Examination of Witnesses (Questions 1200-1219)
SURGEON VICE
ADMIRAL IAN
JENKINS CVO QHS, LIEUTENANT
GENERAL KEVIN
O'DONOGHUE CBE, SURGEON
COMMANDER DAVID
BIRT, BRIGADIER
ALAN HAWLEY
OBE, WING COMMANDER
MICHAEL ALMOND
AND COLONEL
STEVE HOWE
CBE
22 OCTOBER 2003
Q1200 Mr Cran: In Iraq?
Lietenant General O'Donoghue:
Yes, it is fully manned in Iraq, all of the operational deployments
are fully manned. The definition of full manning, I cannot give
you numbers of regulars and numbers of reserves because it is
an amalgam, it is a regular and reserve balance, it is the use
of NHS teams. The definition of fully manned is enough capability
to deliver what is required according to defence planning assumptions,
you will accuse me of copping out. If we cannot get enough regular
anaesthetists over the next two or three years I have to find
a different way of doing it.
Q1201 Mr Cran: I have heard a definition
and I think that requires a whole other investigation to actually
establish what all of those words meant. Alas I have to say we
do not have the time but we are on your side.
Lieutenant General O'Donoghue:
There are two bits of work going on, one is the deployable medical
capability requirement work done by me and by the single services
to sort out what the requirement is, what the readiness for that
requirement has to be and so how much of it has to be regular
and how much of it can be at 30 days readiness At the same time
slightly behind that is the manpower strategy which is looking
at the sort of things we have been talking about, have we got
people trained correctly, and a great variety of things, such
as can we use nurses in some areas where we do not at the moment.
There is a lot of work in hand due to report in February.
Mr Cran: Doubtless we will be investigating
again.
Q1202 Mr Roy: Can I clarify something,
you said that the manning levels were okay when you needed them,
however if you needed them in the future you do not know whether
they would be, will you be looking at that over the next year?
Have you used up your kudos in the last few months and does that
change in a year's time?
Lieutenant General O'Donoghue:
We have not used it all up. There are some rules about the use
of reserves, you cannot redeploy reserves too quickly, you can
of course deploy regulars.
Q1203 Mr Roy: What is "too quickly"?
Surgeon Vice Admiral Jenkins:
It is nine months out of 27 for war fighting and it is 12 months
out of 36 for non-war fighting. I know it is the same but there
is a subtle difference.
Lieutenant General O'Donoghue:
The regulars you can deploy all of the time but the difficulty
with that is they get fed up and leave.
Q1204 Mr Viggers: Whilst we respect
the manner in which you are getting by in the present situation
at the end of the day there is an establishment for key specialties
like general surgery, orthopaedic surgery and general medicine
can you give us a snapshot of the current manning in those keys
areas?
Surgeon Vice Admiral Jenkins:
Orthopaedic surgery or general surgery is give or take 50% of
the consultant requirement. With anaesthetists we have a gap of
70% of consultant anaesthetists on the old manning assumptions,
with physicians we have 35% of the total number that we should
have of trained independent practising consultant physicians.
While we have people in the senior levels of high training we
are using some of our advanced specialist trainees in consultant
lines where they can be supervised by the other consultants and
that is how we are going to get by.
Q1205 Mr Viggers: A number of initiatives
have been put forward to enhance retention, do you get the impression
these are working? Statistically are you improving the situation?
Surgeon Vice Admiral Jenkins:
Some of them are very new initiatives and it is very early to
say. What is happening is that for consultant training, we demand
a three year return of service before the person has completed
their time. What I do not know with the numbers of specialist
in training at the moment is how many of those people are deciding
to stay on beyond that three year period, it is a bit early to
give you statistics at the moment although they are monitored
now because it is critical to us. Generally speaking we in the
military have no difficulty in encouraging young people to go
into professional training, our difficulty is retaining them after
the three year return to service point. As I say anaesthetics
is the most critical speciality.
Surgeon Commander Birt: In terms
of keeping on training military training is something which is
very attractive, it is much more adaptable to the individual and
where it is training in general since the culmanisation—a
dreadful word—of registrar training in the NHS people have
tended to train in the region and not moved about in military
training where you can move about and get wider experience and
that seems to retain registrars during the training period. What
happens after the three year return of service, is it more difficult
to stay in the military for reasons other than the professional
side, they enjoy the military, the people they work with and the
experience of deployment, you have to look at wider issues rather
than just pay and conditions, the job they do in the Military
District Hospital Unit and the NHS side of it.
Q1206 Mr Viggers: Of those personnel
who are deployed how many medical staff were employed on administrative
duties?
Lieutenant General O'Donoghue:
That is a question I do not think I can answer. We would need
to send you a note. Do you mean medical military like commanding
a hospital. I think we will have to send you a note, I do not
have that.
Q1207 Mr Jones: Can I ask about medical
reservists, we have seen press comments about Operation TELIC
and people resigning, it would be interesting to know what your
views are on that and what mechanisms you are putting in place
to retain people as reservists? Are there any lessons out of Operation
TELIC or other operations that you learned?
Lieutenant General O'Donoghue:
A lot of the bad press was while they were still out in Iraq.
I understand that that from the Army only 17 medical reservists
have put their papers in since Operation TELIC, that is not very
many. After any conflict one would expect a number to put their
papers in, I do not know of the Navy and Air Force figures, I
am not aware of a problem. Meeting them coming back at the airports
as they came back in there was not a general air of dissatisfaction
at all, there was an air they had done a good job and they were
pleased to be used in the role for which they trained.
Q1208 Mr Jones: I agree with that.
We went to Safwan and talked to some nurses there who obviously
reiterated the point, they thought that the experience was valuable
but the thing that came over was it was this indetermination of
how long the tour was going to last, is that an issue that was
borne out by other people?
Lieutenant General O'Donoghue:
That is right. As far as the specialists are concerned at the
moment we are now looking at a six or eight week turnaround for
consultants who need, as the Surgeon General said, to keep their
hand in and keep practising. What we need to do in the future
is apart from the actual period of war fighting, where people
have to be there and stay, is offer greater flexibility. Some
consultants would welcome more than one deployment of six weeks
in a twelve month period others would prefer, perhaps on the GP
side, to shutdown their practice for six months, three months
whatever it is. If we can offer some flexibility that will make
life a lot easier.
Q1209 Mr Jones: Is that creating
any problems with the hospital trusts? In terms of Operation TELIC
that was a lot longer than we thought, I would be interested to
know what your views are in terms of consultants? I know from
my experience with the Royal Marines it varies from hospital to
hospital trust, the policy of releasing reservists for training
which they have to do to be part of a combined unit. Is there
any work done to try and even that out to ensure you get a uniformity
across trusts?
Lieutenant General O'Donoghue:
We are certainly looking at a new way of doing business. We need
to sort out two things, one is that we need to get our people
out for military training and deployment and on the other hand
the trusts, the chief executives need, if we are not all going
to war, a greater degree of surety about how much effort the military
is going to offer to that trust. There is work in hand to see
if we cannot even that out and offer both sides a better way of
doing business and a more predictable way of doing business. Going
back to TELIC, I am not aware of any real concerns amongst the
trusts, nothing has come back to me through the Department of
Health. Certainly those trusts who lost military people or who
cleared wards because they thought they were going to take patients
have been recompensed by the military by some twelve million pounds
in the last financial year and it looks like 19 million in the
coming year, and that was for pulling in locums from private medicine.
I am not aware of any huge dissatisfaction other than the comment
that there ought to be a better way of doing it. I agree we are
looking at that.
Surgeon Vice Admiral Jenkins:
Can I mention something that is more provocative, some of my colleagues
might not agree with me, there is a problem historically. As you
know TA field hospitals are recruited, obviously, on a geographical
location basis. If you were a hospital chief executive, and going
back again to the conversation you had with our reserve colleagues
about mobilising formed units, if you suddenly found that because
you are the centre of the cell and if all of the NHS want to go
because they are part of the cell you would have a huge problem.
From their point of view they would prefer to learn if you want
so many general surgeons and so many anaesthetists and the trust
chief executives would see how best they can mobilise their reservists
within their own environment so that it does not disrupt them
too much. This is all emerging thought processes.
Q1210 Mr Jones: Is that something
if we go into more expeditionary warfare that there is going to
be more use of reservists and that is going to be increasingly
an issue for hospital trusts?
Surgeon Vice Admiral Jenkins:
Yes.
Lieutenant General O'Donoghue:
Full manning, whatever that is, will make that a lot easier. At
the moment we are drawing in quite a small pool of specialists.
Q1211 Mr Harvard: Can I turn to equipment
and supplies. Our understanding is that some of the 170 urgent
operational requirements were for medical support, what medical
support was procured through the UOR process? Was all that medical
support procured through this route delivered on time? Did it
work?
Lieutenant General O'Donoghue:
Yes, you are right. We spent £35 million on UORs. As I mentioned
earlier because of the strategic level planning we had a pretty
good idea of what medical equipment and drugs were needed and
they were put together in medical packs. The orders were we were
allowed to talk in general terms to industry about how quickly
they would react in November and we were allowed to place the
orders in December. All of the equipment that we had on order
was with the Medical Supplies Agency in Ludgershall by 15 March,
some sooner but it was all there by 15 March. They assembled it
into modules and it was shipped out to theatre. Some of those
modules were not necessarily complete but where they offered an
operational capability if not the total operational capability
they were dispatched and the bits that were missing were sent
later. I am not aware, and I turn to the Brigadier who was in
command in theatre, that any equipment that was critical was not
in place on time.
Brigadier Hawley: I would agree
with that. From where I was no one informed me of any clinical
care that was compromised by a lack of equipment. I have to say
that it was very tight. There were a number of factors that combined
to produce this rather tight, fraught situation, one of which
was the release of money for UORs, this coincided with two things,
first of all the new process of medical equipment modules, as
you heard the General said, modules of specific capability, anaesthetic,
resuscitation, paediatric, accident and emergency, they were in
the process of being built and procured and the deployment cut
right into that. The second thing is the change in responsibility
for medical supply, it was right on the cusp of that change, that
moved from a medical function to a logistic function. The systems
in theatre needed some pretty fancy foot work on deployment in
order to fix. It worked but I have to be honest and say that it
only just worked. It subsequently has got much better but at the
time when we were involved in the war fighting phase there was
not much spare.
Q1212 Mr Harvard: The reason for
asking the question is the Chief of Defence Logistics said no
UORs were prosecuted if they could not be delivered at the six
month point, which was 31 March. What we were trying to find out
is did you then not order something simply because it was not
going to come within the timetable and, if so, what were those
things? Whilst it was tight you had nifty footwork and you did
not experience a problem in relation to that?
Lieutenant General O'Donoghue:
No. There are two key lessons to come out of it, one is that the
medical supply squadron needs to be deployed earlier, it did deploy
within the first two weeks but it needs to be out there really
very much sooner. That has been taken on board. The second point
is that we had to procure too much equipment by UOR, we need to
have more on the shelf. Just-in-time is fine but we do not want
to procure too much equipment which then sits on the shelf and
gets out of date. But we do not have the balance right at the
moment and we are spending money on that.
Q1213 Mr Harvard: The balance is
very difficult to achieve, we wanted to know your experience?
Lieutenant General O'Donoghue:
It was not right for TELIC, we are now spending money to make
sure that for future deployments it is right.
Q1214 Mike Gapes: To follow that
up, did the Defence Medical Service personnel have all of the
specialised equipment available to them that they would need if
there had been a possible chemical or biological attack?
Lieutenant General O'Donoghue:
Yes, they had the chemical modules and the biological modules.
They had collective protection.
Brigadier Hawley: I think it is
fair to say there were two modules, one was the old scale and
one was the new scale. As I mentioned this is on the cusp of change
between those two modules. In terms of collective protection and
environment in which casualties could be treated and that was
done and was deployed and we had extra equipment if I decided
to deploy it.
Q1215 Mr Viggers: The 1988 Strategic
Defence Review announced a range of equipment improvements, how
well did these enhancements work during Operation TELIC?
Lieutenant General O'Donoghue:
The Argus was probably the finest role three facility anywhere
out there, the Americans were all queuing up to come to the Argus,
it is an excellent PCRF. Some of the other equipment measures
we talked about were known about, they were held as UORs but the
balance was not right. We need to procure some of those quicker.
With one exception all of the measures proposed in SDR have either
been completed, they are on track or they have slipped off to
the right for obvious reasons, a lack of manpower or funding.
The one exception was the ambulance train.
Q1216 Mr Viggers: What about the
two hospital ships?
Lieutenant General O'Donoghue:
We have a hospital ship, its replacement is in the equipment programme.
The second one is off to the right, it is a funding issue.
Q1217 Mr Roy: We are told that the
Surgeon General recently held a conference to discuss what went
right and what went wrong, can you give us an outline of the findings
of that conference?
Surgeon Vice Admiral Jenkins:
We held a medical conference, it was a clinical, scientific conference
on 14 October in Birmingham and there were over 250 people there,
regulars and reserves, and a number of civilians as well. Many
of whom, if not the majority, had been deployed and many of those
who were deployed, some sitting at this table now, produced scientific
papers for us to learn the clinical lessons. What I can tell you
is this, and I am not being complacent in saying this, I can categorically
assure you that clinical outcomes were uncompromised. Yes there
were problems with supply, equipment and everything else, mobilisation
of reserves, support and this and that and the other but the clinical
outcomes were first class. I can put my hand on my heart and say
that nobody suffered inappropriately because of a lack of medical
requirement. That was the outcome of the conference. That was
broken down to all of the sub specialties which were deployed,
planning and everything else to go with it, it was a broadly comprehensive
programme which concentrated on clinical delivery and clinical
provision and clinical outcome.
Q1218 Mr Roy: Away from the clinical
lessons, I am thinking of Operation TELIC, what went well and
what did not go so well? How will we find out if you have recognised
them?
Lieutenant General O'Donoghue:
I will ask Colonel Howe to speak in a minute. We have a lessons
identified list, it is quite a long list and some are quite small
and others, such as the balance of equipment, are more significant.
From that list we will pick up other things that did not go so
well or the things that might not have gone so well had the circumstances
been different. What went well is, as the Surgeon General said,
that it worked. Nobody was disadvantaged in any clinical outcome.
Q1219 Mr Hancock: Can I raise an
issue with you, I apologise for being late, I was held up somewhere
else, I had a member of the armed forces ring my office and subsequently
following that phone call they wrote a detailed letter to the
Committee and some questions I understand have been raised. I
would like to read this one bit to the Admiral, it is very telling
in what you just said. This man was a Major in the army and a
Chief Superintendent in the police in normal life. "On my
return flight I sat next to a reserve medical Major, he is a consultant
anaesthetist in Newcastle General and he was emotionally upset
by an operation he had participated in on a young United Kingdom
infantry soldier, the soldier was shot by a negligent discharge
by a colleague. The soldier received four bullets wounds into
the upper leg. The doctor was particularly angry that if his team
had had a vascular repair kit, which they did not have, they would
have been able to redeem that young soldier's leg, as it happened
they had to take his leg off". How do you square with what
you just said, Admiral, with what two people on the ground have
written to this Committee and said?
Surgeon Vice Admiral Jenkins:
If I can have the details of the case I will answer your question
and I will have it investigated.
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