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Meeting of Veterans plenary - 28 March 2007
VETERANS PLENARY CONFERENCE- 28 MARCH 2007IN-SERVICE HEALTH AND MEDICAL CARE
Chris Williams - Defence Medical Services Department
As Oscar Wilde famously observed, or perhaps complained:
There is only one thing in life worse than being talked about, and that is not being talked about.
Well, I’m not so sure. To be frank, the Defence Medical Services would prefer to get on quietly with the business of saving lives and looking after the health of our Service men and women, rather than find themselves an almost daily subject of media attention – some of it mis-informed in content and malign in outcome. But since we are where we are, I’m delighted to be given this chance to set out for this audience what the Defence Medical Services do nowadays, and why, and how good they are it.
Put simply, the Defence Medical Services exist to maximize the numbers of Armed Forces personnel fit for duty in peace and war, and to deliver a deployable military medical capability to look after our casualties, from the point of wounding to recovery back in the UK.
A theme in current concerns is to look back to the end of the Cold War and subsequent reductions in the size of the UK Armed Forces, and what that meant for the viability of dedicated military hospitals. Now, it was already clear by the early 1990s that there was no longer a sufficient patient volume or range of military cases to develop and maintain the skills of our medical personnel. This would, over time, have damaged the level of care we would be able to provide to our military patients. And of course, medical science has become even more specialised in the meantime.
So by 1998 the decision was taken to phase out the remaining military hospital at Haslar and consolidate training our medical personnel within the NHS. Incidentally – to puncture a topical urban myth, Haslar is not closing in a few days time on 31 March 2007. While it ceases to have the formal status of a “military hospital” this month with the withdrawal of the Commanding Officer, in reality it has not been a military hospital for several years. But Haslar will still be open for business on 1 April, used by Portsmouth Hospitals NHS Trust, as in recent years, and with some continuing military medical support, to provide health care for the local community until late 2009.
But for the treatment of most military patients, and to develop and maintain the skills of military medical staff, we developed from the mid 1990s onwards the Ministry of Defence Hospital Units (MDHUs) hosted by 5 NHS hospitals - Derriford, Frimley Park, Peterborough, Portsmouth and Northallerton - plus the Royal Centre for Defence Medicine (RCDM) at Selly Oak in Birmingham. The skills our doctors and nurse acquire in these hospitals enable them to deliver the excellent medical care that saves our troops lives on deployed operations.Another urban myth you will see in print is that there are ‘thousands’ of Service personnel ‘languishing on NHS waiting lists’. In fact, less than 0.5% of the Forces are unfit for any military duties. Furthermore, we annually commission about £29M of activity (outpatient and inpatient care) from the six NHS locations I mentioned. Some £22.5M of this buys accelerated access, over and above current NHS waiting times.
The MOD’s targets – which we aim to deliver in full by April 2009 - are for 100% of referrals to be seen in outpatients within 4 weeks and 100% of those requiring elective treatment to receive it within a further 6 weeks. Many of the MDHU Host Trusts are already delivering a good percentage of their activity against these targets as a result of our contract incentivisation programme. Our targets compare very favourably with the current NHS targets of 13 weeks for outpatient assessment and 6 months for elective surgery, and still show a distinct improvement over the NHS aim to achieve an 18 week total time to treatment by Dec 2008.
It is important to remember that mobilised Reserves are also eligible for treatment for injuries sustained on operation until they are deemed to have reached a steady state of fitness. They are then demobilised and are taken through a transition from military to NHS care.
Actually, the most common reason for a member of the armed forces not being fully fit is because they have a musculoskeletal injury – just like the injuries encountered by players in a major national sports team. To get them back to fitness quickly, we have a dedicated network of 15 Regional Rehabilitation Unit (RRUs) around the UK and in Germany to provide assessment and treatment. For over 2 years, we have arranged rapid access to diagnosis and – for the minority who are then found to need it - surgery in NHS facilities. Typically we achieve a decision as to which path the patient will follow within 10-20 days of injury.
The majority – needing only physiotherapy or rehabilitation - are treated in MOD’s own rehab units – so no NHS waiting list issue arises. Typically, these patients will start physio within 4-6 weeks of the decision on their treatment path.
Those commentators who would recreate dedicated military hospitals should recognise that with innovations such as the RRUs, and because the Forces are generally fit and healthy, on any one day there will now be no more than 60-75 service personnel as in-patients in NHS hospitals across the whole of the UK. This would barely fill two wards in a typical hospital, even if it were appropriate - and it is not, clinically or practically - to bring them all together. And some of our patients who are aeromedically evacuated to the UK require the expertise of a major trauma centre, providing care at the leading edge of a range of medical disciplines.
That is what they receive now at Selly Oak Hospital – with no waiting list, of course. Again it’s worth mentioning a few numbers to keep things in perspective. This year, in all the Birmingham hospitals we use, on a typical day there will be an average of 13 in-patients with battle injuries, and around 5 or 6 in patients with non-battle injuries or illnesses.So we have more made a more than adequate provision in creating a Military Managed Ward (MMW) at Selly Oak Hospital, currently consisting of two six-bedded bays, with access to four additional side isolation rooms, making a potential total of 16 beds for patients with trauma/orthopaedic needs. Preference will be given to allocating military patients to the ward when clinically appropriate. It is in effect a “ward within a ward”, being part of a larger 34-bed trauma/orthopaedic ward at Selly Oak Hospital.
We have appointed a Military Ward Manager who is responsible for all military patients and staff. She is supported by three military deputy ward managers.
There are now 19 qualified military nurses as well as 6 military health care assistants on that ward - military nurses will always be on duty. By this summer, we will have increased the military nursing cadre on the ward yet further and created a separate partitioned area of the main ward where its military patients will usually be placed.
A military surgical consultant has been appointed as the military trauma patient co-ordinator. He liaises with colleagues to provide advice on Service issues and ensures that military aspects of their treatment are taken into account.
The development of the ward would not have been possible without the close and enthusiastic support of the hospital Trust. Furthermore, through our participation in the NHS’s Birmingham New Hospitals Project, we will be part of the largest and most modern critical care unit in Europe, scheduled for completion around 2010 - 2011.
Some more numbers to convey the scale of the facilities we shall be able to access when RCDM moves in. Central to the development is a 1,213-bed acute teaching hospital on the 50-acre Queen Elizabeth site. Of these, 780 will be in-patient acute beds, 100 will be critical care, 108 will be day surgery, and 68 will be for acute assessment. 15 will be burns unit beds. There will be 30 operating theatres. That is where the future of defence medicine lies.
When our patients leave hospital, the more seriously injured will often be referred to Defence Medical Rehabilitation Centre (DMRC) at Headley Court. As well as offering the facilities of a Regional Rehabilitation Unit, it contains the Complex Rehabilitation and Amputee Unit. This provides high quality prosthetics and adaptations, manufactured on site and individually tailored to the specific patient. Priority is given to enabling Service personnel to resume service duties if possible – and we have even seen some return to front line duties with prosthetic limbs.
Turning to mental health…
Since an independent review in 2001, we have restructured and enhanced our community mental health teams. Furthermore, in line with current best practice, where there is a requirement for in-patient facilities, we now provide treatment regionally, through our contract with the Priory Group.
We have established 15 military Departments of Community Mental Health (DCMH) across the UK plus satellite centres overseas to provide out-patient mental healthcare. 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. The full range of psychiatric and psychological treatments are available including medication, psychological therapies and environmental adjustment where appropriate.
Research conducted by Kings College London has looked
at the mental health of those deployed on recent operations in Iraq. It
concluded in May 2006 that “There is no increase in psychiatric disorders in TELIC regular
personnel compared to the rest of the UK Armed Forces…Later deployments
have not been associated with any worsening of mental health consequences
compared to the initial TELIC 1 group”.
We continue to fund research with Kings to ‘keep our finger on the
pulse’ in this area.
Where the Kings research showed there was a measurable effect of deployment on the mental health of reservists, MOD responded with our new mental healthcare programme for those demobilised since January 2003. This provides a dedicated mental health assessment conducted by appropriately qualified members of the Defence Medical Services, plus out-patient treatment at one of our Department’s of Community Mental Health for those with a combat-related mental health condition.
Finally, the Minster has already mentioned the pilot phase of a new community-based mental health arrangement, specifically designed to address concerns about the NHS’s ability to deal with the mental health problems of veterans who have left the Services.
So to return to where I started, and the current media interest in military medical maters. Now I do not claim that ‘we never make mistakes’. And if any members of the Armed Forces or their families are unhappy about their treatment, then we will investigate, with the NHS on their behalf if necessary. If something has gone wrong, we are committed to putting it right if at all possible.
It is frustrating that patient confidentiality means we simply can't discuss individual cases being investigated – though this does not appear to stop the media featuring them. Despite what the papers would have you believe, a rolling survey this year of military patients undergoing treatment at Selly Oak shows an almost total agreement across those who responded that their treatment overall was good, very good, or excellent.
So to end with another quote - On 13 March 2007 General Sir Richard Dannatt, Chief of the General Staff said in a BBC interview:
“There is nowhere better in the country, nowhere more expert at polytrauma medicine, than the hospital in Selly Oak. That’s why our people are there.”
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