Supplementary memorandum from Terence
Lewis
I have submitted to this Committee on
two occasions and in two different roles. The first was a written
submission sent on 9 May 2007 in my role as Civilian Advisor in
Cardiac Surgery, Medical Director of Plymouth Hospitals and current
NHS Medical Director to ASCAB. That letter is in your possession
and is self explanatory. More recently, on 21 June 2007, I attended
the Council House in Birmingham and gave an oral submission on
behalf of Plymouth Hospitals NHS Trust as one of the largest MDHUs
in the United Kingdom.
Following that event, I would like to
make some written comments on issues emerging from that meeting
and, therefore, in my role as Medical Director of Plymouth Hospitals,
taking into account the documentation made available at the time
of the meeting from the existing clinical units.
It seemed to me that the submissions
and the paperwork coming from the clinical units, including Birmingham,
valued the link with the military but with reservations. The MDHUs
raised concerns regarding the clinical exposure of military staff
to patient case mix to allow the development and maintenance of
the skills required on deployment to care for injured military
patients. There were concerns regarding the appropriateness of
the care for military patients in a holistic manner, close to
their families and communities, with an aim to returning them
to duty within an acceptable period of time, as well as concerns
of the practicality of the delivery of the above within the host
Trust's clinical, financial and strategic envelope. The submission
from Birmingham was surprisingly defensive, but I do understand
that they have had a difficult and unjustified bad press. One
or two of the MDHUs giving evidence were too small to provide
the wide range of clinical expertise and specialties, which are
necessary for the provision of a modern Trauma Centre, especially
important where military trauma is involved. Peterborough commented
on the difficult paradox of receiving military patients at the
same time as losing military medical staff operationally.
The impression arising from the day was
of an extremely Birmingham centred discussion. I can understand
that the Select Committee would want to support Birmingham as
strongly as they felt able, however, there does need to be some
balance. The MDHUs were hardly mentioned in any of the available
literature and the Briefing Paper was a remarkable document, entirely
Birmingham focused without any understanding of the limitations
of this form of provision or thought for strategic development.
Indeed Plymouth, which was not even mentioned by name, is by far
the largest, most comprehensive integrated tertiary service provider
amongst the MDHUs with 1200 beds under one roof and virtually
every tertiary service including Neurosurgery, Cardiothoracics,
Pancreatic and Hepatic Medicine and Surgery, as well as being
one of only two or three Trauma One Units in the UK according
to the Templeton Criteria. There is already a military managed
ward (Stonehouse Ward) and there is one of the largest collection
of ITU/Critical Care beds in Europe within the one building. There
is a heli-pad within 50 yards of the resuscitation admission area
and a fixed wing airport half a mile away with an international
airport only 35 minutes away and a motorway into a hospital site
which is never gridlocked. Sellyoak is a relatively small hospital,
part of a much larger Trust, and their rationalisation by 2012
will give the same kind of configuration and centralised expertise
as already exists in Plymouth.
Most importantly the demographics of
the service personnel involved needs to be considered very seriously.
It is inappropriate for complex and often protracted therapies
to be undertaken far away from family, children, schools and community.
Three Brigade Royal Marines, who have a high and early involvement
in theatre of war, are centralised around the Plymouth area. There
is a military ethos and tradition to the place and the community
is tight-knit and self supporting, this includes medical services.
It is entirely inappropriate that these patients are obliged to
be cared for elsewhere when the capability manifestly exists within
their own community. With the reorganisation of military centres,
it would seem to me that the most appropriate UK distribution
of battle casualties should reflect this, perhaps the James Cook
in the North, Birmingham in the Midlands and Plymouth in the South.
James Cook and Plymouth are fairly similar organisations with
a comprehensive range of services. Birmingham will achieve that
following rationalisation and rebuilding in the fullness of time.
Plymouth already has a military medical headquarters facility
on the Hospital campus, military medical management within the
Hospital, and is close to extensive military infrastructure, including
Mess facilities. We train and provide staff for RFA Argus which
I did not raise at the meeting as I am not sure how appropriate
it is to air Argus" rather sensitive role in public. Be that
as it may, we provide a highly comprehensive advanced battle receiving
station in the absence of day to day management of repatriated
battle trauma, which seems wholly inappropriate. With three centres,
such as this, an integrated and networked approach to the treatment
of repatriated battle casualties could be fostered with the flexibility
that may be required with surges of activity when necessary.
One or two other separate points emerged
during the day. The first is concerning outcomes. Modern medicine
is driven by information. Quality is improved by clinical governance
of which audit and an assessment of outcomes is vital. There appeared
to be very little, if any, attention given to the discussion of
outcomes and how they might be managed during that day. An advantage
of a three centre provision for battle casualties would be the
possibility of the development of an integrated outcome assessment
for these complicated cases where final results may only be realised
a considerable time down the line, often within the community.
Very little discussion was had concerning
reservists which are a considerable challenge for employing Trusts
and for the military as referred to in my written submission.
The tendency for senior medical military personnel to be removed
from the clinical environment at a time in their life when they
are approaching their most experienced seems perverse and should
be addressed.
There was mention made that military
clinical deployments are as a "purple', ie tri-services,
organisation. My experience is that the tri-services element of
military medicine does happen in the field with Naval and RAF
personnel deployed to land operations. Integration elsewhere in
my experience is extremely limited. It would seem to me that lip
service is paid to the tri-services element of military medicine.
In summary, speaking with my Plymouth
Hospitals strategic hat on, the case for Plymouth to be involved
more comprehensively in the provision of military medicine, including
being part of a network of three receiving centres for repatriated
battle casualties, seems to be very strong. It is an established,
single site, major trauma and teaching hospital with virtually
the complete range of tertiary services, a medical school and
a fast developing research record. There is already significant
infrastructure that could be utilised for supporting functions,
including accommodation and administration, with the cost savings
that that brings with it. To involve Plymouth would avoid concentrating
all the eggs in one relatively small basket in Birmingham. Rationalisation
of military presence into three major trauma centres, one in the
North, one in the Midlands and one in the South, would allow the
development of proper networking and a comprehensive framework
for the consideration of results and outcomes. Patients would
be able to be repatriated to the centre nearest to their parent
base unit to allow the unit to be able to continue contact and
friends and family ease of access. All DMS staff would see the
wounds of war in their Hospital and not just on operational deployments.
The DoH is shortly to produce an assessment of civilian trauma
services which will be very interesting and is likely to be critical
of NHS existing provision. Plymouth is extremely well placed to
become a major international contributor to the development of
trauma services and I believe that the military should be a part
of this. We would be anxious in Plymouth for reasons already explained
to augment the presence of military medicine as, left the way
that things are, it will become a smaller and smaller proportion
of our overall activity. In order for such a development to make
strategic sense for a rapidly developing Trust there needs to
be the "carrot" of elective work as well as training.
All aspects of this provision need to be considered in the round
and relationships with the NHS will need to be a fundamental part
of such consideration.
I hope that these points are helpful.
I don't believe that any of them, which arise from the meeting
in Birmingham in June, fly in the face of my original written
submission. I believe the two are complimentary. Please let me
know if you require further amplification of any of the points
made.
31 July 2007
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