Introduction – The work of the Review Team

1. Following an announcement in December 2000, the Medical Quinquennial Review (MQR) Team began work in February 2001, under the leadership of Professor Graham Winyard, with the remit to conduct a single quinquennial review of the Surgeon General (SG)’s four medical Agencies and, more widely, to review medical arrangements for personnel in Germany and Northern Ireland, and the inter-relationship between primary and secondary care. As a result, the scope of the exercise is substantially broader than is usual for an Agency quinquennial review, and it effectively covers the way Defence Medical Services (DMS) operate as a whole. The Team’s over-arching objective is to chart a coherent and pragmatic way forward for the DMS, building on the Government’s policy statement " A Strategy for the Future", published in December 1998.

2. The Review Team’s work is being carried out in phases. The first phase, resulting in a preliminary report which has been considered by Ministers, has included an examination of the four medical Agencies (the Defence Secondary Care Agency; the Defence Medical Training Organisation; the Defence Dental Agency; and the Medical Supplies Agency) against the backdrop of the Government’s commitment to deliver better and higher quality public services as part of its ‘Modernising Government’ initiative, as well as a study of wider issues affecting the Defence Medical Services (DMS) as a whole. The main emphasis of the next phase of the Review Team’s work will be to confirm and support their provisional conclusions, and also to assist the Agencies, the single Services and Surgeon General’s Department (SGD) in tackling the areas identified for improvement, while consulting further with customers and identifying lessons and good practice. The Review Team has identified a number of specific work packages to deliver key recommendations and tackle unresolved questions.

3. During the course of the Review the Team has consulted widely with Ministry of Defence, single Service and Agency staffs. In addition, families’ groups, professional associations and patients have been consulted, and informal discussions held with NHS staff.

4. The Review Team’s preliminary report finds that, while considerable progress has been made since the announcement of the Government’s Strategy for the DMS in 1998, there are still some underlying weaknesses in defence medical support which have not yet been resolved. These weaknesses contribute to a continuing inability by the Armed Forces to meet satisfactorily the key "output" requirements of 

• deployable operational medical capability

and

• appropriate, timely healthcare to maximise the availability of Service personnel for deployment.

In addressing these issues the report aims to build on and develop the approaches set out in the 1998 policy statement.

5. The Review Team’s provisional conclusions can be summarised as follows:

• In line with the policy laid down by the Government in its 1998 Strategy for the DMS, there is a need to define more clearly the responsibilities of the single Services, while retaining and strengthening a clear tri-Service strategy and policy focus within SG’s Department. This central function of SG’s Department should be combined with continuing responsibilities for owning tri-Service Agencies, and for joint planning with the NHS. The overall objective is to create a better tri-Service structure for the DMS, built on stronger single Service foundations.

• To this end, SG should be given responsibility for effective oversight and direction of the DMS, and be empowered to provide strategic policy, standards and audit functions across the whole medical services organisation.

• At the same time, the single Services should have clear responsibility for the recruitment and personnel management of the military staff required to deliver their agreed Service requirements, while acting within a collaborative tri-Service framework.

• Management capabilities across the DMS should be reinforced from parent Services – and elsewhere if necessary – and corporate, tri-Service approaches to conducting business adopted throughout the DMS.

• A more comprehensive partnership should be established with the NHS, with the NHS playing a fuller role in support of the Armed Forces, and also with private sector healthcare providers as necessary. This develops the approach outlined in the Government’s 1998 policy statement, which confirmed the need for a strengthening of the vitally important relationship between the DMS and the NHS, and for the two organisations to work closely together at all levels, thereby making most effective use of the vital national resource that the medical services represent.

6. The Review Team has produced the following provisional organisational recommendations, which will be confirmed as part of the team’s next phase of work:

• The two principal functions of the Defence Secondary Care Agency (DSCA) should be separated, with the training and placement of DMS personnel in NHS Trusts transferred to an enhanced Defence Medical Training Organisation (DMTO), and planning and contracting for secondary and tertiary care re-established in a new joint MOD/DoH/NHS planning and commissioning unit reporting direct to SG.

• The Defence Dental Agency (DDA) should be retained as an Agency, undertaking a business review aimed at delivering performance improvements, and transferring certain training functions to an enhanced DMTO.

• Ownership and management of the Medical Supplies Agency (MSA) should be transferred to the Defence Logistics Organisation (DLO).

• The management and delivery of healthcare to British Forces Germany should continue unchanged for the time being.

• Responsibility for the management and funding of all medical functions (including secondary care) in Cyprus and Gibraltar should be vested in the respective overseas Commands.

• Delivery of primary care should remain the responsibility of the single Services, but with SG having a key strategic role in planning for Defence-wide primary care provision. This recommendation, which will be confirmed in further work by the Review Team to produce sound and workable management arrangements, addresses the requirement identified in the Government’s 1998 policy statement for organisational improvements to create coherent management and budgetary arrangements, which would in turn enable the production of an overall strategy for the DMS and the management of resources in the most effective way.

7. It has not been possible in the first phase of work for the Review Team to make any realistic assessment of the costs or other resource implications of their recommendations, and these will be addressed in the further work now proposed. The areas in which additional costs are likely are improved arrangements for access to secondary care, and the reinforcement of management capability across the DMS. There may, however, be offsetting savings from a simplification of the Agency structures. In the longer run the restoration of DMS manning levels would, of course, entail significant personnel costs.

8. Although the Review Team proposed an implementation date of 1 April 2002 for the new arrangements proposed in their preliminary report, the programme of further work that they have proposed should be put in hand to confirm and support in detail their emerging conclusions makes such an implementation date largely unachievable. Furthermore, for technical reasons it is likely that proposals involving complex changes to the Ministry of Defence’s budgetary structures could not be implemented before 1 April 2003.

9. Ministers have endorsed the broad approach of the Review Team’s preliminary report, and have underlined the importance they attach to this work as a key part of the overall strategy for restoring the defence medical capability. They have agreed that the Team should now embark on a further programme of work to confirm and support these emerging conclusions, and to define robust solutions which, taken together, will meet the key objective of delivering a deployed operational medical capability. Ministers have also confirmed that, once agreed, any changes should be implemented as quickly as possible; and, to this end, the Review Team have been asked to identify in their further work those areas where early improvements can be achieved.