Examination of Witnesses (Questions
21 JUNE 2007
Q166 Chairman: Gentlemen, and lady, welcome.
If I may begin by asking you to introduce yourselves and say where
you are from and what you do.
Mr Lewis: My name is Terence Lewis.
I am a consultant cardiothoracic surgeon and I am Medical Director
of Plymouth Hospitals. I am here representing, I suppose, the
opinion of Plymouth Hospitals. I separately submitted written
evidence in my own right because I am a civilian consultant adviser
and I sit on ASCAB. I have been involved with military medicine
for a very long time.
Mr Morris: Andrew Morris, Chief
Exec, Frimley Park Hospital. Frimley is about five miles from
Aldershot, just in case you are not familiar with the geography.
Q167 Chairman: And you gave some
very good care to my own family recently.
Mr Morris: Thank you.
Mr Permain: I am Neil Permain.
I am the Operational Services Director for South Tees Trust, which
is the James Cook University Hospital in Middlesbrough but also
the Friarage Hospital in Northallerton. The Friarage Hospital
is very close to Catterick Garrison. My responsibility in terms
of military healthcare is the senior board lead for the contract
with the military both on treatment and hosting of personnel.
Mrs Wilkinson: Mrs Chris Wilkinson,
Director of Nursing from Peterborough and Stamford Hospitals.
Q168 Chairman: I wonder if you could
explain briefly what sort of services you provide to Forces personnel.
You do not all have to come in on this because you probably provide
fairly similar services.
Mr Morris: Frimley Park Hospital
provides a broad range of what I would call district general hospital
services to MoD personnel. We treat around 14,000 outpatient attendances
for Service personnel and around 2,500 inpatients and day cases.
It could be a dermatological problem, it could be someone needing
a hernia operation or an orthopaedic procedure. It is a broad
range of activities that you would expect to find in that group
Mr Permain: Similarly, district
general hospitals, marginal orthopaedics, general surgery, around
1,800 inpatients and day cases during the year, and 8,000 outpatient
episodes during the year. Predominantly that is from the Garrison
in Catterick but also we have an orthopaedic service that takes
patients from a much wider geographical area through referral
from the Regional Rehabilitation Unit run by the military, so
we do have a reach up to Scotland and sometimes down into the
Midlands, patients in orthopaedics on the so-called fast track
Mr Lewis: We are a somewhat different
organisation and, therefore, we are in a position to provide a
very different kind of support for services than actually we do
at the moment. We are a major tertiary service provider, one of
the biggest hospitals in Western Europe under one roof, and one
of only two or three trauma one units in the UK. We do not provide
any trauma infrastructure to military personnel despite the fact
that we are in the middle of a very considerable provider of personnel
serving in the Armed Forces. We regard that as being a great pity.
We provide every single service that is required for a trauma
one unit under one roof. We have a helipad 50 yards from our A&E
and trauma resus area and we have a fixed wing airport only half
a mile away. It is particularly inappropriate that we should be
having our military personnel, for instance we have a personnel
from 42 Commando at the moment who is being looked after up here
when actually he should be looked after by us because we have
the facilities to do it, we have a very large military staff able
to do that but we are not part of that side of the organisation,
which I think is a great pity.
Q169 Chairman: That is very interesting.
Mrs Wilkinson, would you like to add anything?
Mrs Wilkinson: We provide district
general hospital services similar to that of my colleagues.
Q170 Mr Jenkins: Mr Permain, you
mentioned a "fast track service". Last week one of our
witnesses made the claim that we have thousands of Servicemen
languishing on NHS waiting lists, yet when we followed this up
we found it not to be the case. Can you explain what you mean
by a "fast track service"?
Mr Permain: If I could talk about
the fast track service but also the waiting time issue in general
because I think it is maybe of some interest. This is a service
by referral within musculoskeletal services where there is a defined
period of time within which a referral would be expected and further
treatment. Predominantly two military consultants in orthopaedics
deal with these patients. To be honest, I would not want to be
quoted on exactly what the timescales are but they are pretty
short run-through timescales to be referred and then to be treated
as an inpatient. There is also a system within the contract of
financial recognition for accelerated treatment for Service personnel
across all of the different specialties, so we track and monitor
waiting times for access to first outpatient appointment and also
subsequent inpatient appointment. It is a particular part of the
contract that we try to accelerate that treatment as fast as possible
and our times are improving.
Q171 Mr Jenkins: Would you recognise
what we were given as a waiting time of ten days?
Mr Permain: Would I recognise
that as a waiting time of ten days for inpatients or outpatients?
Q172 Mr Jenkins: Inpatients.
Mr Permain: I think that would
not be usual. The military would like us to aim for referral within
42 days and subsequent treatment within the same time period as
an inpatient. Some patients will access within ten days but that
would not be the norm, no. I would say at the moment the waiting
times are probably slightly shorter than NHS waiting times, although
they are reducing all the time as well.
Q173 Mr Jones: Can you explain what
the procedure is for people accessing that service? How does that
actually work in terms of the connection between the military
and yourself in terms of, say, a squaddie at Catterick who needs
an orthopaedic operation, for example? How does it work?
Mr Permain: Service personnel
will be seen by military GPs within Catterick, there is a primary
care centre there, and, as I mentioned, on a wider geographical
patch there are the Regional Rehabilitation Units which are run
by the military. It would be a referral from a military doctor
from either of those two sources. There is an administration centre
run by military personnel on site at Friarage Hospital in Northallerton
who will then make the administrative arrangements directly into
our booking and outpatient services and inpatient services to
agree a date and communicate that to Service personnel to inform
them of the date and subsequent communications from the hospital
in the normal way about their clinical care.
Q174 Mr Jones: Is that dealt with
separately from, for example, someone living in Northallerton
who went to a GP? Is it a separate track or Chain of Command that
it goes through? Are they dealt with differently?
Mr Permain: It is separate up
until the point where your appointment is made within an outpatient
department and then the system is essentially through our staff
within the outpatient department to when they see the patient
and then subsequent inpatient correspondence will eventually fit
into the same system. The initial referral and dealing with that
referral and some of the administration has a dedicated service
for military personnel.
Q175 Chairman: Mr Lewis, can I pursue
a point that you raised about somebody being inappropriately treated
here when you have the speciality and the skills where you are
to treat him in your MDHU. What happens if you ask Selly Oak for
your patient back, as it were, and that patient asks, "Can
I go to be treated by Mr Lewis, please?" and his family asks?
Does any of that sort of communication take place?
Mr Lewis: We do get involved in
the longer term care of our local Service personnel who have been
repatriated back home and have got continuing problems, and that
is completely appropriate. If we were to be approached by people
wanting to be transferred to us then that would be fine, we would
have absolutely no problem with that. The problem is that we have
a relationship now developing between the military whereby the
contracting basis for work is completely separate from the business
of educating and training military doctors. We have 260 Regular
staff in our organisation, 250 of whom departed to Iraq with virtually
no notice. If you read the Ministry of Defence briefing document
that has been released today for the first time it does not even
mention the fact that Plymouth exists, which is entirely inappropriate.
It does not mean that our staff within the organisation, who are
highly trained and very senior and carry considerable roles and
responsibility within military defence services, are not exposed
to any of the trauma battlefield training at all and in the long-term
it will become a real difficulty for them keeping their skills
alive, and it is not necessary. The way that the NHS is developingthe
NHS is changing very fastI believe that we will end up
with a small number of complex multi-specialists in very large
organisations and a series of district general hospitals, some
of which will do surgery and have A&E departments and some
of which will not. The kinds of things that trauma patients need,
and we do an awful lot of trauma as the tertiary services centre
for the South West Peninsula, will have to more and more be concentrated
in large organisations. My feeling is that the large organisations
are suitable for the care of military trauma patients and that
the expertise needs to be gained by the military staff who are
being trained by those organisations. Pari passu with that,
I think it is inappropriate for the routine work, which is the
incentive, the carrot, for organisations such as my own to want
to carry on training military personnel, the work should and must
go with them. In the past there has been a penalty in terms of
funding but now with tariff and PDR that is not necessary, it
should not be a financial risk to the Armed Forces and there needs
to be concentration on Armed Forces' medicine within a smaller
number of organisations which by and large are at the complex
end of things. That does not mean to say that I think all services
should be there. If, in fact, certain services can be entirely
military as a proper critical mass in terms of people's careers
and critical mass throughput, such as rehabilitation, mental health
services, counselling, that kind of thing, I have no problem with
that at all, but most of it is increasingly complex, it increasingly
depends on interdigitating specialities and I think that services
need to be rethought and fundamentally rethought.
Q176 Chairman: Should there then
be a smaller number of MDHUs?
Mr Lewis: In my opinion, yes.
I think that the MDHUs need to be concentrated, wherever possible,
where there is an ethos of care and involvement in the military
and where they are close to conurbations which provide those kind
Mr Permain: Just to give the context
because the debate is moving that way, I think it is worth pointing
out that at South Tees Hospitals, which includes the James Cook
as a major site, we have a cardiothoracic centre and a neurosciences
centre and vascular services which are provided to the sub-regions,
so as a hospital equally we have very high level complex services.
In terms of the relationship the military have with the centre,
we do have the services. When you asked me which services we provide,
at the moment we are not a direct referral centre for the military
for those complex needs but we do have that capability. I thought
it was worth emphasising that. Particularly on the hosting side
of staff as well, that does give opportunities for staff who are
working within the unit to get experience in all of those specialties.
Although the general services are provided to the personnel, staff
are working in all areas. In fact, in our relationship with the
MDHU staff locally we have continued to increase their presence
in Accident & Emergency, in ITU and in other specialist services.
I just wanted to emphasise that rather than just focus on where
treatment is focused at the moment in our hospital, which is in
the more general areas.
Q177 Chairman: Mr Morris, do you
want to add anything?
Mr Morris: Nothing, apart from
the fact that typically 95 per cent of the referrals are all looked
after within the organisation, so very few people have to go on
elsewhere to get a service. Clearly there is a balance to strike
between proximity of MoD personnel and where people need to go
for specialist care. The majority of Service personnel around
Aldershot would look to Frimley for a service, and that is literally
just down the road.
Q178 Chairman: Mrs Wilkinson, do
you agree with Mr Lewis?
Mrs Wilkinson: I think that the
specialist care is very important to go wherever the clinical
outcomes are going to be the best for the patients. There are
different issues around where MDHUs should be hosted for the training
requirements of the staff who are going to go to places of conflict.
Q179 Mr Havard: Heaven forefend that
I should interfere with this competition process in the health
service, which I did not vote for! This is an interesting argument
though because, as I understand it, in 1999 there was a competition
held to have the host for the medical centre and this organisationBirminghamwon
that competition and that is why it is where it is. You seem to
be suggesting in slightly different ways that that question about
where the training is all concentrated in relation to this might
be something that needs some form of re-evaluation and then the
provision is perhaps a different level of discussion because people
can be physically transferred after original assessment, as it
were. What was said to us previously, as I understand it, was
that Birmingham wants to be the reception centre and effectively
has become that, by default or design that is what is happening,
so they start by arriving in Birmingham. Mr Lewis, you seemed
to be suggesting that some of them ought to arrive in Plymouth.
There is a difference of opinion there, presumably, about the
strategy of having the reception all in one place and the training
in one place. Do I understand that correctly or are you just making
a bid that you did not make in 1999?
Mr Lewis: No, this is not a fashion
parade at all. We have got a very large civilian following in
Plymouth and we have to respond to that. We are expected to do
so and we are delighted to do so as part of our ethos. We want
to look after our troops, many of whom come from that part of
the world, particularly the Marines and the Navy, and we expect
to be part of their long-term care as well and that is one of
the advantages of being looked after from the very beginning to
the very end in that the acute episode is just that, an acute
episode, but too many of these episodes have very long-term follow-up
requirements and we would want to be part of that. Where I am
coming from, having been involved with the provision of Armed
Forces' medicine for a very long time, is that there needs to
be a radical rethink of the relationship between the Armed Forces'
medicine and the NHS. The NHS is changing dramatically fast, it
is not the same as it was before. My own organisation is not the
same as it was in 1999. Our consultant numbers have gone up from
98 to 315 in seven years and we have become a tertiary services
engine for the South West; we were not in 1999. Things are changing
very rapidly. We need to play our role within Armed Forces' healthcare
and we think that our role should be changed and different from
what it has become, which is at the moment a trainer of a large
number of Regular military forces and a provider of lots of Reservists
who come and go with increasing regularity. We get contract work
in terms of orthopaedics and various things like that in relatively
large numbers, although I cannot give them to you, but we are
not involved in the major trauma side of things, which is an absolutely
key part of what we provide to our local population. We are a
very major trauma centre and we need to, and feel that we ought
to, be part of that as well as just a trainer of Regular forces.