Letters to Editor

Dear Sir,

I refer to the recent JMVH article¹ regarding the 2004 Stevens Review² with respect to command of the ADF’s health services.

Military health care is similar to civilian occupational health practice in that it involves three stakeholders: the clientele, their employer (ie commanders), and health service providers.To remain relevant military health organisations must give priority to caring for their clientele, and it is accepted that ADF health staff do so in at times demanding circumstances.However:

• <!–[if !supportLists]–>Military health organisations also have to meet the expectations of commanders.The instigation of the latest review suggests that the ‘treatment service’ model implemented as a result of the two ANAO audits and other ‘pre-Stevens’ reviews does not meet ADF command expectations regarding (but not limited to) non-deployed operational health support, occupational, environmental, public health and disaster health services, medical fitness surveillance and health promotion.
• <!–[if !supportLists]–>Military health organisations also have to be attractive to work in If they are to retain high quality staff.Endemic retention difficulties suggest there is little point dwelling on ADF pay and conditions of service in isolation from the specific professional, social and related expectations of ADF health staff, such as (but not limited to) life/work balance, career progression, and performing work that value-adds to the Service population that they serve.

If the ADF’s health services are not meeting current command expectations, it is unclear how this would improve by placing them under the command of the Surgeon General.The article’s references to the German and South African models (where health services form the ‘fourth military arm’) offer nothing new, however:

• <!–[if !supportLists]–><!–[endif]–>The South African Military Health Service (SAMHS) also provides dependent health care.This gives SAMHS the critical mass necessary to function independently that it would not have otherwise.Dependent care also arguably distracts SAMHS from its primary role of facilitating operational capability through personnel conservation.³It is therefore unclear how SAMHS can be more efficient and effective than the ADF’s current health services.
• The German Zentraler Sanitätsdienst (Sanitätsdienst for short) has 17,600 health staff⁴for 250,000 personnel (including conscripts)⁵ in a country 4.6% the geographical area and 89.2 times the population density of Australia⁶It is therefore suggested that the relevance of the Sanitätsdienst model for the ADF is at best debatable.

It is not known whether senior commanders of the South African National Defence Force (SANDF) or Bundeswehr want their health services arranged as at present; however there is evidence that SANDF commanders at the unit level do not⁷

It is also noted DI(N) PERS 30-1⁸ states that CO’s (the officers appointed in command of ships, submarines, naval establishments, naval air squadrons, clearance diving teams, or other non-commissioned naval or ADF units), have military authority over all other officers and sailors borne with respect to the activities and operations of their commands, irrespective of rank and seniority.The DI(N) also refers to ‘special’ command as the authority given to any RAN member by virtue of special office, duties, skill or experience, to give lawful orders to subordinates, equals or superiors.

RAN health staff exercise ‘special’ command only with respect to providing health services: it is their CO who has military command.This is particularly problematic for RAN Area Health Service Senior Health Officers: it is difficult to see how they can exercise military command of Army or RAAF health units if they do not for their own facility.

Furthermore, DI(G) PERS 54-1⁹ states that Chief of Navy commands all RAN members unless assigned to Deputy Chief Joint Operations, or as agreed via Navy’s command chain per Defence Force Regulations (DFR) 4 instruments, as approved by CDF. The DI(G) states that DFR 4 instruments do not affect the normal chain of command of any Establishment, Unit or Detachment. Specific Service practices, such as the Navy’s Divisional System, coexist with the chain of command.

Although the ADF health services are therefore required to comply with single service practice with respect to its RAN staff, there is evidence that this does not occur, particularly in the deployed triservice setting¹⁰.It is suggested this does not meet whatever expectations naval health staff may have, that they be managed in accordance with the Service that they actually chose to join.

Finally, the article suggests that one service provides health care for the entire ADF.Again this is nothing new: this option still does not resolve command health requirements for the other two services and arguably would not meet the aspirations of all ADF health personnel.I also note that Stevens referred to:

• <!–[if !supportLists]–>The requirement for single service knowledge and experience with respect to providing support and advice to commanders (as previously discussed above);
• <!–[if !supportLists]–>Difficulties with health professional recruiting and the view that the ability of potential candidates to select a Service of their choice was a recruiting advantage;
• <!–[if !supportLists]–>The nature of the change and potential impact on immediate retention, and
• <!–[if !supportLists]–>Such a change would still not eliminate the need to coordinate health support between services that are inherent to the current arrangements.¹¹

The ANAO audits, DER and DRP reviews were focused on efficient and effective treatment services in the non-deployed setting.While addressing some systemic issues with three health service ‘stovepipes’, their implementation resulted in unintended consequences for the other health services required by commanders across all three services.These reviews also had unintended consequences for the aspirations of ADF health personnel that may not have facilitated retention.

Whilst not seeking to criticise the author, the article therefore offers nothing new: it merely perpetuates the same ten-year-old assumptions as the pre-Stevens reviews while ignoring the resulting unintended consequences that he identified.It is suggested it is time to move on.

Yours sincerely,

N. WESTPHALEN

MBBS (Adel) Dip AvMed, MPH, FRACGP, FAFOEM psc

Commander, RAN