, in this House, but I thought it was somewhere in the further reaches of frivolity to suggest, as she did, that things might have been different if we had been in power. Nevertheless, let us continue with the debate.

It seems to me that your Lordships would wish to consider three points. The first was brought out by a speaker whom I call my noble friend, formerly the noble and gallant Lord, Lord Bramall. It concerned Front Line First and whether it succeeded in doing what the Government pretended it succeeded in doing. In our view, DCS15 did not do so: it destroyed an essential area of what was behind the front line. There was no definition between the front and second lines, and indeed the third line. I am sure that all noble Lords, including the noble Earl, accept that those who risk their lives and bodies in military operations should be offered proper protection. That is not the case at the moment, as the House of Commons Select Committee points out.

Secondly, as the noble and gallant Lord, Lord Carver, points out, it is no good saying that a lot of money should be channelled into this, that and the other medical service. The problem is that civilianisation--the balance between civilian and military care--has been somewhat obscured by the difficulties experienced by those with proper civilian qualifications who go into military operations but have to operate in a military environment. That gives rise to a very severe problem. It is all very well saying that the NHS can cope with this, that and the other. Nevertheless, those who have to operate in a military environment, as the noble and gallant Lord, Lord Carver, points out, must operate in entirely different circumstances. There is no considered time in which to protect the people for whom they have responsibility.

Thirdly, we accept that there must be a flexible structure between civilian and military services, but we believe that there is an imbalance between the two as a result of the defence costs study. The medical services have been run down and morale has been reduced to a point where there is no longer any effective interlink between the Defence Medical Services and civilian medical services; in other words, the two are so divorced and the morale in the Defence Medical Services so bad that the two cannot conceivably work together in any operational situation.

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The noble Earl will be aware that the House of Commons has made a number of serious criticisms. Its firm view is that,

    "the state of morale at all levels of the Defence Medical Services is lower than we have ever encountered in the armed forces".

I quote further from the report:

    "We conclude that the staff shortages in the Defence Medical Services are so serious"

--the noble and gallant Lord, Lord Bramall, referred to this point--

    "that it is not clear whether it will recover".

The report goes on to say:

    "The current state of the Defence Medical Services is an indictment of MoD's ability to manage change. No amount of self-justification can disguise the fact that the country does not have a medical service capable of looking after the maximum number of soldiers the UK plans to deploy in a crisis".

That is the most serious indictment of government that I can imagine coming from a committee of a House of Parliament.

The noble Lord, Lord Lyell, asked for action today. I am sure that he is right: there should be action today. But we are still in opposition. We do not know the true facts of the matter. We are not in government. If the noble Earl says that there is going to be action today, tomorrow he will walk into his office and say this and that has to happen, then let him say so; otherwise he will almost certainly have to hand it over to us. I am afraid that it will be a problem, because, as the noble Earl knows, we are committed to a review of the whole range of services and the Armed Forces, and we shall see what results. I leave it with the noble Earl: either he says that the Government are going to take action on the basis of what the noble Lord, Lord Lyell, and the noble Baroness, Lady Park, have said, or else he will have to leave it to us to clean up the mess.

10.35 p.m.

Earl Howe: My Lords, my noble friend Lady Park, has with her customary seriousness of purpose brought to the House an issue of fundamental importance both to the Armed Forces and to the Government. For that reason I welcome the opportunity in the short time available to explain our policy and to bring the House up to date on how we are implementing it. I am grateful to all noble Lords for their contributions this evening and shall do my best to answer as many questions as I can. I shall of course respond in writing to any questions I do not cover.

I should like to make it clear at the outset that the Government are totally committed to providing medical care to UK service personnel to a standard that is second to none. Equally, to the military personnel who make up the DMS, we are determined to provide a career that is professionally fulfilling, fairly paid and properly underpinned by fair terms and conditions of service. Those are our starting points; and, while during the course of what follows I shall readily acknowledge that there are some important issues that need our continuing attention, I shall hope nevertheless to demonstrate that the Government's commitment is absolute and that we

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have in fact made some encouraging progress over the past year or so towards the goals that we have set ourselves.

If I could characterise the tone of this evening's debate it has perhaps had a tone of constructive concern. There is concern that the structure of the Defence Secondary Care Agency is not right; that morale has been damaged in the reorganisation; that military ethos in the Ministry of Defence hospital units is fragile; and, most importantly perhaps, that not enough is being done to address the shortages of personnel in key specialist disciplines. Those issues are indeed of central importance, but the situation as we find it today has to be put into context.

The restructuring of Defence Medical Services was vitally necessary and long overdue. In the late 1980s the National Audit Office criticised the structure of Defence Medical Services and the high level of funding devoted to it. A number of studies, culminating in the Defence Cost Study, recommended a significant restructuring of the medical services. The key to the reorganisation was to provide sufficient rapidly deployable units, primarily manned by service personnel to support forces deployed on operations, and a more efficient and cost-effective support structure, including the establishment of a number of agencies to provide secondary medical care and recognised training for medical personnel.

The review sought to go back to first principles by analysing the number of regular medical personnel needed to support the national contingency force in the light of a completely changed strategic environment. The result of the study was to recommend a secondary care structure based on a single core hospital at Haslar, a continuing military medical presence at The Duchess of Kent's Military Hospital, Catterick, and three Ministry of Defence hospital units located in NHS district general hospitals at Plymouth, Frimley Park and Peterborough.

My noble friend Lady Park has expressed her strong reservation about the MDHU concept. However, we considered then and believe now that it was essential to move Defence Medical Services in the direction of closer integration with the NHS, mainly because the Royal Colleges had made it clear that the separate small service hospitals simply could not provide a wide enough clinical base for accreditation for service medical officers. With advances in medical techniques and the overriding importance of ensuring that our doctors and nurses have the best possible skills to support our forces, it was of the utmost importance that we took steps to improve the training of medical personnel in peacetime, and there is no doubt that DMS personnel now benefit from closer links with the NHS in terms of wider clinical experience and training.

This does not mean that military ethos is no longer important or relevant. We totally support the need to maintain the military ethos within the DMS, particularly at the military district hospital units, which operate within the NHS environment. With this is mind, I can tell my noble friend Lord Lyell that we have already put in place measures to improve the nurses' accommodation at Frimley Park. In May we will start

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converting 10 large double rooms to form 20 single rooms, and the living-in personnel will be involved in the design and choice of furnishings. Similarly, MDHU Peterborough personnel are fully integrated into service life at RAF Wittering and take every opportunity to participate in social and other activities there.

The establishment of agencies within the defence medical services was also a key element of the restructuring; notably the Defence Secondary Care Agency, the Defence Dental Agency and the Medical Supplies Agency, all of which were launched last year. Again, my noble friend has criticised this decision. I believe she feels that agencies with their natural emphasis on budgetary rigour and cost effectiveness fail to take sufficient account of the human element in what is essentially a people-oriented service. I have to say to her that I believe her fears are misplaced. The need for a tri-service structure in secondary care was blindingly obvious to eliminate wasteful duplication, and budgetary discipline is a natural concomitant of this. Each agency is headed by a chief executive who reports to the surgeon general. In that way direct channels of accountability are maintained to the three services and the chief executives know that the wellbeing of the medical staff whom they direct is of critical importance to the delivery of an effective service. It is a measure of the importance that we attach to this that I can tell the House that the chiefs of staff are kept in close touch with progress of the new structure and the service it provides.

We recognise that the changes flowing from the DCS have been unsettling for many personnel. It would perhaps have been surprising had this not been so. That is not meant to sound complacent but if we are to get defence medical services right for the long term we were bound to face a period of adjustment. The most serious problem we face, as my noble friend and others have pointed out, is that of staff shortages in some specialisations. But this is nothing new. We have for many years suffered from shortages among surgeons and anaesthetists, a situation directly mirrored in the NHS. There are also shortages in nursing staff. That has meant, for example, that we have been unable to open some wards as soon as we would have wished. These manning problems cannot be resolved instantly; but what we can do, and are doing, is to devise and implement a coherent strategy to address them.

In the short term, to help overcome a shortage of nursing personnel, the Secondary Care Agency is planning to employ additional civilian staff at Haslar on contract terms. But the real issues are recruitment and retention. This is not simply a matter of finding additional money, although that is certainly part of it. It is about looking closely at terms and conditions of service; examining the rationalisation of career structures across the three medical services; and at a management level looking at such basic needs as accommodation.

Recruiting to the DMS is generally satisfactory, and young officers are being attracted into the DMS on cadet schemes. Early signs are encouraging and an increasing number of them are prolonging their service to take

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advantage of the important facilities and opportunities offered by the new structure. Proposals for improvements in the pay and pensions of medical and dental officers are currently being considered by the Armed Forces Pay Review Body and its report is due to be published in April. The Government will look positively, as they always do, on the AFPRB's recommendations and there is no reason why those recommendations should not be examined on a stand alone basis. They certainly do not depend on the final resolution of recommendations arising from Sir Michael Bett's independent review, as announced the week before last. Some other changes will shortly be implemented. For example, extensions of short career commissions to allow higher professional training to be undertaken--with a concomitant return of service--are currently only permitted in the Royal Air Force, but are now to be introduced in the Royal Navy and the Army.

Despite dwelling at some length on that point, I can tell the House that the staff shortages which we currently face in the DMS are manageable.

A number of noble Lords, including the noble Lord, Lord Williams, have expressed concern about the ability of the Defence Medical Services to provide adequate medical support for military operations. That was an area of concern also for the House of Commons Defence Select Committee in its report published last week. I should say to the noble Lord and other noble Lords that we are confident of the DMS's ability to provide medical support for any likely military deployment involving British troops. Currently, they are supporting military operations in Northern Ireland, the Falkland Islands and Bosnia as well as British air operations over Iraq. We are doing that in the main from regular medical manpower. However, we are also using the Reserves, as we have done for some years, for an element of that medical support, particularly in certain specialties. Even with those deployments continuing, we could still provide the necessary medical support for a simultaneous deployment of the Joint Rapid Deployment Force, such as might have arisen in Rwanda, should such a crisis arise.

The noble and gallant Lord, Lord Carver, referred to the risk of skill-fade. In order to alleviate that problem, which is one which we recognise, surgeons and anaesthetists on Operation Resolute now undertake a three-month rather than a six-month deployment.

I have already touched on the subject of morale. A number of noble Lords have expressed concerns about that. We recognise that because of the reorganisation, morale is fragile in some parts of the medical services. However, that is far from being a universal difficulty. Indeed, in many areas I believe morale to be good and improving all the time as the new structures settle down.

My noble friend Lady Park referred to problems in relation to service personnel obtaining priority treatment. We recognise that there have been such difficulties and undue delays in receiving treatment. Those clearly have an impact on the operational capabilities of the Armed Forces as well as having the potential to damage morale. Waiting lists have been

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caused in part by manpower shortages, but it is also true that a backlog of patients was inherited from the service hospitals on their closure. Urgent steps have been taken by the Secondary Care Agency to reduce waiting lists. I am pleased to report that the agency has already achieved a significant improvement in the waiting time for out-patient appointments. For example, the waiting time for orthopaedic appointments at the MDHU at Frimley Park has been reduced from 35 to 15 weeks. The agency aims to reduce waiting times to four weeks across all specialties.

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