Memorandum from the Royal College of Physicians
We are pleased to submit evidence to the above
Inquiry. The Royal College of Physicians (RCP) plays a leading
role in the delivery of high quality patient care by setting standards
of medical practice and promoting clinical excellence. We provide
physicians in the United Kingdom and overseas with education,
training and support throughout their careers. As an independent
body representing over 20,000 Fellows and Members worldwide, we
advise and work with government, the public, patients and other
professions to improve health and healthcare.
The RCP has a number of members who work in
defence medicine, and our evidence has involved some of their
views.
BACKGROUND
Following the closure of military hospitals
in the UK, Ministry of Defence Hospital Units (MDHUs) were integrated
within NHS Trusts. The current situation sees consultants involved
in defence medicine give 75% of their time to the trust, and 25%
to the military. For deployable specialties, this time is mainly
made up in time abroad.
In 1995, there were small-scale deployments
of clinical defence staff to the Balkans. However, over more recent
years, since the second Gulf war and other military activities,
such as in Afghanistan, the increased commitment to providing
medical services is greater than is accounted for by defence planning
assumptions. This will inevitably have consequences for defence
medicine, such as resourcing.
CURRENT HEALTHCARE
FOR SERVICE
PERSONNEL
Secondary care in the UK during peacetime has
generally been good. Contracts with NHS Trusts which host MDHU
encourage them to give priority to defence service personnel,
where operationally necessary. The MoD pays for this "enhanced"
service. If there is no MDHU available, service personnel can
be sent to a non-MDHU NHS hospital.
Secondary care provision for UK personnel in
Germany is provided by the MoD through a contract with Guys and
St. Thomas' hospital. Again, the provision of secondary care in
Germany seems to be good.
MEDICAL SUPPORT
FOR OPERATIONS
AND FACILITIES
PROVIDED FOR
THEM
There are small deployed military hospitals
in Basra and Afghanistan for service personnel. The capability
of these hospitals is appropriate for addressing current need,
which means that not all specialties are represented on the ground.
Provision includes the following:
— The vast majority of care is around
Disease and Non Battle Injury (DNBI). Historically this has been
the largest makeup of medical provision.
— Medium scale deployment might consist
of a consultant general surgeon, consultant orthopaedic surgeon,
3 anaesthetists, 1 SpR (for 3 months training) and 1 consultant
physician. There are also SHO's, nursing staff, radiographers,
laboratory staff and physiotherapists. Psychiatric nurses are
also deployed, but are not based within a hospital. No psychiatrists
are deployed.
— Tele-radiography and digital imaging
are routinely available, and support the deployment of CT scanning.
Scans can now be sent back to the relevant UK hospital in seconds,
with consultant reporting thus available in a very short space
of time. This facility has been available for approximately 3
years.
Medicine
Acute medicine has an increasingly important
role in defence medical provision and needs further support in
the future.
Historically, the MoD has tried to provide a
range of specialties, with the emphasis on infectious disease,
which has been the major issue for defence medicine. The norvovirus
outbreak in Afghanistan in 2002 is an example of this.
Provision around infectious disease includes
the following:
— Funding is now available to send
junior doctors to do Diploma in Tropical Medicine and Hygiene
(DTM&H).
— 1 physician is accredited in infectious
disease from the Centre for Control of Communicable disease (CCDC).
— 4 SpR's are trained in infectious
diseases.
Despite advances and current provision, there
is currently a lack of adequate deployed laboratory facilities.
This is of particular concern because of the development of new
diseases, the increased complexities of TB and the on-going threat
of "deliberate release" (bio-terrorism).
Trauma
The management of trauma is constantly improving,
and there is an on-going trauma audit being carried out. This
is important work as expectations around timelines for dealing
with and treating trauma have changed. Whereas delivering initial
trauma care was once known as the "golden hour", medical
care is now expected to react within 10 minutes. However, military
operations can be far away from hospital facilities, which raises
questions about how to provide trauma care. If military operations
are more than an hour's helicopter flight to the base hospital,
other medical provision needs to be delivered. This is largely
around resuscitation, which A&E teams can deliver. By design,
trauma and medical patients are sent to Birmingham for their on-going
care.
The deployment of neurosurgical teams is now
happening in Afghanistan, as head injuries are becoming more prominent
with improvements to body armour. Currently, the UK is the only
nation that has this capability.
MEDICAL SERVICE
DELIVERY AND
MOD ENGAGEMENT
WITH NHS
As discussed above, military evacuees currently
receive their care in Birmingham. The trust is in 2 locations,
which are the Queen Elizabeth Hospital and Selly Oak hospital,
where A&E, trauma and ICU are located.
Although there has been some call for a separate
military hospital for service personnel, the generally accepted
plan has always been that tertiary care be provided by NHS hospitals.
In previous years, personnel arrived in Birmingham and NHS staff
may not have appreciated the environment they have come from.
However, the feeling now is that there is a better understanding
of such issues, and staff are committed to the "cause".
Welfare support
Although, as indicated above, many aspects of
secondary and tertiary care are good, welfare support has not
yet reached an acceptable standard. This includes issues such
as the transfer of a patient to a hospital nearer to their family
or unit or facilities enabling family to stay with the patient
at the hospital. It is our understanding that the Centre for Defence
Medicine is to review the process around these issues, and that
there is now at least some accommodation for family members. In
Birmingham, defence healthcare staff do make at least one visit
each day to personnel. The Welfare Department look after other
issues too, including use of library facilities and access to
a phone.
It is important that both defence medicine staff
and the individual military units take responsibility for ensuring
that personnel get the appropriate welfare support they need.
CONCLUSION
Initial concern at the closure of military hospitals
has abated. There was no way of knowing then about the EU working
time directive and changes in training, for example, which would
have had significant impact on military hospitals.
We believe in particular that trauma care is
regarded as outstanding, considering the facilities available.
New technology has allowed defence clinical services to take advice
more readily on medical issues, such as with the deployment of
CT scanners. Such developments are important for providing the
best possible treatment for service personnel.
Welfare support has been highlighted as an area
that needs improving, in order to ensure on-going care and support
of service personnel.
RECOMMENDATIONS
— Physicians should maintain their
skills in acute medicine, as this fits well with the current emphasis
on infectious disease
— Defence planning assumptions must
take into account current and future medical resourcing needed,
if there are to continue to be on-going military operations of
this scale
— Investment in appropriate facilities
is essential, for example laboratory and CT scanning. It is important
that the MoD support laboratory deployment, to help deal with
emerging infections and deliberate outbreak
— Efforts to improve social care around
medical care must continue
— Military nursing is experiencing
similar shortages in specialist care as the NHS, such as in critical
care. It is difficult to recruit nurses from the NHS, and efforts
must be made to address this
— Hospital accommodation should be
provided for soldiers in the UK which allows them to have access
to en-suite facilities, welfare and other support
— There is a sense of entitlement that
more should be provided for personnel in terms of medical, welfare
and social support than the NHS can provide. Efforts must be made
to ease tensions between civilian and military expectations regarding
service provision and treatment.
15 May 2007
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