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
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