Select Committee on Defence Minutes of Evidence

Examination of Witnesses (Questions 180-199)


21 JUNE 2007

  Q180  Mr Jones: What are you doing differently? I know the James Cook very well because most of my constituents go there for heart specialism. I think you are saying that personnel trainers have different specialisms but what prevents you, Mr Lewis, from allowing them to get experience in terms of trauma, which you are obviously a good centre of in the South West?

  Mr Lewis: Nothing at all. I am not here to rubbish anybody else, not Birmingham, not any other healthcare organisation, I am here to state the situation as we perceive it in Plymouth.

  Q181  Mr Jones: What stops you from using those people you are training to get expertise in trauma areas and other expertise?

  Mr Lewis: We do not need the expertise, we have got every regional specialty that is provided except paediatric cardiac transplantation and liver transplantation.

  Q182  Mr Jones: You are training people, are they getting experience in trauma medicine in your Trust?

  Mr Lewis: They are getting a lot of experience in civilian trauma but there is a difference between civilian trauma and battle trauma.

  Q183  Mr Jones: That is what I am trying to get at.

  Mr Lewis: Our civilian consultants, and we have 80 doctors who work, the rest of the 260 or something are nursing staff, technical staff and the rest of it, our doctors are deprived from battle wound experience but they see an enormous amount of general trauma.

  Chairman: We are falling behind quite badly now. Kevan Jones, can you move on, please?

  Q184  Mr Jones: In terms of the requirements for Service medicine, can I ask you what are the challenges that Service populations put to you and what do you do to cater for them differently possibly than the ordinary civilian population?

  Mr Morris: I think the key challenge is accessing treatment. Most people in the Services want to get back to the job they are doing, so there is enormous pressure on us to fast track soldiers so they can go back to their barracks and Service. The contract is structured such that there is a significant incentive for us to provide faster access to outpatient services and treatment services. A lot of us are hitting points where 75 per cent of people are seen within four weeks and 90 or 100 per cent are treated within 13 weeks if they need surgery, and I think that is the key concern along with welfare support and access to our sites. If you come into Frimley for an arthroscopy for a day, a knee procedure, and you are stationed in Maidstone, having the ability to stop overnight in Aldershot and just come down the road the following morning for your day procedure is quite important. That is where we work closely with colleagues in the MoD to make that pathway as smooth as possible. We do the procedure on a day case basis, it is cheaper for the MoD and the soldier is housed in an MoD environment before coming to Frimley if he has got difficulty in getting to Frimley.

  Q185  Mr Havard: Given the time, we would have liked to have asked you a lot more questions but what is clear from what you have said is there are lots of questions about the benefits as well as the problems organisationally and the connections between the MoD and NHS, but that is a developing agenda. Can I ask you whether or not your Trusts, which are particular because of your relationship with the MoD, have considered becoming involved in the provision of healthcare overseas, Germany, wherever, because we have got people in a number of locations? You have not?

  Mr Permain: No, we have not.

  Mr Morris: No.

  Mr Lewis: You mean providing to civilian overseas patients?

  Q186  Mr Havard: Yes essentially at the first level.

  Mr Lewis: Increasingly we now get patients from all over the South of England and abroad in terms of our cardiac surgical outfit which has got amazing results. We are running businesses now and our businesses have got to deliver a surplus in order to reinvest in our organisations. We would be very short-sighted in terms of marketing not to work out what our opportunities are. The opportunities for us in the South West are fairly considerable due to where we are and access to it. We would have no problems at all, particularly for our tertiary services. Secondary services are different, we have to concentrate and realise the core responsibility for us is to provide secondary services for the 450,000, 470,000 patients of the immediate Plymouth environment and for the 1.7 million patients in Devon and Cornwall. For tertiary and specialist services, which we have a complete range of, we must look wider where we have the spare capacity but not where we do not.

  Mr Havard: Can I ask you a question about overseas in a different way. We are going to take some evidence from the BMA in a little while who are going to tell us there are all sorts of shortages in terms of the right sorts of people in the right place and so on, and we have TA personnel and there is a reliance on Reservists within the medical service. People get engaged in that process, we have got consultants flying on helicopters in Helmand going out and doing things, so people do get experience in all sorts of different ways for different reasons. The suggestion is that in some way or another if you get involved in this there are disincentives and you could be discriminated against or in some way be seen to be disadvantaged in terms of your medical career. What is your experience of trying to engage, because you have a lot of people involved in this way, presumably? What is your direct experience? Is that true?

  Q187  Chairman: I wonder if we could ask Mrs Wilkinson to start off with that because we have been keeping you too quiet.

  Mrs Wilkinson: Thank you. I think you are asking about military medical consultants.

  Q188  Mr Havard: Yes, nurses and people going in formed units or whatever.

  Mrs Wilkinson: The way we work with the MDHU in Peterborough is we work towards as full integration as we can so the opportunities that are available to our military colleagues are the same as those available to our NHS colleagues. We work very closely in all of the decision-making policy boards and so on, so I do not see disadvantage for opportunity within the NHS spectrum of experiences for my military colleagues.

  Q189  Chairman: Would anybody like to add anything to that? Mr Lewis?

  Mr Lewis: I do not want to be seen to be hogging this, I am sorry. I think there is a real threat there particularly in terms of the Reservist side of things. We are increasingly running ourselves as businesses and chief executives and medical directors, next or after next, are likely to be much more hard-nosed about the thing. Personally, in terms of a business I would not appoint a whole raft of Reservists if I knew they were more and more likely to disappear from our organisation. When we lost 250—not lost, but when they disappeared—into Iraq with zero notice, we have to bear in mind what these people were and they were absolutely crucial to the organisation: they were surgeons, anaesthetists, intensivists, high technology technicians, they are in A&E, they were in orthopaedics. Losing those in an organisation such as ours has a very major effect. In addition, if you are going to bleed your Reservists as well I think that is a real danger to their appointment and you could find them being negatively considered in years to come. Not now, we are absolutely committed to the whole manoeuvre, but I want to make sure that the critical mass of the military within my organisation is correct. It has stayed the same now for nine years and we have tripled in size, so it is becoming—

  Q190  Mr Jones: Mr Lewis, what is the solution to that?

  Mr Lewis: The solution is making a larger critical mass of military and spreading it through a smaller number of hospitals, particularly the extremely complex high-tech ones because that is the way that medicine is going to go. That does not mean to say that secondary care needs to be directed in the same direction. It would help as a financial carrot to trusts to carry on being involved in the military, but people need to be under no illusions as to how difficult is to have a very large military medical presence in a hospital because they do disappear all the time.

  Q191  Mr Havard: Would you see that map of five, seven, or however many it is, coterminous with the future super garrison sort of map?

  Mr Lewis: I do not see why not, it works perfectly well. That would allow long-term care of those patients as well. A lot of the R&D in terms of military medical care is not just about the acute episode, it is about what happens to these people in the middle and long-term. We have a very large population of such problems and we need to be in it at the beginning, the middle and the end.

  Q192  Linda Gilroy: Do any of you have observations about how we can address the reported shortages, particularly in areas like anaesthetics?

  Mr Permain: No specifics other than to link it to the last point. The practical difficulties in a hospital that you have heard from Birmingham as well of a large military contingent are about deployments and variability in staffing levels, but we have learned to adapt with that. It does legislate against whole units or predominant units covered by military staff, but maybe for anaesthetics certainly we would be able to take more military personnel and to a marginal degree in other areas as well. Because we are increasingly using James Cook as well as Northallerton we probably could take on more staff and help to develop and train those people. Not on a wholesale basis but a marginal increase is possible. There are more opportunities in the existing MDHUs to take people if there is a shortage of specialties, fine. We react to that: to ophthalmology recently we have had two requests and I think we have had two requests to anaesthetics as well and we have taken those people on board at consultant level and integrated them into the service that we provide. There are opportunities there.

  Chairman: Thank you very much indeed to all of you for coming to Birmingham to see us and help us with our inquiry, it has been extremely helpful and also very interesting. Thank you very much.

Witness: Dr Brendan McKeating, Chairman, Armed Forces Committee, British Medical Association, gave evidence.

  Q193 Chairman: Dr McKeating, could you tell us what your role is and why you do it?


  Dr McKeating: Good afternoon. It is actually a voluntary role. My name is Dr Brendan McKeating. I am Chairman of the British Medical Association's Armed Forces Committee. Just to give you a little bit of background on myself, I served for 16 years as a Regular in the Royal Navy as a medical officer, both at sea and ashore, both in the UK and overseas, and both in secondary and primary care both in the NHS side and military hospital side of the work as well. I am a Gulf War veteran. I have now served for the last seven years as a Reservist in the Naval Reserve and recently commanded my local Royal Naval Reserve unit. I am an NHS GP full-time and a GP trainer. I am Chair of this thing called the Armed Forces Committee of the BMA. We represent the views of members of the BMA who serve in the Armed Forces, be they uniformed, Reservists or civilians as well working as CMPs, civilian medical practitioners, both GPs and consultants for the MoD. We represent their views both within the BMA itself and obviously to external bodies. Most of our work is based around providing evidence to the Armed Forces Pay Review Body and that is a lot of what we do throughout the year, but obviously we get involved in other work such as this as well.

  Q194  Chairman: Thank you, that is helpful, Dr McKeating. You have given us a list of a number of shortfalls in DMSD manning levels in a number of medical specialties. For example, there is a shortfall of, I think, 32 per cent in orthopaedic surgeons, 69 per cent in pathologists and 100 per cent in neurosurgery. Where do you get these figures from and what is the evidence for your figures?

  Dr McKeating: These figures are provided to us by the MoD, by the Defence Medical Services, so directly from the MoD themselves.

  Q195  Chairman: What impact are the shortfalls having on an operational basis?

  Dr McKeating: In terms of the operational basis, that is actually difficult to quantify. Certainly the guys who deploy around the world with the Armed Forces will give their all for their patients and they are part of the same organisation. They will look after their people to the best of their abilities, as I think we have heard. In terms of actual patient care, we have no evidence of any detriment that we are aware of to patient care on the frontline or coming back through the casualty evacuation process, but obviously what does happen is if you look at these shortfalls it is going to put a strain on certain pinch point crucial areas, such as surgeons, GPs, anaesthetists, because if you have got a small cadre of people who have been repeatedly deployed, if you look at the numbers here for deployable trained strength of general surgeons, we are looking at 12 and that puts a very heavy strain on those individuals. For a number of years we have been doing a cohort study looking at the attitudes and views of people as they move through their career with the Armed Forces and certainly this factor of turbulence and family separation is something that comes through all the time when we send out our questionnaires and I think that is where it is hitting people. The problem is as the group gets smaller the burden on these key groups who are going to repeatedly deploy gets heavier and I think that is the problem. We are asking a lot of these people. Not only do they have to meet all the requirements of their civilian colleagues, they have to be trained as GPs and consultants as per the NHS, they have to meet all the training requirements of the Royal Colleges and keep up-to-date and keep their standards going through appraisal just the same, and they also then have to be able to do that job in a military environment and they have to be safe and be able to function in the air, under the sea, on the sea and on the ground. These people are quite a national resource and the burden is falling on significant sub-groups of them repeatedly to meet the operational tempo at the moment.

  Q196  Chairman: I was talking to one this morning who was regularly shot at, which is an additional burden to bear, I dare say.

  Dr McKeating: It certainly is. As a Gulf War veteran a similar thing happened to me and it does focus the mind.

  Q197  Chairman: How do these shortfalls compare with the National Health Service?

  Dr McKeating: If the NHS was undermanned by 55 per cent for trained GPs and consultants in terms of their stated requirement it would be a very significant problem. Obviously the military have to have some flex in there, they have people doing staff jobs, people in training, various other posts, but we are looking at a very, very significant shortfall in terms of what goes on in the military. As far as I am aware, I do not think the shortfall in the NHS is anywhere near that and if you look at what has been going on recently in terms of the training of junior doctors, certainly the situation in the military is much more acute than in the NHS.

  Q198  Linda Gilroy: Looking ahead, some commentators suggest that there may well be almost a surplus, unbelievably, of doctors in a few years' time, domestic overproduction, so do you see this changing? Do you care to comment on the balance between having generalists available for deployment rather than specialists?

  Dr McKeating: I will take that in two parts. First of all, yes, I understand that if you look at the people leaving the Armed Forces' Medical Services, the doctors—these are MoD's own figures—8.4 per cent was the resignation rate in 2004-05 and 3.8 per cent in 2005-06 and that is falling and we believe that may be lower this year. Why is that? Well, it may be due to turbulence on the outside, it may be that people are perhaps hedging their bets and waiting until things settle down in the NHS with the changes in training and structures within the NHS. In terms of the training pipeline, the military have always done relatively well. They can recruit people early on in their careers but traditionally their problem is keeping the trained product, the trained accredited GP, GP trainer and the trained accredited consultant, that has been the problem. In terms of deploying generalists, you could argue that all military surgeons have to be able to perform some general surgery and if you look at what has gone on in recent operations people are certainly extending their roles, but the way doctors have been taught and the way they are being trained, people are working in very specialist areas now. If we are going to continue to provide the high level of care that we do to people, our forces on the ground, then we are going to need to keep those specialists within the military.

  Q199  Chairman: Okay, so that is the problem, what is the solution?

  Dr McKeating: Certainly we see that there are a number of issues relating to why people go. One is turbulence and the problem is this becomes a vicious circle because if the cadre gets smaller then the burden falls more and more upon those who remain. That is one issue. Whenever we do our studies looking at how people feel and what the factors are that make them leave, it tends to come out that it is separation from family and turbulence, and also turbulence in terms of how it affects your clinical work as well being repeatedly deployed away. Certainly most hospital specialists are working within an NHS environment now, so they are working with their colleagues just the same as any other cardiologist or surgeon would do and that puts pressure on their workload. Pay is another issue. We still feel there is a differential between what people are being paid in the NHS and in the military. A few years ago we were not far off parity when a new pay scheme was brought through to military doctors, but hot on the heels of that came the new GP and NHS consultant contracts which moved the goalposts for us. Certainly in terms of the consultant cadre we feel that over a career they are probably about four per cent behind their NHS colleagues looking at introducing a system of quality rewards, such as the local clinical excellence awards that NHS consultants get, and also some sort of out-of-hours supplement that the NHS consultants get, that will add another five per cent. In terms of the GPs, overall career-wise we think there is a career earnings differential of 4.8 per cent there, looking at our figures, but that differential in the early years of when you accredit is greater. If you are looking at the first one to 12 years you are looking at somewhere between an 11 and 14 per cent pay differential between what you would earn in the NHS and what you would do in the military. Pay is not everything and people do not serve in the Armed Forces, serve their country and put themselves through what they do when they join the military for the pay, but when you approach that time in your career and you are accredited as a GP or a consultant, you may then have a partner, may have children, you are looking for more stability in your life perhaps, if you then look and you perceive there to be a pay gap as well then that is going to have an effect. The third issue is around work issues, promotion, flexibility, flexible careers, career breaks, part-time working and that sort of thing. We know this is something that when we have spoken to the Defence Medical Services Department and also to the MoD about these issues they are looking at them, but these things are crucial. If you look at who go into medical school now, 50 per cent-plus and rising are female medical students. As time goes by they will want perhaps to manage their careers differently from the traditional role that the military have seen doctors working through in the past. There may be times when they want to take career breaks and may need flexibility in their working patterns and the hours that they work. These are all issues, I think, that come together to influence people to decide to go. As I say, we know that the PVR (requests for premature voluntary release from the Armed Forces) rates, the requests for premature release, are slowing but that may be due to changes and the turbulence in the NHS at the moment with what is happening with medicine rather than what is going on in the MoD itself.

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