Select Committee on Defence Seventh Report

2  Treatment of casualties from operations

Procedures for operational casualties

18. DMS personnel are deployed on operations in both of the major theatres, on Operation HERRICK (Afghanistan) and Operation TELIC (Iraq). Personnel are deployed on a tri-Service basis, and there is heavy reliance on Reservists, especially in terms of deployed hospital care and specialist roles. Around half of the Army's deployed secondary care capability has been met by the Territorial Army, and four TA field hospitals have provided services for a 12-month commitment in Afghanistan (HERRICK 6 and 7), beginning in April 2007.

19. The medical personnel deployed on operations provide assessment and immediate treatment for all casualties, whether injured in combat or otherwise, through Incident Response Teams (IRTs). There are also Deployed Rehabilitation Teams (DRTs) and Deployed Mental Health Teams (DMHTs) in-theatre to provide a first line of treatment and guidance on any further treatment or referral necessary.

20. Seriously injured casualties are generally given initial treatment and stabilised by medical personnel in theatre then aeromedically evacuated to the UK when appropriate.[6] The deployment of a full range of clinical staff to field hospitals has allowed much more extensive treatment of casualties in-theatre. The decision to evacuate is a clinical one. Between January 2006 and April 2007, 367 UK personnel were evacuated from Afghanistan and 866 from Iraq (although not all of these were battle injuries).

Birmingham as the centre for treating operational casualties

21. Since 2001, the main receiving unit for casualties evacuated from operational theatres has been the Royal Centre for Defence Medicine, based at the University Hospital Birmingham Foundation Trust (UHBFT) (though there was some use made of The Princess Mary Hospital at RAF Akrotiri in Cyprus during the most intense phase of Operation TELIC 1 in Iraq in 2003). The decision to establish a partnership with UHBFT was taken because, according to the Ministry of Defence, "the medical needs of the Armed Forces are best served through access to facilities and training in a busy acute care hospital that is managing severe trauma on a daily basis".[7] Selly Oak Hospital, one of the five specialist hospitals within UHBFT and the home to most of the treatment received by operational casualties, is highly experienced in treating the most common types of injuries sustained by Service personnel, such as polytrauma. In addition, the main arrival point for casualties is RAF Brize Norton, with which Selly Oak has good links.[8]

22. Julie Moore, Chief Executive of UHBFT, explained that Birmingham had been a particularly suitable partner for the MoD:

In terms of its central location, located near to a big airport and its good road networks, I think that was one of the major factors in choosing it so that patients can be easily transported when they are aeromedically evacuated back to Birmingham. In addition, it has got very strong partnerships with local universities, again feeding the training environment at the Royal Centre for Defence Medicine.[9]

Dr David Rosser, the Medical Director at UHBFT, added that:

The range of clinical specialties we have is very extensive. The only major specialties we do not provide are paediatrics and obstetrics and gynaecology. If one is injured in any form of major trauma any part of the body can be affected and we have surgical specialists particularly skilled in dealing with virtually every part of the body.[10]

23. We heard evidence from the Army Families Federation (AFF), the Royal British Legion (RBL), SSAFA, Combat Stress and the Royal Air Forces Association (RAFA) to support the decision to work with UHBFT, and to attest that the clinical care offered at the RCDM was first-class. Ms Sammie Crane, Chief Executive of the AFF, told us that:

The feedback I have had is that the clinical care at Selly Oak is so good it could not be replicated elsewhere and therefore that it is the correct place to which serious casualties should be taken.[11]

24. UHBFT stressed that the arrangements which were put in place were "to operate in peacetime not in times of conflict or war".[12] Instead, a plan by which the NHS as a whole would become involved in the treatment of substantial numbers of casualties was devised, the Joint Casualty Reporting and Reception Plan (JCRRP). This was refined in 2002 into Reception Arrangements of Military Personnel (RAMP). That notwithstanding, RAMP has been used only once, in 2003. UBHFT has taken all other casualties sent back from Operations TELIC and HERRICK.

25. UHBFT suggested that it has become the dominant reception centre for casualties because there was a strong preference for using it among military personnel. Aeromedical staff preferred to transfer to UHBFT because it was a regular occurrence, and the clinical staff were familiar with the procedure. Military doctors in Afghanistan and Iraq preferred to return casualties to an atmosphere which they knew and trusted.[13]

Clinical care and welfare services

26. In order to achieve the level of specialised treatment which was required for injured Service personnel, it was deemed necessary to place casualties in the appropriate clinical environment—burns patients were treated in the burns unit, neurosurgical injuries in the neurosurgical unit and so on. UHBFT told us that its initial contract with the MoD specifically asked for military casualties to be treated in the appropriate area, rather than in a specific ward. Similarly, military clinical staff were deployed in different areas within the hospital rather than on a specific ward, in order to give them the most appropriate experience and opportunity for training and skills development.

27. Initially, there was also a military-managed ward to allow DMS staff to gain experience of clinical management. It was not a trauma unit but a mixed-sex general surgical ward. However, this arrangement was brought to an end when the majority of the ward staff were deployed to Afghanistan at 24 hours' notice.[14]

28. Prior to our inquiry, there had been considerable, often adverse, press coverage of the standards of care at Selly Oak Hospital in particular. This included allegations that patients had been asked to remove their uniforms for fear of causing offence and had been verbally abused by visitors who opposed the war in Iraq. We asked Ms Moore, the Chief Executive of UHBFT, if there had been any complaints related to the stories highlighted from a number of newspapers. These included a report in the Daily Telegraph that an injured paratrooper had been verbally abused by a Muslim visitor, a story in the Daily Star that an injured Servicemen had been told to remove his uniform for fear of causing offence and an article in the Mail on Sunday that a soldier at Selly Oak had been accosted by a group of Muslim women.[15] She confirmed that the trust had received no complaints. She went on to tell us that scrutiny by the press had placed considerable demands on the Trust:

The time taken to deal with this has been quite considerable. The senior nurse in charge of the ward at one time said she felt she was doing organised visits round the ward instead of looking after patients, and that cannot be right.[16]

Her written memorandum on behalf of the Trust highlighted the same concern.

My concern is that these debates [over the standard of care] 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.[17]

29. The evidence from UHBFT, that the negative press coverage had not been based on accurate representations of factual cases, echoed what we had been told by the MoD. It seems clear that there has been much inaccurate and irresponsible reporting surrounding care for injured Service personnel at Birmingham, and that some stories were printed without being verified or, in some cases, after the Trust had said that they were untrue. We condemn this completely. Editors have a responsibility to ensure that their newspapers report on the basis of verified fact, not assumption or hearsay. The effect of such misrepresentation on the morale of clinical staff and Service personnel and families was considerable. We consider the publication of such misleading stories as reprehensible.

30. Another criticism in some sections of the media was the loss of the military-managed ward, with some people emphasising the importance of Service personnel being treated in a military atmosphere in which they would be comfortable. In response to this, in late 2006 UHBFT was asked to provide a new Military Managed Ward (MMW), in which the senior nurse in charge would be a military nurse. The preference of the DMS was that this should be the trauma ward where most injured Service personnel are treated. However, there was not a military nurse with the required skills and experience to manage a ward, so it was necessary to train someone to fulfil that role. Furthermore, there were insufficient military nurses to staff the ward, and it was claimed at the time that it would not be possible to reach the required numbers to have a 70% military staffing level until July 2007.[18]

31. We asked the Minister about progress on the Military Managed Ward when he appeared before us in November 2007. He explained that there were around 39 military nurses at Selly Oak, a Regimental Sergeant-Major ward manager to deal with discipline and matters relating to Service life, and two liaison facilities who maintained links with patients' parent units. He concluded:

You walk around Selly Oak now, and it is like new. There are a lot more military people and uniforms […] the hope going to the new ward is that we can put in an actual ward manager who would have responsibility on that ward for all the things that happen in that ward.[19]

32. There were also criticisms of the welfare and support services provided at Selly Oak. When we spoke to representatives of welfare organisations in June 2007, they assured us that the clinical care at Selly Oak was of a very high standard, but that, in the words of one witness, "support for people who visit and for the individuals whilst there in terms of providing basic essentials is currently provided by charities which some […] suggest is perhaps not appropriate".[20] Among the issues identified were travel assistance for families of injured Service personnel, provision of toiletries and basic clothing for Service personnel who had been separated from their possessions, and accommodation for relatives of patients. Improvements were taking place, but some of the slack had been taken up by welfare organisations. For example, the Army Families Federation had paid for the temporary refurbishment of flats originally built for doctors and nurses so that they could be used by patients' families.[21]

33. One significant development which bridged the gap between clinical care and welfare was the appointment of a Standing Joint Commander (Medical), who was an experienced infantry officer. His role has been to take responsibility of command and control issues and to coordinate the care pathways for casualties brought into Birmingham. Lieutenant-General Baxter stressed the importance of this appointment: "an experienced soldier is going in there, he knows the issue in the operational theatres, he knows what it is like looking after soldiers".[22]

34. We acknowledge the progress which has been made at Selly Oak in terms of creating a military environment, to take advantage of the healing process of being surrounded by those who have been through similar experiences, to make patients feel comfortable and give them familiar surroundings. The MoD has made substantial efforts in this regard, and we look forward to hearing of further progress in the response to this report. The MoD must make sure that the issues of welfare for patients and families are central to its planning in developing its medical facilities in and around Birmingham.

35. We also welcome the improvements in welfare provision and pay tribute to the work of welfare and charitable organisations. We consider that there is nothing intrinsically wrong in welfare and charitable organisations contributing to the support of our injured Service personnel. Indeed, quite the reverse is the case, since it builds on a proud tradition in the United Kingdom of linking the community with the Service personnel who have been injured fighting on their behalf. The MoD and the voluntary sector should engage openly with the debate about which services are more appropriately provided by the Government and which by charities and voluntary groups.

36. However, we also underline the fact that many of the improvements set out above are relatively recent, and there has been a great deal of change over the past 18 months. The MoD should not be complacent: they have had to learn important lessons and it is clear that the picture at Selly Oak was not always so positive. Nor should progress now stop, but the MoD should continue to learn lessons from its experiences in treating injured Service personnel at Selly Oak.

The concentration of services: criticisms and plans

37. While there was almost unanimous praise for the clinical standards at Selly Oak, the decision to site a single trauma unit in Birmingham was questioned by Mr Terence Lewis, Medical Director of Plymouth Hospitals NHS Trust. Mr Lewis pointed out that his trust had one of the biggest hospitals in Europe under one roof, was a major tertiary care provider and was home to one of only a handful of level-one trauma units in the UK. He therefore regarded it as "a great pity" that his trust did not provide any trauma infrastructure to military personnel.[23]

38. We put this criticism to the Parliamentary Under-Secretary of State for Defence, Derek Twigg MP, in November 2007. He told us that the advice he had received was that the use of Birmingham as a single site for the treatment of operational casualties was right "because of the concentration of our medical expertise and the range of cases that our people are seeing and, of course, the NHS people are seeing as well". He added that "there is an argument as well—and this has come over quite strongly from the individual Service personnel—that they like to be grouped together, which of course we can do." He concluded that the numbers of operational casualties, while higher than they had been before 2001, were relatively small compared to other conflicts, and were not high enough to require or allow the treatment in several different locations.[24]

39. The Surgeon-General added two points in support of the Minister's answer. The first was that a criterion in choosing Birmingham had been the presence of a university, which there had not been at that time in Plymouth. The second was that Birmingham was a large conurbation, which would allow the MoD to "spread out in a local way should the number of casualties exceed the capability of whatever it was that we chose". He noted that the three short-listed facilities had been in large conurbations: Birmingham, Newcastle-upon-Tyne and Guy's and St Thomas' in London.[25]

40. Another criticism of the Birmingham site which we heard from Service personnel when we visited in June 2007 was that it was not close to any major Service population (unlike, say, Plymouth or Portsmouth), which meant that the families of the injured being treated there often had to travel considerable distances, and that personnel serving in Birmingham did not feel that there was a sense of community, sometimes making it an unpopular posting.

41. The MoD has plans to develop the facilities in and around Birmingham. When we visited the RCDM, we were told that it had been involved from a very early stage in the Birmingham New Hospitals Project, which would provide brand new facilities, including dedicated military areas. We were also told that there were plans to develop facilities for training and messing at Whittington Barracks in Lichfield. This was part of the Midland Medical Accommodation (MMA) project, which would bring together on one site the headquarters of the DMS, DMETA, the Defence Medical Services Training Centre and 33 Field Hospital (currently based at Gosport).[26]

42. Lieutenant-General Baxter explained to us in oral evidence that the MoD intended Birmingham and Lichfield to form a "dumb-bell" in terms of shape:

We are looking […] to continue to build on that, if you like, fissionable mass, bringing the various components together, making sure the thinking piece goes into the training and the education and to look at concentrating other bits of training. Our eyes are on taking Whittington Barracks and converting that into a satellite to the main Birmingham piece. We are looking at plans now, we are looking at budgets and we are looking to what we call a Main Gate submission, the investment decision, early in the New Year [2008].[27]

43. We acknowledge the case for concentrating the main clinical and training assets of the DMS and DMETA on one cluster of sites. While Birmingham may not be close to a major Service community, we accept that it is suitable in terms of transport links and proximity to a university, both of which are important factors. However, the MoD needs to make its case for the Birmingham-Lichfield 'dumb-bell' more explicitly, and we expect the Government response to our report to set out in detail the plans and progress on this. The MoD and, where appropriate, the voluntary sector should also make sure that there are adequate travel and accommodation arrangements for families visiting patients in Birmingham, and, as important, that these are easily understood and accessible.

44. The UHBFT/RCDM services are delivered at Selly Oak in buildings which are in many cases ageing. Delivery of the PFI development is scheduled to bring new, state-of-the-art buildings and facilities by 2012. We expect the MoD, as part of its annual reporting process, to state whether delivery on the Birmingham New Hospitals project is on target.

6   That is, transported by air, accompanied by medical personnel. Back

7   Ev 91 Back

8   ibidBack

9   Q 108 Back

10   Q 109 Back

11   Q 2 (Ms Crane) Back

12   Ev 107 Back

13   ibidBack

14   Ev 106 Back

15   Q 161 Back

16   Q 159 Back

17   Ev 107 Back

18   Ev 107 Back

19   Q 409 (Mr Twigg) Back

20   Q 3 (Ms Freeth) Back

21   Q 23 Back

22   Q 409 (Lieutenant-General Baxter) Back

23   Q 168 (Mr Lewis) Back

24   Q 407 (Mr Twigg) Back

25   Q 407 (Lieutenant-General Lillywhite) Back

26   Ev 97 Back

27   Q 406 (Lieutenant-General Baxter) Back

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Prepared 18 February 2008