Scope of the inquiry

1. In October 2006, the Defence Committee decided to undertake a wide-ranging inquiry into the provision of healthcare for the Armed Forces. While there was at the time considerable media interest in the treatment of casualties from operations in Iraq and Afghanistan, we wanted to look at the subject in the broadest sense, and to examine how Service personnel and their families were cared for. We were also keen to examine the arrangements made for veterans and the way in which the Ministry of Defence (MoD) cooperated with the National Health Service (NHS) to deliver appropriate care.

2. We decided to examine six key areas. The first was the treatment of personnel seriously wounded on operations, and the procedures for caring for them, from the point of wounding to evacuation to and treatment in the United Kingdom. The second, interrelated, area was the rehabilitation work for those with serious, generally musculo-skeletal or neurological, injuries. The third was the relationship between the Ministry of Defence and the National Health Service in terms of delivering healthcare. The fourth area we examined was the care for veterans and Service families. The fifth issue was mental healthcare, both for Service personnel and for veterans. Finally, we examined the role of Reserve personnel in the Defence Medical Services.

3. During the course of our inquiry, we conducted a number of visits. In November 2006, during a visit to Cyprus, we were shown round The Princess Mary Hospital (TPMH) at RAF Akrotiri. In June 2007, we visited the Defence Medical Rehabilitation Centre (DMRC) at Headley Court; Combat Stress's care home, Tyrwhitt House, in Leatherhead; and the Royal Centre for Defence Medicine (RCDM) and Selly Oak Hospital in Birmingham. During our visit to Iraq in July 2007, we saw the deployed field hospital in the Contingency Operating Base (COB) at Basra Air Station, which we had previously visited when it was at Shaibah Logistics Base in 2006. In September 2007, we visited the Primary Casualty Receiving Facility (PCRF) on board RFA Argus, a Royal Fleet Auxiliary vessel, on exercise in the Solent. In October 2007, we visited 2 Medical Brigade and the Army Medical Service Training Centre at Strensall in Yorkshire, and the Regional Rehabilitation Unit (RRU) and Medical Reception Station (MRS) at Redford Barracks in Edinburgh. In addition, some of us visited the Ministry of Defence Hospital Units (MDHUs) at Frimley Park, Portsmouth, Plymouth and Northallerton.

4. We held four evidence sessions in the course of this inquiry. On 12 June 2007, we took evidence from representatives of Service welfare organisations. On 21 June 2007, in Birmingham, we took evidence from the University Hospital Birmingham NHS Foundation Trust, the five Trusts which cooperate with the MoD to run MDHUs, and the British Medical Association. On 11 October 2007, in Edinburgh, we took evidence from the Royal College of Psychiatrists, the St John and Red Cross Defence Medical Welfare Service, and officials from the Scottish Executive. On 27 November 2007, we took evidence from Ministers and officials from the Ministry of Defence and the Department of Health.

5. In addition to our evidence sessions and visits, we conducted a two-stage Internet-based consultation, in summer and autumn 2007, the results of which are summarised in Annex B.

Earlier reports

6. Our predecessors have inquired into Armed Forces medical care on a number of occasions. Key reports were produced during the mid- to late 1990s, a period of profound change for the UK Armed Forces following the end of the Cold War and the attempt to make good on the so-called 'peace dividend'. There were reports in 1995[1], 1997[2] and 1999[3].

7. All of these reports examined the way in which military healthcare was adapting to the changing circumstances, military requirements and resource constraints of the 1990s. An understanding of current health provision for the Armed Forces needs to take account of the changes of the past fifteen years, and we examine those changes in more detail below.

Changes in the provision of military healthcare

8. The first major post-Cold War review of the UK's military requirements was 1990's Options for Change. This included a review of defence secondary care in the UK, which proposed a rationalisation of the seven existing military hospitals to three single-Service facilities, at Haslar (Royal Navy), Aldershot (Army) and Wroughton (Royal Air Force). Secondary care for overseas garrisons such as Cyprus and Gibraltar was to remain the responsibility of the existing stand-alone hospitals.

9. The care provided by the three Service hospitals was to be augmented by 300 beds based in National Health Service hospitals, staffed by military personnel. These would be known as Military District Hospital Units or MDHUs (though they were subsequently renamed Ministry of Defence Hospital Units, retaining the original acronym). Engagement with the NHS was intended not only to ease the burden on MoD resources but also to encourage the broadening of clinical skills and the interchange of experience.

10. There was a further review the following year, 1994, as part of Front Line First. This recommended the closure of Aldershot and Wroughton, and the consolidation of provision at a tri-Service hospital at Haslar. The review also re-endorsed the creation of three MDHUs, and suggested the creation of four 'Next Steps' agencies, to manage: secondary care, dental care, medical training and medical supplies. Each agency was to have a Chief Executive who would report to the Surgeon-General.

11. Although the MoD had originally planned to maintain the Royal Hospital Haslar, primarily as a centre for training, after the closure of the hospitals at Aldershot and Wroughton, it was found that the number and range of cases required to maintain skills and make clinical services viable was not available. Therefore, in December 1998, the Government took the decision to close Haslar in phases and to consolidate its training activities within the NHS, based around the MDHUs. Haslar ceased to be a military unit on 31 March 2007, though it continues to be owned by the MoD and will continue to function until late 2009, when clinical services will transfer to the Queen Alexandra Hospital at Cosham in Portsmouth.

12. The realignment of medical care, and especially the provision of secondary care, was not without its problems, as our predecessor committees found. It is also clear to us, especially from contributions to our web-based consultation on this inquiry, that there remains considerable strength of feeling in the Service community and beyond. Many passionately opposed the closure of Service hospitals and continue to regard it as a mistaken policy. The existence of identifiable, military-owned and run facilities was clearly important and a source of much pride and affection, and a number of the contributors to our web forum wanted to see them re-established.

13. We acknowledge that stand-alone military hospitals were important to the Service community, and we also appreciate the argument that it is beneficial to injured Service personnel to be treated in their own community, in familiar surroundings. On our visit to Headley Court in June 2007, we saw for ourselves the benefits to be gained from harnessing the power of the camaraderie of the Armed Forces to help the healing process, both mentally and physically. We further acknowledge the existence of such facilities in the United States, to which opponents of the closure of military hospitals often point.

14. However, 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, a situation which can still be seen, for example, at The Princess Mary Hospital at RAF Akrotiri, which we visited in November 2006. We are also persuaded that the small volume of patients, combined with the limited case range presented by the Service population, was inadequate to maintain the skills of Armed Forces medical personnel. 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. We heard from Service personnel on a number of our visits that the current arrangements were much preferable in clinical terms to stand-alone Service hospitals.

15. There was further administrative streamlining of the Defence Medical Services in 1998. Defence Medical Services: A Strategy for the Future gave the Surgeon-General complete oversight of the DMS by making the individual Service Medical Directors-General report to him rather than to their Chiefs of Staff. The administration of medical services was further altered in 2002, with the appointment of a non-medical Deputy Chief of the Defence Staff (Health) to manage the administrative work of the Defence Medical Services Department, while clinical services remained the responsibility of the Surgeon-General.[4] In November 2007, we took evidence from the Surgeon-General, Lieutenant-General Louis Lillywhite MBE QHS, and the Deputy Chief of the Defence Staff (Health), Lieutenant-General Robert Baxter CBE, and we are satisfied that this 'double headed' approach is an efficient and effective one.

Current organisation of Armed Forces medical care

16. The Surgeon-General and the Deputy Chief of the Defence Staff (Health) jointly oversee the work of three organisations. These are:

• The Defence Medical Services Department (DMSD): the administrative headquarters of the DMS, which is responsible for strategic direction;
• The Defence Medical Education and Training Agency (DMETA): a tri-Service organisation which provides personnel to meet the secondary care requirements of operational deployments as well as educating and training medical personnel. DMETA has command and control over:
  • Ministry of Defence Hospital Units;
  • The Royal Centre for Defence Medicine (RCDM);
  • The Defence Medical Rehabilitation Centre (DMRC) at Headley Court;
  • The Defence Medical Service Training Centre (DMSTC) at Keogh Barracks;
  • The Defence Medical Postgraduate Deanery, and
  • Retained military tasks at the Royal Hospital Haslar, managed in conjunction with Portsmouth Hospitals NHS Trust and due to close in late 2009.
• Defence Dental Services: a tri-Service organisation which employs both military and civilian personnel and provides dental services in the UK and on operations.[5]

17. The individual Services each have a responsibility for delivering primary healthcare and the requisite medical support on operations. The Surgeon-General and the Deputy Chief of the Defence Staff (Health) produce medical policy for the Royal Navy, Army and Royal Air Force Medical Services, which are responsible to the Service Chiefs of Staff.

2   Defence Committee, Third Report of Session 1996-97, Defence Medical Services, HC 142 Back

3   Defence Committee, Seventh Report of Session 1998-99, The Strategic Defence Review: Defence Medical Services, HC 447 Back

4   The first DCDS (Health) was Lieutenant-General Kevin O'Donoghue, now General Sir Kevin O'Donoghue, Chief of Defence Materiel. Back

5   Ev 89-90 Back