MEMORANDUM SUBMITTED BY MINISTRY OF DEFENCE (CBPS 36)

1. This Memorandum aims to provide the House of Commons Welsh Affairs Committee with relevant background information to aid their inquiry into cross-border provision of public services for Wales. In accordance with the Committee's invitation to the Ministry of Defence to submit evidence, this Memorandum focuses on the provision of healthcare for Armed Forces personnel, their families, veterans and Reservists.

PROVISION AND FUNDING OF HEALTHCARE TO THE ARMED FORCES

2. Members of the regular Royal Navy, Royal Marines, Army and Royal Air Force have access to a wide range of medical and dental services. The range of services in the UK includes: Primary Healthcare; Dental Services (including dental hygiene); Secondary Healthcare in NHS hospitals; Rehabilitation Services provided by the Defence Medical Rehabilitation Centre (DMRC) and at the Regional Rehabilitation Units (RRUs) and Mental Health Services provided by regional military community-based out-patient and private sector in-patient facilities. MOD also provides healthcare outside the UK at our permanent bases or on deployed operations; details are outside the scope of this memorandum.

PRIMARY HEALTHCARE

Service Personnel

3. The MOD funds primary healthcare for Service personnel and provides primary care facilities at major military population centres. Service personnel are also entitled to access NHS primary care on an emergency or immediate care basis. In addition, Service personnel can register on a temporary basis with a NHS GP for up to 3 months should the individual be unable to use a reasonably accessible military facility.

4. The MOD provides a range of Primary Care Services including medical centres located throughout the United Kingdom. The size and 'skill mix' of each medical centre varies depending on factors such as location and the size and health needs of the population served. The typical medical centre provides access to General Practitioners, Practice Nurses, Military Medical Assistants and Physiotherapists and Remedial Instructors. Some of these personnel will be uniformed Defence Medical Services (DMS) personnel and others will be civilian practitioners. The medical centres provide medical diagnostic and treatment services similar to those provided by a civilian medical practice, but they also provide occupational medical services, which is a major component of their activity. In the main, Service personnel have access to a medical centre in the immediate vicinity of their unit but in some areas where the serving population is few in number, personnel will have access to a military medical centre elsewhere or, occasionally, a NHS practice may be contracted to provide this service.

Dependants

5. In the UK, dependants of Serving personnel are entitled to NHS provision of primary care and the majority are registered with NHS GPs. In a few locations, military GP practices in the UK register families so that the practice can meet the criteria required of a GP training practice (so that military GPs can attain the appropriate qualifications) or because the military practice has spare capacity. No funding flows from the local PCT or Local Health Board to MOD in such cases. The medical centre at MOD St Athan treats about 350 dependants, and the one at RAF Valley treats around 200.

DENTAL SERVICES INCLUDING DENTAL HYGIENE

Service Personnel

6. The Defence Medical Services provide unit- and regionally-based dental centres. These centres operate under the command of the Defence Dental Service (DDS). The DDS provides local access for Serving Personnel to Dentists, Dental Nurses and Dental Hygienists. These specialists provide routine diagnostic and treatment services, but also offer valuable occupational screening services ensuring that serving members of the Armed Forces are 'dentally fit' to undertake their role.

Dependants

7. Dependants of Service personnel are entitled to NHS provision of dental care. They are not entitled to DDS dental care in the UK.

SECONDARY MEDICAL CARE IN THE UK

Service Personnel

8. All Service personnel are entitled to access the full range of NHS secondary care and community services. The MOD no longer runs its own secondary care facilities ('military hospitals') in the UK. Funding is allocated to PCTs and Local Health Boards (LHBs) based on the National Census (with Service residents included). The MOD informs the Health Departments in the various parts of the UK if there is likely to be a significant reduction (such as a base closure) or increase in the local Service population. The military population is included when the calculations take place for funding allocation from the Department of Health to PCTs in England; and from the Welsh Assembly Government to the LHBs.

9. In addition to accessing local NHS secondary care by referral from local (military of civilian) GPs, 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[1] (MDHUs) and University Hospital of Birmingham Foundation Trust (UHBFT) where the Royal Centre of Defence Medicine (RCDM) is based. The MDHUs are situated in areas with a higher military population. Personnel based in, or living in, Wales who are sent for accelerated access treatment, are usually treated at UHBFT, but it may be at one of the other MDHU host trusts, depending on the particular patient's circumstances.

10. In addition to the accelerated access purchased from the MDHU Host Trusts, the MOD has developed a specific orthopaedic fast track programme to meet the relatively high incidence of musculo-skeletal cases arising 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 or rehabilitation treatment (the majority) are treated in MOD's own Regional Rehabilitation Units (RRUs) - so no NHS waiting list issue arises. If surgery is necessary (for the minority of cases) we can and do arrange fast access to surgery in the MDHU Host Trusts or other NHS Trusts, typically within 6 weeks of the decision on their treatment path.

Dependants.

11. All secondary care and community services for the dependants of Service personnel in the UK are obtained from the NHS. The MOD provides no funding for this care.

OPERATIONAL HEALTHCARE FOR ARMED FORCES

Selly Oak Hospital.

12. Since 2001, the Royal Centre for Defence Medicine (RCDM), based at the University Hospital Birmingham Foundation Trust (UHBFT), has been the main receiving unit for military casualties evacuated from an operational theatre overseas. In the Birmingham area, military patients can benefit from the concentration of five specialist hospitals (including Selly Oak Hospital) to receive a very high standard of care. Indeed, Selly Oak is at the leading edge in the medical care of the most common types of injuries (eg polytrauma) our casualties sustain. The medical needs of the Armed Forces are best served through access to facilities and training in a busy acute care hospital that is managing severe trauma on a daily basis.

13. Additional funding has been provided to help meet the travel and accommodation costs of patients' families who need to travel to Selly Oak. Accommodation available includes seven flats, plus a number of family rooms. Some of the flats have benefited from recent refurbishment funded by the Soldiers, Sailors, Airmen and Families Association (SSAFA), which is helping to provide a more suitable environment for the families of the patients concerned. Additional transport for patients and families is also being provided from public funds.

Defence Medical Rehabilitation Centre (DMRC) and Regional Rehabilitation Units (RRUs).

14. MOD has made considerable investment in rehabilitation in recent years and now adopts a tiered approach. Most primary care centres have been reinforced by physiotherapists. When necessary, patients are referred to one of 15 Regional Rehabilitation Units (RRUs) which focus on the assessment and treatment of musculoskeletal injuries and sports medicine and are staffed by specially trained Doctors, Physiotherapists and Rehabilitation Instructors.

15. Military patients requiring further rehabilitation care may be referred to the Defence Medical Rehabilitation Centre (DMRC) at Headley Court in Surrey, which is the principal medical rehabilitation centre run by the Armed Forces. DMRC also accepts direct admission from hospitals, and most combat casualties are referred directly to DMRC from Selly Oak. DMRC provides both physiotherapy and group rehabilitation for complex musculo-skeletal injuries, plus neuro-rehabilitation for brain-injured patients. The Complex Rehabilitation and Amputee Unit, based within DMRC, provides high quality prosthetics and adaptations, manufactured on site and individually tailored as necessary for the specific patient. Where possible, the provision of prosthetics aims to enable Service personnel to resume service duties.

Mental Health

16. 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 undertaken by fully trained and accredited mental health personnel.

17. 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 15 UK military regional Departments of Community Mental Health (DCMH) centres sited in military bases staffed 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.

18. In-patient care, when necessary, is provided regionally in specialised mental health units under a contract with the Priory Group, and when appropriate in NHS hospitals. The in-patient contract is due to expire at the end of November 2008 and we are currently conducting a competitive tendering exercise to place a new contract.

19. 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.

ARMED FORCES PERSONNEL BASED IN WALES

20. The Army has two medical centres in Wales: one at Cawdor Barracks, near Haverfordwest serves a military population of around 650; the second, at Brecon, which also has a bedding-down facility, serves around 460 personnel. In addition there is a medical centre at Beachley Camp, near Chepstow, serving a military population of around 630. Although the town of Chepstow is in Wales, the camp and Medical Centre are in England.  Some dependants living in England will be registered with Welsh GP practices.

21. There is also a small number (less than 30) of Army personnel based in North Wales who are treated in Chester Medical Centre.

22. The RAF's medical centre at MOD St Athan provides primary and occupational health care, including a physiotherapy department, to a military population of almost 1800. These include Serving personnel from all three Services, but primarily the Army and RAF, and some dependants. The RAF also runs a medical centre at RAF Valley in Holyhead, looking after almost 700 people, including some dependants.

23. For emergencies (A&E) as well as for minor requirements Service Personnel based in Wales use NHS hospitals in Wales. For elective secondary care referrals they may go to Birmingham or to local Welsh NHS hospitals. Service Personnel based in England but on courses, exercises or adventure training in Wales receive emergency secondary health care from NHS hospitals in Wales if required.

24. MDHUs have not, thus far, been created in the Devolved Administrations. They have an important role in maintaining and developing the skills of our military doctors, nurses and other health professionals. When they were set up, the locations of the MDHUs were selected to take advantage of existing links and proximity to the then-remaining military hospitals. This does not, however, mean that Service patients based in Wales do not have access to the same standard of care that applies in England. Most personnel receive treatment in local NHS hospitals and our Service medical personnel have developed good working relationships with local NHS units to help achieve excellent secondary care for Service personnel.

25. There may be circumstances when Service personnel based in Wales might be asked to attend a Host Trust in England. This is often for a specific occupational assessment but may also be in order to benefit from the contracts for accelerated access for elective referrals agreed with the MDHU Host Trusts, as explained earlier, or to access a particular specialism not available locally. If it is necessary for a Serviceman or woman to travel for a medical appointment then their expenses will of course be paid. For those admitted to hospital, there are support provisions in place to provide transport and accommodation for close family members to visit if the appropriate medical authority considers that it would assist the patient's recovery.

26. There is no RRU or DCMH in Wales at present, although this is kept under review, particularly with the planned expansion of MOD St. Athan in around five years' time. Service personnel living in or based in Wales who require treatment at a DCMH go to the Centre at Donnington. Those requiring treatment at a RRU go to a number of units in England depending on the workload of the units and the individual's personal circumstances. However, in May 2008 a new RRU is to open in Lichfield and it is likely that many personnel based in Wales will receive treatment there from that date.

RESERVISTS

27. Whilst mobilised, reservists are treated exactly the same as members of the Regular forces. If a medical officer assesses that a mobilised member of the reserve forces requires treatment or rehabilitation, they will be treated in exactly the same way as regular personnel. This may include treatment and rehabilitation at a military RRU or the DMRC at Headley Court, Surrey, or - if the problem is related to their mental health - treatment at a military Department of Community Mental Health (DCMH) or admission to the Priory Group.

28. When reserve personnel are demobilised, they are given a medical assessment. During this process, if it is identified that they are in need of hospital care they may be referred to NHS hospitals hosting Ministry of Defence Hospital Units (MDHUs) or the RCDM at Selly Oak Hospital. They will be treated within military timeframes which can in some cases offer faster access to treatment than is the case for NHS patients. Reserve personnel will receive treatment for injuries sustained on operation until they are deemed to have reached a steady state of fitness. They are then demobilised, and taken through a transition from military to NHS care, if they have continuing healthcare needs. The patient may express a preference for treatment in a hospital nearer to their home, which may be a non-MDHU hospital. In accordance with NHS protocols, if they are referred on to a non-MDHU hospital, then access to treatment is according to clinical priority.

29. Prior to mobilisation and following demobilisation, medical care including dental care is the responsibility of the reservist's own local NHS primary care trust and the majority of reservists' physical and mental health needs are met by these provisions. All reservist personnel while on duty (whether mobilised or not) are eligible for emergency treatment from the Defence Medical Services (DMS) but with the current structures of both the DMS and NHS, non-mobilised Reservist casualties requiring further treatment in the UK will transfer to NHS care. If seriously injured on duty they will receive the most appropriate clinical care from facilities available through the DMS, if such facilities are not available in the NHS, following their initial emergency treatment.

30. In addition, the MOD recognises that it has an expertise to offer in certain specific circumstances, and in November 2006, it launched a new initiative - the Reserves Mental Health Programme (RMHP). The RMHP is open to any current or former member of the UK Volunteer and Regular Reserves who has been demobilised since 1 January 2003 following an overseas operational deployment as a reservist, and who believes that the deployment may have adversely affected their mental health. Under the RMHP, the process of self referral can be initiated by the reservists or the individual's GP and offer a mental health assessment at the Reserves Training and Mobilisation Centre in Chilwell, Nottinghamshire. If diagnosed to have a combat-related mental health condition, we then offer out-patient treatment via one of the MOD's 15 UK DCMHs.  If more acute cases present, the DMS will assist access to NHS in-patient treatment.  We are working with the UK health authorities to ensure that GPs across the UK are aware of the initiative.

Deployment of Welsh Field Hospital Reservists

31. The Committee may wish to be aware that 46 Reservists from 203 (Welsh) Field Hospital (Volunteers), based in Cardiff, are to deploy to operations in Afghanistan for three months from April 2008.

VETERANS

32. When personnel leave military service their healthcare becomes the responsibility of the NHS.  That has been the policy of successive governments since 1948.

Priority treatment for Veterans in Wales

33. In November 2007, the Welsh Assembly Government Health Minister announced that all veterans suspected of having a health condition related to their military service will get priority NHS treatment and care, subject also to clinical need.

34. Previously, only those in receipt of a war pension or an award under the Armed Forces Compensation Scheme were entitled to priority treatment. These measures will extend the arrangements to any of the UK's five million veterans whose conditions are suspected of being due to service.  Beneficiaries of this move include any former member of the Armed Forces with a condition recognised as being due to service, whether related to conflict (e.g. the operations in the Falklands, Afghanistan and Iraq) or to service more widely.

35. It is not expected that there are many veterans who will come forward for priority treatment for service-related conditions who did not already qualify, but it is hoped that this change will benefit a small number of people whose conditions become problems after discharge and who have not yet applied for a War Pension. The main conditions are likely to be mental health, audiology and orthopaedics.

Mental Health services for veterans

36. Ex-service personnel are entitled to receive treatment through their GPs but we recognise that many health professionals may have limited experience of dealing with veterans with mental health symptoms arising from their service experience. In addition, the military ethos of strength and self-reliance may, for some veterans with mental health symptoms and illness, be an obstacle to accessing civilian health care; we are also aware that some veterans are concerned that there will be no or only limited understanding by GPs of the context of their illness.

37. In conjunction with the Department of Health and Health Departments in Wales and Scotland, we are now launching a number of community mental health pilots for veterans. Cardiff is one of six sites across the UK taking part in the two-year pilot scheme which, if proved successful, may be rolled-out to other locations. The facility will have a trained community veterans' mental health therapist and veterans will be able to access this expert service directly or through their GP, ex-service organisations, the Veterans' Welfare Service, or Social Service departments. This is on top of the mental health services to which GPs can refer patients, including in-patient treatment or referral to a specialist service if that was clinically appropriate.

38. The facility will be based at the University Hospital of Wales, Cardiff and will cover the Cardiff and Vale, Pontypridd & Rhondda and North Glamorgan Trust areas. The facility will be funded by the Welsh Assembly Government and Ministry of Defence.

39. For areas not yet involved with the community mental health pilots the MOD has extended the scope of the Medical Assessment Programme (MAP), based at St Thomas' Hospital in London, to any veteran suffering mental health problems who has served in operations since 1982.

40. MOD also provides funds in respect of the fees for individual war pensioners undergoing remedial treatment at Ex-Services Mental Welfare Society ("Combat Stress") homes. MOD is the single biggest contributor to Combat Stress. Last year we gave them £2.5 million by way of individual fees, and the Minister for Veterans recently announced a further increase of 45 per cent in the rate of fees to be met by the Department.

Rehabilitation Study to Support Ill 1990/1991 Gulf Veterans

41. The Medical Research Council recommended that further research into Gulf War illnesses should aim to improve the long-term health of Gulf War veterans with persistent symptoms. The Ministry of Defence is therefore looking to place a contract with the aim of designing and testing a programme of rehabilitative interventions to meet the needs of this vulnerable group of veterans. This work might have wider application to other groups similarly affected by debilitating illness.

42. The aim of the Rehabilitation study entitled, "Trial platform to support ill 1990/1991 Gulf veterans achieve optimal health and well being", led by Dr Jonathan I Bisson, Clinical Senior Lecturer in Psychiatry at Cardiff University, is to identify and address physical, personal, psychological, social and occupational obstacles to recovery and functioning. There is a strong evidence base showing that paid work is generally good for physical and mental health with benefits in well-being, self esteem and social skills. The Cardiff team were selected to undertake this programme because of their special expertise in this field.

MOD RELATIONS WITH THE NHS AND WELSH ASSEMBLY GOVERNMENT

43. MOD maintains regular contact at both working level and the highest official levels with counterparts in the health departments and Veterans' units of the Devolved Administrations to ensure that health issues affecting both Serving personnel and their families and veterans are given the consideration they deserve. As well as in these specific areas, the MOD has a Head Office team responsible for managing Devolution issues in general as they affect the Department and maintaining relations with the Devolved Administrations and Territorial Offices. We recognise that, with devolution increasingly leading to more varied provision and delivery of public services across the UK, there is an increasing challenge to educate Service families, who continue to rely on locally delivered services, about what they may expect in different areas of the UK.

Partnership Board

44. The key outputs of the DMS are supported by a close working relationship with the NHS, supported by the MOD/Department of Health (DH) Partnership Board. A Concordat, which sets out how the DMS and the NHS will work together to further their individual and mutual aims of delivering high quality healthcare to both the UK Armed Forces and NHS patients, was extended in March 2005 to include the Health Departments of Scotland, Wales and Northern Ireland. 

45. The 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 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 of and healthcare provision for Service personnel, their dependants and veterans and in the delivery of deployable operational capability.

Veterans Forum

46. The Under Secretary of State for Defence chairs the Veterans Forum where he meets regularly with officials from the Devolved Administrations and other stakeholders to discuss and address issues of concern to the veterans' community. He also speaks with Ministerial counterparts where issues of concern justify engagement at this level and spoke most recently to Edwina Hart on a range of veterans issues on 4 December 2007.

47. Officials also have regular contacts and a good working relationship with officials in the Welsh Assembly Government on veterans matters.

20 March 2008

[1] Derriford, Frimley Park, Northallerton, Peterborough and Portsmouth