How To Determine The Entitlement To Healthcare In The Nhs

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1 Journal of Public Health Medicine Vol. 21, No. 3, pp Printed in Great Britain Entitlement to military healthcare limitations of the NHS model Major Martin C. M. Bricknell Summary The Defence Medical Services provide to a British population healthcare services that are funded from taxation and are free at the point of delivery. This paper reviews some principles for determining entitlement to healthcare for the population cared for by the Defence Medical Services. The starting point for entitlement uses the principles under which the National Health Service (NHS) was established. These are then extended to acknowledge the limitations of an NHS model when considering occupational health issues and geographical variations in healthcare provision. Keywords: military, priority, entitlement Introduction It is widely acknowledged that demand for healthcare services cannot ever be completely matched by resources. Thus all healthcare systems have a mechanism for regulating demand. The process may not be explicit and may rely on surrogates such as waiting lists to manage demand. It is becoming accepted that the setting of priorities for treatment should be an explicit process that supports the allocation of resources within healthcare. 1 Innovations in healthcare will increasingly pose questions for health services about entitlement to access that naturally fall out from the process of rationing. 2 Discussions within the British medical press on rationing, priority setting and entitlement naturally concentrate on the National Health Service (NHS). The British Armed Forces also provide a healthcare service that is centrally funded from taxation and is free at the point of delivery. This paper debates the principles for determining entitlement to healthcare of military personnel, their dependants and veterans and discusses the limitations of using an NHS model to define these arrangements. The Defence Medical Services (DMS) exist to provide to the Armed Forces a comprehensive medical service in peace, war and operations other than war to standards at least equal to those of the NHS. 3 When not involved in operations, the aim of the DMS, both uniformed and civilian, is to maintain the fighting strength of the Armed Forces by the prevention of illness or injury and, if these occur, to return Service personnel to active duty as soon as possible. In peace the focus is on providing the trained manpower necessary to support military operations. Healthcare services are provided for all uniformed personnel and, in certain overseas locations, for dependants of Service personnel and civilians working for the Ministry of Defence (MOD). Primary care services are provided for Service dependants in a small number of UK garrisons to enable trainee military doctors to meet the educational requirements of postgraduate training. The organization of healthcare provided by the DMS has fundamentally changed during the course of the 1990s. At the beginning of the decade healthcare for military personnel was provided through single-service systems that allowed the full range of healthcare services to be provided. The creation of the purchaser provider split within the NHS was mirrored by the creation of the Defence Secondary Care Agency (DSCA), the Defence Dental Agency (DDA) and the Medical Supplies Agency (MSA) within the Armed Forces. It was envisaged that these agencies would act as providers of secondary care services, dental services and pharmaceuticals, respectively. Healthcare for British Forces in Germany is organized in a similar fashion, with services being commissioned by the Health Commission and being provided by The Health Alliance. These changes have created a new interface across the purchaser provider divide. The Armed Services no longer act directly as providers of a complete healthcare system but commission a proportion of healthcare provision from the DSCA and other external agencies. Thus the issue of entitlement to military healthcare now has visible financial implications. This issue was not so explicit when healthcare was delivered through single-service arrangements. Pillars of the NHS All UK nationals are entitled to healthcare from the NHS. Members of the Armed Forces are entitled to full use of NHS hospitals on the same basis as civilians if appropriate military provision is not available. 4 Thus one element for the entitlement of access to healthcare for military personnel must reflect the principles behind the provision of healthcare services from NHS. Army Medical Directorate, Keogh Barracks, Ash Vale GU12 5RR. Martin C. M. Bricknell Faculty of Public Health Medicine 1999

2 326 JOURNAL OF PUBLIC HEALTH MEDICINE Table 1 Principles of equity in healthcare in the NHS Universal entitlement Shared financial costs through taxation Free at the point of use Comprehensive Equality of geographical access and outcome Equality in standards of care Selection on the basis of clinical need The NHS was established on the key value of equity. This incorporates the seven key principles shown in Table 1. 5 The Government has reaffirmed these principles in its strategic plan for the NHS. 6 The NHS will remain a nationally organized service that offers fair access to health services based on clinical need irrespective of geography, class, ethnicity, age or gender. In spite of these ideals there are significant variations in health associated with social class, geographical location and provision of healthcare services. 7 The governmentcommissioned independent inquiry into inequalities in health has provided a strategic basis for future policy development to reduce health inequalities. 8 The report of that inquiry stressed the importance of equity in access and equity in resource allocation in the provision of health care services. The Government has acknowledged that the health of the economy depends on the NHS to help ensure a healthy workforce. Indeed, the workplace has been identified as one of three key settings for health improvement. 9 NHS and military healthcare settings There are several key differences between NHS and military healthcare settings. Figure 1 shows the age distribution of the UK national population 10 compared with that of the UK military population. 11 It can be seen that the two populations have significantly different age structures. This might be expected to affect the demand for types of healthcare services. It is difficult to directly compare demand for health services between the UK national population and the UK military population. There are no summary statistics available for military primary care activity. Demand for secondary care services by the military population cannot easily be measured because there is no single healthcare provider. Death is the only comparable outcome measure between the two populations. Figure 2 shows the distribution of causes of death for the UK national population compared with that for the UK military population. These groups have not been matched for age because the discussion relates to the comparison between the demand from the two health systems, the NHS and the military. It can be seen that injury and poisonings are the principal cause of death in the military population and circulatory disease is the principal cause of death for the UK national population. On this basis, it would make sense to limit the use of the NHS model for healthcare by the military to those areas that address similar populations. The Acheson report 8 recommended the following specific areas for policy development in addressing the health of young people and adults of working age: preventing suicide, promoting healthier lifestyles, promoting sexual health, Figure 1 Age distribution of UK national population and UK military population.

3 ENTITLEMENT TO MILITARY HEALTHCARE 327 Figure 2 Distribution of causes of death of UK national population and UK military population. encouraging physical exercise, reducing tobacco smoking and reducing alcohol-related harm. These recommendations show that meeting the demand for healthcare by the military population should emphasize preventive rather than treatment services. Service personnel who are unfit for military service are medically discharged. It is possible to use this as a surrogate for the distribution of long-term ill-health in the military population. Figure 3 shows the distribution of causes of medical discharge from the Armed Forces in The majority of ill-health is due to musculoskeletal conditions, of which a large proportion is a direct result of employment. Figure 3 Causes of medical discharge from the Armed Services.

4 328 JOURNAL OF PUBLIC HEALTH MEDICINE Military healthcare is funded directly from the defence budget. The costs of the healthcare system and the costs of ill-health lie together, in contrast to the situation for the NHS, where there is no direct link. Thus controlling demand by the use of waiting lists or diluting services (making less time available for healthcare) has a direct economic effect on the performance of the defence budget. Meeting the demand for healthcare from the military health system requires a different balance of preventive, treatment and rehabilitation services compared with that for the NHS because the age-structure, the causes of ill-health and final results required are different for the two populations covered. Principles The first principle is that, when not involved in military operations, military personnel and their dependants (where entitled) should receive a healthcare service at least equivalent to that given by the NHS, with priority given on the basis of clinical need. This equality with the highest standards of civilian practice is embedded into policy. 3 Service general practitioners (GPs) have the same filter role to manage demand as in the NHS. Members of the Armed Forces are entitled to full use of NHS hospitals on the same basis as civilians if appropriate military provision is not available, in accordance with direction from the Department of Health. 4 The key raison d être for the DMS is the nation s moral obligation to provide acute treatment for its citizens who might be injured during the course of military conflict. This also has the benefit of reducing the impact of ill-health on military manpower and sustaining morale. This service is maintained in peace to ensure that the capability is available for military operations and as such cannot be demand led. Although it will always be an aspiration to provide medical care of an equivalent standard to that of the NHS on military operations, this may not be achievable. The size of the force deployed may not justify a full range of secondary care facilities and it will nearly always be impossible to provide tertiary care capabilities. Casualties will be given priority in accordance with clinical need unless demand exceeds resources, and then casualties will be sorted on the basis of ability to benefit from intervention. This is the basis of military triage. The NHS model has limitations in meeting the needs of the Services in peacetime. The military healthcare model also fulfils the functions of an occupational health service. These are: to ensure the maximum performance at work of employees by the provision of advice to prevent ill-health, the appropriate medical selection of personnel, the provision of rapid access to treatment and rehabilitation in the event of injury or illness and the medical assessment of personnel whose fitness deteriorates whilst in service. Thus the demand for medical time will be different from that in the NHS model, with a relative increase in the proportion of medical time spent advising on the prevention of ill-health, planning and training for war, conducting medical assessments and rehabilitating personnel back to work compared with that spent providing acute treatment services. Military personnel need to be physically fit to undertake their duties. Therefore the output from military healthcare services is individuals who have achieved the maximum level physical fitness compatible with the cause of their ill-health. This is different from the NHS output, which is currently measured as reduction in demand for healthcare services (by waiting lists) and not in terms of functional recovery. Therefore military personnel should receive sufficient treatment to return them to military duty. This may require a level of service greater than would be expected under NHS arrangements. The requirement for Service personnel to be returned to duty as quickly as possible has already been identified. Individuals have different skills, some of which may be in critical demand (e.g. pilots). Units (collections of individuals) are at varying warning levels for deployment and the absence of key individuals may have a critical effect on the operational performance of units. Therefore, the Services may require relative priority to be given to some individuals on the basis of their importance to the organization rather than clinical need as judged by time spent on a waiting list. Thus the Service commanders may specify priorities for treatment on the basis of the operational impact of the absence of an individual from duty. 13 The NHS does not provide the full range of clinical services to treat every medical condition. Access to services such as cosmetic surgery is restricted by waiting lists or by explicit cash-limited budgets. The most effective provision of some services, such as alcohol rehabilitation, may not be the most cost-efficient in terms of rate of relapse per unit expenditure. However, cost-efficiency in NHS terms may not represent cost-efficiency in defence terms because the NHS does not carry the economic loss of trained manpower represented by treatment failure. Thus if an individual s fitness for work will be enhanced by the provision of a treatment there may be an economic argument for this to be commissioned by the DMS if there is likely to be a significant wait for treatment from DMS provider units or access to treatment under the NHS is not possible. Dependants of Service personnel are entitled to full NHS services in the UK. The Government has set in train significant changes that are likely to decentralize the delivery of healthcare in the UK. The principal change is the creation of Primary Care Groups (PCGs) based on local GPs. PCGs will determine priorities for healthcare provision in their localities. In small garrison locations dependants register with NHS GPs and compete with other populations. In larger garrison locations dependants may register with Service GPs and therefore they will not be registered as NHS patients with PCGs. The needs of dependants of military personnel will need to be recognized by PCGs. Service dependants are entitled to the same equality of access to healthcare from the NHS as other residents in the same locality.

5 ENTITLEMENT TO MILITARY HEALTHCARE 329 Table 2 Principles for entitlement to military healthcare Universal (1) In peace, military personnel and their dependants (where entitled) should receive a healthcare service at least equivalent to that of the NHS, with priority given on the basis of clinical need (2) In war, if demand for health services exceeds supply, priority should be based on ability to benefit rather than clinical need Military personnel (1) Treatment should be sufficient to return them to duty (2) Priorities for treatment may be based on the operational impact of the absence of an individual from duty (3) If an individual s fitness for work will be enhanced by the provision of a treatment this may be commissioned by the DMS if there is likely to be a significant wait for treatment from DMS provider units or access to treatment under the NHS is not possible Dependants (1) Service dependants should have equality of access to healthcare from the NHS compared with other residents in the same locality (2) Service dependants should have geographic equality of access to healthcare from the NHS (3) The health of Service dependants should be actively promoted through manipulation of the social determinants of health (4) The posting of Service personnel overseas may be affected as a result of the health of their dependants, to ensure access to healthcare of NHS standards and to prevent excess costs against the defence budget Veterans (1) Veterans should have access to healthcare on a basis that recognizes that their contribution to society through service in the Armed Forces may have had a direct impact on their subsequent health Waiting lists are an inevitable consequence of the delivery of healthcare in the UK. The Army encourages accompanied service. Therefore dependants of serving personnel are implicitly obliged to move when the Service person is posted. Unfortunately, Service dependants may lose their relative position on a waiting list if the change of residence involves crossing health authority boundaries. In addition, there is geographical variation between health authorities on the provision of services, thus a Service dependant may lose the opportunity to receive healthcare when moving between health authorities. Access to healthcare by dependants may be adversely affected as a direct consequence of the spouse or parent belonging to the Army. As a principle, Service dependants should have geographic equality of access to healthcare from the NHS. The Government recognizes that there are social factors that influence health. Examples include housing, education, income, diet, smoking and alcohol intake. Many of these social determinants of health can be directly associated with social class. The Army has direct control of many of these factors. The health of Service personnel and their dependants can be actively promoted through manipulation of these social determinants of health. The military is uniquely able to influence access to healthcare by its personnel and their dependants by controlling the location of their work. In Germany, healthcare for Service personnel and dependants is commissioned from The Health Alliance. In Cyprus, Gibraltar and the Falkland Islands dependants have access to the same healthcare arrangements from military sources as Service personnel. In these locations it is not possible to provide the full range of services as in the NHS and thus families are medically screened to ensure that they do not impose a demand for healthcare that cannot be met by the existing facilities. In addition, it is inappropriate for the defence budget to incur preventable costs that should lie with the Department of Health. Thus it may be necessary for the posting of Service personnel overseas to be affected by their health or the health of their dependants, to ensure access to healthcare to NHS standards and to prevent excess costs against the defence budget. The final group to be considered is veterans (ex-service personnel). The contribution of Service personnel to society was recognized well before the advent of the NHS. War Pensioners remain entitled to priority treatment from the NHS for conditions attributable to their military service. 14 However, the word priority is a relative term that only has value if it is clear how access to healthcare is improved relative to other groups of NHS patients. Many explicit statements of equity within the NHS state that there should be no discrimination on the grounds of employment status or social position. This is the complete antithesis of giving priority to War Pensioners. 15 Veterans are entitled to access to healthcare on a basis that recognizes that their contribution to society through service in the Armed Forces may have had a direct impact on their subsequent health. Conclusions This paper has examined the limitations of the NHS model in establishing the principles relating to the entitlement of Service personnel, their dependants and veterans to healthcare at government expense. Service personnel should be entitled to a healthcare service that provided services to at least the standard of the NHS but is extended into a model based on an occupational health service. Dependants of Service personnel should not be penalized by their spouse s or parent s contribution to national defence. Therefore access to health services should

6 330 JOURNAL OF PUBLIC HEALTH MEDICINE ensure equity on both a locality and national level. Finally, society must ensure that its debt to its veterans is repaid by ensuring that access to healthcare reflects military service. The principles for entitlement to healthcare are summarized in Table 2. Note This paper is the opinion of the author and does not represent Ministry of Defence policy. References 1 Klein R. Puzzling out priorities. Br Med J 1998; 317: Marinker M. Looking and leaping. In: Marinker M, Peckham M, eds. Clinical futures. London: BMJ Books, Surgeon General s policy and standards for the Defence Medical Services Internal MOD document. 4 Treatment of Service patients in NHS hospitals. HSG (97) 29. London: Department of Health, Whitehead M. Who cares about equity in the NHS? Br Med J 1994; 308: The new NHS. CM London: Stationery Office, Drever F, Whitehead M. Health inequalities. Office for National Statistics. London: Stationery Office, Acheson D. Independent inquiry into inequalities in health report. London: Stationery Office, Our healthier nation. CM London: Stationery Office, Office for National Statistics. Social trends 28, 1998 edn. London: Stationery Office, Defence statistics London: Defence Analytical Services Agency, Tri-Service health indicators Bath: Defence Analytical Services Agency (Information Systems). 13 Surgeon General s policy letter. Medical priority for operational reasons, 23 April 98. Internal MOD document. 14 Priority treatment for war pensioners. HSG (97)31. London: Department of Health, Hope T, Hicks N, Reynolds DJM, Crisp R, Griffiths S. Rationing and the health authority. Br Med J 1998; 317: Accepted on 12 April 1999