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MC 07
Memorandum from Ministry of Defence
1. This Memorandum aims to provide the House of Commons Defence Committee (HCDC) with relevant background information to aid their inquiry into medical care in the Armed Forces.
INTRODUCTION
2. The strategic intent of the Defence Medical Services (DMS) is that every Serviceman and woman enjoys a level of health that is appropriate for the tasks they are required to perform by the Chain of Command. To that end, the DMS have two key measurable outputs: the provision of medical support to deployed operations (from theatre back to the UK); and the provision of healthcare to the Armed Forces[1] to ensure that the maximum numbers possible are "fit for task". The DMS also provide advice to commanders to support them in the discharge of their responsibility for the health of their personnel. There have been many significant developments in support of the DMS' outputs since the HCDC last reported on the organisation in 1999. These are summarised within the sections below.
3. The DMS are headed jointly by the Deputy Chief of Defence Staff (Health) (DCDS(H)) and the Surgeon General (SG). DCDS(H) is accountable for the overall outputs of the DMS, and SG is the clinical head of the Department with responsibility for the professional performance and development of military medicine. They oversee the work of three separate organisations:
a. Defence Medical Services Department (DMSD) - The Head Office for the DMS, which provides strategic direction to ensure coherent delivery of all medical outputs;
b. Defence Medical Education and Training Agency (DMETA) - A tri-service organisation that provides secondary care personnel to meet requirements for operational deployments. It also underpins medical support to the UK's Front Line forces by educating and training medical personnel. The Agency delivers annually over 300,000 man training days across 2,000 clinical courses to the single Services. DMETA has command and control over:
(1) Ministry of Defence Hospital Units (MDHUs);
(2) The Royal Centre for Defence Medicine (RCDM);
(3) The Defence Medical Rehabilitation Centre (DMRC) at Headley Court;
(4) The Defence Medical Services Training Centre (DMSTC) at Keogh Barracks;
(5) The Defence Medical Postgraduate Deanery; and
(6) Retained military tasks at the Royal Hospital Haslar, which is managed in partnership with Portsmouth Hospitals NHS Trust (due to close in late 2009).
c. Defence Dental Services (DDS) - a tri-service organisation employing both Armed Forces and civilian personnel, providing dental services in the UK at service establishments and to personnel on operations.
5. DCDS(H) and SG also produce medical policy for the three Single Services. The Royal Navy (RN), Army and Royal Air Force (RAF) Medical Services are responsible for delivering primary healthcare to their respective Service Commanders in Chief and for providing the requisite medical support on operations;
PROVISION OF MEDICAL SUPPORT TO DEPLOYED OPERATIONS
MEETING OPERATIONAL REQUIREMENTS
6. DMS personnel are currently deployed on operations in Iraq (TELIC), Afghanistan (HERRICK) and Bosnia and Kosovo (OCULUS), as well as supporting military training (e.g. in Sierra Leone) and other standing commitments worldwide. For example, the DMS provide uniformed personnel to meet some of the medical manpower requirements of the medical services provided by Commander Joint Operations (CJO) within the Permanent Joint Operating Bases (PJOBs) (Cyprus, Gibraltar, The Falkland Islands (FIs), Ascension Island (ASI) and the British Indian Ocean Territories (BIOT)). The majority of the manpower requirement lies within the PJOBs in Cyprus and Gibraltar, where both Primary and Secondary medical care is provided, as well as primary Dental care, Environmental Health and Community Mental Health services. Lesser requirements exist in FIs, ASI and BIOT, where DMS services are predominantly primary care based, utilising local Secondary Care facilities as appropriate.
7. The DMS' medical manpower commitments are met by utilising personnel from all three Services with RN, Army and RAF personnel serving along-side each other. Reservists continue to make a significant contribution to medical capability, most importantly for deployed hospital care and in niche specialisations. Close to 50% of the Army's deployed Secondary Care capability has been found from the Territorial Army (TA). For example, four TA Field Hospitals are covering a 12 month period (HERRICK 6 & 7) in Afghanistan starting in April 2007. Early indications are that deployment as formed units is welcomed and strongly supported by TA volunteers. In addition, early engagement with NHS employers of TA volunteers has also had had a positive impact on the TA deployment process.
8. To date, the DMS have met all the operational requirements placed on them (although harmony guidelines[2] have been broken for some cadres). In addition, whilst some manpower shortfalls exist, the manning situation is improving and the standard of medical care provided to Service personnel remains high. Further details of the DMS manning situation can be found at Annex A.
MEDICAL OPERATIONAL PATHWAY
9. The DMS provision of medical support on deployed operations covers treatment and casualty evacuation from the deployed theatre back to the UK. This managed patient care pathway ensures that patients are assessed and treated in a timely fashion and that they receive high quality treatment and rehabilitation, aimed at maximising functional outcome and returning them to operational fitness, when this is clinically possible.
10. Pre-Deployment Training. Comprehensive military pre-deployment training of DMS personnel is conducted prior to deployment. Pre-deployment collective medical training is also essential as deployed field hospital manning is found from a wide range of donor units. Mission rehearsal for hospitals is conducted at the Army Medical Services Training Centre Strensall (2 Med Brigade). Experience in field medical units is also provided and personnel attend specific training courses, such as the Battlefield Advance Trauma Life Support (BATLS) course. Secondary Care personnel, both Regular and Reserve, are also routinely employed within the NHS to ensure the currency of their clinical skills (further details at paras 59-62).
11. Treatment in Theatre. The size of the deployed force, specific mission and prevalent threats, determines the capability and capacity of medical support provided in theatre. In-theatre medical staff provide assessment and immediate treatment for all casualties, whether as a result of hostile action or non-battle illness or injury. The medical element of Incident Response Teams (IRTs) provides the link between initial medical care and evacuation to a hospital facility. Our Concept of Operations for delivering the medical component of IRT is saving lives. For example, a recent innovation on Op HERRICK has been to deploy a hospital-based consultant forward on the IRT to recover severely injured casualties. This hospital physician led team has become known as the Medical Emergency Response Team (Enhanced) (MERT(E)), a step up from the Emergency Medicine Nurse/Paramedic lead Medical Emergency Response Team (MERT)).
12. Deployed Rehabilitation Teams also contribute to force conservation by retaining and treating in Theatre those who would otherwise have to be evacuated. For example, the fielding of Deployed Rehabilitation Teams provides for the treatment and return to duty of some patients with musculo-skeletal injuries. The teams will also provide guidance on the most appropriate further course of treatment, if required. Similarly, Deployed Mental Health Teams will also treat in theatre and provide guidance on further courses of treatment for patients with mental health conditions.
13. More detailed information on the medical treatment facilities available to UK personnel on operations can be found at Annex B and in the section below on mental health.
14. Evacuation of Casualties . Where casualties have been seriously injured on operations, the usual care pathway is for our deployed medical support to treat and stabilise the patient's condition and then aeromedically evacuate them back to the UK at an appropriate point in their treatment. UK strategic Aeromedical Evacuation (AE), provided by the RAF, is widely regarded as delivering an exceptional service. For example, the RAF are able to transfer critically injured and ventilated patients by using specialist teams capable of maintaining a patient's condition when in transit. The UK has also agreed to provide strategic AE to some coalition partners. This has been activated, when required, as part of a multinational agreement.
15. Patients are evacuated on the basis of clinical need. From 1 Jan 2006 to 15 April 2007, 367 UK personnel from Afghanistan and 866 from Iraq were aeromedically evacuated back to the UK on medical grounds (not just battle casualties). Casualty statistics are updated regularly on the following MOD webpages:
http://www.mod.uk/DefenceInternet/FactSheets/OperationsFactsheets/OperationsInAfghanistanBritishCasualties.htm
http://www.mod.uk/DefenceInternet/FactSheets/OperationsFactsheets/OperationsInIraqBritishCasualties.htm
16. Selly Oak Hospital. Since 2001, the Royal Centre for Defence Medicine (RCDM), based at the University Hospital Birmingham Foundation Trust (UHBFT), has been the main receiving unit for military casualties evacuated from an operational theatre. In the Birmingham area, military patients can benefit from the concentration of five specialist hospitals (including Selly Oak Hospital) to receive a very high standard of care. Indeed, Selly Oak is at the leading edge in the medical care of the most common types of injuries (eg polytrauma) our casualties sustain. 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. By contrast, the last of our UK military hospitals, the Royal Hospital Haslar, had for many years nothing like the range of medical facilities and expertise that is found at a major trauma Trust hospital such as Selly Oak. The clinical skills that our personnel need to deliver excellent medical care on deployed operations would have suffered if we had not taken steps to develop and maintain them in a busy acute care environment. In addition, Selly Oak offers much better links to the military airhead at Brize Norton, and a regional civilian airport that can handle our largest aircraft within easy reach of the receiving hospital. That is why Selly Oak Hospital now acts as the primary receiver of our overseas casualties.
17. Wherever practicable, military patients are allocated to one of the military consultants who work at RCDM. However, by far the largest proportion of specialist care is provided by NHS consultant staff, which reflects the range and capabilities of the knowledge, skills and resources the NHS makes available to our patients. We do, of course, appreciate the importance of military casualties continuing to feel part of the military family, where practical. They will obviously benefit from being treated, where clinically feasible, in a predictable and understandable environment, with care delivered by staff who can empathise with patients. That is why at Selly Oak Hospital we have created a Military Managed Ward (MMW), located within the main orthopaedic/trauma ward at Selly Oak Hospital. The MMW reached Initial Operating Capability just before Christmas 2006. A combined team of military and civilian personnel provide care for military patients whose clinical condition allows them to be nursed in this ward. Military nursing managers work at all levels on the ward and military nursing staff, including military nurses and military health care assistants, are on duty on every shift. Full Operating Capability (FOC) for the MMW will be declared once the military presence on the ward has been assessed as having achieved sustainable increased staff numbers, together with the skills and experience levels required to take over fully the management of the ward from UHBFT and to have a predominantly military nursing presence on the ward. A works project also started on 14 May 2007 to change the layout of the ward to produce a separate area for some military patients whose condition allows them to be nursed together, utilising the two bays and isolation rooms at the far end of the main orthopaedic/trauma ward. FOC for the MMW will be achieved by summer 2007. [3]
18. The new MMW is one of several improvements we have made to the treatment of military patients. Each military patient in the Birmingham area now has a named military nurse whom he or she can contact at any time on clinical and other issues. Community psychiatric support has also increased, with two full time Community Psychiatric Nurses now in post. A military nurse team member visits every military patient being treated at a Birmingham hospital three times a day. This is in addition to the welfare support we receive under contract from the Defence Medical Welfare Service (DMWS), which has four welfare officers based at UHBFT who visit our patients regularly.[4]
19. Additional funding has been provided to help meet the travel and accommodation costs of patients' families who need to travel to Selly Oak. Accommodation available includes seven flats, plus a number of family rooms. Some of the flats have benefited from recent refurbishment funded by the Soldiers, Sailors, Airmen and Families Association (SSAFA), which is helping to provide a more suitable environment for the families of the patients concerned. Additional transport for patients and families is also being provided from public funds.
20. Military staff at Selly Oak hospital are assisted by the staff of the Aeromedical Evacuation Cell, the Military Patient Administration Cell and the Defence Medical Welfare Services, which are all part of RCDM. The military chain of command also works to maintain links between the individual patient and their parent single Service unit.
21. Although Service patients are nursed with other Service patients when this is clinically feasible, the over-riding factor in the treatment of any patient must be their clinical condition and need. The patient must be placed in the most appropriate specialist environment, with associated equipment and trained personnel who have the necessary skill sets.
22. Defence Medical Rehabilitation Centre (DMRC) and Regional Rehabilitation Units (RRUs). MOD has made considerable investment in rehabilitation in recent years and now adopts a tiered approach. Selected primary care centres have been reinforced by physiotherapists. When necessary, patients are referred to one of 15 Regional Rehabilitation Units (RRUs) which focus on the assessment and treatment of musculoskeletal injuries and sports medicine and are staffed by specially trained Doctors, Physiotherapists and Rehabilitation Instructors. Further details on the benefits of RRUs can be found at Annex C.
23. Military patients requiring further rehabilitation care may be referred to the Defence Medical Rehabilitation Centre (DMRC) at Headley Court in Surrey, which is the principal medical rehabilitation centre run by the Armed Forces. DMRC also accepts direct admission from hospitals, and most combat casualties are referred directly to DMRC from Selly Oak. DMRC provides both physiotherapy and group rehabilitation for complex musculo-skeletal injuries, plus neuro-rehabilitation for brain-injured patients. The Complex Rehabilitation and Amputee Unit, based within DMRC, provides high quality prosthetics and adaptations, manufactured on site and individually tailored as necessary for the specific patient. Priority is given to the provision of prosthetics to enable Service personnel to resume service duties.
24. Deployed Rehabilitation Teams help to determine the most appropriate location for a patient and, in the UK, the Defence Rehabilitation Evaluation Coordination Cell is improving the management of operational patients with musculo-skeletal injuries or rehabilitation needs. This has led to improvements in clinical outcomes and more effective return to fitness and duty.
25. Mental Illness. It is our policy that mental health issues should be properly recognised and appropriately handled and that every effort should be made to reduce the stigma associated with them. Diagnosis and treatment of mental illness in the Armed Forces is performed by fully trained and accredited mental health personnel. The MOD recognises mental illness as a serious and disabling condition, but one that can be treated.
26. Measures are in place to increase awareness of mental health at all levels and to mitigate the development of operational stresses. These include pre-and post-deployment briefing and the availability of support, assessment and (if required) treatment, both during and after deployments. This is available to all personnel, whether Regular or mobilised Reservists.
27. During a pre-deployment medical, whilst deployed, or during the post- deployment normalisation period, all personnel including reservists can identify themselves to any Medical Officers or their chain of command if they believe they are suffering from any mental health condition. The families of returning personnel are also offered a presentation and issued with leaflets to alert them to the possible after-effects of an operational deployment.
28. In the deployed operational arena, commanders and their medical staff can call upon mental health professionals that can provide assessment and care in theatre. Theatres are regularly visited by consultant psychiatrists who audit the service provided by the in-theatre mental health professionals. If personnel do need to leave the operational environment, then their care continues either on an out or inpatient basis in the UK.
29. Following the Medical Quinquennial Review, whose conclusions were published in 2002, our mental health services have been re-configured in line with national best practice, meeting the standards of the National Institute for Health and Clinical Excellence, to provide community-based mental health care. We do this primarily through our 15 military Departments of Community Mental Health (DCMH) across the UK (plus satellite centres overseas), which provide out-patient mental healthcare. The DCMH mental health teams comprise psychiatrists, mental health nurses, clinical psychologists and mental health social workers. The aim is to see referred individuals at their unit medical centre and, with the patient's permission, to engage with general practitioners and their chain of command to help manage mental health problems identified in personnel. A wide range of psychiatric and psychological treatments are available, including psychological therapies, environmental adjustment and medication, where appropriate. The Defence Mental Health Services have particular expertise in psychological treatments for mental health problems in general and psychological injury in particular.
30. In-patient care, when necessary, is provided in psychiatric units belonging to the Priory Group of Hospitals, through a central contract with MOD[5]. Close liaison is maintained between local DCMHs and the Priory units to ensure that all Service elements relating to inpatient care and management are addressed. The arrangement with the Priory Group means that the majority of patients can be treated much closer to their parent units than was the case when we maintained the last of our own psychiatric hospitals.
31. It should be noted that medical discharge from the UK Armed Forces due to psychological illness is low. As at Jan 2007, out of almost 180,000 Regular Service personnel only about 150, or less than 0.1%, are discharged annually for mental health reasons, whatever the cause. Of these, only 20-25 meet the criteria to be diagnosed with PTSD at discharge.
32. Reservists. Any mobilised serviceman or woman injured when on operational deployment is entitled to and will receive the same level of medical treatment and support, irrespective of whether they are a member of the regular or reserve forces. If a medical officer in-theatre assesses that a member of the reserve forces requires treatment or rehabilitation back in the UK, they will be treated in exactly the same way as regular personnel. This may include treatment and rehabilitation at a military RRU or the DMRC at Headley Court, Surrey, or - if the problem is related to their mental health - treatment at a military Department of Community Mental Health (DCMH) or admission to the Priory Group.
33. When reserve personnel are demobilised, they are given a medical assessment. During this process, if it is identified that they are in need of hospital care they may be referred to NHS hospitals hosting Ministry of Defence Hospital Units (MDHUs) or the RCDM at Selly Oak Hospital. They will be treated within military timeframes which can in some cases offer faster access to treatment than is the case for NHS patients. Reserve personnel will receive treatment for injuries sustained on operation until they are deemed to have reached a steady state of fitness. They are then demobilised, and taken through a transition from military to NHS care, if they have continuing healthcare needs. The patient may express a preference for treatment in a hospital nearer to their home, which may be a non-MDHU hospital, and some reservists opt for this route. In accordance with NHS protocols, if they are referred on to a non-MDHU hospital, then access to treatment is according to clinical priority.
34. Once demobilised, it is a long established tradition that reserve forces' medical care becomes the responsibility of their own local NHS primary care trust and the majority of Veterans' physical and mental health needs are met by these provisions. However, the MOD recognises that it has an expertise to offer in certain specific circumstances, and in November 2006, it launched a new initiative - the Reserves Mental Health Programme (RMHP).
35. The RMHP is open to any current or former member of the UK Volunteer and Regular Reserves who has been demobilised since 1 January 2003 following an overseas operational deployment as a reservist, and who believes that the deployment may have adversely affected their mental health. Under the RMHP, we liaise with the individual's GP and offer a mental health assessment at the Reserves Training and Mobilisation Centre in Chilwell, Nottinghamshire. If diagnosed to have a combat-related mental health condition, we then offer out-patient treatment via one of the MOD's 15 DCMHs. If more acute cases present, the DMS will assist access to NHS in-patient treatment. We are working with the UK health authorities to ensure that GPs across the UK are aware of the initiative. Full details of this programme, and how to access it, are published on the following web site: www.army.mod.uk/rtmc/rmhp.htm.
36. For the wider veteran population, MOD officials, the Health Departments, the NHS and the specialist mental health charity Combat Stress have been working together to develop a new community based mental health service for veterans. Advised by national clinical experts, this service will reflect NHS good practice and procedures and will be made up of clinical networks. This will allow civilian and military experts from the public and charitable sectors to work together, sharing experience and expertise and delivering appropriate evidence-based interventions in a culturally accessible and acceptable way. Plans are now well advanced for the model to be piloted at sites across the UK, including one each in Scotland and Wales. The pilots will run for two years and will be fully evaluated ahead of wider roll out.
37. We also have work in hand to ensure that Service leavers can recognise the signs of stress and know where to go for help, using suitable magazine-style material. In addition, the Government funds courses of care at Combat Stress facilities for those veterans whose condition is due to service and for whom this is an appropriate course. In 2005/06 this amounted to some £2.9m.
FURTHER DEVELOPMENTS IN SUPPORT TO OPERATIONS
38. Details of further key developments in the provision of medical support to operations can be found at Annex D.
PROVISION OF HEALTHCARE TO THE ARMED FORCES - MAINTAINING HEALTH
39. Members of the regular Royal Navy, Royal Marines, Army and Royal Air Force have access to a wide range of medical and dental services at all times when they are not on operational deployment overseas. The range of services includes: Primary Medical Care; Dental Services (including dental hygiene); Secondary Medical Care in NHS hospitals; Overseas Healthcare; Rehabilitation Services provided by DMRC and the 15 RRUs (see paras 22 - 24 above) and Community and Inpatient Mental Health Services (see paras 25 - 31 above).
PRIMARY MEDICAL CARE
40. The MOD provides a range of Primary Care Services including medical centres located throughout the United Kingdom and Service base areas overseas. The size and 'skill mix' of each medical centre varies depending on factors such as location and the size of the population served. The typical medical centre provides access to General Practitioners, Practice Nurses, Military Medical Assistants and Physiotherapists and Remedial Instructors. Some of these personnel will be uniformed DMS personnel and others will be civilian practitioners. The medical centres provide medical diagnostic and treatment services similar to those provided by a civilian medical practice, but they also provide occupational medical services, which is a major component of their activity. In the main, Service personnel have access to a medical centre on their unit or barracks but in some areas where the serving population is few in number, personnel will have access to the medical centre of another military unit.
DENTAL SERVICES INCLUDING DENTAL HYGIENE
41. The DMS provide unit- and regionally-based dental centres in the UK and overseas base areas. These centres operate under the command of the Defence Dental Service (DDS). The DDS provides local access for serving personnel to Dentists, Dental Nurses and Dental Hygienists. These specialists provide routine diagnostic and treatment services, but also offer valuable occupational screening services ensuring that serving members of the Armed Forces are 'dentally fit' to undertake their role.
SECONDARY MEDICAL CARE IN THE UK
42. Service personnel are entitled to secondary care from the NHS. In addition to local NHS access, the Ministry of Defence provides access to secondary care services at the NHS Trusts hosting MDHUs[6] and at UHBFT where the RCDM is based. The MOD have agreements with the NHS Trusts (referred to as 'Host Trusts') in these areas, to provide accelerated access for elective referrals of Service personnel to meet operational requirements. The MDHUs are situated in areas with dense military populations so the trusts are ideally located to provide the required accelerated access.
43. The MOD has developed a specific musculo-skeletal fast track programme to meet the relatively high incidence of these disorders within the military environment. Unit-based General Practitioners and Physiotherapists can refer personnel to Multi Disciplinary Injury Assessment Clinics (MIAC) located at their local RRU to seek specialist opinion and treatment of musulo-skeletal injuries. This involves rapid access to assessment by multi-disciplinary teams, investigations (specifically MRI scan) and treatment, which includes physiotherapy, rehabilitation and orthopaedic surgery when clinically indicated. The latter has been very successful, enabling personnel to return speedily to operational fitness, thus reducing the burden on fit personnel, and enabling the MOD to meet its commitments. Further details on MDHUs are provided at paras 59 - 62.
44. The MOD also has contracts with some NHS Trusts and other organisations to provide specialist diagnostic, treatment and screening services in areas such as Cardiology and Cervical Cytology screening.
45. The Army is also responsible for the Duke of Connaught Unit in Belfast, a diagnostic and treatment facility providing access to secondary care services equivalent to those at MDHUs in mainland Great Britain.
OVERSEAS HEALTHCARE
46. Germany and Isolated Detachments (ISODETS). Medical support is provided by British Forces Germany Health Services (BFGHS) which comprises a partnership between MOD; Guys and St Thomas's; DMWS and SSAFA; and the Defence Dental Service (DDS) who seek to provide seamless primary, community, secondary and tertiary care. Those aspects of primary and community care currently provided by SSAFA are in the process of being re-competed.
47. Hospital support is provided through Guys and St Thomas's Hospital who subcontract with five German provider hospitals. These hospitals provide a service tailored to the requirements of UK patients and UK primary care (for example, providing an outpatient service, an additional evening meal, enhanced privacy and UK television). The Department of Health now funds tertiary care in Germany, obviating the need to return patients to the UK for this purpose.
48. BFG Health Services has also recently assumed responsibility for medical support to ISODETS and is currently scoping the local medical services being provided.
49. Permanent Joint Operating Bases (PJOBs). The Permanent Joint Headquarters (PJHQ) oversees the provision of primary, community, secondary and tertiary care for our Service population and their families in the PJOBs.
50. Primary Healthcare in all of the PJOBs is provided directly by PJHQ, using predominantly Service personnel.
51. Secondary Healthcare is provided locally, by the Princess Mary's Hospital and the Royal Naval Hospital, in Cyprus and Gibraltar respectively. A variety of local civilian provider hospitals and UK- based NHS Hospitals are also used to access services that cannot be provided through MoD resources. The facilities are manned by a mixture of Service and civilian staff, the latter generally under UKBC contracts or as part of an arrangement with SSAFA. The DMWS also provides welfare support to patients in Cyprus.
52. For the remaining PJOBs (FIs, ASI and BIOT) there are no local MoD Secondary Healthcare facilities. Secondary Healthcare is therefore provided exclusively through either local civilian facilities or via UK-based NHS hospitals.
53. Land Overseas Bases. Primary and Secondary care is provided at LAND overseas bases[7] through a variety of routes, depending on the location and size of the base. Primary care is provided by Medical Reception Stations, Medical Centres or local GPs. Dental Services are also provided for personnel locally. Secondary medical care is made available by local government hospitals, private clinics/hospitals or through referral overseas or back to the UK.
VETERANS
54. When personnel leave military service their healthcare becomes the responsibility of the NHS. That has been the policy of successive governments since 1948.
55. War pensioners are entitled to priority NHS treatment for accepted disablements. This arrangement has been in place since 1953 when Ministry of Pensions hospitals were transferred to the NHS. Priority is decided by the clinician in charge and is based on clinical need. Regular reminders of the provision are sent out by the NHS Executive to Trusts and clinicians.
56. War pensioners are also entitled to free prescriptions for accepted conditions and are paid treatment allowance (i.e. reimbursement of lost earnings) and travel expenses for out-patient attendances in respect of accepted conditions. In addition, where there are patient costs under the NHS (e.g. dentistry, eye examinations or spectacles), war pensions funding is also appropriate.
57. There remains in war pensions legislation a discretion (Article 21of the Service Pensions Order 2006) whereby any necessary expenses in respect of the medical surgical or rehabilitative treatment of accepted conditions, aids and adaptations for disabled living may be defrayed. However, no expenses can be defrayed where treatment, aids or appliances are provided for under other legislation of the UK. Essentially, this discretion does not therefore apply to treatments which are the responsibility of the NHS. This power to meet the individual costs of war pensioners undergoing "remedial treatment" at homes run by Combat Stress is a long standing arrangement and predates clarification of the NHS responsibility.
MEDICAL DISCHARGES
58. Once personnel are identified as potential medical discharges, a comprehensive programme of resettlement assistance is given. That resettlement assistance lasts for the rest of the service leaver's lifetime. The programme includes comprehensive advice on future employment and assistance in specific training for future employment. Advice can also be obtained on other regional matters such as schooling and housing
RELATIONSHIP WITH THE NHS
MINISTRY OF DEFENCE HOSPITAL UNITS (MDHUS) - TRAINING DMS PERSONNEL
59. The MOD took the decision in the mid 1990s to close military hospitals and open Ministry of Defence Hospital Units (MDHUs) within NHS hospitals after it had become clear that our existing military hospitals did not have sufficient patient volume or the range of military cases to develop and maintain the skills of our medical personnel. On average, the total number of military in-patients in hospitals across the UK is currently only about 60-75 for all illnesses and injuries, however sustained. Those kinds of numbers do not provide the kind of breadth of experience that our military doctors and nurses need to stay on the cutting edge of medical care. Neither does it make sense to bring together in one place such a small number of patients from all across the country.
60. At the MDHUs, Service medical personnel are integrated throughout the host NHS Trust, enabling them to maintain their clinical skills in an active, up-to-date environment, while also contributing to the NHS clinical capacity. This ensures that they retain their qualifications, allowing them to deploy quickly to areas of conflict, providing the essential medical support to frontline forces. Indeed, the vast majority of the Reservist medical personnel whom we deploy to operations are NHS employees. The training they gain in their NHS jobs is indispensable for ensuring the quality of the frontline care they help to provide. The role of the MDHU is to provide administrative, business and training functionality and they enable clinical staff to concentrate on honing their medical and military professional skills. It is precisely because of the success of the adopted model for training military medical personnel and providing care for our personnel in NHS hospitals, that we can deliver our excellent levels of medical care in the UK, overseas and on operations.
61. When the decision was taken to close military hospitals, it was originally intended to retain the Royal Hospital Haslar, primarily as a centre for training. But the required number and range of cases did not occur, and in December 1998 the Government announced its decision to phase out Haslar and consolidate training within the NHS, building on the establishment of the MDHUs. Since then, Haslar has undoubtedly continued to provide a first class service for the local community , but 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. And the fact is that for many years Haslar has had nothing like the range of medical facilities and expertise that are found at a major trauma Trust hospital such as Selly Oak. In addition, Selly Oak offers much better links to the military airhead at Brize Norton, and a regional civilian airport that can handle our largest aircraft, within easy reach of the receiving hospital. That is why Selly Oak Hospital now acts as the primary receiver of overseas casualties.
62. Although it ceased to be a military unit on March 31, the Royal Hospital Haslar continues to be owned by the MOD and will continue to function, under a partnership arrangement with the Portsmouth Hospitals NHS Trust, until late 2009 when clinical services, along with both NHS and some military staff, will transfer to the redeveloped Queen Alexandra Hospital in Cosham, Portsmouth. Other military tasks currently retained at Haslar will be transferred to the RCDM and elsewhere. Until the hospital's closure military doctors and nurses will continue to serve at Haslar, many of them as part of the Portsmouth MDHU. The MDHU will continue to play a major role for the foreseeable future in providing training for our medical people, as well as providing healthcare for both military and civilian patients. There will, therefore, continue to be a strong military medical presence in the Portsmouth area when Haslar eventually closes.
ROYAL CENTRE FOR DEFENCE MEDICINE (RCDM)
63. RCDM opened in April 2001 as a centre of military medical excellence, with academic, teaching and clinical roles. RCDM, with its host UHBFT, provides a stimulating working environment for the DMS staff and an opportunity to develop academic ties with universities. Defence medical personnel gain valuable work experience primarily at UHBFT's Queen Elizabeth and Selly Oak sites (although other hospitals in the Birmingham area are used for particular specialisms), and some work closely with the Universities of Birmingham and Central England and with other academic partners in research and teaching roles. Many of the DMS Nurses and Allied Health Professionals gain their professional qualifications through the academic courses provided at these universities. The Defence School of Health Care Studies is a unit of RCDM. RCDM's roles also include the provision of clinical feedback to operational areas, the development of clinical doctrine and the focus for curriculum design and development for clinical operational preparedness.
64. The Surgeon General's vision for defence medicine in the 21st Century is for RCDM to develop into an internationally recognised centre of excellence for military medicine. This vision is being principally implemented through the Midland Medical Accommodation (MMA) project and the MOD's close involvement in the Birmingham New Hospital Project.
65. The Midland Medical Accommodation (MMA) project is currently planned to bring together on one site the Headquarters of the Royal Centre for Defence Medicine (RCDM), the Headquarters of the Defence Medical Education and Training Agency (DMETA), the Defence Medical Services Training Centre, and 33 Field Hospital. The site will also provide living accommodation and facilities for military training and sports. Whittington Barracks, Lichfield has been selected as the preferred option to meet the requirement. The project is currently undergoing its Assessment phase which should be concluded around the end of this year. A "Main Gate" decision will then be taken on the major capital investment that would be involved. Assuming that the Lichfield site's suitability is confirmed, redevelopment could be completed around the end of the decade.
66. The NHS Birmingham New Hospitals Project will replace the existing Queen Elizabeth and Selly Oak Hospitals, and will provide acute and mental health hospital services in South Birmingham. It is Birmingham's first new hospital for nearly 70 years, and is scheduled for final completion in 2011. The main partners in the project are UHBFT and Birmingham and Solihull Mental Health Trust (BSMT). Central to the development will be a 1,213-bed acute teaching hospital on the 50-acre Queen Elizabeth site. There will be 30 operating theatres, as well as specialist treatment units for angiography, CT scanners, ultrasound, MRI scanners, and fluoroscopy. The patient care and training elements of RCDM will form part of this main new hospital building under long term arrangements that have been concluded between the MOD and UHBFT. The new hospital will thus give the MOD access to some of the best medical "state of the art" facilities in Europe. We will take the Military Managed Ward (MMW) concept forward in our discussions with UHBFT to confirm our footprint in Birmingham's new hospital. Options will be examined to see how we might resource an MMW of up to 32- bed capacity for the treatment of operational casualties and elective patients, where these can be brought together on clinical grounds. This would mean the ward would have military ward managers, and patients on this ward would be nursed by predominantly military personnel.
PARTNERSHIP BOARD
67. The key outputs of the DMS are supported by a close working relationship with the NHS, supported by the MOD/Department of Health (DH) Partnership Board. A Concordat between the DH and the MOD has been in place since 2002, which sets out how the DMS and the NHS will work together to further their individual and mutual aims of delivering high quality healthcare to both the UK Armed Forces and NHS patients. The Concordat was extended in March 2005 to include the Health Departments of Scotland, Wales and Northern Ireland.
68. The MOD/DH Partnership Board meets three times a year to monitor the effectiveness of the Concordat and to explore mutual areas of co-operation. Its membership consists of representatives from MOD, the DH, the Health Departments of Scotland, Wales and Northern Ireland and NHS Trusts. Its work is supported by desk level liaison on a day to day basis to ensure the progress of Partnership board projects in between Partnership Board meetings.
PROCESS/ORGANISATIONAL IMPROVEMENT
THE DEFENCE HEALTH PROGRAMME
69. The Defence Health Programme (DHP) is the performance management tool that enables the DMS to deliver the changes and improvements needed for it to continue to provide Service personnel with the level of health care support necessary to maintain their medical fitness for their operational role. The following key strands of work are being undertaken under the umbrella of the DHP:
a. Director General Medical Operational Capability (DG Med Op Cap) Project. The principal achievement of the project to date has been the endorsement of the DMS regular uniformed manpower baseline (see Annex A) together with a number of recommendations for future work on manpower issues, including the Reserves. Additionally, a project report has now been produced which provides an assessment of the operational outputs (clinical, organisational and equipment) required of the DMS and their associated processes. During the same timeframe, a number of recommendations to further improve our capability in medical logistics have been identified[8]. An integrated Implementation Programme is now in place to expedite the findings and recommendations of the DG Med Op Cap project and to take forward the recommendations of the uniformed medical manpower requirement work and the Medical Logistic End-to-End Review.
b. Leadership, Management And Governance Of The Defence Medical Services study. In parallel to the above project, DG Med Op Cap has also been tasked with reviewing the extent to which the DMS Top Structure is effective in delivering the two pathways of Medical Operational Capability and Healthcare. It has been decided that the Department will pursue the development of a "Joint Medical Service" manned by people recruited by the single Services to fill a joint medical manpower liability that is globally managed. A short study (the DMS Leadership, Management and Governance (LMG) study) is now taking place to determine how this restructuring will be delivered. The study will recommend the future functions, structure, leadership responsibilities and outputs of a Joint Medical Service, which builds on the currently agreed organisation of the DMS. The review is due to complete in summer 2007.
c. Managed Military Health System. The MMHS Project was conceived within the Service Personnel plan to improve pan-DMS management and delivery of health and healthcare (medical and dental) to the Armed Forces and other entitled personnel. The project was concluded in Jul 06 and follow-on work to further develop the MMHS is now be undertaken as part of the Director General Healthcare's routine work. The aims of the MMHS are to maximise the number of Armed Forces personnel Fit for Task; contribute to deployed Medical Operational Capability and improve morale in the DMS. The MMHS scope is limited to UK non-deployed personnel. However, many of the changes expected from it will beneficially impact on Health and Healthcare provision across the MOD including the overseas Commands. The project has already delivered a number of significant improvements through the development of the Fast-Track treatment regimes, rehabilitation and the provision of Mental Health Services (see above). Further work is now underway to:
(1) Develop enhanced Primary Care services (General Practitioners with Special Interests and (Advanced Nurse Practitioners) (2) Implement patient Care Pathway tracking across Defence Primary Health Care (3) Implement common processes and standards (4) Develop Performance Management processes and structures (5) Expand our Healthcare capabilities and capacities to meet need. (6) Develop relationships with the Department of Health and the NHS (7) Implement connectivity between the MoD and NHS ICT services (8) Put in place the MoD response to the Governments initiatives on Health.
d. Defence Medical Information Capability Programme (DMICP). DMICP is a major IS-enabled business change programme. It will provide an integrated healthcare information system across the DMS, and will also link to the NHS's major new National Programme for IT. The roll-out of the system to pilot UK sites started earlier this year. It should be available in all fixed medical and dental centres in the UK and Germany by mid-2008. DMICP will provide an integrated Health Record - including both medical and dental data - for all members of the Armed Forces. This will promote improved medical treatment by enabling medical staff worldwide to have immediate access to a complete, up to date Health Record at the point of treatment. The system will also link electronically with the NHS from 2010, which will bring benefits for Armed Forces patients receiving secondary care in NHS hospitals. The programme will bring improvements to patient management, enabling improved appointment booking for both primary and secondary care. A deployed version of the system will be available from late 2008 to medical staff on operations. The system will also improve information handling, and provide a range of data about health patterns in the Armed Forces, as well as health information on forces about to deploy. The system has been designed with confidentiality controls to ensure that only medical staff with a legitimate relationship with the patient have access to a health record.
ANNEX A MANNING IN THE DEFENCE MEDICAL SERVICES
1. To date the Defence Medical Services
have met all the operational requirements placed on them and while shortfalls
exist they have never resulted in the Defence Medical Services being unable to
meet its operational commitments. Overall, manning levels within the Defence Medical Services are rising (see
figures below). However, we acknowledge that manpower
shortages remain a problem, especially in some key specialties like Accident
& Emergency, Anaesthetics and General Practice. We are taking active steps to address the shortfalls, through a
range of pay and non-remunerative initiatives including: (a) Working to ensure pay remains comparable with the NHS;
(b) Managing medical deployments on a tri-Service basis allowing the work load to be shared more evenly and maximising capabilities;
(c) Prioritising resources to support operations;
(d) Establishing alternative means of meeting operational commitments to reduce overstretch (e.g. use of Reserves and civilian agency contractors and working closely with Allies on operations).
(e) Payment of "Golden Hellos" to direct entrants into specialist areas where there is greatest shortfall.
(f) Payment of FRI to encourage nurses in operational pinch point specialties to return to and remain in specialty
(g) Continued development of Military career pathways. For example, we are implementing the Defence Nursing Strategy to enhance the career pathway for military nurses. As part of this initiative, Defence Specialist Nursing Advisors have been appointed for each specialism, to plan and manage recruitment and retention in their own specialism.
(h) Encouraging personnel to train and remain in operational pinch point specialties.
2. On 27 March 2007, the Under Secretary of State announced the introduction of an improved military medical manning structure following a review of the DMS manpower requirement. The review analysed lessons learned from recent operations to establish a credible baseline on which the DMS can base its planning and ensure that the excellent level of healthcare which it provides both on operations and, in collaboration with the NHS, in peacetime, is sustained into the future.
3. One of the reasons for the changes is to reflect advances in military medicine that enable us to save more seriously injured battlefield casualties. They also reflect the changing roles of our Field Hospitals, which are now smaller but better equipped to stabilise patients before their return to the UK for further treatment. When the requirement was previously set, single-Services generally operated on their own. Increasingly, medical personnel are operationally deployed on a tri-Service basis, which shares the work load more evenly and maximises capabilities
4. The overall result of this work is that the uniformed manning requirement for medics has now been set at 7,573 posts, supported by a manning and training margin of 678, giving a grand total requirement of 8,251. This compared to a previous requirement of 8,970, set by the Strategic Defence Review eight years ago, which did not separately specify a supporting training and manning margin.
ANNEX B MEDICAL TREATMENT FACILITIES ON OPERATIONS
1. The DMS plans to provide a seamless continuum of medical support encompassing preventative medicine, evacuation, primary, secondary and tertiary care. For UK personnel on deployed operations this is delivered via three echelons of medical treatment facility: Role 1, which is integral to the Force elements and provides primary health care and the initial management of combat casualties which might involve initial resuscitation and preparation for evacuation; Role 2 which will deliver reception and triage of casualties, damage control surgery when required and the care necessary to ensure survival to hospital; and deployed Field Hospitals (Role 2 (Enhanced) and Role 3) providing, among other things, emergency medical care, diagnostic support, primary surgery and hospitalisation.
UK MEDICAL GROUP (MED GP) OP TELIC
2. In Iraq, facilities include the Battle Group Role 1 facilities, as well as two fixed Role 1 facilities supporting personnel in Basrah Palace and Contingent Operating Base (COB) and a Role 2 (Enhanced) deployed Field Hospital at the COB in Basrah. In addition to the Hospital Squadron, the UK Med Gp also includes elements of a Medical Regiment providing close medical and evacuation support to operations. RAF personnel provide Forward, Tactical and Strategic aeromedical evacuation. In Feb 2007 the Defence Medical Service were deploying some 372 staff in Iraq
UK MED GP OP HERRICK
3. In Afghanistan the UK has: ten Role 1 facilities supporting fixed locations the Manoeuvre Operation Groups (MOG) and the Operational Mentoring and Liaison Teams (OMLT); and a Role 2 (Enhanced) Field Hospital at Camp BASTION in Helmand Province. Evacuation of casualties is supported by Medical Emergency Response Teams and RAF personnel delivering Forward, Tactical and Strategic Aeromed, including a theatre specific Critical Care Air Support Team and an Air Staging Unit. The Multi-National Headquarters of the ISAF Regional Command (South) in Kandahar (currently UK lead) maintains a Multi-National Role 3 Field Hospital, which provides hospital care for coalition personnel. In Feb 2007 the Defence Medical Service were deploying some 247 staff to support the operation in Afghanistan.
COLLABORATION
4. UK medical support continues to be augmented by coalition partners under a process of burden sharing utilising bilateral, trilateral and multi-national agreements. In both Iraq and Afghanistan, collaboration occurs in several ways: mutual use of treatment facilities, embedded staff and liaison officers, Multi-National Field Hospitals and sharing of evacuation assets to transfer patients from theatre. At Kandahar, the Field Hospital is currently led by the Canadians with the UK, Dutch and Danish in support. In Kabul, UK personnel have access to either the Czech or Greek Role 2 facility. A Czech surgical team was embedded in the UK Field Hospital in Iraq for two years. In Iraq and Afghanistan, UK personnel also use United States' facilities. The United States can also evacuate UK casualties to Ramstein in Germany, should it be required. However UK strategic aeromedical evacuation and the UK aeromedical Critical Care capability have proved reliable, resilient and responsive.
DEFENCE MEDICAL WELFARE SERVICE
5. The Defence Medical Welfare Service (DMWS) has provided hospital based welfare support to Service patients at home and overseas since 1943[9]. It is currently based in the MDHUs, RCDM, Germany and Cyprus and is deployed on operations in Iraq and Afghanistan. Its prime purpose is to address the welfare needs of patients admitted to hospital and to refer on to appropriate agencies those who will need prolonged welfare support. ANNEX C
REGIONAL REHABILITATION UNITS (RRU) END OF YEAR RESULTS - 1 APRIL 2006 - 31 MARCH 07
1. The Table below shows the number of new cases that have actually attended the RRU assessment clinics in Year 3 and the accumulative total for year for the 3 years.
2. The following specific benefits of RRUs have been noted at the time of in the 2007 End of Year Results.
(a) 80%+ of patients successfully treated by physio/rehab alone (b) 10% only required accelerated access to fast-track orthopaedic surgery. (c) In the past all of these patients would probably have been referred to orthopaedic surgeons and/or DMRC with long waiting times to be assessed and treated. (d) Over 10000 patients have been discharged, the vast majority fully fit for task. This figure will always lag behind those assessed as rehab takes time to complete successfully. (e) The development of the RRU Programme has permitted DMRC to focus on the more complex rehab cases, including amputees and neuro-rehab for brain injured patients.
ANNEX D FURTHER DEVELOPMENTS IN MEDICAL SUPPORT TO OPERATIONS DEPLOYED CAPABILITY
1. The Maritime Role 3 Medical Capability (MR3MC), or Joint Casualty Treatment Ship (JCTS) is a proposed (2020 timeframe) replacement for the Primary Casualty Receiving Facility (PCRF) - a capability of RFA Argus, which delivers secondary healthcare and primary surgery in an afloat hospital environment. RFA Argus entered Service in 1990. It was upgraded substantially prior to the 2003 Iraq conflict, where it was deployed in support of operations afloat and ashore.
2. Work on Improving Medical Support to a Brigade (IMSB) will deliver, by 2011, a rebalanced Army Medical Service to provide support at Brigade rather than Divisional level in line with defence policy which requires the DMS to move routinely to a medium scale of effort. It will deliver five Medical Regiments each to support an Armoured or Mechanised Brigade, and two hybrid Medical Regiments (V) to provide to Logistics Brigades. One specialist Medical Regiment for 16 Air Assault Brigade and one Divisional Medical Regiment (V) will be retained. Deployed hospital care will be provided by a Force Support Hospital (FSH) or a number of Close Support Hospitals (CSH), depending on the scale of effort.
3. There have been major equipment enhancements to our deployed Field Hospitals. For example, a CT scanner has been deployed since 2004 in Iraq. A second scanner, deployed to Afghanistan, has reached initial operating capability and is due to be declared fully operational in May 2007 once a satellite link is established. It is considered that the deployment of CT scanners will be the norm for future enduring operations.
4. In the near future Role 1 and Role 2 (Light Manoeuvre) facilities deploying on operations will undertake pre-deployment validation training and audit. This is in line with best practice for Role 3 and Role 2 (Enhanced) Pre-Deployment Training.
5. A full review, by Defence Consultant Advisors, of all medical modules will be conducted in May 2007.
FIRST RESPONDER LEVEL
6. In 2005 and 2006 several enhanced haemostatic products (designed to stop catastrophic blood loss) were successfully introduced in Operational Theatres. The urgent introduction of these products; HemCon(r), QuikClot(r), CAT(r) tourniquet and the new FFD, as well as the Team Medic capability, have already been attributed with saving over three lives by 2006. More recently the introduction of Intra-osseous Needles, Javid Vascular Shunts and Improved Pelvic Splintage are part of the continued rapid application of emerging capabilities into current operations.
ADDITIONAL SUPPORT 7. DMS has led the UK in the introduction of telemedicine; in support of operations, land-based and maritime, and in support of our permanent deployments overseas. The DMS Telemedicine Unit has received national awards, DEFENCE MEDICAL RESEARCH AND TRAINING 8. The RCDM Academic Division has expanded within the Birmingham Research Park to accommodate a new Defence Professor of Nursing and enlargement of the new Defence Professor of Surgery's department
9. Initial work on military trauma patients commenced in 2003 at Frimley Park. A trauma nurse coordinator and database were set up at RCDM in 2005, giving on- the-spot audit of trauma cases and looking at trends to inform best practice.
10. The RCDM Academic Department of Emergency Medicine was awarded the Hospital Doctor "Training Team of the Year Award" in 2006. The Team was led by Colonel Tim Hodgetts, 'Individual Hospital Doctor of the Year'.
11. Sergeant Rachel McDonald, A Royal Air Force Paramedic has been awarded the "Paramedic of the Year Award 2007" by the Ambulance Services Institute.
12. Prof Keith Porter took up his Honorary Chair in Traumatology at the University of Birmingham (2006) and moved into the RCDM facilities at the Birmingham Research Park.
16 May 2007
[1] and other entitled personnel, eg MOD Civil Servants serving overseas and dependents accompanying Service personnel posted overseas.
[3]. Military nursing staff allocated to the MMW at FOC will be:
· 11 Orthopaedic (specialist) nurses. · 15 General nurses. · 13 Health Care Assistants. TOTAL 39
These numbers include the military ward manager and her three deputies.
[4] DMWS staff also provide welfare support in Germany, Cyprus and deployed field hospitals [5] The Priory Group was awarded its current contract on 1 April 2004, when it won a competitive bidding process as its bid best met our requirements for access to high quality, regional care. [6] Derriford, Frimley Park, Northallerton, Peterborough and Portsmouth [7] Brunei, Nepal, Kenya, Canada and Belize [8] Work carried out with Medical Stores Integrated Project Team on Medical Logistics [9] The MOD's current contract with the DMWS was awarded in 2001 |