" Care for the Courageous "


Book Reviewer
I know not everyone in DMS has access to the ' Heads Up' e-bulletin from JMC - and I thought this piece was worth reprinting - apologies to those who may have already seen.


Care for the courageous
Following the Cold War, a defence review and other studies, stand-alone military hospitals were closed. Uniform secondary healthcare was transferred to busy district general hospitals close to areas of high military activity, such as Frimley Park, Northallerton and Plymouth. Military command and control was effective through the Ministry of Defence and the Ministry of Defence Hospital Units (MDHUs) embedded within the host hospitals.

During military operations, casualties are given first aid at the point of wounding 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. Responsibility for providing acute Role 4 care was passed to the NHS.

In December 1998, in response to the Laurence Report, concern for 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 was to provide professional leadership, provide 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.

The option of developing the Royal Haslar Hospital in Gosport, itself uplifted and developed into a successful tri-service hospital, was dismissed because of the necessary collaboration with a major NHS hospital.

“The strong civilian-military partnership is a role model for co-operation, co-ordination and achievement”

Selection of Birmingham

Following an extensive pre-qualification and tendering process, three major teaching hospitals were shortlisted – Newcastle-upon-Tyne Hospital NHS Trust, Guys and St Thomas’ Hospital NHS Trust and University Hospital of Birmingham NHS Trust. In December 1999 it was announced that the University Hospital Birmingham was selected on the basis of its strong academic and clinical partners.

Royal Assent was granted in 2000, the same year that 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.

Early aspirations

The joint vision of the MOD and its partners was that by 2010 the RCDM would be an internationally-recognised centre of excellence for all UK military medicine. It would be a teaching focus for military medical research, training and education.

These aims have been achieved. Although not an initial stated objective, the unpredictable clinical work load generated by the two theatres of operation in Iraq and Afghanistan has led to significant clinical enhancements with the RCDM being part of a robust chain of highly successful clinical care.

The RCDM Research Centre hosts 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, particular 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 that of Allied Health Professionals.

Clinical care is delivered by a hybrid model whereby operational casualties are initially treated and evacuated through a military medical chain, repatriated (now) 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 in Surrey, or through regional rehabilitation units.

From the outset, it was recognised that service personnel, and in particular battle casualties, should be placed in cohorts and nursed together wherever possible, initially at Selly Oak Hospital and now at the new hospital, Queen Elizabeth Hospital Birmingham. A military-managed ward was established to nurse together service patients, providing their clinical condition allowed.

An increase in military staff allowed the RCDM to cater for casualties who, for valid reasons, must be cared for on a different ward or different hospital (for example, the Birmingham Midland Eye Centre). There is now sufficient military staff, both clinical and non-clinical, including psychological care, welfare and support personnel to create a virtual “military bubble” around the patient group.

Landmark developments

There have been many important developments in the evolution of Role 4 care. These include: an increase in military staffing in key specialties (anaesthesia, trauma and orthopaedics, plastic surgery), which allows the services to meet surge requirements; uplift capabilities have developed, with the capacity for critical care beds improving (sometimes up to five patients on a single military repatriation flight); extended theatre operating times, including additional lists (sometimes two to three additional all-day lists are required when the service is particularly busy).

A further key step was the establishment of a robust military ward round / 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 was used to provide 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 all key specialty consultants present (sometimes this can be up to six specialties).

Another improvement was putting in place an on-going team to handle the demand and logistics of theatre requirements. This often includes the reception of up to nine patients in a single cohort. These multiply 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 and mycological challenges and the needs in relation to patient care
A full understanding of the specific critical care challenges of military trauma, particularly in relation to blast injury
Robust comprehensive trauma data collection
Services delivered mostly by consultants.


The one weakness to date has been an inability to exploit clinical achievements, which has largely been 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, Ministry of Defence, University Hospital Birmingham and DoH jointly funded to the sum of £20million over five years, which will 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 further recognition of clinical excellence and academic capability which will generate world-class research.

Professor Sir Keith Porter, Honorary Professor of Clinical Traumatology, University of Birmingham, Queen Elizabeth Hospital Birmingham

Based on an article originally published in Aesculapius

Since nobody else is likely to say it - well done you lot :judge:

( and I have no idea what the Prof has against MDHU Portsmouth or MDHU Peterborough - suspect he was subbed!)

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