I wish to contribute to this important debate from my experience gained over the last 20 years fulfilling a number of roles with Armed Forces Medical Services as: (i) Civilian Advisor in Cardiac Surgery to the Royal Navy since 1987; (ii) Medical Director of Plymouth Hospitals NHS Trust, one of the largest and most committed Ministry of Defence Hospital Units since 2000; and (iii) current NHS Medical Director to the Armed Services Consultant Advisory Board (ASCAB).

  The issues that I would like to air are mainly, but not exclusively, concerned with relationships with the NHS. For brevity and clarity I will deal with them as bullet points.

—  To provide the critical mass to deliver high quality Medical and Surgical Specialties, all of which now interlink, and to train Military Clinical Staff of all types, Military Medicine needs an enhanced and rationalised relationship with the NHS and must at all costs resist the temptation to retrench into non viable "Forces Only" Units except where these could be of sufficient critical mass—for example, Rehabilitation and Mental Health.

—  The NHS is changing fundamentally and fast. Trusts must behave as businesses, cut out unnecessary capacity, and operate at a surplus in order to reinvest and develop. My own Trust is no exception. Waiting lists are becoming a thing of the past and target culture is moving on to an emphasis on quality in a competitive environment. The Military requires flexibility which can be at odds with the new world of the NHS. Trusts need to be incentivised to provide manpower flexibility by the commitment of clinical activity. With Tariff, this should not now be a financial risk. The temptation for Armed Forces Medical Services to increasingly rely on Reservists must be very carefully considered as Trusts are bound to become increasingly wary of appointing Reservists who they believe may be regularly deployed.

—  The NHS Hospital system is also changing. With the European Working Time Directive together with new training and Governance arrangements for Doctors; those Trusts providing the specialised services required by the Military, are getting larger. The model for the future is likely to be a small number of very large complex multi-specialty centres, a few of which will contain the appropriate specialties under one roof to qualify as Trauma One Units together with a network of District General Hospitals some of which will provide 24 hour General Surgery and Accident & Emergency, and some of which will not. The Consultant numbers at my Hospital have grown from 98 to 315 in roughly 8 years. In that time, Military Consultant numbers have remained about the same at 18. The Military is, therefore, becoming a smaller and smaller proportion of the Hospital which is good for neither party. To my mind, this means rationalisation of Military clinical activity to fewer, larger centres.

—  Specialisation is good for clinical standards, but the loss of generalists within large NHS Trusts and, therefore, the Military is good for neither. A new model for both General Medicine and General Surgery is necessary for both. We are developing such a model which will be a real collaborative opportunity for both NHS and Military Medicine.

—  As NHS Trusts are becoming more efficient they are taking out excess capacity. To make significant savings this means whole wards. One or two of these wards in the MDHU network could be converted to the requirements of the Military and mothballed until needed by any surge in clinical activity. This would cost only maintenance and capital charges and would provide inpatient intermediate medical facilities in an "all Military environment" following the usually specialist episode.

—  The quality of our Military Clinical Staff is very high. However, some are highly specialised in ways that must limit their clinical worth for the Forces and expose Trusts to added risk on deployment. This may have been necessary in times of difficult recruitment but leads to retention problems and is, in any case, not now necessary with domestic overproduction of Doctors possible. Also, successful Military Consultants are promoted to a rank which requires decreasing clinical involvement at an age when clinical experience is approaching its most useful. This is not good for Trusts or retention for Military Medicine. Losing the expertise of top class clinicians at or about 50 is not medically good nor to my mind necessary.

—  The provision of reliable, flexible, well trained Medical Services for the Military needs Armed Forces Medicine to work in close harmony with the NHS to the advantage of both. The three wings of the Armed Forces must integrate fully despite having different emphases. This needs careful consideration, taking into account the expectations of all involved—non-Medical Armed Forces, the NHS and the public—and must address immediate, intermediate and longer term care such as Rehabilitation, Mental Health and Counselling services.

  I hope that the above points are helpful. Please let me know if the Committee requires any amplification or addition.

Terence Lewis, Medical Director

9 March 2007