Below is the text of BAFF's evidence as submitted to the House of Commons Defence Committee Inquiry in 2007-8 into medical care for armed forces personnel and their familes.
Memorandum from the British Armed Forces Federation (BAFF)
INTRODUCTION
1. This Memorandum is submitted on behalf of the British Armed Forces Federation, an independent, representative staff association formed in December 2006 for serving members of the armed forces. Former members of the forces may also join. Members are drawn from all three services, including the reserves, with no restrictions as to rank.
2. BAFF's membership includes serving and retired Defence Medical Services staff, and at least one member who has experienced the casualty evacuation chain from operations in Afghanistan.
3. Recent media stories about alleged deficiencies in forces medical care have been deplored as "bad for morale". We agree, but real deficiencies could be worse. Confidence is not increased by denying deficiencies when they are first raised in the media, only for remedial action to be announced much later, rendering the original criticisms "out of date". A case in point is that of helicopter availability for battlefield casualty evacuation in Afghanistan.
4. We therefore warmly welcome the opportunity afforded by the Defence Committee's Inquiry to establish the facts in an impartial cross-party setting. We have played our part in helping to publicise the Inquiry and to encourage individuals to participate in the Committee's online forum.
SUMMARY
5. BAFF seeks not to turn the clock back to the previous network of Military Hospitals, but argues that the present system requires more attention and investment before it fully comes up to the claims made for it. Anything less than world-class medical services for our country's armed forces will damage recruitment, retention and operational efficiency. We welcome improvements which have been made. We also draw attention to a number of concerns relating to the after-care of discharged personnel, especially in the area of mental health.
HEALTHCARE FOR SERVICE PERSONNEL
6. It is, of course, the norm for advanced countries to maintain dedicated military hospitals for their armed forces. The former Naval Hospitals, British Military Hospitals, and RAF Hospitals had much to commend them, and criticisms of them by those seeking to justify the present arrangements have sometimes been exaggerated. An updated, streamlined system of military hospitals is theoretically feasible, although the investment required for a fresh start would be daunting.
7. Some military hospitals were able to treat non-military patients from service families or, in some places, from the local community. This widened the clinical experience of staff as well as, arguably, increasing value for money for the taxpayer. It has been suggested that a restored system of military hospitals could treat ex-service people ("veterans") as well as serving members of the armed forces. We do not, however, consider that there is a realistic case for our UK veterans to be treated separately from other non-serving patients, with the exception of treatment for service-related psychiatric disorders, discussed further in this Memorandum.
8. We recognise the premise underlying the present arrangements that the more patients who are treated in any particular clinical specialisation, the better the average outcome is likely to be. In any type of hospital whether military, NHS or private there will always be some sub-optimal patient outcomes, for whatever reason. While we have no figures, we suggest that the standard of treatment provided to UK military patients is high, and that many of the reported problems relate to inadequate patient management rather than to clinical deficiencies. Nevertheless, poor management of a patient can have a very harmful effect on the psychological outcome of their physical injury.
9. The need for a strong military presence within, or dedicated to liaison with, the NHS is paramount. This is achieved at the MDHUs, and to an extent at RCDM, but is more difficult in non-MDHU NHS facilities.
10. The Military Administrative Officer (Civil Hospitals) ["MAO(CH)"] concept is good, but is severely under-resourced. These individuals have to track all Service personnel in NHS hospitals across the UK, and in addition need to engage with Primary Health Care trusts to track Service personnel under non-military GP care. Without a properly co-ordinated and mutually understood system in this area, any military input to (or even knowledge of) after-care is impossible. Again, the essential occupational aspect of the Service patient is missed, as civilian GPs (and indeed hospital practitioners) are unaware of the specific stresses placed on Service personnel.
11. The NHS is not an occupational service. It is not interested in getting people back to work, but in getting them out of hospital beds. For Service personnel this has a particular disadvantage. Civilian patients are discharged to the care of their NHS GP, and to their home environment. The Service patient may be a single individual living in barrack accommodation, and his "family" (including in some instances his Service GP) may be away on an operational tour—so there may be no real supervision of this individual.
12. Military medical records remain a problem area. Part of the problem relates to the need for records for Service personnel on posting to be transferred manually at present; speeding up the introduction of DMICP (Defence Medical Information Capability Programme) will undoubtedly assist in this. However, the complexities involved in this should suggest avoiding too rapid an approach, lest the technical necessities are overtaken by user unfamiliarity. Continuity of care may also be challenged by the frequent move of Service personnel, including, of course, the medical personnel who look after them, and the requirement for medical personnel to be removed from their "peacetime" locations for operational tours. Too great a reliance on civilian medical staff (either employed by the MoD or contracted to the NHS) removes the essential occupational medicine input to the military—an input which is needed to maintain their individual health and the operational effectiveness of the Defence Forces.
13. There must be no repetition of the widespread "disappearance" of inoculation dose records for personnel who served on Operation Granby (Gulf 1990-91), which remains a source of understandable concern to both serving and retired personnel.
MEDICAL SUPPORT FOR OPERATIONS
14. Albeit from a small sample, BAFF has received favourable reports of the standard of medical care provided in operational theatres. In-theatre and strategic casualty evacuation should be reviewed. Our comments here concentrate on the after-care of operational casualties.
15. In addition to the after-care of sick and injured who are returned from operations but are still members of the Forces, we also attach importance to the continuing after-care of those who have left the Service whether voluntarily, or otherwise.
16. In respect of physical injuries, the Defence interest in post-discharge after-care is transitional. For example, a patient who leaves the Service while on the waiting list for an operation, and returns to his or her home area, may well find themselves back at the bottom of the waiting list. There are also record-transfer issues.
17. From a purely medical perspective, the treatment and support of an amputee may be little different whether the injury occurred on the battlefield, or in a motorcycle accident. Service-related psychiatric disorders such as PTSD demand a more tailored approach, however.
DELIVERY OF HEALTH CARE FOR THE ARMED FORCES
18. The crucial point is the properly worked out, contractually agreed and mutually workable interface with the NHS. The limitations of the existing contractual arrangements (under the "Concordat") need to be recognised, and managed for the future. The NHS may not be equipped to deal with specific problems of military service, such as PTSD.
19. The MAO(CH) system is not only under-resourced, it is single-service. The recent introduction of Sickness Absence Management has helped, but there remains a need for a tri-service system. In many cases lines of communication and protocols between hospitals and patients' units are insufficiently defined, leading to duplication of effort. A combination of charities, senior officers' wives and unit personnel may descend upon the patient and however welcome they may be, confusion can sometimes result.
MENTAL HEALTH ISSUES
20. Whilst we understand that PTSD may typically present within six months of the traumatic event, this may not be the case with service patients, for two reasons. Firstly, the military PTSD-sufferer may have experienced repeated events, having a cumulative effect which may not be apparent until some further event brings the problems to the surface much later. Secondly, serving members of the armed forces are supported by feelings of comradeship and esprit de corps, and may succeed in coping with their trauma while still in uniform; they may, indeed, successfully conceal their problems for a time for reasons of machismo and, even, the real fear of damaging or losing their career.
21. We welcomed the MoD announcement on 11 June, 2007 to extend the Medical Assessment Programme (MAP) to allow more former Service personnel to seek "professional advice" on mental illnesses which they feel are linked to their time in the Armed Forces. Apparently the "advice" will, however, only comprise screening. So as not to deter eligible individuals from seeking screening under the MAP, we would welcome an assurance that the results may not be used in relation to any pension or compensation issue without the consent of the patient.
22. We are also aware—as many NHS practitioners clearly are not—of the tri-Service Reserves Mental Health Programme (RHMP) established at Chilwell. This facility needs to be publicised much more effectively.
23. Eligibility under the RHMP is currently restricted to those reservists who have been demobilised from an operational theatre since January 2003. Eligibility under the MAP is restricted to those veterans who have served since 1982. Both of these date restrictions are arbitrary and unjustifiable, and we would urge the MoD to remove them.
24. Whilst ex-forces sufferers from mental health problems must not be directed away from the NHS if that is the treatment they prefer, NHS psychiatric services may not in some cases be the best source of treatment. Ex-forces PTSD sufferers have, on occasion, been asked not to continue NHS group therapy because their recounted experiences were upsetting the other patients.
25. Every veteran suffering from mental health issues linked to their past service should be eligible for whatever treatment they need either directly under Defence arrangements, or from Combat Stress (Ex-Services Mental Welfare Society) with adequate MoD funding.
26. We note the comprehensive arrangements in Canada for treatment of "Operational Stress Injury" both for serving personnel, and for veterans. British personnel and their families are given helpful information sheets on issues which might arise after an operational tour, but these sheets may be easily lost or discarded. In Canada, the information remains readily available to veterans and their families by various means, including the internet.
PRIORITY NHS TREATMENT FOR WAR PENSIONERS
27. War pensioners and equivalent are supposed to be entitled to "priority NHS treatment" for the condition for which their pension was awarded. There are two problems with this provision. Firstly, many NHS staff are unaware of it, and it seems likely that awareness will diminish as time goes on. Secondly, priority "is a matter for clinical judgement based on clinical need which means that the case with the greatest clinical need will receive precedence" (MoD 2007). Since the prime criterion is clinical need, and NHS staff are also required to apply numerous targets none of which include "care for veterans", the priority entitlement appears in reality to be virtually meaningless.We
18 June 2007
