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Lord Hunt of Kings Heath: My Lords, noble Lords may say "Oh", but given the size of the budget for the NHS, and the proportion which relates to public finance as a whole, it is inevitable that government have to take decisions on funding which give them flexibility over the whole public finance field.
If we are talking of the hypothecation of the entire NHS budget, that inevitably makes the service more susceptible to economic downturn than the current financial arrangements. I agree with the noble Baroness when she said that undiluted private health insurance is not the answer. I had hoped that today's debate might have flushed out what Dr Liam Fox meant in his article in the Daily Telegraph today. He talks about encouraging greater use of private healthcare and wants incentives to be given to individuals and firms to use the private sector. What is difficult to work out is how one relates that to the other initiatives which the Opposition have announced--the patient guarantee and the tax guarantee. The question is whether he suggests that private health insurance is a way forward when the patients who would be forced
We have already increased spending around 5 per cent growth in real terms over this year and the next. By the end of the next health spending round, as a proportion of GDP the figure will be around 7 per cent. The Prime Minister made clear that we shall find the funds and are confident that we can sustain an increase in funding that allows us to match the EU average. Of course, detailed decisions on the additional moneys to be made available will be taken in the current spending review which will set spending plans up to the year 2003-2004. Growth in the NHS spend depends on the economy, our sound management of it, and ability to pay.
My noble friend Lord Davies put his finger on the point as regards private health insurance. The very people who need most care are those who are most at risk of ill health and they are the people least able to obtain it. The second reason that private health insurance is the wrong answer is that if one were to do as Dr Fox appears to suggest--to provide tax relief or subsidies to those private health insurances--one is diverting hundreds of millions of pounds which should be spent on the NHS into a huge cash hand-out in tax reliefs and subsidies. Not only would one reduce support for the NHS, and from those with private health insurance, undoubtedly one would risk a two-tier system. The NHS would be left as a safety net service for the poor. Experience in the US and Australia also suggests that tax incentives to encourage private healthcare will fuel the spiralling costs of insurance premiums.
The noble Earl, Lord Howe, and the noble Lord, Lord Lucas, considered social insurance a better runner. Having been in your Lordships' House for a little more than two years, it is probably the first time that I have heard noble Lords opposite look to France and Germany for inspiration. Germany's social insurance system is a heavy cost on employers. For instance, German employers have to pay about 7 per cent on top of the cost of each worker's salary for healthcare. In France, employers have to pay about 12 per cent on top of each worker's gross wage for health social insurance. We should be wary about going down that route. In many cases, it could have a negative impact on our economy and the competitiveness of our businesses. I do not think that we should go down those routes.
When the Second Reading of the NHS Bill which set up the NHS was debated in this Chamber, although in another place, Aneurin Bevan promised that it would lift the shadow of fear of the financial consequences of illness from millions of people. He promised that it would relieve suffering, provide a higher standard of practice from the medical profession and make a great contribution to the well-being of the people of this country.
Baroness Cumberlege: My Lords, during 10 years in your Lordships' House I have learnt that the way to win gratitude is to bring these five-hour debates to a brisk conclusion. I shall be brief, but I want to make one comment. I am not surprised and have been enormously encouraged by the intellectual range, expertise, innovative suggestions and practical experience that your Lordships have shared with us tonight. It has not been a trivial bang-about. I have sensed that people have been listening. There has been a real search to analyse what is wrong with the NHS and to find new and better ways to rejuvenate it.
I thank the Minister for his masterly and careful summing up, but I am not sure that he picked up all the nuances that were put forward in the suggestions. I know the pressure on ministerial life and that there is a great temptation to say, "Phew, that's another night over". However, I hope that he will read Hansard carefully and try to tease out some of the suggestions that were made. There is a huge feeling of consensus in the Chamber tonight. We are willing the NHS to succeed, but we feel that it is a time of crisis and that there must be some new thinking.
In recent years, they have proved again and again that they are willing to make these sacrifices: in Northern Ireland; in the Gulf and Falkland wars; in Bosnia and in Kosovo. But the current state of the DMS can be seen as a betrayal of their trust. As we have this debate tonight, I believe that France is opening its 15th military hospital, while we are closing our last. Admiral Brigstocke's paper, reported in The Times on 24th January, stated:
The issues include problems of retention of senior staff who cannot quickly be replaced by the current recruitment drive, and closure of facilities which cannot quickly be reopened in the event of an influx of casualties. Closure of military hospitals and transfer to an already overburdened NHS means that military personnel cannot receive the treatment they need when they need it. Career opportunities for medical, nursing and paramedical personnel are severely truncated, adversely affecting morale and commitment. Premature voluntary retirements (PVRs) result, with a backlash on those still in service, who find themselves working for longer hours than civilian counterparts, often for lower salaries. Their loyalty is being tested beyond endurance and many more are contemplating leaving. The downward spiral is continuing with disastrous consequences.
Perhaps I may give a few examples. First, RH Haslar, the UK's only remaining military hospital, has been scheduled for closure. A stay of execution has been granted, but staff know that they are on death row and the implications for morale are obvious. Also, soon after the new intensive care unit at Haslar was opened at great cost and with great pride, the decision was made to transfer it to Queen Alexandra Hospital.
Is that coherent planning? If it were appropriate to have an ICU for the DMS at Haslar, why the change so soon afterwards? If it was not appropriate, why the massive expenditure and triumphalist opening? Little has changed by way of demographic trends or service needs. The reversal of policy represents a gross waste of money for the taxpayers and a confusion of policy extremely detrimental for DMS personnel.
My second example refers to the costly transfer of the Royal Defence Medical College from the well-established and easily accessible centre in Millbank to Gosport. Now another relocation, this time to Birmingham, is being mooted, costing some £140 million. These apparently ill-thought-out moves conjure up a bizarre picture of a kind of Walt Disney procession of DMS personnel marching from London to Gosport and then turning round and marching off to Birmingham, except that the numbers in the procession are dwindling and morale is much lower than in the real Disneyland.
The third issue concerns transfer of DMS facilities and staff to an NHS which is already overburdened and unable to cope with crises such as the recent flu epidemic, even in peace time. Civilian patients with malignant disease have had operations postponed, with life-threatening consequences. How can such an overburdened NHS cope with an influx of military casualties? Last August, I asked a Question on staff shortages at the QA Hospital, about to take over intensive care facilities from Haslar. The Minister's reply detailed some of the staffing problems already besetting the hospital. This is the overburdened NHS into which our DMS are being transferred while, as I already mentioned, France is opening a brand new military hospital--its 15th.
Have any other NATO countries closed all their military hospitals and are relying entirely on civilian hospitals? Furthermore, what has happened to other military hospitals, such as the RAF hospital at Wroughton? It had been a splendid state-of-the-art hospital. It has been closed and become derelict. With no air conditioning, high-tech operating theatres are contaminated with fungus and mould. The Government are talking about building an array of new hospitals. Why not use those already built, which have already cost a great deal of money and which are now going to waste?
The fourth issue relates to pay and conditions of service. I shall deal first with pay. Although basic salaries are broadly comparable to civilian counterparts, those for senior personnel, such as qualified GPs and consultants, do not take into account opportunities in civilian practice to earn additional NHS fees and/or to earn from private practice. While new merit awards are welcome, they benefit only a few. And the much-heralded 1999 pay award is, after tax, only 0.6 per cent higher than the NHS pay award. It is hard for military personnel to resist the temptation to take PVR. This temptation is increased by seeing colleagues of comparable age in civilian practice having a much better quality of life. Overstretch in the DMS often results in long hours on duty, perhaps working one in two nights and weekends, with separation from families and stress for all concerned.
These problems are compounded by truncated career prospects. Last summer, I asked the Government how promotion rates for medical officers in the Royal Navy compared with those for regular officers. The Minister's reply confirmed the average
The Government have offered moderately enhanced salaries to compensate for relatively slow promotion. This misses the point. Your Lordships will be aware of the significance of rank in service life and a little more salary is not compensation for delay in recognition of service and equality of status with peers. Also, delay in promotion has adverse effects on pensions.
No amount of recruitment of young medical personnel can fill the vacuum created by the loss of experienced clinicians in the provision of patient care or in the training of junior colleagues. I suspect that we may hear from the Minister glowing accounts of the proposed new centre for defence medicine. This prestigious centre may serve a useful role as a centre of excellence. However, it cannot solve the grave and diverse problems besetting a DMS now verging on catastrophe.
One positive suggestion has been made by leading representatives of the medical profession such as Dame Turner Warwick, who have proposed the establishment of an inter-collegiate faculty of defence medicine to complement the proposed centre. Such a faculty, with tripartite representation of the MoD, the Department of Health and the medical and nursing professions, could be a valuable resource for addressing current crises and longer term policies.
As I conclude, I am sorry to have been so negative. However, many Members of your Lordships' House have been expressing grave concerns over the problems of the DMS for a long time. Successive governments have failed to address those concerns. Now time is running out. DCS 15 has been predictably disastrous. Perhaps I may ask the Minister who has been or should be called to account for such gross errors of judgment.
Lord Craig of Radley: My Lords, I welcome this opportunity which the noble Baroness, Lady Cox, has given the House to debate the Defence Medical Services. I warmly congratulate the noble Baroness on her trenchant remarks and many probing questions.
Last spring, I had indications that there could be a considerable number of servicemen and women who were not available for duties due to delays in being seen by consultants and receiving treatment. In four Questions for Written Answer tabled last May, I sought information on the number of personnel of each of the three services who were unfit for duty, who were waiting for secondary care medical treatment, and what percentage of personnel who required medical care in the NHS were having to be treated in turn with non-service patients. The answers I received, some weeks later, were that the Ministry of Defence did not maintain central records of the number of service personnel who were unfit for duty while awaiting secondary care medical treatment; a surprising admission when the shortage of service manpower is already so acute.
I was informed that all service personnel requiring secondary medical care in a National Health Service hospital were placed on the hospital consultant's waiting list and were then treated in turn with other NHS patients on the basis of clinical need. This is a very disturbing attitude from the point of view of the Armed Forces. I learned that there are financial incentives in Ministry of Defence contracts with NHS trusts to encourage a trust to meet critical operational priority targets set by the Defence Secondary Care Agency; but there does not seem to be any way that the Armed Forces can be guaranteed universal fast-track medical treatment within the NHS. The attitude seems to be that service personnel must be treated along with civilian patients on an equal footing.
I do not think that any of this is satisfactory for the services. My view seems to be reinforced by the remarks attributed in recent newspaper articles to Admiral Brigstocke, a recently retired Second Sea Lord and Chief of Naval Personnel. Regardless of the precise accuracy of the figures which the admiral mentioned--these will change from day to day--his fundamental point was that the Defence Medical Services were in a parlous state. Relying on the National Health Service was not proving to be a satisfactory solution.
Service training is not cheap. When it comes to fast jet aircrew, the costs to reach front-line requirements are today measured in millions of pounds. The effective operational flying life of the fully trained airman or woman is completed in perhaps three or
I believe that the run-down of the Defence Medical Services over a very long period of years has now reached a point where much more drastic measures are called for; measures which need not be expensive and which could even yield savings to the defence budget. If personnel "waiting time" for treatment could be cut back to days rather than remain at weeks, months or even years, there would be considerable increases in operational availability. That would be very welcome given that recently the commitments of the Armed Forces have been so high. Furthermore, there could be a saving in defence resources. Indeed, part of this saving could be directed to treatment of service personnel in the private health sector.
As Chairman of Council for the King Edward VII's Hospital for Officers (Sister Agnes'), which has had a close association with the Armed Forces over the past 100 years, I can assure your Lordships that we have all the necessary facilities required to get individuals back speedily to fully effective duty. The same can, of course, be said for many other hospitals in the private sector. I hope that the Government will not dismiss such a solution on grounds of principled objection to the use of the private health sector. Indeed, it could help to alleviate some of the overloading on National Health Service facilities to the overall benefit of the community.
Have the Government taken a long, hard look at the overall cost-effectiveness of the Ministry of Defence turning to the private healthcare sector to speed up the treatment and return to duty of our very valuable front-line aircrew and other key personnel? I hope that we shall learn tonight that this approach, if it is not already in place, will be studied and adopted. It cannot be resolved by the Ministry of Defence alone. This has to be tackled on a broader front by the Government. Surely this problem is an excellent candidate for a positive demonstration of joined-up government.
Baroness Park of Monmouth: My Lords, the Strategic Defence Review was published in July 1998, over 19 months ago. By then it was well known that thanks to the monstrous depredation of Front Line First, the Defence Medical Services were collapsing. In the SDR debate of 8th July 1998, the Minister rightly referred to the, "hollowed out" and "demoralised Defence Medical Services", and pledged to make new money and personnel available to "revitalise them". He promised a great many things. One of those was that 200 specialists and other medical staff would be
When I asked the noble Baroness, Lady Symons, in the debate on the Queen's Speech last November--17 months later--where were the hospital ships, one promised as a matter of urgency, I received a written reply which , while both full and helpful in responding to the issues I had raised, said that the MoD specification for the vessels was currently being developed and was expected to be completed early this year; namely, in 2000. The requirement would then be passed to the Defence Procurement Agency, where an implementation scheme had already been formed. The in-service date remained April 2005. Therefore, a project described as a matter of urgency in 1998 is expected to take seven years. Is it so high-tech that the MoD needs seven years to test all the equipment; or could it be that either the Defence Medical Services have been told that there is no money for the project or that it has been put on hold more or less indefinitely?
The Government must recognise that, like housing and education, access to good medical care for the Armed Forces now serving out of the UK in large numbers is a basic requirement. Recently we have committed ourselves to further UN operations anywhere, any time. What use then will there be in blueprints for a hospital ship? That is one of the easier things that have been promised.
Some good things have been achieved, although I fear that they are quite small. The Defence Secondary Care Agency is now headed by a serving officer, who understands the needs of the forces. That is a great advance. At Frimley MDHU, although there is still no mess and virtually no opportunity for the tri-service staff to work in a military environment, plans at least are inching forward for a fitness centre and the upgrading of some of the living quarters.
However, there are two major threats to the survival of the Defence Medical Services: the desperate and continuing shortage of doctors and nurses. To no one's surprise, the latter are defecting to the NHS. After all, they are obliged to do a great deal of NHS work, but without the overtime that the NHS nurses receive. All too often the patients for whom they care are NHS patients, including geriatrics, and they work in conditions very far from the military environment with its opportunities for adventure training, travel and other challenges for which they joined. Retention can scarcely be helped by the fact that, unless things have changed, the review of nurses' pay by the Armed Forces Pay Review Body is not due to report until 2002. By that time, the outcome of the review may be largely academic as far as the nurses are concerned.
I hope that the Minister will be able to tell us how many nurses, consultants and other medical personnel respectively asked for premature voluntary retirement in the years 1998-2000. Last year the Defence Committee was told that five consultants who served at Haslar had asked for PVR on hearing that Haslar was to close. On that occasion the British Medical Association quoted a Ministry of Defence statement of
I turn briefly to the future of Haslar, which the noble Baroness, Lady Cox, has already dealt with in considerable detail. However, it is worth repeating some of the issues. In 1998-99 the annual operating cost of Haslar was £49 million. The net saving to the defence budget from the closure of Haslar was expected to be £14 million per annum after allowing for the creation of a centre for defence medicine and a new MDHU at Portsmouth. That is a paltry sum. Incidentally, I should like to know how much it would cost per annum to run a comparable NHS hospital.
The centre of defence medicine was to consist of one ward and four consultants. However, as well as being a centre of expertise, it was thought that it might be a reception unit for patients who were aero-medically evacuated to the UK in peacetime. Like the MDHUs, it would, of course, be associated with an NHS institution. Therefore, no doubt its beds also would be open to pre-emption by the NHS. We need to know from the Minister, as do the service families who increasingly are anxious about the proposed closure, what provision has been made in all those plans for the repatriation and accommodation of families from abroad? Provision for that exists at Haslar, but there is no such provision at the MDHUs and, presumably, none at the centre.
The BMA has expressed considerable concern that the closure at Haslar will, in its view, seriously damage the Defence Medical Services' ability to train doctors, particularly for operational military medicine. It is scandalous that, as reported recently, young men in the Navy have not been able to receive the orthopaedic and other treatment which they need to allow them to return to service, and that the effectiveness of that service has been reduced correspondingly. Moreover, a surgeon in an MDHU attempted to clear six beds for much-needed orthopaedic operations but had to cancel them because the NHS wanted and took the beds. Are we not allowing the NHS tail to wag the MDHU dog for, I am sorry to say, largely financial reasons? Surely the DMS exist in peacetime primarily to enable the injured to be returned to fitness and to their service duties promptly? The noble and gallant Lord, Lord Craig, made the point that that, curiously enough, would save money.
Does the MoD really want to add yet one more anxiety for service families by closing Haslar, without which there is no planned provision for family repatriation? In the very useful letter, which I have already quoted, the Minister told me that Haslar will not close until the MDHU at the Queen Alexandra Hospital is ready. That was not expected "for several years". Meanwhile, however, is the MoD producing any statement to meet the anxieties of the families and to say to them, with some degree of fairness, what the alternative arrangements will be?
Another aspect of health provision for the services which once would have been a part of the contribution made by the four service hospitals is the needs of families. Given the immensely valuable services which the MDHUs deliver to the NHS, why is it not possible for the MoD to negotiate a binding agreement applicable throughout the country on the issue of NHS waiting lists? That question has often been raised by the families. Again and again, a family on posting will just have reached the head of a list at hospital A, only to have to start again at the bottom at hospital B. That is a most stressful process, not helped by statements from at least one NHS hospital that Army families have less priority than civilians since they are not, after all, regular local residents and are owed no consideration.
Through the Task Force, the Army Families Federation has pressed for a guarantee that a "credit" be given to ensure that no one waits for more than a maximum total of 18 months in a continuous process between two or even three hospitals. Surely that is not unreasonable, and it is the least that the services should be able to expect as a quid pro quo for the major contribution which service doctors and nurses make daily in the MDHUs in taking on some of the NHS load--in my view, far too big a contribution.
The House has just debated the state of the NHS. The health of our soldiers, sailors and airmen deserves equal consideration and equally effective financial support. Failure to fund that seriously and effectively will be one more reason for failure to retain our forces. Our soldiers and their families, too, are members of the human race.
Lord Carver: My Lords, we are all extremely grateful to the noble Baroness, Lady Cox, for having raised this important issue. No one who has read the excellent report of the Defence Select Committee in another place on the Defence Medical Services, published at the end of October last year, can have any doubt in their minds that the Defence Medical Services are in a state of crisis. There are enormous difficulties to be faced and grave doubts about whether they can be solved.
I want to concentrate, first, on the question of the hospital at Haslar. I declare a personal interest because I live near Portsmouth and over the past 15 years I have been a regular out-patient and, for a very short time for a small operation, an in-patient. Over that time, Haslar has been "mucked about", as has the whole of the Defence Medical Services, but perhaps more than any other part of the defence service. I have seen it as a completely naval hospital and as a hospital being transformed into a joint service hospital with the concept that it would remain the one joint-service hospital. I have seen that hope removed and now there is a great deal of uncertainty about the future.
The report from the Defence Select Committee gave a great deal of attention to the whole question of whether or not there should be a core service hospital. The committee studied and argued the matter with
However, the report also highlighted and gave great emphasis to the relationship of the run-down of Haslar with the establishment of the Centre for Defence Medicine. It expressed severe doubts, as I myself have, about whether the Defence Medical Services as they stand can manage the combination of the run-down of Haslar with the establishment of the Centre for Defence Medicine at Birmingham.
When the Minister replies, will he tell the House what "MD" stands for in "MDHU"? The Defence Select Committee report refers to it as a military district hospital unit and the Defence White Paper, a few months later, referred to it as a Ministry of Defence hospital unit. I should be grateful to know what it really stands for.
The report assumed that the MDHU at the Queen Alexandra Hospital at Cosham, or, at any rate, one in the Portsmouth area, would have been set up by 2002, but the most recent Defence White Paper, which has already been quoted, forecast that the Centre for Defence Medicine will open at the University Hospital in Birmingham in April 2001--not a very long time away--but that the MDHU at the Queen Alexandra Hospital at Cosham is dependent on the development of that hospital under the PFI which is expected to take several years. We are assured that Haslar will not be closed until that MDHU is up and running.
The Queen Alexandra Hospital, Cosham, is a very good hospital but it is under great pressure now. It is absorbing patients not only from Haslar but from St Marys. From the point of view of somebody at Haslar, that last statement--that it will take several years--means more uncertainty, and probable continual run-down which will not be compensated for by the employment of civilians, who are already employed in considerable numbers at Haslar. It will inevitably mean a further large number of resignations, particularly in important specialties.
This report deals in considerable detail and in a very balanced way with the problems posed in the MDHUs, to which reference has already been made. It is of vital importance to ensure that those MDHUs function properly and in a way that is satisfactory to the NHS hospitals, the service personnel in them, and to the service community which the MDHU serves. I am not satisfied that that is so at present. Some are undoubtedly better than others--for example, the MDHU at Colchester does not ever seem to have had any great problems. That is a really high priority issue.
The whole question of reservists and the TA hospitals is of very great importance. Because of the difficulties of the regular element of the Defence Medical Services, any major military operations are
What does the Ministry of Defence propose to do about all that? First, without doubt, it should cancel the application of the infamous 3 per cent savings imposed by the Strategic Defence Review. It was infamous in all areas, but its application to the Defence Medical Services is scandalous--and I should not say anything but that.
What this problem deserves is something like the action which the noble Lord, Lord Carrington, took when he was Secretary of State for Defence in relation to procurement in the Ministry of Defence, which was in a mess. He called in Derek Rayner of Marks & Spencer, later Lord Rayner, and said, "Now, you look into this; tell me what is needed; and then I will put you in charge of putting it right". I believe that the Defence Medical Services need somebody like that. They need somebody of high standing in the medical world to come from outside and not, I hope, to produce a lot more changes. What is needed now is to accept the changes that have been proposed but to make certain that they work. Only by infusing the Defence Medical Services with that sort of spirit will it be possible to retain the essential people who are leaving at present, not quite in droves but in a steady trickle.
Lord Swinfen: My Lords, like other noble Lords, I am extremely pleased that my noble friend has asked this Question this evening, for those serving in the Defence Medical Services are very concerned that they will not be able to cope in the event of conflict. They are concerned also that not enough is being done to put that right. It is an appalling situation.
At Question Time on 2nd December, I asked the noble Lord, Lord Burlison, who is to answer the debate this evening, what was the establishment in the Defence Medical Services of medical consultants. He did not know but he promised to write to me with the answer. However, last month, as I had heard nothing, I tabled a Question for Written Answer and I received the Answer from him yesterday. He told me that on 1st December 1999, there were 174 accredited medical consultants in post against an operational requirement of 443. That is a shortfall of 269 which, if my arithmetic is correct, is well over 50 per cent. That is certainly not a satisfactory position.
Also, when the Minister replies, will he please tell the House how many of those 174 who are still in post have applied for premature voluntary retirement? After they have retired, how many consultant orthopaedic surgeons will still be serving and what is the operational requirement for orthopaedic surgeons? Likewise, what are the operational requirements for anaesthetists, burns and plastic surgeons and accident and emergency consultants?
Will the Minister also tell the House how the number of regular service consultants today, and after those applying for PVR have left, compares with the number serving just before it was announced in December 1998 that the Royal Hospital, Haslar, was to close? It is my belief that that announcement shattered the morale of many in the Defence Medical Services and was a major cause of the current rot.
It is quite obvious that those ghastly deficiencies need to be made up. How many orthopaedic and general surgical registrars are there in training in the Defence Medical Services? How many of the other specialties which I have mentioned in my speech are in post and in training at present?
I understand that last year's targeted recruitment campaign--which cost, I am told, £100,000--resulted in no medical recruits and just a handful of nursing recruits. That was money wasted. It was certainly not well spent.
How can the hospital cadre of the Defence Medical Services be expected to survive without a flagship tri-service hospital of sufficient size to train and retain a surgical and anaesthetic cadre capable of taking care of service personnel in peace and war? The effective disintegration of the service hospitals dealt a lethal blow to the morale of hospital service doctors who ask, "Why should I stay?". Further, the loss of institutional memory which resulted from the haemorrhaging of senior hospital doctors will have a catastrophic effect the next time we go to war for real. Some predict a second Crimea with old lessons being re-learnt at the expense of making mistakes in managing war-injured casualties, which means losing and crippling our servicemen.
I understand that ships in the Royal Navy that carry a consultant surgeon as part of their complement do have one, but that that surgeon rotates, par roulement, about every six weeks. In my view that cannot help to build up the necessary esprit de corps and confidence among the crew.
I am also told that the 100-bed primary casualty receiving ship, the RFA "Argos", can be manned at present for short exercises. However, can the Minister, when replying to the debate, assure the House that both the RFA "Argos" and the new 200-bed hospital ship currently being procured will be fully manned in the event of conflict? In order to operate effectively, our Armed Forces need to know that they will be properly cared for if wounded in action. As a nation, we have a duty to provide that medical care.
Lord Bramall: My Lords, in this interesting and timely debate, for which we are grateful to the noble Baroness, Lady Cox, we have usefully heard both justifiable criticism and constructive suggestions. I am sure there is more to come. I agree with everything said by my noble and gallant friend Lord Carver.
However, I hope that in answering, even if it is not his department, the Minister will find an opportunity to admit or at least recognise that the medical plan hatched by the central staff to the Ministry of Defence under intense Treasury pressure in the context of the defence costs study, better known as Front Line First, was probably one of the most disastrous initiatives ever to emanate from that department. It was made all the worse because far from such criticism being in hindsight, repeated warnings had been given in advance, directly to Ministers in your Lordships' House and in another place, that major mistakes were about to be made. They were warned that the consequences to the medical services, secondary care of service personnel and operational sustainability would be very serious indeed, as has now proved to be the case.
The root of the trouble was that too many core hospitals; that is, military hospitals, which were the cornerstone of the medical services in terms of professional incentives, motivation of specialists and the ability to expand for operational emergencies, were done away with; five out of six, if I recall correctly. As mentioned by my noble and gallant friend Lord Carver, the only one left is Haslar. That is now under threat of closure, and was probably in the wrong place, as many warned at the time.
As pointed out by the noble Baroness, Lady Park, that knocked the stuffing out of the medical services with the disastrous manning consequences this Government has now inherited. The Ministry of Defence, still in pursuit of yet more savings, with the term "Front Line First" pushing in the direction of support areas 'but what is the front line? Certainly the medical services should be considered as such' passed the buck of secondary care to the National Health Service, which had many problems of its own.
It did that by grafting on to National Health hospitals--some, I have to say, of varying quality--small medical and surgical teams from the medical services who, though promised it, never achieved the status of having their own wing around which morale could be built up.
There is certainly nothing wrong with Armed Forces doctors and specialists having a greater contact with civilian practitioners and patients. That occurred increasingly in military hospitals and has many advantages. However, such rushing in to complete integration meant that many of the military staff found themselves in geriatric wards. They were swept up in all the problems of the National Health Service. The result, predictably, was that specialists left. The loss of surgeons and anaesthetists was particularly serious to any operational commitment. The waiting list for appointments for service personnel became longer and longer. As pointed out by the Second Sea Lord, that had a serious effect on manning and, therefore, on the operational availability of battalions, ships and aircraft.
I take the point made by my noble and gallant friend Lord Craig: waiting in a long queue may be highly inconvenient for civilians but for service personnel it means a loss of operational capability. Such "hand in glove" with the National Health Service is still not working as well as it should. The Government are doing their best to correct the shortage of specialists. However, as stated by my noble and gallant friend Lord Carver, the services have had to rely disproportionately, indeed almost exclusively, on the reserve forces for their field hospitals and field ambulances in the event of significant operations occurring in support of our bullish foreign policy.
However, the reserve forces from the medical point of view is the health service, which has its own manning shortages. The release of those people cannot be relied upon in anything but the most major emergencies. As has been said, if the Kosovo operation had degenerated into a two-sided shooting war with serious casualties, which undoubtedly would have occurred, the medical services could have found themselves quite unable to cope because everything has deteriorated so much since the time of the Gulf War.
Now, the Government must put that right if the utility of our forces as a force for good in the world, about which the Government are always boasting, is not to be compromised. A starting point must not be to just tinker around with the management structure and this and that committee. It should first be admitted that the MoD got it all wrong. Then, as and when more doctors, specialists and manpower generally become available, the Government must start to put back some of the things which have been removed. That will require major resources, so that, among other things. specialists can be paid the sort of salaries which would attract and retain able people, as would be done in the marketplace.
There must also either be a new core hospital or Haslar should be reprieved. If we have gone too far down that road and the people are not available, we must build up proper wings of the National Health Service hospitals instead of the very unsatisfactory arrangement which exists at present. The centre of excellence, if given some bed spaces, could turn itself into a core hospital. That must be brought into action as soon as possible.
It is important to build up medical reserves, as is being done, to some extent. However, although an immense help, that is no substitute for a hard core of regulars who are available to train others and for active service at the drop of a hat, come what may.
I hope that the Government, with their heart so much in the right place over defence, will prove that they are better than the previous government at keeping the Treasury at bay. Their good intentions could then be backed by those extra resources, undoubtedly more than have been so far budgeted for, which are needed to put right this very serious state of affairs. However, because of past mistakes, that can no longer be done "on the cheap".
Lord Wallace of Saltaire: My Lords, I, too, have read the report of the Defence Select Committee in another place. I have also read a helpful BMA briefing and wish to echo strongly the sentiments expressed by successive speakers in this debate.
The Defence Medical Services are at a low point; they are close to falling below the critical mass needed to rebuild. If one is going to maintain an effective Defence Medical Service, urgent action needs to be taken to review the levels of staffing; to reverse low morale and to give a sense of a core activity and core commitment back to the service.
We have had a drift downhill over the past 10 years. I agree with the noble and gallant Lord, Lord Bramall, that Front Line First was a classic mistake. It cut the logistical tail without which it is not possible to project forces on a sustainable basis. That, of course, was a failure of the previous government. The failure of our current Government has been to reverse that decline. They have at last conducted a Strategic Defence Review which should have considered not just the need for long-range strategic transport, but also the need for a full logistical tariff, including a defence medical dimension.
Clearly, further investment is needed; that is to say, more money. I am sure the noble Earl, Lord Attlee, will comment on this. I listened on the "Today" programme this morning to the new Conservative Shadow Chancellor promising yet again that he would cut taxes. I merely wish to ask: if one is going to provide this sort of increased investment, how will it be done while squeezing other expenditure further?
What do we need? One starts from the Strategic Defence Review and asks what this Government need and want to do with defence policy? It is really rather ambitious. Someone remarked earlier today that our current Government have a very activist foreign policy in terms of future deployment of forces abroad, partly in the service of defence diplomacy--one of the new themes of the Department for International Development--and partly in terms of the Government's European Defence Initiative. I know that at the European Council in Helsinki in December--very much on the initiative of the British Government--Members of the European Union agreed that we would constitute within the next three years a military force of 60,000 people, of which a quarter is likely to be provided by the British. That is to be sustainable at a distance from Europe for up to one year. There was nothing in the detail that I read relating to the medical dimension. There was a lot about strategic air lifts and strategic sea re-supply. But again, if one wants a sustainable force, the medical dimension is important.
One may say, as indeed the British have said in some of the discussions, that the British will provide most of the spearhead elements of this integrated European defence initiative and others will provide more of the logistical back-up. I remember at the time of the Gulf War that a large number of European countries fell over themselves to offer field hospitals, because that
How do we supply that? As has already been remarked, here there is a clear link with the earlier debate today. One cannot at the same time rebuild the Defence Medical Services in competition with an under-funded and over-stretched National Health Service. Yet again, joined-up government requires one to think about those two things together. At the moment--it is well set out in the front-line documents to which I have referred--the weaknesses of each increase those of the other. There is rivalry over qualified staff; there is resistance from National Health Service trusts to the potential compulsory call-up of reserves, and thus to encouraging their staff to join the reserves.
If we want to rebuild core Defence Medical Services, there are clearly a number of things which need to be done soon. Better pay has to be part of that. There must be greater incentives to stay on, and concern about pensions for those who will retire earlier than they would retire from the National Health Service. It is an unavoidable part of any rescue package. There must be sufficient core facilities to provide a continuing sense of identity, not being swamped by the National Health Service. As the noble and gallant Lord, Lord Bramall, said, we need a Centre for Defence Medicine which is large enough and separate enough to have a clear military ethos. We need to have MDHUs--whatever that stands for and I have no doubt the noble Lord, Lord Burlison, will enlighten us on that question--which are sufficiently large and sufficiently autonomous to have a sense that they are not simply some small part of an over-stretched NHS hospital.
There needs to be a training margin. In everything that I have read it is clear that that training margin has been lost, and once it is lost it is difficult to rebuild. It is also difficult to retain existing staff. There needs to be a clear sense--I am not entirely sure what the Defence Secondary Care Agency is--of distinction between primary care operations and secondary care in terms of back-up. The secondary care must be particularly concerned with provision and training in specialisms in military medicine.
This is a question of priorities within the defence budget as well as of the overall size of the budget. The Strategic Defence Review set out some ambitious objectives. Her Majesty's Government, in the European Defence Initiative, in many ways are being even more ambitious. If there is not enough money in the budget, then Her Majesty's Government should not pretend to be so ambitious.
My noble friend explained the problem with her usual clarity. I do not propose to revise the points of my noble friend or other noble Lords. I do not take issue with anything said so far tonight. Even the noble Lord, Lord Wallace of Saltaire, holds similar views to myself.
Last week I took part in an Unstarred Question debate. I do not believe that the noble Baroness, Lady Symons, replied to any of my helpful questions about depleted uranium ammunition; I cannot think why. So I hope that the Minister will be more forthcoming tonight. Of course, he may not be able to answer all my points, but the ones which he does not, I shall retable as Written PQs.
Anyone who follows defence matters will be well aware that DCS 15 was not a perfectly developed policy. Well over three years ago, when I was still on the Cross Benches, I was on an All-Party Defence Study Group visit to the Defence Secondary Care Agency. It was a nightmare visit. We immediately became aware of the substantial problems that we all now know about, and applied pressure on the Minister, both in the House and outside. What is interesting is that this Government's policy is not markedly changed, despite all the criticisms. We still have MDHUs and the agency structure. However, the Government have taken the policy further and decided to close the last service hospital--the Royal Hospital at Haslar. My noble friend Lord Swinfen talked about the effect on morale that that decision brought about. It is to be replaced by an MDHU nearby and a Centre for Defence Medicine. But Haslar is becoming run-down before the CDM is up and running. The noble and gallant Lord, Lord Carver, touched on the challenges involved.
Moreover, morale and retention in the DMS, if anything, is even worse. The Government have had this problem for nearly three years and have known about it for much longer than that. Is it not the case that in three years they have not made much of a dent in the problem? Surely if the DMS personnel were confident in the Government's plans, the loss of staff could have been stemmed, or even reversed.
During the previous debate, the Minister, the noble Lord, Lord Hunt of Kings Heath, proudly talked about how the NHS had attracted staff back to it. Why cannot the MoD do this with the DMS? Is the Government's plan for the DMS the final answer, the final solution to the problem? Can the Minister assure the House that the CDM will be up and running by April 2001? It appears to be a challenging target; nearly as much so as the efficiency targets that are causing the MoD so much difficulty.
It is clear from the contributions tonight that the problems of the DMS are largely to do with personnel. Unfortunately, the DMS has to compete with the NHS for staff. Worse still, it competes for the same specialties, as was noted by several noble Lords. There are particular problems with anaesthetists and orthopaedic surgeons. Perhaps when the Minister answers a question posed by my noble friend Lady Cox about orthopaedic surgeons he could say how many
Noble Lords have identified two problems: pay and conditions of service. My noble friend Lady Cox raised the point that DMS staff do not have an easily exercised opportunity of engaging in private practice which could increase their earnings considerably. But on top of relatively poor salaries, the conditions of service life are not as good as they once were.
Furthermore, with the appetite of this Government for engaging in operations, there is no end in sight to the problems of overstretch. The noble Lord, Lord Wallace of Saltaire, said that the Government were "ambitious"; I think that he used the word more than once. Military personnel need to undertake military training in order to be able to survive in the field. They also expect opportunities to undertake sport and adventure training. But this is proving very hard to achieve in the DMS. This is a vicious circle and the Minister will have to explain to your Lordships tonight how that circle is to be broken.
The Minister will point out that setting levels of pay is a task for the Armed Forces Pay Review Body. He is, of course, correct. The Minister will at least send out positive signals by telling the House tonight that future pay awards will not be staggered. The Minister may respond to the point of the noble and gallant Lord, Lord Carver, on the state of our reserves. As the noble and gallant Lord explained, there are anxieties there as well. Because of the overstretch in the Regular Army, clinicians are reluctant to join the Territorial Army due to the fear of being called up for operations and, thus, damaging their own careers.
The noble and gallant Lord, Lord Craig of Radley, raised the issue of servicemen waiting for appointments with consultants. He explained how important it was for servicemen to be treated rapidly. Does the Minister recognise the need to treat servicemen rapidly in order to keep them at their peak of physical fitness?
If it were not for the need to be able to conduct operations away from the home base, the problems faced by the Government would be much simpler. Much has been said about what would have happened if Kosovo became what I call a "hot operation". It may not quite have been intensive warfare, but it certainly involved significant engagement and, sadly, numerous casualties. The noble and gallant Lord, Lord Bramall, and my noble friend Lord Swinfen covered this point. Hopefully, the casualties would be from the opposition, but they would still have to be properly treated and to our own standards of healthcare. We have a frightening ability to inflict casualties on an
This debate has quite properly focused on personnel issues; but there are also equipment issues. First, what are the plans for hospital ships? As my noble friend Lord Swinfen asked, would it be possible to man them?
The second issue concerns casualty evacuations. Many noble Lords may fondly believe that every serious casualty will be evacuated by helicopter. This is certainly the case with our current operations. We have only a limited number of helicopters, and in a "hot operation" demand soon could outstrip capacity. The Army has numerous tracked armoured ambulances called the FV432 Armoured Personnel Carrier. Is it correct that they are over 30 years old and that spare parts are difficult to come by? Are they able to keep up with the modern Warrior armoured fighting vehicles during manoeuvre warfare? Do the radios with which they are fitted actually work? It is no use having armoured ambulances if the commanders cannot direct them to casualties.
Lord Burlison: My Lords, I am aware that the noble Baroness, Lady Cox, takes a deep interest in the DMS. She has made known her concerns most effectively during the course of this debate. I join noble Lords in thanking her for the opportunity to debate this important issue this evening. I hope to respond to most of the points that have been raised tonight. However, if there are any issues that I do not address in the detail that they deserve, I shall certainly respond in writing to the noble Lords concerned.
I should like to start by reiterating the Government's commitment to ensuring that our Armed Forces have the medical support that they need. I am sure that noble Lords would wish to join me in paying tribute to the manner in which the Armed Forces carry out their tasks, both at home and abroad, often under very difficult circumstances. Of course, they must have the very best possible medical care. It is my view that this is being provided by members of the Defence Medical Services.
It is undeniable that the DMS faces a number of problems. The Government have long recognised this and have set about rectifying the situation. The Strategic Defence Review, which the Government initiated on coming to office, identified shortages both in medical manpower and in equipment.
As noble Lords have recognised, the main problem facing the DMS is a shortage of manpower, and specifically the retention of trained personnel. The current shortfall of doctors is running at about 28 per cent and the shortfall in respect of nurses stands at some 42 per cent. Despite these shortages, I should like to emphasise that the DMS has, to date, met all of its operational commitments. I recognise that this is due in no small way to the dedication of those who serve in the DMS.
I am particularly mindful of the turbulence caused to medical personnel who experience frequent operational deployments due to shortages in their specialty. In order to reduce the frequency of deployments for consultants, our national hospital at Sipovo, in Bosnia, became a multinational facility in May 1999, which means that manning is now shared with allies. This arrangement is working well and has saved a number of United Kingdom medical posts. We are exploring the possibility of a similar arrangement in Kosovo.
The deployment of reservists on a voluntary basis in the Balkans is also helping to reduce overstretch among regular medical personnel. There are currently some 60 medical reservists serving in the Balkans who volunteered their services. This is useful experience for them and, of course, we welcome the contribution that they make.
The noble Baroness, Lady Cox, asked whether the DMS is able to provide appropriate healthcare for the Armed Forces in the event of future conflict. Depending on the scale of any possible additional operational commitments, the call up of medical reservists might be necessary. Defence policy has always been based on the call up of reserves to supplement regular personnel when necessary. The need to call up reserves, including medical reserves, is kept under review as part of contingency planning.
The Strategic Defence Review placed an increased emphasis on the use of volunteer reserves and, in particular, increased the number of reserves in the Territorial Army to support the Army medical services. This increase comprises 2000 personnel, of whom over 600 are medical reserves, with the remainder being drivers and other general support personnel.
A major Territorial Army recruiting campaign for medical reserves was launched in September 1999. The initial response has been encouraging and around a thousand enquiries have been received. It is not yet clear how many people will eventually join, but this is a very promising start.
As I mentioned earlier, an additional £140 million was made available to the Defence Medical Services following the Strategic Defence Review. Among the measures being taken to enhance the operational capability of the DMS is the provision of two 200-bed primary casualty receiving ships, the increased
As I have already acknowledged, retention of experienced personnel is the main problem facing the Defence Medical Services. The re-structuring of the services that took place following Defence Costs Study 15 in 1994 damaged morale and resulted in many medical personnel deciding to leave prematurely. It will inevitably take some time to restore manning levels in the DMS.
There are no quick or easy solutions to the problem, as it takes three years to train nurses and up to 12 years to train consultants. Recruitment into training is generally satisfactory and the number of medical cadetships and nurse training places has been increased. Recruitment of direct entry qualified doctors is difficult, however, and work is in hand to identify the barriers to such recruitment and, where possible, to take steps to remove them.
A key element of the new strategy for the Defence Medical Services which we announced in December 1998 was the creation of a Centre for Defence Medicine in association with a National Health Service centre of excellence. As your Lordships are aware--and has been mentioned during the course of the debate--the University Hospital Birmingham NHS Trust has been selected as the host for the Centre for Defence Medicine. The centre is to have an important academic role undertaking medical training and research, as well as providing clinical services and acting as the professional focus for the Defence Medical Services. The trust has provided good proposals which offer a firm foundation for the successful development of the centre. We believe that this new venture offers an exciting vision for the future and will encourage recruitment and retention in the Defence Medical Services.
The noble Baroness, Lady Cox, and the noble and gallant Lord, Lord Craig of Radley, mentioned the leaked letter from the former Sea Lord. No funding was programmed by the Ministry of Defence to reduce waiting lists for service personnel in the current financial year. The possibility of making funds available to pay for additional treatment to reduce waiting lists was considered. In the event this was not possible within the programmed budget. The possibility of action to reduce waiting lists, including orthopaedic waiting lists, in the next financial year is being pursued by the Ministry of Defence.
I refer to the point that was raised of NATO nations with military hospitals. The noble Baroness, Lady Cox, said that France had opened its fifteenth military hospital and asked whether any NATO nations do not have separate military hospitals but rely on partnerships with civilian hospitals. I understand that although the French have opened a new military hospital they have reduced the number of military hospitals from 20 some three years ago to nine now. Some other NATO nations besides the United Kingdom do not have separate military hospitals, for example, Canada, the Netherlands, Denmark and Norway.