But away from the front line, review highlights concern about variation in standards and poor maintenance of buildings.
The Healthcare Commission today (Monday) praised the British military’s “exemplary” trauma and rehabilitation services for personnel injured in battle.
It published the first ever independent review of the Defence Medical Services (DMS), which is responsible for providing healthcare to defence personnel and their families in the UK and overseas.
The independent watchdog conducted the review at the request of the Surgeon General, Lieutenant General Louis Lillywhite.
It praised the care provided to casualties of war, highlighting systems to reach and treat casualties quickly, innovations in the treatment of major injuries, the training of staff, design of field hospitals, clinical audits to feedback important lessons and rehabilitation for injured personnel.
The Commission also identified a range of areas for improvement, urging the DMS to: ensure that universal standards are in place across all services; address problems relating to maintenance and cleanliness at some medical units away from the frontline; urgently replace ambulances in Cyprus; and improve awareness of procedures for safeguarding children.
The DMS provides healthcare to 258,000 people, including service personnel, their families and other civilians entitled to care. It encompasses care provided in the Royal Navy, British Army, Royal Air Force and supporting units.
The DMS mostly provides primary care, such as general practice, dentistry, occupational medicine and community mental health services within the UK and defence outposts overseas.
It also provides medical care in zones of conflict and is responsible for rehabilitation services in Headley Court Defence Medical Rehabilitation Centre in Surrey and at a number of other centres in the UK and Germany.
The DMS commissions inpatient hospital care from six NHS trusts for personnel and their families needing hospitalisation in England. The review does not cover these services as the Commission assesses their performance already as part of the annual ratings for each trust* (see note to editors below for rating).
Sir Ian Kennedy, Chair of the Healthcare Commission, said: “By asking for this review, the Surgeon General has thrown the spotlight on these services in a way that has never been done before. He has invited us to report publicly on the good and the bad. That is something for which he deserves a huge amount of credit: indentifying where problems exist is the first step to getting them fixed.
“There is absolutely no question that personnel injured in battle have a better chance of survival than ever before. That is entirely due to efficient and innovative care, delivered under exceptionally difficult circumstances. The NHS’ urgent and emergency services could learn a lot from how the defence service plans care, trains staff and constantly seeks to learn and improve trauma services.
Sir Ian added: “By the services’ own assessments, they still have some way to go before they can tell all their patients – in all parts of the armed services – that standards are in place to provide high quality care wherever they get treatment. By commissioning this review, the DMS has taken the first step towards achieving this important goal. The results provide a clear agenda for action.
“Away from the frontline and the spotlight of war, the DMS must give urgent attention to the maintenance and cleanliness of buildings. It must also improve awareness that 16 and 17 year-olds are still legally children – military personnel or not – and healthcare workers have a responsibility to act on any suspicion of bullying or abuse.”
The review involved self-assessments by reference to the 24 core standards set out by the Department of Health for the NHS. The Commission received declarations from 153 DMS units or regions encompassing a number of units. This included military hospitals, rehabilitation centres, dental services, community mental health services and general medical services.
This was followed-up by inspections at 53 units in the UK and overseas. The review also incorporated 500 comments from current and ex-service personnel, family members and organisations that work with the DMS.
The Commission praised the following areas of exemplary practice:
- Trauma care is exceptional and has greatly increased the chance of survival and recovery for injured personnel. Trauma care is delivered to personnel injured in war zones, with an aim to save life, stabilise the patient’s condition and transport them for further treatment. A helicopter can be airborne within minutes of receiving a call, transporting highly trained clinical staff to the casualty on the frontline. Casualties are assessed and treated very quickly, greatly improving their chance of recovery. They are then transported for further medical treatment, in a field hospital or in the UK. Aeromedical evacuation teams provide treatment in-flight and can transport injured personnel from the frontline to the UK within 24 hours. The field hospital inspected in Iraq was well-planned and extremely clean.
- Rehabilitation services are excellent. Services are provided at Headley Court rehabilitation centre and regional units in the UK and Germany. Some personnel described services as “outstanding” and “first-class”.
- Innovative “patients’ diaries” aid recovery for those with memory loss. Patients’ diaries are kept for personnel recovering from injury in military hospitals who may suffer from memory loss. Staff record important milestones in recovery and visitors also add messages. This helps patients to fill in time lost from their memories and aids recovery.
- Clinical audits of services for trauma and rehabilitation mean care is continuously improving and innovating. Clinical experts closely examine all aspects of a patient’s treatment, from when a person suffers a major trauma, through to rehabilitation. They then feedback lessons weekly to the field hospitals.
However, the Commission urges the DMS to:
- Ensure that standards are in place across all services. Medical centres and field hospitals inspected in Iraq declared compliance with all core standards and no declarations were overturned upon inspection. But, there was significant variation in compliance with core standards at those services away from conflict zones and seven standards where more than 20% of DMS declared non-compliance, including those relating to important issues such as infection control, appropriate environments and safeguarding of children. Looking across the DMS, standards relating to obtaining consent (C13b) and ensuring that staff update skills and techniques (C5c) were the standards where most units declared compliance (97%). Ninety-six per cent of units declared compliance with the standard relating to treating patients with dignity and respect (C13a). However, declared compliance with the standard relating to participation in mandatory training was low at 64%. Only 69% of units declared compliance with standards relating to infection control (C04a) and appropriate care environments (C21).
- Address problems relating to maintenance and cleanliness of buildings and replace ambulances in Cyprus. The Commission visited three medical centres in the UK and one in Cyprus where primary care was delivered in unacceptable conditions. This included very poor maintenance, inadequate facilities for clinical staff to work in and poor levels of cleanliness. The Commission immediately raised concerns with the DMS, which then implemented a programme of deep cleaning, renovation and maintenance. Standards relating to infection control and the environment were among the standards where declared compliance was lowest. The Commission changed declarations to “non-compliant” at five out of 13 units inspected on infection control and nine out of 19 inspected on the environment. The Commission also raised concern about the continued use of nine ambulances in Cyprus, which had previously been identified in internal inspections as unsafe and needing urgent replacement. The DMS is currently modifying the vehicles. The Commission considers, however, that the ambulances continue to present a risk to the safety of patients. New vehicles are planned to be delivered in June or July this year.
- Improve awareness of procedures to safeguard children. The DMS does not always recognise that personnel under the age of 18 are still legally children. While no concerns were found relating to the practice of treating and safeguarding children, some DMS staff did not know processes for reporting matters relating to child protection or safeguarding, including staff at units providing services to the families of personnel. The standard relating to safeguarding of children (C02) had the fifth lowest level of declared compliance at 73%.The Commission assessed this standard at eight units and overturned declarations of compliance at five.
- Collect information centrally to allow comparison across all services and to provide a clear overview of quality of services across the whole organisation. Currently, regular audits and reviews are conducted differently by each of the navy, army, air force and dental services. This means that it is not possible to make comparisons between areas. The Defence Medical Information Programme being rolled out will provide electronic records for patients and a central database. This is expected to improve the way the DMS collects and uses information.
The DMS commissions inpatient hospital care from six NHS trusts. Defence personnel are integrated with civilian patients, and treated by both civilian and military clinicians. The six trusts and their annual health check rating are:
- University Hospital Birmingham NHS Trust – quality of services “good”, use of resources “excellent”
- Portsmouth Hospitals NHS Trust – quality of services “excellent”, use of resources “good”
- South Tees Hospitals NHS Trust – quality of services “good”, use of resources “fair”
- Frimley Park Hospital NHS Foundation Trust – quality of services “excellent”, use of resources “excellent”
- Plymouth Hospitals NHS Trust – quality of services “fair”, use of resources “good”
- Peterborough and Stamford Hospitals NHS Foundation Trust – quality of services “weak”, use of resources “excellent”
Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.
Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.
The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.