Surgeon General on keeping the Armed Forces healthy
The Surgeon General, Surgeon Vice Admiral Philip Raffaelli, talks to Ian Carr from Defence Focus (DF).
DF: What is the role of Surgeon General (SG)?
PR: My formal position is the professional Head of the Defence Medical Services [DMS]. Which means I have end-to-end responsibility for the appropriate delivery of our three principal outputs: medical operational capability, healthcare provision, and subject matter expert and health advice.
All of which adds up to ensuring we have the maximum number of suitably healthy personnel who are fit for task, and who, as a result of what we do, remain as healthy as possible - ‘Promote, Protect and Restore’.
DF: Why is the SG organisation now part of Joint Forces Command?
PR: I am a very strong supporter of the Joint Forces Command [JFC] concept. The medical services exist either to make people from across the three Services well and keep them fit, or to deploy a medical capability to operations.
Over the years, particularly in the operational environment, we have increasingly been delivering an effect by working jointly. In the Role 3 hospital at Bastion, you don’t know until they take their mask off if that man or woman is Army, Navy or RAF, or even if they are regular or reservist or indeed what nationality they are.
We have a successful track record in harnessing capabilities and focusing on the specific skills we need.
JFC was created to bring together unique military and civilian strengths to support the delivery of success on operations. That is absolutely what we do, so to be part of it makes perfect sense.
DF: So is there a need for Single Service healthcare provision?
PR: I’m convinced that you should do ‘cloth-on-cloth’ care where you can. Recognising and understanding Single Service requirements and the environments in which they operate is important.
But the bottom line is, when you need a doctor, nurse or medical assistant to intervene, you want somebody who is properly trained and as fit for purpose as you can make them. We are not a cheap option, so the more efficient and effective we can make that, the better.
DF: Is it that kind of thinking that is behind the creation of the Defence Primary Healthcare (DPHC)?
PR: Establishment of the DPHC is integral to a commitment made by the Service Chiefs to continue to improve medical care to the Armed Forces.
So medical centres, regional rehabilitation units and departments of community mental health will operate much as they do now, but will be carefully, and over a period of time, brought together under one single organisation with the delivery of primary healthcare run on a regional basis, but in a co-ordinated and harmonious way.
DF: The Service Chiefs are behind the DPHC model?
PR: They and the VCDS [Vice Chief of the Defence Staff] and CDS [Chief of the Defence Staff] clearly support and respect their medical services and recognise the important contribution they make to morale as well as physical fitness, so it was not a position they took lightly.
Last year they spent about six months seeking confirmation and reassurance that the move to a unified primary care service was going to maintain the quality they had grown to expect from their own Single Service primary healthcare.
They have also made it clear that wherever possible they would like cloth-on-cloth service to understand the environment their patients work in.
But they also recognise that a uniformity of delivery of the same policies and practices, given the peripatetic nature of the military and their dependants, will add to the consistency and quality of care their people receive, whichever medical centre they might go in.
DF: Is that desire to achieve a consistent approach affected by the use of locums in medical centres?
PR: Locums can often be extremely high-quality practitioners, certainly those are the type we seek. What they can lack is the occupational health side of the treatment in a military context.
Now, if I have a bad ankle I can see an NHS GP and they will give me the right treatment. What they won’t be so good at is knowing whether I am fit enough to go to sea in a submarine or to parachute out of an aircraft.
That is certainly an area where having healthcare delivered by men and women from the RAF, the Navy or the Army can be an advantage. That’s why we train our civilian practitioners on the same basis, so that they do have that understanding and are familiar with our electronic records so they make sure that your medical category is correct.
DF: You say DMS is not a cheap option. What can you do about that?
PR: We make sure that our posts are properly defined in terms of job spec, the skills and experiences required, and then select the best person for the job.
Now, if you want a tooth taking out I’ll make sure it’s a dentist who does it, if you want your belly opening up, I’ll make sure a surgeon does it, which is why there are some posts that are specifically tied to professional qualification. Outside that we follow the approach laid down in ‘Top Structures, Next Steps’.
First, does the task need doing? If it does, can it be provided by someone outside the organisation? Could it be undertaken by a MOD civilian (many of our civilians provide healthcare, they don’t just work in admin) or is it necessary for a military person to do it?
Finally, must it be a specialist? Each time you go up a step in terms of requirement there is a cost implication.
DF: So what else drives that decision?
PR: Our first requirements are what outcomes do we want for our patients and what do we want to provide our commanders with? Then we look at how we can put in place most efficiently and effectively a structure that does that. For us, form follows function.
DF: Will the organisational changes such as DPHC and JFC increase efficiency?
PR: Creating a single headquarters from five separate ones (the three Single Service organisations plus Permanent Joint Headquarters’ provision overseas in Gibraltar, Cyprus and elsewhere, and the British Forces in Germany) will mean we can remove some HQ function duplication - for instance we will have only one financial team.
Each of the Services work to somewhat different models so we are looking to take best practice from each during the Defence Primary Healthcare initial operating capability phase.
We are going to run a pilot starting in October to test how a clinically-led regional structure backed by a small DPHC HQ works, before we move to full operating capability. And by April 2014, JFC will have been in existence long enough for us to take a wider view of what we need.
DF: What effects will the reduction in the Armed Forces head count have on you?
PR: There will be a couple of significant effects. Firstly, the DMS, like everyone else in Defence, will be expected to deliver our share of personnel reductions - both military and civilian.
The loss of 25,000 civilians across Defence is also important for us. We have spent a lot of time looking at situations where we can use civilian personnel, not just in policy or administration, but in healthcare delivery. So we need to be careful that in making savings we do not affect our healthcare delivery.
If we can reduce duplication and reduce our HQ overheads that will make it an easier ask of our people. Of course as the total Armed Forces population and their dependants reduces, particularly overseas, the number of patients who come through the door will also reduce.
So we will have to ensure that we have the right medical centre in the right areas, manned with the right people for the population they will be expected to serve in the future.
This article is taken from the July 2012 issue of Defence Focus - the magazine for everyone in Defence.