In recent years the military has entrusted acute medical services to the NHS, and psychiatric care to an independent provider. But this has led to claims that the nation is failing those who have fought in its wars. Mark Gould reports

There have been almost as many upheavals in the way medical services are provided to the armed forces as there have been in the NHS. In the past 20 years a number of famous military hospitals have closed. The heavy-handed early 1990s cost-led reorganisations of Defence Medical Services with little input from frontline staff led to a mass exodus of angry nurses and doctors into the NHS, the repercussions of which are still being felt today.

The head of medical services for the armed forces has admitted to HSJ that there remain serious shortages of GPs, psychiatrists, general surgeons and medics. Some specialties are 50 per cent under strength.

But just as in the NHS, revolution is permanent. In 2001 it was decided the military would no longer run acute care services, which were subsequently transferred to the NHS. The Royal Centre for Defence Medicine based at Selly Oak Hospital - part of University Hospital Birmingham foundation trust - would become the main receiving hospital for casualties.

Six Ministry of Defence hospital units, located in NHS trusts near military populations, would treat elective military and civilian cases in mixed wards using NHS and military staff. Inpatient psychiatric care was also transferred out of the services and is now run on contract by the Priory Group.

But families and service personnel ask whether it is appropriate for civilians to be treated alongside military casualties. And ill-informed tabloid stories have alleged poor care of casualties of the Iraq and Afghanistan conflicts.

These most recent conflicts and last year's 25th anniversary of the Falklands war have sparked renewed anger at the plight of veterans. The South Atlantic Medal Association provides help and support for veterans. It estimates that some 300 Falklands veterans have committed suicide since 1982.

"After the Falklands there were ex-Welsh Guards suffering post-traumatic stress disorder trapped in darkened rooms. They never went out of their houses," says former surgeon commander Rick Jolly, who became a national hero during the Falklands conflict.

"I think it is a disgrace that the military does not have its own psychiatric hospital. The military regional hospital set-up was a lot better. It was run by service medical people who understand their patients and it was nearer military towns." His field hospital - nicknamed the Red and Green Life Machine - saved scores of UK and Argentine lives including Welsh Guards who were horrifically burnt on the supply ship Sir Galahad.

Priority treatment

In November 2007 health secretary Alan Johnson announced an extension of the right to priority treatment on the NHS to include all veterans with service-related conditions, regardless of whether they are war pensioners. And last year the military agreed to extend its Medical Assessment Programme to include Falklands veterans.

The programme's initial brief was to offer veterans of the 1993 Gulf war a full medical assessment, amid concerns of Gulf war syndrome. Dr Ian Palmer, who is both a GP and consultant psychiatrist, runs the service from St Thomas' Hospital in London. He can carry out an assessment in a day and then liaise with the patient's GP on the best course of treatment.

Latest MoD figures show 3,717 ex-service personnel have been seen by the assessment programme. The service's patients include veterans of the Gulf, Iraq and Afghanistan, Porton Down volunteers and a handful of Falklands veterans.

But Toby Elliott, chief executive of veterans' mental health charity Combat Stress, says demand is rising while NHS care is patchy. "To suggest that one military psychiatrist is going to make a difference in reducing the challenge of dealing with the increasing numbers is far from an ideal," he says of the assessment programme.

Service personnel and families questioned for a Commons defence select committee report published in February reserved "almost unanimous praise" for medical care given to recent casualties. But the report said Selly Oak is too far from any major service populations, meaning families often had to travel considerable distances to visit loved ones. Despite repeated requests, the MoD decided that it was too problematic to allow HSJ to see for itself how Selly Oak works.

Melanie Pullan from the Army Families Federation feels the centre should provide all-military wards. "People did get upset that they might be in bed next to someone with sympathy for insurgents or somebody who got injured or ill because they were drunk or something."

Then there is the severe shortage of doctors. MoD figures from April 2007 show a shortfall of 47 per cent in fully trained, deployable doctors among defence medical personnel. The deficits are felt most in crucial specialties such as surgery (50 per cent shortfall), general medicine (45 per cent) and psychiatry (54 per cent). The 1998 strategic defence review earmarked£140m to improve recruitment and retention, but figures from March this year showed there remains a shortfall of over 1,500 staff.

In April the health secretary gave a speech to NHS managers and reservist doctors and nurses at the Imperial War Museum North in Manchester to encourage more NHS staff to fill these gaps. He said the Sponsored Reservists scheme would allow specialists who did not have a regular role in the reserve forces to deploy for short periods in areas of shortage. Some 1,600 NHS staff are in the Territorial Army and 21 per cent of medical staff looking after British forces in Afghanistan are in this group.

Better incentives

The British Medical Association's armed forces committee chairman, Brendan McKeating, says Sponsored Reservists will not solve the levels of under-manning exacerbated by recent increased military commitments. "Better incentives such as improved pay and conditions need to be urgently implemented in order to retain fully trained, deployable doctors in the military," he says.

In 2003 the Duchess of Kent's Psychiatric Unit near Catterick in north Yorkshire was closed and outpatient care was moved to the forces' 15 regional departments for community mental health. Independent provider the Priory Group won the contract for inpatient services. The MoD says this means most patients can be treated much closer to their units than when everyone went to Catterick. Priory hospitals treat around 350 military patients a year at a cost of£4m - a third of the cost of running the Duchess of Kent hospital.

However, in the House of Commons last year Conservative MP for Newbury Richard Benyon told veterans minister Derek Twigg the Priory was inappropriate for their needs. Mr Benyon had "heard stories of people being told not to talk about their experiences for fear of upsetting civilian members of the group. We also heard of one case where an individual was sitting next to a woman who was receiving bereavement counselling for the loss of her cat".

Priory Group services liaison manager Chris Higham was an army psychiatric nurse for 26 years. He is also a Territorial Army colonel and led a field hospital in Afghanistan last year.

He says he is not aware of complaints from service patients or civilians. "In the five years Priory has held the contract, I don't recall any problems or negative feelings. With soldiers suffering post-traumatic stress disorder, we do a lot of one-to-one and some group work. Staff have developed a great deal of understanding of military patients."

It takes a lot of security checks, photographs and waiting behind bombproof doors to get into the vast citadel of the MoD in Whitehall to meet surgeon general and head of Defence Medical Services Lieutenant General Louis Lillywhite. He is quick spoken and fiercely intelligent, hopping from subject to subject. Unkind military folk say that his public health qualifications mean he is merely a "drain sniffer". But his parachutist's wings - earned with the Parachute Regiment - also award him action man status.

On the big question of centralising acute care he is emphatic. "Selly Oak is the best place in the UK to get your trauma care, civilian or military. That is why I want casualties concentrated in Birmingham. I don't want them going to [MoD hospital units] around the country - our casualty numbers are not sufficient for them to develop as centres of excellence anyway."

He is equally straightforward about preventing tensions when the military shares wards with civilians: "We try to concentrate the military together, which avoids that. But UK plc can't afford to leave beds empty."

He says most of these problems will be overcome by University Hospital Birmingham foundation trust's new hospitals project, which includes a military-managed ward flexible enough to cope with fluctuating demand.

While he accepts Selly Oak's location may create travel and accommodation problems, the surgeon general says many civilians face the same situation when seeking out the best care.

Selly Oak has been in the media firing line, with stories of a soldier contracting MRSA, staff leaving an amputee in pain and a Muslim civilian verbally abusing an injured paratrooper.

Lieutenant General Lillywhite says journalists have misrepresented the facts. "I believe Selly Oak and Defence Medical Services ended up as ammunition for the press in a political battle they were fighting and that continues to be so."

He refers to the story of Prince Harry's "hero" Ben McBean, who lost an arm and a leg in combat in Afghanistan. A Sun front page alleged Marine McBean, treated at Selly Oak, contracted MRSA. "The article actually said this patient had an MRSA swab taken from his skin. TheSun wasn't saying he was infected but the headline was 'Hero gets MRSA'."

However, he concedes personnel support for soldiers has been "not sufficient for purpose". This is military management-speak for what sounds like a potentially damaging cocktail of grieving, fractured families at the bedside of service personnel with complex injuries who would not have survived a decade ago, and the need to maintain military discipline.

"Nowadays 11 or 12 people turn up from split families, fiancees, live-in partners. You can have three different groups of alleged next of kin."

To restore order, a regimental sergeant-major manager was brought in to deal with discipline and matters related to service life and there are now some 39 military nurses on the ward.

Elsewhere, Lieutenant General Lillywhite refutes the talk of 300 suicides among Falklands veterans and says the overall suicide rate in the military is "broadly in line with or better than" rates in the overall population.

He says the military has better than average mental health, mainly due to strict selection processes and the "healthy worker effect - people at work are generally mentally healthier".

He puts forward a hypothesis on the slow development of mental healthcare for the services. "The biggest contributor could be the loss of armed forces experience in the NHS. Years ago, every doctor would have done at least National Service."

He is against a flagging system on medical notes so GPs are aware of a patient's military career. "All ex-servicemen are handed a letter when they leave to give to their GP, which allows the GP to not only flag them up as ex-serviceman but to send for the notes that were made when they were in the armed forces."

He feels part of the solution to finding and treating veterans are pilot community mental health schemes run by the NHS and the ex-services mental welfare society Combat Stress. The pilots will provide veterans with a service, led by a community veterans' mental health therapist, that will offer understanding of the particular issues for those who have served in the forces.

Treatment options will include referral to Combat Stress. The first pilots will cover Shropshire and Staffordshire and north London, and later this year Cardiff, Cornwall, Newcastle upon Tyne and Scotland.

Lieutenant General Lillywhite admits that a shortage of GPs is the "area of greatest risk". Reasons include a wide pay gap with the NHS and the increased pace of operations, he says. "When they come back to the UK, they find that their practices have deteriorated to a degree while they have been away."

As a result of the 1998 recruitment drive, more doctors are coming through and he predicts some specialties such as anaesthetics will become overmanned and as posts dry up "some doctors will find that the only place to go is general surgery and that will fill up, as will general medicine".

One of the new psychological tools to protect mental health in combat situations is Trim - trauma risk management - which has just been adopted across the army. Developed by the Royal Marines as a buddy system, it can be used by soldiers in combat working with occupational health staff to assess any treatment or support needed.

However, Lieutenant General Lillywhite cautions against too much intervention. "We have to be careful that we don't generate mental illness. Whereas in terms of physical care we have followed the US example, in terms of mental care we are much more cautious. We note that the incidence of mental health illness in the US military is significantly higher than ours. There could be many reasons, one of which may be medicalising ordinary stress reactions."

Lessons from history: military medical services through the ages

The history of an organised medical service for the military dates back to the creation in 1660 of a standing army under Charles II, when a medical officer and assistant were appointed to each regiment.

In 1898, following a series of campaigns, including the Crimea, which exposed tragic failings in the organisation and provision of medical care, Queen Victoria issued a Royal Warrant that created the Royal Army Medical Corps.

The mid-18th century saw the growth of British sea power and designated naval hospitals were built in Portsmouth and Plymouth. The RAF was slower to develop its own medical service, but by 1945, all three forces had well-established medical services.

The end of the Cold War and the withdrawal of UK troops from Britain's former colonies led in 1990 to Options for Change, a major restructuring of defence services. The plan proposed the number of military hospitals be cut from seven to three, with a total capacity of 1,500 beds. A further 300 military beds would be available in NHS hospitals.

But in July 1994, the Defence Cost Review announced another reorganisation. The new structure would comprise one core hospital for all three services, retention of the Duchess of Kent Military Hospital in Catterick and three Ministry of Defence hospital units in NHS trusts close to service populations.

But the plans were unpopular, seen as both rushed and driven by saving money. Medical, nursing and technical staff made their feelings known by leaving in droves for the NHS.

As the MoD now admits, "some of the proposals were inappropriate, lacked detailed analysis and were clearly designed for short-term savings".

Enter in 1998 the strategic defence review, Defence Medical Services - a strategy for the future, to correct some of the more damaging effects of the 1994 strategy.

But this caused yet more controversy, sweeping away single service hospitals and creating one establishment, the Royal Centre for Defence Medicine at Selly Oak Hospital. Defence Medical Services also operates six MoD hospital units in NHS hospitals.

The Selly Oak centre is now the main receiving hospital for aeromedical evacuations and is envisioned as "an international centre for excellence for all military medicine". It should be fully staffed and equipped by 2010 and is set to become "an international centre of excellence, combining treatment, teaching, research and the spiritual hub of the DMS".

Veteran support under threat

As the former commander of a submarine carrying Britain's Polaris nuclear missiles during the Cold War, Toby Elliott knows all about brinkmanship.

As chief executive of Combat Stress, the charity that provides residential treatment and support for mentally traumatised military veterans, he has a blunt message for veterans minister Derek Twigg. "It won't be too long before I will tell the minister that we are turning veterans away. Does the government want us to reach that stage?"

Peer support

Combat Stress - originally the Ex-Forces Mental Health Society - was founded in 1919 to keep shell-shocked former soldiers out of asylums where they were often locked up as "pauper lunatics".

It operates three residential centres that can house around 30 veterans each, usually for two or three weeks at times of crisis. The centres provide intensive psychiatric and psychological therapies, welfare, job and training support. But crucially, says Mr Elliott, they are familiar environments. Veterans can support each other, know each other's slang and jokes, as well as exactly what it is like when someone talks about death and destruction.

"We provide community-based services in a residential setting and that is important when you have gone through some pretty intensive therapy. When you have gone back over seeing your mate's brains down the front of your uniform, you don't want to go home and have an adverse reaction in the middle of the night.

"Here we have 24-hour support from staff and other veterans; it creates its own therapeutic community."

In Mr Elliott's office there are pictures of his old vessel HMS Resolution, one of the UK's three Polaris missile subs.

As his OBE reflects, he is an establishment man. But he is a critic of what he sees as national institutions - government, the NHS and the military - failing those who fight its wars and then suffer post-traumatic stress disorder.

He says the NHS does not succeed with veterans for three reasons: they are a group of people whom civvy street does not understand, the NHS does not provide the right therapies and because service folk are more likely to disengage from treatment.

Lack of NHS help

Mr Elliott concludes NHS and social care of veterans is too variable.

"Veterans who come to us in the main have never found the help they needed in the NHS." Most telling is the fact that there is an average gap of 13 years between discharge and the veterans coming into contact with Combat Stress. Mr Elliott gives examples of tragic cases that could have been prevented: a soldier discovered sleeping in a tent in woods outside Maidenhead and another soldier and his family sleeping in a car.

He says this latter case illustrates the importance of Combat Stress having welfare officers who can help veterans re-engage with "normal services" such as GPs, housing and social services. "We found out about them, then our welfare officer got them re-housed, and we found the children a school and his wife a job within a week. We provided clothes, food and some money for the family and the soldier is in treatment and on the road to repair."

At present, 50 per cent of Combat Stress's clients are self-referrals and around 30-40 per cent are from a wide network of organisations, such as the Royal British Legion or other veterans' societies; just 10 per cent of referrals come from the NHS.

"That is not because the NHS doesn't know we exist. It's because the NHS doesn't know that it has veterans on its books. You go to a GP complaining of nightmares and before you know it, you get given a pill. They rarely get to the heart of the matter - that however many years ago, you were in the services."

Mr Elliott wants veterans' medical records to be signposted so that seeing it would set clinicians' alarm bells ringing.

The MoD says a GP will see one veteran on average every seven years, so specialised training for all is not cost-effective. But Mr Elliott thinks there must be more effort within the NHS - which has overall responsibility for defence medicine - "to understand the beast".

With demand outstripping supply, Combat Stress wants to open a fourth centre in Wales to focus on the problem of mental illness and alcohol dependence. Three quarters of its clients self-medicate with drink to reduce symptoms of stress disorder. It is hoped the Welsh centre will adopt a pioneering US treatment for dual diagnosis among military veterans that tackles both trauma and addiction.

Mr Elliott also wants to create a more formal partnership with the NHS, to avoid reliance on seeking funding for patients from their local primary care trust.

"We are a national organisation and we want the government to fund Combat Stress lock, stock and barrel. If we don't and someone comes to us who we cannot afford to look after, we become part of the problem, not the solution."