The embarrassing admission by the armed forces medical service that it is struggling to achieve its waiting- time targets, despite making them easier, will not surprise those who have monitored its troubled progress in recent years.
Defence Secondary Care Agency chief executive Christopher Callow explained last week that the 19992000 targets had been adjusted downwards to a more 'realistic' level, but even this was proving too tough due to continuing shortages of clinical staff and 'operational demands upon a limited resource'.
This might seem of academic interest to the NHS, but the Defence Medical Services' problems have a direct impact on it. Not only is the DMS recruiting in the same limited market for medical expertise, it is increasingly reliant on pulling reservists out of the already stretched NHS to support military operations in the Balkans and elsewhere.
'I'm hesitant to use the word crisis, but the situation at the moment is that the size of the DMS has dipped below a certain critical mass to be totally professional, ' says Andy Ashworth, British Medical Association council representative for the armed forces and a reservist who served in the Falklands war.
Ministers could 'find themselves unable to deploy' enough doctors and nurses to support the forces.
In October 1997, the then armed forces minister, John Reid, flush with optimism, declared: 'Only a fool would fail to recognise the parlous state of our defence medical services.'
Last month the government was rather less gung-ho. Defence minister Lord Burlison gave a detailed, polite rebuttal of Conservative accusations that the DMS was still in a 'parlous' state. But he had to admit: 'It is undeniable that the DMS faces a number of problems.'
At the end of last year, the total strength of the regular DMS was 6,174, against a requirement of 8,530.
There were 865 medical officers, including trainees, against a requirement of 1,201.There were around 42 per cent fewer nurses than needed.
The reasons for the staff shortages will be familiar to those working in the NHS: low morale, disruption to family life caused by heavy workloads, and staged pay awards.
The shortages are thrown into stark relief by the increasing demands on the armed forces, whether these are military operations in the Balkans, humanitarian operations in Mozambique or future responsibilities in the proposed 60,000-strong EU military force.
'If manpower levels in the DMS are not regenerated, the government may be faced with the choice of either not deploying at all, or of deploying knowing they do not have sufficient medical support, ' says Liberal Democrat defence spokesperson Menzies Campbell.
The government has pointed out that to date the DMS has met all its operational commitments, despite the shortages.Mr Campbell suggests this was by chance rather than design.
'We were lucky there were no heavy casualties [in the Balkans].Had we started taking heavy casualties things may have been different.'
There are currently around 60 medical reservists in the Balkans.The government wants to attract a further 600 medical reserves to the Territorial Army, and claims to have had around 1,000 enquiries from last autumn's recruiting campaign.
This has implications for the NHS.
'There's a finite number of doctors and when you take the reserve away you are taking them away from the NHS, ' says Dr Ashworth.
'We have to be prepared to reduce the service to the NHS and increase waiting lists. It's military operations or surgical operations.'
Lord Wallace of Saltaire claimed in a Lords debate last month that trusts were resistant to 'the potential compulsory call-up of reserves' - not least because of the havoc that could cause to trust waiting-list initiatives.
He added: 'One cannot at the same time rebuild the DMS in competition with an underfunded and overstretched NHS. Yet again, joined up government requires one to think about those two things together. At the moment. . . the weaknesses of each increase those of the other.'
A 'good and realistic' strategy?
The government says its strategy for the DMS provides a 'good and realistic basis for ensuring that the armed forces continue to have the high-quality medical support they require'.
It has made available£140m to the DMS for the four years to 2002 for extra equipment and personnel.
It plans to fund two 200-bed casualty receiving ships, three new ambulance squadrons and an extra air evacuation flight.
It claims that recruitment into medical training is 'generally satisfactory' and that medical cadetships and nurse training places have increased. But it admits it will have to work hard to improve recruitment and retention levels for qualified doctors.
A number of Ministry of Defence-Department of Health liaison groups have been set up to discuss personnel, operational planning and civilian medical practice issues.