Examination of Witnesses (Questions 1180-1199)
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
Q1180 Mr Crausby: One final question
from me about the treatment of Iraqi children, to what extent
did the plan take into account running right through to the treatment
of Iraqi children, was there not something of a gap there?
Lieutenant General O'Donoghue:
No. Our responsibility is to look after our own people, enemy
prisoners of war and make sure that there is provision for the
Iraqi locals, not within the British military medical facilities
but make sure there are drugs and facilities available. As part
of our plan we assumed that the Iraqi medical facilities, which
are excellent, were excellent and are excellent now, would be
available. What we had not counted on was the looting by the Iraqis.
Having said that the field hospitals are all deployed with paediatric
equipment and obstetrics equipment. While some of it was short
and some of it was not what the consultants eventually found they
needed as soon as they asked for it it was put out there, as were
the drugs.
Mr Crausby: We saw some excellent examples
on our visit to Iraq, we were very impressed with that aspect
of it.
Q1181 Mr Viggers: A high proportion
of your regular and reserve medical staff are working in the NHS,
what liaison did you have with them? Did you ask them or tell
them?
Lieutenant General O'Donoghue:
We liaised very closely with the Director of Operations and the
Department of Health. Might I turn that over to my colleague.
Surgeon Vice Admiral Jenkins:
As a follow on from the Concordat which we have between the Defence
Medical Services and the Department of Health which was signed
last year we progressed that in anticipation of TELIC operations
and we set up a forum which was in fact chaired by the Director
of Operations, Department of Health, and attended by me and another
colleague. The other attendees at that meeting were the chief
executives of the Hospital Trusts that host military departments,
MDHUs. It was a very, very close dialogue before mobilisation
in anticipation that we were taking out a number of people from
the NHS. It is a proactive process. It has been so successful
we perpetuated it for the future. What I should say is this conflict,
of course, was the very, very first occasion we have used the
new defence medical plan, as it were, the first time that all
of our people who have mobilised for deployment, be they regulars
or reserves, come almost exclusively from the National Health
Service following the closure of all the military hospitals. As
a corollary to that it is the very first time that all casualties
coming back to the United Kingdom were going to National Health
Service hospitals. It was a first both for us and for the Department
of Health/National Health Service Executive. It was quite critical
that we got this right at the very beginning. I think that I can
say that we have, the principles and the processes are right.
What I have to say as a caveat to that is that we did not sustain
a vast number of casualties so the reception of military casualties
back to the United Kingdom within the National Health Service
did not stretch the system.
Q1182 Mr Viggers: Your initial description
of your planning emphasised military defence deployments needed
in the theatre of operation and did not refer to the effects on
the National Health Service, can I ask whether you modified your
plans because of representation from the National Health Service
or the private medical service?
Surgeon Vice Admiral Jenkins:
To my knowledge in only one area, we deliberately did not select
reservists from National Health Service trusts that hosted MDHUs
because they would have had a double-whammy and they asked us
not to do that and we did not.
Q1183 Mr Viggers: How many objections
were raised to deployment of personnel?
Surgeon Vice Admiral Jenkins:
One only at the Department of Health level.
Q1184 Mr Viggers: You referred to
your projection of possible casualties how would you have coped
with a surge capacity of casualties?
Surgeon Vice Admiral Jenkins:
There was joint planning between the Department of Health and
military medical representatives and each day the Department of
Health decided knowing bed availability nationally where they
would most want the patients to go. It was really a Department
of Health decision. Prior to that each hospital looked at as a
potential reception hospital was identified and agreements made
with the chief executives and trust boards. Also importantly the
air head sustaining that particular hospital was identified. Then,
as I say, on a day-to-day basis it was a Department of Health
decision and where the incoming aircraft with casualties on board
would go. They went to a lot of centres in the country. Probably
the one day that we took most casualties back to a National Health
Service hospital there were twelve only and they went to the new
Edinburgh Royal Infirmary.
Lieutenant General O'Donoghue:
Will it help if I ask the Wing Commander to help?
Wing Commander Almond: Most patients
or battle casualties were routed via Cyprus which gave everyone
time to prepare. We were given at least twelve hours notice of
all of the destinations of the aircraft. The aircraft was either
military or civilian. The reception arrangements on arriving back
in the UK were exceptionally good from our point of view at the
interface handing over to the NHS ambulance teams and civilian
medical officers waiting to receive the patients and distribute
them round the local hospitals associated with the airfield, bearing
in mind the majority of the patients are discharged at the air
head and are met by military transport to take them back to their
home station, RAF station or military practitioner.
Q1185 Mr Viggers: In the case of
consultants there is clinical guidance about the amount of time
they can be deployed, were there cases where these guidelines
were exceeded?
Surgeon Vice Admiral Jenkins:
I think the answer to that has to be no. The guidelines are there
to ensure that people remain technically current, surgeons continue
to operate. One of the problems that we experience on exercise
and deployment is fortunately they are not always clinically challenged
and to some extent when they return from a period of deployment
they might have lost some degree of technical dexterity. That
is the reason for the guideline. If they were clinically very
busy there is not a particular problem with them going over the
three month mark. I have to say that we deliberately extended
the reserve surgeons, anaesthetists, etc so that they could have
been nearer six months rather than three. The reason for that
was because we had to re-earmark the regulars for other potential
operations. We had to use the reservists to their maximum capacity
and hopefully one would not break the regulation which governs
the clinical governance component of it, ie the lack of dexterity,
and that is where I chose the caveat and I do not think they were
put in a position where they lost dexterity.
Q1186 Mike Gapes: In the Kosovo campaign
in 1999 there were some problems with regard to the medical support
and the lack of up-to-date skills of some of the personnel, what
lessons were learned from Kosovo, Sierra Leone and Afghanistan.
Were all of the military medical personnel adequately prepared?
Colonel Howe: I was actually the
Commander Med for entry into Kosovo and I have to say I do not
recognise that. We deployed 22 Field Hospital into Kosovo with
fully integrated capability and I think they were the envy of
NATO when we got on the ground.
Q1187 Mike Gapes: I am talking about
some RAF casualty personnel, they did not have up-to-date trauma
skills which the defence medical training organisation was unable
to meet at times.
Colonel Howe: This was individuals.
Q1188 Mike Gapes: That was recognised
at the time, it was referred to in the previous discussion. What
I am asking for is were lessons learned from that? Were all of
personnel that were deployed this time adequately trained?
Colonel Howe: In terms of lessons
learned we went right back to Granby to look at lessons to make
sure we were testing our plan against them. We were very positive
when we took the plan we made sure that we incorporated all of
the lessons from Granby. As far as individuals are concerned I
really cannot give an answer or account to you.
Q1189 Mike Gapes: Perhaps you can
write to us.
Surgeon Vice Admiral Jenkins:
I have no doubt that the people who led the clinical teams be
they at first, second or third role level were professionally
competent to practice independently. There could be some people
not long out of training and inexperienced, not improperly trained,
but inexperienced on deployment. There will be others who have
vast experience of deployment. There will be a spectrum and as
with everything else the juniors will be learning from the seniors,
even on deployment.
Q1190 Mike Gapes: Did all of the
personnel receive the necessary training to deal with nuclear,
biological or chemical weapons or impacts of depleted uranium?
Brigadier Hawley: This was clearly
something that exercised us greatly out on the ground in terms
of the organisation of the problems of handling as well as treating
casualties, Iraqi and our own, and the possibility contamination
of CW and BW, they are different problems. CW is an area well
known to us, we were dealing with this during Granby and this
is a normal aspect of training, part of what we are required to
do annually and report against the chain of command. In terms
of the chemical threat we were confident that we could handle
that. A possible biological threat is a different kettle of fish
because first of all you have to identify a possible agent, so
we had a system in place where we could identify, diagnose and
then start to treat. That was a system approach and it was built
on the normal clinical practice that our clinicians have with
infectious disease within hospitals of the NHS, both our Regular
and TA personnel are full-time professionals within the Health
Service these days so they were building on those basic infectious
disease control and management. The problem was to move the casualties
from the forward areas to the rear areas where we do not invest
in too much training at the divisional level, move it back to
my area where we would then have more time and more resources.
Q1191 Mike Gapes: What about nuclear
and radiation?
Brigadier Hawley: Yes, rather
than nuclear are you talking about the radiological weapons? The
trick with nuclear was to avoid contamination. Once they were
contaminated it became another CW problem, how you decontaminate
the treatment of nuclear casualties is part of our treatment regime,
there is nothing brand new about that.
Q1192 Mike Gapes: Your intention
would have been to move these people back from the frontline as
soon as possible?
Brigadier Hawley: To return mobility
to the forward units and use us in the rear end to manage properly
and isolate casualties as required.
Q1193 Mike Gapes: Fortunately it
was not necessary.
Brigadier Hawley: Absolutely.
Q1194 Mike Gapes: Can I ask a related
question about the impact of the growing trend in the NHS generally
towards greater specialism amongst surgeons—this is an issue
for constituency MPs, the location of accident and emergency departments
and mergers of hospital but we will not go there—what sort
of problems does this create for you specifically given, as I
understand it, you are going to need a lot of general surgeons
who can put their hand to a number of different areas? If you
have specialists are they really the appropriate people to be
deployed into this situation where you need more generalists?
Surgeon Vice Admiral Jenkins:
That is a very good question and I do wish you had not asked it.
I can honestly put my hand on my heart and tell you we are really
addressing this because it is a very, very major issue not confined
just to the United Kingdom it is true in Europe and America to
a certain extent. You are absolutely right, people are being really
encouraged at an earlier and earlier professional age to go into
a specialty and a sub speciality, it is what the trust chief executives
most demand. As you rightly say in conflict that is no help to
us. The day of the general surgeon is as a consequence being phased
out for whatever reason and we have to find a compromise, a pragmatic
way so we do not lose the skills of the generalist because of
the art of specialisation. We have engaged a number of high powered
people to help us here and I am engaging with the Royal College
of Surgeons of England, who are particularly helpful, and we have
commissioned a study to see how we can address this. The fundamental
problem is not so much whether you are a specialist surgeon or
a general surgeon (a lot of people say a general surgeon is a
specialist in his own right in the different variety of conditions)
but how much you learn in your formative surgical years of general
principles and sometimes post-graduate education in surgery is
now is to go straight into specialist surgery without learning
the breadth of general surgery principles. If we can reinject
that then we could overcome our potential problem. It might well
be that we cannot do that independently on the National Health
Service, it might be in defence medicine we will have to launch
our own training programmes for people to do skills and laboratory
workshops in those areas of deficit. The problem is what we cannot
do in this day and age is practice on the human beings, they cannot
practice on NHS patients unless they are skilled with a sub speciality
that patients expect. That is a long-winded answer to your question
but it identifies the enormity of the problem. There are one or
two other areas we have to look at that are not totally in line
with your questions, that is that we are, in this country fortunately
not grossly experienced in the treatment of ballistic and penetrating
injuries. For those skills we used to send surgeons to the North
American continent but the legislation in North America now is
such that you need a State Board to be able to do hands-on surgery
there. What we are hopefully about to launch, we are literally
finalising the process, is send defined teams of people rotationally
to South Africa with the South African Government's support whereby
they will be exposed in a very short period of time to a vast
experience of ballistic penetrating injuries. We are getting over
that area of the problem by pragmatic means but the basis to your
question remains a fundamental problem to us.
Surgeon Commander Birt: If I can
just add to what the Admiral said, there has always been a tendency
for the military doctor to have an unofficial interest in keeping
themselves general, that goes for anaesthetist and surgeons, although
there is no specific training for military surgeons unofficially
we take it on ourselves to get experience in different areas that
will benefit us on deployment. For some time professors of military
surgery have been going to South Africa to set up these schemes
and trainees tend to go to areas where they are more likely to
experience or treat ballistic injuries. There is an on-going tendency
but it is unofficial.
Brigadier Hawley: Could I add
one thing about TELIC, we did deploy the Professor of Military
Surgery to me as my command surgeon and he pulled together a team
of experienced consultant surgeons and anaesthetist who had done
quite a lot of war surgery in different theatres and use them
to go round and refresh and give confidence to those that were
less experienced. We recognised that problem. We had a cohort
of experienced war surgeons that had dealt with penetrating injuries,
which mercifully we do not see quite so often on the streets of
the United Kingdom, which are implicit in modern war fighting.
Q1195 Mr Cran: Moving on to the questions
on medical manning, the Committee has taken a great interest over
the years and we are quite well aware of the problems that you
have, yet one when one looks at the First Reflections it
states quite clearly that as far as medical components is concerned
it is fully manned. We know how you reach that situation because
we heard this already but just talk us through how difficult it
was to get to where you had to be from where you were in terms
of manning?
Lieutenant General O'Donoghue:
There were some specialties where we mobilised all that we could
and deployed them. We deployed in all about one third of the Defence
Medical Services if you add together regulars and reserves but
in some specialties surgeons, anaesthetists, intensive care nurses,
and so on. We deployed just about all that we could.
Q1196 Mr Cran: I am not sure you
are answering my question, what I am interested in and the Committee
is interested in is we know that you have shortages in all sorts
of specialisms, and so on and so forth, and you have to make up
those shortages for something like Iraq, what I am really interested
in knowing is how easy it was to make up the manning. I ask that
question against the background that there are all sorts of voices
around saying that the way that you do it affected them, and I
will get on to that in a minute?
Lieutenant General O'Donoghue:
It worked. We cross-deployed, there were RAF and Navy in the field
hospitals, one of the field hospitals was all regular, one was
all reserve and one was half regular and half reserve. We took
most of the specialisms out from the reserve and deployed them.
I am not sure I am answering your question. There is a process
that we went through and we got there and it worked. It was very,
very close, yes, in certain areas.
Q1197 Mr Cran: Can you tell us how
close?
Surgeon Vice Admiral Jenkins:
The answer to your question is, yes, we were fully manned for
the medical support operation. If you asked me whether we could
match it again tomorrow I could not put my hand on my heart and
say yes. We have used all our resources. You heard earlier on
from the reserves' representatives that in fact you have a finite
period of time in which you can use your reserves over a 36/27
month period. We exhausted many of those periods for many of our
reserve critical clinical colleagues. We have emptied the box
to a large extent, that is a slight exaggeration, but in general
terms in the major specialities for war requirement we have emptied
the boxes. That then, of course, raises another question and that
is that of course we are sustaining other mature operations, the
Falklands, Northern Ireland, Sierra Leone and the Balkans of course
and we are having to re-invite reservists to contemplate supporting
some of those operations. We are obviously using our regular people
again in our rotations and that is adding to the over-stretched
disharmony and everything else which encourages them to consider
whether they are going to stay or not. If I can jump back just
to put this in perspective, when we go back to the DCS 15 days
when some of our manning problems really started. There were three
fundamental flaws to the problem. You will remember the science
behind it that in fact only people in uniform would be retained
if they had deployable need. Of the three fundamental flaws, one,
it presumed that everyone was medically fit and physically fit
and available to deploy on day zero. We know from experience that
is not true. It did fail to recognise that some of the casualties
could be medical staff which, in fact, fortunately has not happened
since. We were lucky this time that only one colleague was injured.
That has not been a major problem but it is a fundamental defect
in the planning. The other thing which is most important and relevant
to the question you just asked there is no roulement of people
to move back into theatre, and we have suffered from that ever
since the mid-nineties.
Q1198 Mr Cran: The Committee is interested
in how sustainable this is for the future. John Ferguson the Chairman
of the BMA Armed Forces Committee says very clearly he thinks
the whole has had a detrimental effect on the NHS. The question
we want to know is, can we go on?
Surgeon Vice Admiral Jenkins:
We have to look for new solutions. We know about the regular numbers
we would like to aspire to. We are trying to identify better methods
of pay and non-pay options to encourage more people into the military
and to retain the people that we have. That has exercised us quite
considerably. We have received a lot of central support for that.
The other thing is that we cannot just do this by using anachronistic
methods, we have to look at new, more positive 21st century employment
methods and there is a vast variety of these, do you want people
with conditions such as sabbaticals, joint working, shared working
or do we look to the National Health Service where they can contract
with us to form teams. We have a pilot with the Birmingham Hospital
Trust whereby a team, a surgeon, an anaesthetist, an operating
theatre sister and an operating department practitioner went as
a formed unit to the Balkans as a trial last year and that was
outstandingly successful. We have permission to approach the National
Health Service to make that a model for the future, albeit in
a safe environment. That would help us. That is an option. We
are looking at opportunities where we might even be able to contractorise
out to a health provider other than the National Health Service.
Some of these opportunities, and these are literally things that
we are doing now because we recognise in answer to your question
because we cannot guarantee sustained requirements by using existing
methods.
Q1199 Mr Cran: What is your definition
of fully manned? There can be very many definitions of that. In
addition to that, is the medical component fully manned at the
moment?
Lieutenant General O'Donoghue:
No, the medical component is not fully manned in total in the
United Kingdom. Across the armed services the medical component
is certainly not fully manned.
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