Partnership agreement between Ministry of Defence and NHS England for the commissioning of health services for the armed forces

Version 5

1. Joint statement

1.1 This Agreement sets out the strategic intent and commitment for the Ministry of Defence (MOD)[1] and NHS England to work together.

1.2 We recognise our respective statutory responsibilities and independence, while collaborating and cooperating to achieve our aim of ensuring safe and effective care, which deliver value for money and improves health outcomes for the Armed Forces community[2] and supports the principles of the Armed Forces Covenant.

1.3 The Armed Forces Covenant, within the Armed Forces Act 2021, sets out the relationship between the Nation, the State, and the Armed Forces (AF). It recognises that the whole Nation has a moral obligation to members of the Armed Forces and their families, and it establishes how they should expect to be treated. It exists to redress the potential disadvantages that the Armed Forces community faces in comparison to other citizens and to recognise the sacrifices that they have made.[3] To achieve this the MOD and NHS England will work with the Devolved Administrations (DA) and any disparities within healthcare across the UK will be addressed through the MOD/UK Departments of Health Partnership Board.

1.4 The vision is that all parties will continue to deliver strategy and policy and commission services that deliver high quality, safe and effective care to meet Service and patient need, from a wide range of settings across England. As part of commissioning we will also review performance to make sure that our patients are not disadvantaged by their serving status and that Armed Forces personnel and their families receive excellent healthcare from the NHS, tailored to their particular needs, in accordance with the Armed Forces Covenant and consistent with civilians in the area where they live.[4]

1.5 This will present challenges across departmental and organisational boundaries which require a joint approach by the MOD and NHS England that goes beyond the words written in this document and is embedded into the way in which we work. In recognising the unique healthcare needs of the Armed Forces there is a commitment to work together when opposing variances between MOD requirements for operational fitness and NHS priorities present, this may mean working in different ways to enable us to make the challenging decisions that will set the direction for transformational change and improved healthcare outcomes. This will need to be done by a combination of core NHS funded and delivered services and those funded or provided from elsewhere including those commissioned and provided by the MOD.

1.6 This Agreement is an enabling one and sets out a partnership approach, which enables the MOD and the NHS to work together in planning and organising the delivery of healthcare and supporting policies. The effectiveness of this agreement will be monitored through the MOD/UK Departments of Health Partnership Board and through NHS England Armed Forces Oversight Group.

Dr P Homa, Director General – Defence Medical Services.
Lt Gen J Swift, Chief of Defence People.
Kate Davies CBE, National Director Health and Justice, Armed Forces and Sexual Assault Services Commissioning, NHS England.

29 November 2022.

2. Context and shared purpose

2.1 Responsibility for Armed Forces healthcare is split between the MOD and the NHS. Defence Medical Services (DMS) provide a range of services for regular serving personnel in the UK, those serving overseas and in some cases their families.

2.2 The Health and Social Care Act 2012 provided opportunities to deliver a more consistent standard of care for those serving in the Armed Forces in England. The Health and Social Care Act 2022 strengthens this approach and states that NHS England will retain commissioning responsibility for those patients who are registered with Defence Medical Services (DMS), delivered through a single national Armed Forces Health team and for the wider Armed Forces community via the 42 NHS integrated care boards (ICBs) who will be required to demonstrate how they are giving due regard to the health and social care needs of the Armed Forces community in the planning and commissioning of local services.

2.3 There is also a need to ensure continuity of care for those moving between NHS care in England, Devolved Administrations (DAs) and Defence Medical Services (DMS) facilities in the UK and overseas and when there are opposing variances between MOD requirements for operational fitness and NHS priorities.

2.4 Service personnel will become veterans and an increasing number of Reservists will be mobilised. Good continuity of care for those entering, serving, and leaving Armed Forces services is paramount. Similarly, due to the mobility of Armed Forces personnel and their families, there will be regular changes to their service provider and commissioners[5]. All parties will need to consider the wider circumstances beyond the immediate health needs of those that are serving.

2.5 The MOD is charged with protecting the UK and Crown Dependencies. Service personnel are based across the UK and overseas and can return to the UK to receive NHS care. Service personnel must experience no disadvantage in accessing timely, comprehensive, and effective healthcare in England and the DAs, especially when access to care is cross border within the UK. Although the DAs are responsible for commissioning care for the Armed Forces registered in their countries, any disparities within healthcare across the UK will be addressed through the MOD/UK Departments of Health Partnership Board.

2.6 The purpose of the NHS is to promote health, prevent illness and injury, diagnose, treat and rehabilitate those whose health can be improved and manage the care of those that cannot. It is essential that the health inequalities and healthcare needs of service personnel across the UK and overseas are fully recognised to ensure service personnel are fit for their operational tasks. Therefore, it is understood that some clinical pathways, and health interventions may not fit within the core offer of the NHS and may be commissioned by others. It is also appropriate to recognise that veterans and the families of serving and former serving personnel may have unique health care needs that need to be addressed by the

2.7 This Agreement is intended to facilitate a single point of contact for access for the MOD to engage with other commissioning, provider, and collaborative parts of the NHS (including NHS England; the 42 Integrated Care Boards (ICBs), NHS Trusts, etc.). The Armed Forces Healthcare commissioning team in NHS England will act as that point of contact.

2.8 Similarly, healthcare plans, within Defence Healthcare will act on behalf of the MOD and provide the principal point of contact for the NHS with other providers and stakeholders in the MOD for matters related to healthcare delivery.

2.9 Armed Forces People Support, within the Defence People area[6], will act on behalf of the MOD for health, wellbeing and welfare personnel related matters and provide the principal point of contact for the NHS with other providers and stakeholders for this

2.10 The MOD and NHS England will work together to ensure that the MOD’s health and welfare arrangements with the NHS are co-ordinated to provide the best outcomes and experience for patients, families, and their

2.11 The Partnership Agreement sits below the UK-wide, interdepartmental MOD/UK Departments of Health Partnership Board and the NHS England Armed Forces Oversight Group (as a sub-committee of the NHS England Commissioning Board) to set the strategy for the delivery of the mandates and instructions given by the respective departments. The DHSC and the Office for Veterans Affairs are not a party to the Partnership

2.12 This framework provides a working document for staff in each organisation and a reference for other organisations, covering how we will work together to achieve the jointly agreed strategic aims and priorities.

2.13 Collaboration is not limited to the details laid out in this document. This will include working in a flexible fashion in order to improve outcomes and the quality of healthcare services provided to the Armed Forces community.

3. Ambition

3.1 The MOD and NHS England are committed to working together to ensure safe and effective services which improve health outcomes for the Armed Forces community. These services must:

  • Be tailored to the needs of the Armed Forces community, in accordance with the Armed Forces Covenant; The Armed Force Act 2021 and the Health and Care Act 2022.
  • Ensure that patients experience a seamless transition between services, minimising any risks associated with accessing care commissioned and provided to the Armed Forces community.
  • Provide as a minimum the same standards and quality of care that can be expected by the civilian [7]

4. Joint strategic aims

4.1 Together the NHS and the MOD will agree strategic aims on which to work over the period of the agreement. More detailed priorities to support these aims are at Annex A and will support the key areas of work below:

A. Identify the health needs of the Armed Forces community.

  • Work in partnership, informed by the Armed Forces public and patient voice assurance group using lived experience to assist in the identification of health inequalities and any existing Health Needs Analyses (HNA) of the Armed Forces community and commission any new HNA, as
  • Improve physical and mental health services for veterans, reservists, and the Armed Forces community (including those of families of serving, reservists, and veterans).

B. Development and delivery of a co-commissioning plan

  • Review data in relation to referral and outcomes and work with the NHS to manage demand and recovery.
  • Incorporate any changes relevant to the unique health needs of the Armed Forces community and identify who will commission, fund and provide, these
  • Develop appropriate evidence based clinical pathways which meet the specific needs of the Armed Forces community and maximise their operational
  • Take account of evolving methods of delivery and advances in clinical
  • Integrate, collaborate and deliver jointly or separately, where appropriate, and where agreed.

C. Delivery

  • Ensure that Armed Forces personnel are seen by NHS-based healthcare providers (these may be clinicians and others in the DMS Joint Hospital Group), in line with the NHS Constitution referral to treatment wait times.
  • Ensure high standards of patient care, safety, and experience to deliver the core values set out in the NHS
  • Utilise data and quality measurement tools to drive continuous improvement in services and outcomes.
  • Identify data and evidence to support the development of new or alternative pathways, including those that cross between DMS and NHS led and commissioned
  • Identify agreed procedures that are within the core NHS Offer and those that will normally require separate
  • Agree a process of dealing with potential disagreement where the specific healthcare needs of the Armed Forces community and NHS Constitution may
  • Ensure that regional variations to healthcare commissioning are understood and plans to mitigate variation are in place to ensure delivery for the Armed Forces Community and enable equity of provision
  • Work in partnership on any appropriate future Emergency Preparedness Resilience & Response programmes including RAMP.
  • Work to ensure CORTISONE aligns and interfaces with the national NHS Digital Transformation programme.
  • Agree an MOU for the Public Health screening and immunisations services that are provided to the MOD by NHS England.

D. Transition

  • Improve the health transition of service personnel and families into civilian Develop an MOD Veterans’ Strategy for its veteran responsibilities, which will encompass health and wellbeing.

5. Roles

5.1 NHS England

5.1.1 NHS England is a non-government departmental ‘Arm’s Length’ (ALB) public body which operates within the wider health and social care system. Its overarching role is to ensure that the NHS delivers continuous improvements in outcomes for patients within the resources available.

5.1.2 NHS England is responsible for the direct commissioning of specialised care and the oversight of local health and care systems and some aspects of public health for the general population (i.e. national screening programmes and the vaccinations and immunisation programmes). At the heart of commissioned services is the patient and public voice and lived experience.

5.1.3 NHS England has the responsibility for delivery of the systems’ Emergency, Planning, Resilience and Response (EPRR) functions and framework, which includes RAMP and leadership of coordination to meet the requirements of the Civil Contingencies Act 2004, the NHS Act 2006, the Health and Care Act 2022, the NHS standard contract, the NHS Core Standards for EPRR and NHS England business continuity management framework. EPRR may request external organisational support and input in delivery of these functions.

5.1.4 NHS England will fulfil this role through its responsibilities as a direct commissioner of healthcare services for the Armed Forces and through working in partnership as co-commissioners of Armed Forces healthcare with the 42 ICBs and a wide range of stakeholders. It will:

  • Secure better outcomes set by the DHSC, the NHS Long Term Plan and the Armed Forces Forward View.
  • Actively promote the rights and standards guaranteed by the Health and Care Act 2022; the NHS Constitution; the Armed Forces Covenant and the Armed Forces Act 2021.
  • Provide national consistency in areas such as quality, safety, access, and value for money.

5.1.5  Except where otherwise stated, the NHS can only discriminate between different groups within the population on the basis of clinical need (and not on employment type) but should seek to minimise any disadvantage and meet consistently the particular health needs of individual population groups, such as the Armed Forces community.

5.1.6  The single, national NHS England Armed Forces Health team in partnership with the MOD, charitable partners and others will:

  • Develop a strategy in consultation with the MOD, DHSC, and Health Departments in the Devolved Administrations to support the commissioning of a range of services to meet the health needs of the Armed Forces and those dependants registered with Defence Primary Health Care (DPHC).
  • Directly commission a range of specialised and secondary healthcare services for DMS registered patients.
  • Work with the 42 ICBs to contribute to improving the health and wellbeing for the whole of the Armed Forces community ensuring the patient and public voice and lived experience underpins this.
  • Deliver a more joined-up experience of care for serving personnel and their families as they move around the country, and transition from service to civilian life.
  • Commission a service that offers improved access to high quality, personalised and responsive physical and mental health services for veterans. Improve health inequalities and vulnerabilities through better informed policies, pathways, commissioning, and collaborations.

5.1.7  As a national body NHS England also has a wider role to support ICBs and their integrated care systems (ICSs) in their duty to demonstrate ‘due regard’ for those parts of the Armed Forces community for which they have responsibility (i.e. veterans, their families and service families registered with NHS GPs and non-mobilised reservists). ICBs will be required to demonstrate their ‘due regard’ via an assurance framework that aligns to the commitments in the Armed Forces Forward View.

5.2 Headquarters Defence Medical Services

5.2.1 Healthcare Plans sits under Defence Healthcare within Headquarters Defence Medical Services (HQ DMS). In the context of this document, HQ DMS has the following specific roles:

  • Develop a strategy in consultation with NHS England, DHSC, and Health Departments in the DAs to support the NHS in commissioning specialised services, secondary and community healthcare to meet the health needs of the Armed Forces and those dependants registered with Defence Primary Health Care (DPHC).
  • Commission community and in-patient mental healthcare services for service personnel to meet their specific needs, meeting, for example, the lower admission threshold for access to specialist services required for Armed Forces
  • Develop, implement, and sustain an effective strategy for commissioning Defence specific specialist clinical services where necessary.
  • Deliver a primary care service[8] to entitled personnel within the UK and the Armed Forces community when overseas and, where necessary, refer patients to NHS services (community, secondary or specialised).
  • Work with Partnership Agreement members, and their sub-groups to ensure that there is continuity of clinical care between those moving between the MOD and NHS commissioned or provided

5.3 Chief of Defence People

5.3.1 Chief of Defence People (CDP) is the MOD’s Strategic Human Resources Business Partner, providing advice to the Secretary of State, Chief of Defence Staff and Permanent Secretaries. Further, CDP is Defence’s functional owner.

5.3.2 As more is asked of the Armed Forces, including on operations where risks and living conditions may be more demanding than in recent experience, Defence will need to support their physical and mental health, well-being and resilience. This support is extended to families who are an important part of that resilience, as critical enablers of operational readiness when Armed Forces personnel are deployed or moved in response to Defence needs. Defence will work to reduce the impact on Armed Forces personnel and families through greater predictability and, where possible, stability. In addition, the Armed Forces Covenant with the nation ensures that military families and those who have served in the military are managed beyond their Service, ensuring veterans and Service families have fair access to national health, welfare and support structures.

5.3.3 In the context of this role, AFP Support will:

  • Work with Partnership Agreement members, and their sub-groups to maximise opportunities for all Service personnel and families to enjoy a state of positive physical and mental health and
  • Oversee the delivery of the Defence People Health and Wellbeing
  • Work with the DHSC and NHS England to support health needs of personnel transitioning out of the Armed Forces and engage as appropriate on veterans’ health issues.
  • Provide the main point of contact for the Armed Forces
  • Sponsor certain service-related veteran healthcare initiatives, such as Integrated Personal Commissioning for Veterans.

6. Governance for delivering joint aims

6.1 This agreement has been driven by the views of NHS England and the MOD, who will work together at all levels to implement this Agreement in practice. These will be supplemented by stakeholder interface meetings.

6.2 The agreed governance structure is summarised in Table 1 below:

Table 1: Stakeholder Interface and key committees/boards:

Meeting

Aim

Frequency

NHS/DH/DAs

MOD

MOD/ UK Departments of Health Partnership Board

Deals with cross-Governmental

issues across the UK

Termly

Director NHS Quality, Safety, Investigations, DHSC

Director of Health and Justice, Armed Forces and SASS,

Director of Transformation Armed Forces Healthcare NHS England

Chair of the Armed Forces PPV Advisory Group NHS England

Devolved Administrations

DG DMS

Surgeon General Director Defence Healthcare

Director Medical Personnel and Training

Director Armed Forces Personnel Policy 

NHS England Armed Forces Oversight Board

Is a subcommittee of the NHS England National Commissioning Group

Quarterly

Director of Health and Justice, Armed Forces and Sexual Assault Services Commissioning

 

Armed Forces Joint Commissioning Group

Delivers Annual Commissioning Plan in England

Termly

Director Armed Forces Transformation, NHS England

Hd HCP

AH Future Healthcare

AH SCT

D/Comd DPHC

SO2 Reqmts SCT (Sec)

DHd Health Policy

Armed Forces Clinical Reference Group

Gives clinical advice and support to the development of strategy and the delivery of the Annual Plan

As necessary

Chair of Armed Forces Clinical Reference Group

 

Hd HCP

D/Comd DPHC

DHd Health Policy

6.3 The Partnership Agreement will be reviewed annually, and changes made by mutual agreement.

6.4 NHS England and DMS staffs will use appropriate data, statistics and research to inform the development of clinical services and pathways, and to support their decisions.

6.5 The Armed Forces Clinical Reference Group (CRG) and the joint MOD /NHS England Research Group will provide independent holistic clinical advice.

6.6 NHS England will use patient voices and lived experience to shape services and provide feedback. All partners will develop methods to become more responsive to the needs and wishes of patients and wider stakeholders.

7. Governance for delivering joint aims

7.1 The partners will co-operate fully in relation to the disclosure and exchange of information, intelligence, evidence, policy formulation and documentation in a timely way and in accordance with relevant legislation and case law. There will be occasions when shared information (such as guidance or standards etc) cannot be disclosed either publicly or to other organisations unless explicit consent is obtained and except as required or permitted by law. This protocol is subject to the duty of confidentiality owned by each partner to those providing the confidential information.

8. Communications strategy

8.1 NHS England and the MOD will develop and implement a joint communications strategy to support and underpin the shared principles, priorities and plans within this

9. Governance for delivering joint aims

9.1 Complaints

9.1.1 All complaints originating from those under DMS care, including MOD commissioned care pathways and DPHC, should be raised through the care provider’s complaints procedures.

9.1.2 All complaints in community, secondary and specialised healthcare should be raised via the NHS England complaints procedure.[9] This does not include those functions for which NHS England is not responsible for commissioning. These should be raised with the local ICB.

9.2 Dispute resolution

9.1 All issues which relate to concerns by commissioners regarding healthcare providers should be actioned as a dispute. Dispute processes cannot entertain complaints by individual patients or their representatives.

9.2 Where a dispute emerges between providers of healthcare these should always be raised in the first instance, and at the earliest opportunity with the provider and copied to the commissioner. Issues should be put in writing and any resolutions recorded and reported via the National Armed Forces Health Commissioning team to the JCG and upward via the appropriate internal governance routes for the MOD and NHS England.

9.3 In the event that disputes cannot be resolved at this level, they are to be raised in writing with the Partnership Board. The Board’s decisions will be recorded in writing and partners will be expected to respond to the decision agreed.

10. Governance for Delivering Joint Aims

10.1  The governance arrangements established are in order to ensure effective working as set out above. These will be supplemented by specific task and finish groups established to take forward the joint priority areas at Annex A. These stakeholder arrangements are summarised in Table 1 and will be kept under review.

Date TOR to be reviewed: December 2023

Annex A – Joint Priorities for NHS England and MOD – 2022-2024

11.1 The workplan areas to achieve the joint aims will be reviewed routinely. They reflect key areas of work that are derived from joint discussions between NHS England and the MOD and drive the key areas of work for 2-3 year periods.

11.2 The agreed priorities are:

  • Adopt a joint approach to population health management, assessment, research programmes and initiatives.
  • Align NHS-DMS – systems, digital and data, recording, workforce, research and clinical (including IT/CORTISONE)
  • Restoration and recovery of referral to treatment times following the COVID 19 pandemic.
  • Improve the healthcare of the Armed Forces community:
    • Families and carers.
    • Serving personnel.
    • Ex serving women’s’ healthcare.
  • Equality, diversity, inclusion and intersectionality.
  • As co-commissioners of healthcare for the Armed Forces community work with the Integrated Care Boards to ensure they are paying ‘due regard’ to the Armed Forces Covenant.
  • Communications and raising awareness of the health needs of the Armed Forces Community and services and resources developed with and for them.
  • Timely access to NHS treatment to assist in numbers of serving personnel able to serve and deploy.
  • Increasing the number of reserves (Reserves Forces 30) and the roles of reserves.
  • Emergency Preparedness Resilience and Response programmes including RAMP.
  • MOD and NHS England MOU for the Public Health screening and immunisations services provided to the MOD by NHS England.

References

[1] Ministry of Defence (MOD) is defined as the Chief of Defence People (CDP) and Defence Medical Services areas of responsibility for the purposes of this agreement.

[2] For the purpose of this document, the Armed Forces community will consist of serving members of the Armed Forces and their families registered under Defence Medical Services practices in England and Reservists while mobilised or those posted overseas, who choose to return to use NHS services in England. It also includes veterans and their families /carers living in England.

[3] Armed Forces Act, 2021.

[4] Healthcare for the Armed Forces community: a forward view should be seen as a companion document to the NHS Long Term Plan (LTP), outlining the commitments NHS England and NHS Improvement is making to improve the health and wellbeing of the Armed Forces community, serving personnel (regulars and reservists), veterans and their families/ carers. March 2021.

[5] NHS England will be the main commissioner for those under DMS practices (i.e. there are some areas such as primary care and elements of mental health that remain the responsibility of DMS).

[6] The Head of Armed Forces People Support (within CDP’s area) and the Medical Director to the DMS Surgeon General co-chair the MOD Health and Wellbeing Leadership Team.

[7] Healthcare for the Armed Forces community: a forward view should be seen as a companion document to the NHS Long Term Plan (LTP), outlining the commitments NHS England and NHS Improvement is making to improve the health and wellbeing of the Armed Forces community, serving personnel (regulars and reservists), veterans and their families. March 2021.

[8] Including primary medical and dental care, occupational health, travel medicine, mental health and rehabilitation services.

[9] For the NHS England complaints procedure, see www.england.nhs.uk/contact-us/complaint. This includes information about how to appeal via the Parliamentary and Health Service Ombudsman (PHSO).

Publication reference: PR1838