It is clear that military medicine has been transformed in its advances of world-class medical care for military patients since the Cold War and following a landmark Defence review and other key studies.
It has been a long journey. By the mid-1990s, dedicated military hospitals were closed down and military secondary healthcare was switched to bustling NHS hospitals such as Frimley Park, Northallerton and Plymouth. Military command and control was effective through the MOD and the MOD Hospital Units (MDHUs) were established within NHS hospitals.
In an article originally published in Aesculapius - Journal of the University of Birmingham Medical and Dental Graduates Society, Sir Keith documents the extraordinary progress made in providing military clinical care.
He describes how, during military operations, serious casualties receive first aid at the point of injury and are evacuated and treated at several echelons of care, which are normally described as ‘Roles’. Role 1 is integral to a unit, ship or station. Role 2 provides a higher level of care, Role 3 is a field hospital and Role 4 refers to definitive care at the home base. Following the closer of dedicated military hospitals responsibility for providing acute Role 4 care was passed to the NHS.
Back in 1998, in the wake of the Laurence Report, mounting concerns over training standards, maintaining capability for deployment and staff retention, the Government announced a new strategy for Defence Medical Services which included setting up a Centre for Defence Medicine (CDM), recognising that military medicine was a distinct discipline in its own right.
The centre would provide professional leadership, a centre of training and develop a centre of excellence for research. From the beginning, it was recognised that the CDM should be developed in partnership with a civilian centre of excellence, preferably a teaching hospital.
It didn’t make sense to sustain the relatively tiny number of military patients in a dedicated military hospital. Following an extensive tendering process, it was announced in late 1999 that the University Hospital Birmingham was selected for its strong academic and clinical partners.
Royal Assent was granted in 2000, and later that year it was announced that the Royal Defence Medical College would move from Fort Blockhouse (Gosport) to Birmingham. In October 2000, a Service Level Agreement confirming the partnership arrangement to cover the next 20 years was signed.
The joint vision of MOD and its partners was that, by 2010, the Royal Centre for Defence Medicine (RCDM) would be a world-renowned centre of excellence for all UK military medicine. It would be a teaching focus for cutting edge military medical research, training and education.
Professor Porter is doubtlessly proud that these aims have been achieved. It is a fact that the unpredictable clinical workload generated by conflicts in Iraq and Afghanistan has produced significant clinical enhancements with the RCDM being part of a chain of highly successful clinical care.
The RCDM Research Centre integrates the Medical Director, Defence Professors and the Military Director of Research. The unit maintains strong links with the Defence Scientific Technical Laboratories (DSTL) at Porton Down, particularly in relation to its Combat Casualty Care Programme. A strong educational link has been established at undergraduate level with Birmingham City University for the delivery of nurse training and health professionals.
Clinical care is delivered by a hybrid model where battle casualties are initially treated and evacuated through a military medical chain, repatriated to the Queen Elizabeth Hospital Birmingham, before returning to the military chain for rehabilitation, either at the Defence Medical Services Rehabilitation Centre at Headley Court, Surrey, or at regional rehabilitation units.
Professor Porter writes:
From the outset, it was recognised that Service personnel, and particularly battle casualties, should be nursed together wherever possible, initially at Selly Oak Hospital and now at the Queen Elizabeth Hospital Birmingham where a military-managed ward was established.
An increase in military staff allowed the RCDM to cater for casualties who must be cared for on a different ward or hospital (for example, the Birmingham Midland Eye Centre) with sufficient military staff, including psychological care, welfare and support to create a ‘military bubble’ around patients.
**Sir Keith also describes how many important developments have evolved in Role 4 care. They include: an increase in specialist military staffing; (anaesthesia, trauma and orthopaedics, plastic surgery) to meet increasing demand to cater for critical care beds (sometimes up to five patients on a single military repatriation flight) and extended theatre operating times.
Professor Porter writes:
A further key step was the establishment of a robust military ward round/multi disciplinary team (MDT meeting), involving relevant specialty consultants including a rehabilitation consultant from Headley Court, junior doctors, nurses, allied health professionals, mental health and trauma nurse practitioners and trauma audit personnel.
A dedicated phone conference provided comprehensive military feedback to Afghanistan and supporting services, such as the aero medical evacuation team. Furthermore, critically injured patients are reviewed in the operating theatre between two and four hours of arrival at QEHB with up to six key specialty consultants present.
A further improvement was establishing a team to handle the demand and logistics of theatre requirements. This includes the reception of up to nine patients in a single cohort. These extensively injured patients require frequent visits to theatre; one patient recently required 37 visits to theatre, totalling 75 hours and 15 minutes operating time.
Other important developments include:
• An evolving understanding of the microbiological challenges and the needs in relation to patient care
• A full understanding of the specific critical care challenges of military trauma, particularly on blast injury
• Services delivered mostly by consultants.
**Professor Porter notes that the key weakness to date has been an inability to exploit clinical achievements, largely due to unrelenting work load pressures. However, the recent establishment of the National Institute for Health Research (NIHR) Centre, which will focus on surgical reconstruction, medical microbiology, regenerative medicine and rehabilitation, will address this deficiency. The centre is underpinned by a strong four-way agreement between the University of Birmingham, MOD, University Hospital Birmingham and DoH providing £20m of funding over five years, to provide a catalyst for world-class research and outputs.
The QEHB and the Royal Centre for Defence Medicine are proud of gaining recognition as the leading hospitals for trauma in the UK and of their world-class reputation. The strong civilian-military partnership is a role model for co-operation, co-ordination and achievement. The recent recognition and selection of the QEHB, MOD and the University of Birmingham as a partnership in establishing the NIHR centre is recognition of clinical excellence and academic capability that will generate world-class research.
Professor Sir Keith Porter is an Honorary Professor of Clinical Traumatology at the University of Birmingham based at the Queen Elizabeth Hospital Birmingham.
Based on an article originally published in Aesculapius - Journal of the University of Birmingham Medical and Dental Graduates Society.