MC 10

 

Memorandum from University Hospital Birmingham NHS Foundation Trust

 

 

 

Thank you for inviting University Hospital Birmingham NHS Foundation Trust (UHBFT) to submit evidence to your enquiry. I enclose a report and I am pleased that we will be able to discus these issues with you more fully during your visit to Birmingham. If you would like any further information ahead of your visit, please do not hesitate to contact me. I would like here to provide a brief overview of the contract and recent events.

 

The contract to base the Centre for Defence Medicine in a major teaching hospital was entered into for the following reasons:

 

· The increasing specialisation of medicine means that only a major teaching hospital has the range of specialist services and staff to provide the education and experience for the military clinical staff.

· Much evidence exists to show that all patients do better in terms of survival and recovery if treated in a specialist centre by specialist staff.

· Major University Teaching hospitals have the expertise to support the research aspirations of the defence medical services.

 

The number of military patients meant that a stand alone military hospital of sufficient size could not be sustained by such a small population base. In addition, the small volume of patients was not sufficient to enable comprehensive education and training of the military clinical staff.

 

Since the agreement commenced in 2001, partnership working has grown and strengthened and is highly valued on both sides. Feedback has been received that

the training given to military staff when deployed at UHBFT has enabled them to provide much better care to the injured when deployed to areas of conflict. The knowledge they have acquired whilst at UHB about treatment available at UHBFT has also allowed care on the frontline to preserve and maintain function prior to the patients being transported back.

 

Furthermore, the nature of injuries being seen now in the injured troops has not been seen in the UK for decades and the level of expertise in the UK in treating such injuries has declined with lack of exposure. However, at UHBFT, the civilian and military clinicians together have now developed a significant level of expertise in treating such injuries. They are now undertaking extremely sophisticated surgery and procedures to preserve and restore function in severely injured military casualties. It is doubtful that this level of expertise exists in many other institutions in the UK.

 

To achieve this level of specialised treatment requires that the injured military staff are treated in the appropriate clinical environment, eg, burns patients in the burns unit, neurosurgical injuries in the neurosurgical unit. Indeed the contract specifically asked for any military casualties to be treated in the appropriate area and not in one specific ward. Similarly, to ensure that the military clinical staff received the most appropriate experience, they were to be deployed within the hospital to different clinical areas and not be deployed on one ward.

 

Initially, there was a military managed ward to enable the military staff to gain and maintain experience in clinical management. This was a mixed sex general surgical ward (not trauma). This arrangement ceased on deployment of the majority of the ward staff with 24 hours notice at the start of the Afghanistan operation. Since that time the military had not managed a ward within UHBFT.

 

We have now been asked to have a military managed ward (ie senior nurse in charge is a military nurse) and the military preference is that this is the trauma ward where most of the injured soldiers are cared for. We have agreed to this and are working with the military to achieve this. The limiting factor is that the military did not have a nurse with the required skills and sufficient seniority to manage a ward. Over recent months we have been working with the military to train someone to assume this function. The military also did not have enough nurses to staff the ward and will not reach the required numbers to have a 70% staffing level (remaining 30% NHS staff) until July 2007.

 

Whilst there were inevitable teething problems and refinements to be made to the partnership, it has been extremely successful in delivering its objectives of education and training of the military clinical staff and providing specialist care for military personnel.

 

However, this was the contract to operate in peacetime not in times of conflict or war. For periods of conflict with increased numbers of injured casualties, a plan for the entire NHS to be involved in the treatment of the injured would come into play. This plan was initially called Joint Casualty Reporting and Reception Plan (JCRRP) and in 2002 was refined into Reception Arrangements of Military Personnel (RAMP). It was never envisaged that UHBFT would take all casualties from areas of conflict or war. RAMP has only been called into play once in 2003. With this one exception, UHBFT has taken all casualties sent back from both Afghanistan and Iraq.

 

This may be for a variety of reasons. There is a strong belief within the military that casualties should be sent to UHBFT. Aeromedical staff prefer to transfer to UHBFT where this is a regular occurrence and the staff are familiar with the process. Military doctors in Afghanistan and Iraq prefer the injured to return to clinical staff that they know and trust. The staff have also taken great pride in the care given to the military patients and have taken great efforts to create the capacity to ensure that the casualties can be admitted at UHBFT.

 

However, the partnership has been placed under tremendous strain by the recent negative press coverage and a lot of the good will that allowed UHBFT to continue to take all the casualties, has evaporated.

 

With hindsight, although there were excellent clinical reasons for the contract to be as it is, I believe that this was not communicated to senior non-clinical military officers and associated personnel, who expected to find all injured soldiers in one ward being cared for solely by military personnel. During several conversations with very senior military officers, they have admitted that this was the case, that they did not understand the nature of modern medicine and the increasing specialisation of medicine and the need for specialist care. I think that this is now understood.

 

I acknowledge that there are some things that could have been improved and where these have been brought to our attention, we have done so immediately. I certainly agree that the physical environment for all our patients is less than ideal as our current buildings are in excess of 70 and 100 years old. We are building a superb new hospital on track to open in 2010 and we are pleased that the RCDM is part of this development.

 

My concern is that these debates were played out in the press rather than by considered discussion between those concerned and senior hospital staff. This sustained negative press campaign has had a significant demoralising effect on clinical staff, NHS and military, I am sure it has affected the morale of deployed troops and their families and it has certainly affected our reputation with our own population and patients. In the report, there are details of the amount of press attention that we have had over this issue.

 

There are positive aspects to this however, in that I am now certain that senior military officers understand the nature of specialist healthcare and why military hospitals could not provide this. Furthermore, relationships between senior military officers and senior UHB personnel have now been established enabling speedy communication of concerns and resolution of issues.

 

18 May 2007