Quarry House Quarry Hill Leeds LS2 7UE Tel: 01132 545843 FOR INFORMATION Gateway Number: 10070 20 June 2008 To: SHA Chief Executives Dear Colleague HEALTH SERVICES FOR THE ARMED FORCES, THEIR FAMILIES AND VETERANS GUIDANCE FOR SHAs 1. The purpose of this brief paper is to highlight the particular needs of the Armed Forces, their families and veterans to help SHAs ensure that their PCTs commission the right services to meet their needs. SHAs need to assure themselves that their PCTs and providers are meeting the requirements of the Operating Framework in terms of the Armed Forces, their families and veterans, and this paper provides some information which will help them in this. What are the NHS s responsibilities? 2. Attached at Annex A is a note about who is responsible for providing different healthcare services for the Armed Forces, their dependents and veterans. In summary, Armed Forces dependents and veterans are generally the responsibility of the NHS; and the NHS is responsible for Armed Forces secondary care in England, but not primary care. Numbers involved? 3. There are about 140,000 Armed Forces based in England, with about 350,000 dependents. 60% are concentrated in 10 PCT areas. There are about 5 million veterans (a person is classified as a veteran if they have served for one day in the Armed Forces). Meeting the specific needs of the Armed Forces, their families and veterans 4. SHAs will be aware of Section 3.15 in the Operating Framework for 2008/09 titled Commissioning services for military personnel and veterans. The SHA planning checklist for the Operating Framework included the following: For PCTs with armed forces based in their area, do their plans take account of the needs of the armed forces and the needs of their dependents? In particular, do they take account of the particular difficulties that can arise from frequent moves, eg dependents' access to NHS dentistry, immunisation programmes and health promotion activities? Do
plans take account of the particular needs of veterans, eg for effective transition of care from the Defence Medical Services to the NHS and for culturally sensitive mental health services? 5. DH is working with the 15 PCTs which have the largest number of Armed Forces personnel and dependents, to look at ways of making sure that the needs of the Armed Forces dependents are met. The focus first is on access to NHS dentistry, as this is the issue that provokes the greatest number of complaints among dependents. The Primary Care Contracting website contains information on this issue, and the intention is for PCTs to share good practice through this: http://www.primarycarecontracting.nhs.uk/278 6. More generally, MoD is encouraging their bases to contact local PCTs to make sure that they feed into the Joint Needs Assessments and that their commissioning plans reflect the needs of the Armed Forces and their dependents. Many of the dependents come from quite socially deprived backgrounds, and problems accessing the services they need may be exacerbated by frequent moves and living in rural areas. It is therefore very important for PCTs to encompass this group of people in their plans to tackle health inequalities. 7. In relation to waiting lists, patients whose care transfers between organisations can experience extended pathways. It is important, therefore, that NHS organisations have processes in place to ascertain how long patients who move have waited already - and to treat these patients without unnecessary delay according to their clinical need. In line with this, and as set out in the Operating Framework, guidance has been issued setting out the minimum data set that should transfer with patients who transfer between providers whilst on a referral to consultant-led treatment pathways. 8. Patients who are moving can also help the NHS by discussing - if appropriate - arrangements for transferring their care to a new provider with the clinician (professional) who referred them. To support this approach, we are also working with the MoD and the 15 PCTs with the largest number of Armed Forces personnel and families on the best way to communicate with military personnel and their families who may be asked to move home frequently and at short notice. 9. There is a particular issue around IVF services, where families have to move during a course of treatment, and this issue is being looked at separately. 10. In relation to veterans, awareness of the priority treatment provisions is not as high as it might be (Dear Colleague letter at Access to health services for military veterans : Department of Health - Publications 11. Most veterans are elderly people who have the same health care need as other elderly people. The main issues for younger veterans are: people discharged with significant health problems: the MoD normally liaises with the local PCT and provider if there are significant ongoing health needs. The Responsible Commissioner Guidance covers continuity of care issues for those leaving the Armed Forces. There is a very small number of amputees being discharged who have prostheses which may well be different from the ones that are provided on the NHS, as they are provided through the military rehabilitation services. The MoD are working with provider units to ensure that they can maintain and replace those prostheses, but it will be important to ensure that PCT commissioning arrangements allow this. Guidance on this has been issued recently see Annex B. people discharged with no significant health problems: there have sometimes been problems with GPs accessing past records for discharged members of the Armed Forces. There are points of contact for accessing them if GPs are having difficulty, and they are attached at Annex C. Veterans may well develop service-related mental health problems long after discharge, and there is some evidence that they have difficulty in accessing mainstream services. For this reason, MoD and DH are
running a range of pilot studies looking at how best to provide community mental health services which meet veterans needs. 12. In relation to promoting reservists in the NHS, the evidence is that the NHS benefits very significantly from the leadership and clinical skills that reservists learn both in training and when mobilised. We are currently considering how best to get this message across to NHS employers, so as to ensure that they are supportive of any staff who wish to volunteer. MoD plans 13. SHAs and PCTs should be aware well in advance of significant changes in Service personnel and dependent numbers, so that they can plan for those changes. This is generally happening at local level, but we have asked MoD to provide information about long-term plans, so that SHAs can be aware. We will ensure that individual SHAs which might be affected have this information. Links between MoD and UK health departments 14. The relationship between the departments is governed by a Concordat, and is monitored by a partnership board. That board has a work programme and three working groups (operations, policy and workforce) to support it. Queries 15. If you require further information or details regarding your local MoD contacts, then please do not hesitate to contact Jane.Allberry@dh.gsi.gov.uk or Dave.Rutter@dh.gsi.gov.uk Lyn Simpson Director of NHS Operations Enc
Annex A Current responsibilities for healthcare for Armed Forces, their dependents and veterans Arrangements for the provision of healthcare for the Armed Forces in England Health Service Guidance from 2005 (Health service guidance covering arrangements between the Ministry of Defence and the NHS : Department of Health - Publications) covers the treatment of service personnel in NHS hospitals and the continuing health care of service personnel on retirement or discharge from the Armed Forces. The same Guidance also covers the use of Defence Medical Services (DMS) personnel in NHS Trusts. The Guidance sets out a series of underpinning principles. These are that: the treatment of service personnel should, as far as is appropriate, align with NHS arrangements for the treatment of civilians MOD is able to secure higher levels of access where required for operational reasons from any NHS Trust or other provider as appropriate, in return for enhanced payments NHS improved performance will also benefit healthcare for service personnel, and hence operational effectiveness DMS personnel working at Medical Defence Hospital Units (MDHUs) or other NHS Trusts should be fully integrated into the host NHS Trust, and host NHS Trusts should not be financially disadvantaged as a result of hosting employment of DMS personnel or of provision of treatment. Responsibilities are as follows. In primary care, members of the armed forces are removed from GP practice lists when they enlist (as required by NHS Regulations), and are not able to register whilst they are serving. During this time, the MoD is responsible for their primary medical services through the DMS. However, where a member of the Armed Forces does not have ready access to DMS (eg when on leave), they can join the list of a local GP practice as a temporary resident. In relation to secondary care, members of the Armed Forces based in the UK are entitled to the full use of NHS facilities on the same basis as civilians if appropriate military healthcare provision is not available. Equally, members of the armed forces serving overseas are also entitled to full use of NHS secondary care facilities without charge, should they return to England for their treatment. Primary Care Trusts (PCTs) are responsible for securing the provision of secondary care treatment for such personnel in the UK, ie they must make sure that services are available for them if they are not accessing military healthcare provision. The MoD is responsible for the provision and/or commissioning of healthcare to entitled personnel in the majority of places where service personnel are stationed abroad. In addition to normal NHS responsibilities, the DMS contracts with the NHS to provide secondary care facilities for forces based in the UK. It has specific contracts with 6 NHS/NHS Foundation Trusts. MDHUs have been established within the following: Plymouth Hospitals NHS Trust Frimley Park Hospital NHS Foundation Trust Peterborough and Stamford Hospitals NHS Foundation Trust Portsmouth Hospitals NHS Turst South Tees Hospitals NHS Trust, and at the Royal Centre for Defence Medicine at the University Hospital Birmingham NHS Foundation Trust. At the MDHUs, the MoD have agreements with the NHS Trusts to provide accelerated access for elective referrals of service personnel to meet operational requirements. There are also single contracts between the DMS and particular Trusts when needed.
Continuing health care of service personnel on retirement, demobilisation (in the case of reserves) or discharge from the Armed Forces The NHS is responsible for the health care of service personnel on leaving the Armed Forces provided the individual is entitled to residency in the UK. It is the responsibility of the individual to register with a general medical practice. The vast majority of personnel leave the Services fully fit or with minor ailments only. For the small number of service personnel who leave the forces with a serious health problem, any outstanding or on-going care will usually have been arranged prior to discharge. Guidance also covers priority treatment for war pensioners and veterans. It is long-standing practice (ie since the early 1950s) that NHS hospitals should give priority to war pensioners, both as out-patients and in-patients, for examination or treatment which relates to the condition or conditions for which they receive a pension or received a gratuity (unless there is an emergency case or another case demands clinical priority). The Government has recently extended this priority to all veterans for service-related conditions. Veterans priority is covered within the Operating Framework for the NHS for 2008/09 and in the attached Dear Colleague letter (Annex C). The families of service personnel The families of UK armed forces members can - and would normally - remain registered with GP practices although they are able to access health care from the DMS when overseas. They will access all NHS services on the same basis as any other UK citizen. The particular pressures placed on families who may move around the UK on a more frequent basis than the general population are recognised and the Operating Framework for the NHS for 2008/09 asked PCTs to make sure that armed forces families are not disadvantaged as a result of frequent moves. NHS local funding and commissioning arrangements Funding arrangements and guidance on commissioning services for local populations provide the framework for PCTs to meet the needs of service personnel and their families. PCTs are responsible for funding the healthcare provision of all patients registered with GPs in practices forming the PCT. PCTs are also responsible for residents within their geographical boundaries who are not registered with a GP. With regard to the Armed Forces, service personnel are included in the secondary care elements and PCT revenue allocations, and excluded from the primary care elements, as these services are provided by the DMS. UK Armed Forces dependents and former service personnel are included in all elements of PCT revenue allocations, as of course the PCT is responsible for their healthcare.
Annex B guidance on prostheses for ex-service personnel May 2008 Under the Responsible Commissioner provisions, PCTs are expected to provide continuity of care for personnel who are discharged from the Armed Forces and become resident in their area. The Ministry of Defence generally liaises with individual PCTs and providers about the continuity of care for members of the armed forces who are discharged with significant on-going health needs, and these arrangements work well. The Ministry of Defence is currently working with a number of provider units to prepare them to maintain and replace the prostheses of a small number of amputees who will be discharged from the Armed Forces over the coming years. If the clinical need remains, good clinical practice would make it appropriate for these ex-service personnel to have their current prostheses maintained in the NHS - whether or not they are of a type that the NHS would have provided - and for appropriate replacements to be provided that continue to meet their individual needs. Assessment of clinical needs should cover the psychological as well as the physical/functional aspects. Action: The commissioning of prostheses services in PCTs should allow for ex-service personnel to get their prostheses maintained and replaced appropriately on the NHS.
Annex C - New Patients discharged from military service When members of the armed forces are discharged, they are given a summary of their medical records to give to a GP when they register, along with contact details for the GP to go to if they need fuller records. On occasion, the new patient may not have to hand the summary or the contact details. The contact details to obtain summary or full records are as follows: Royal Navy British Army Royal Air Force MDG(N) Medical Records Section Institute of Naval Medicine Alverstoke Hampshire PO12 2DL Secretariat Disclosure 3 (Medical) Mail Point 525 Army Personnel Centre Kentigern House 65 Brown Street Glasgow G2 9EX ACOS Manning, Medical Casework Room 1, Bldg 22 RAF High Wycombe Buckinghamshire HP14 4UE