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Abstract
The Role 1 orientated JRAMC of September 2012 was a welcome addition to the body of Role 1 literature. In particular, the Role 1 capability review by Hodgetts and Findlay detailed both current issues and future aspirations for Role 1 provision. This personal view considers issues still prevalent during Op HERRICK 18 namely the provision of primary healthcare by combat medical technicians on operations and the organisational issues that contribute to historical structural and attitudinal obstructions to the employment of combat medical technicians in firm base primary healthcare. It also considers a dynamically updating dashboard capable of displaying risk across the Role 1 network with the implied move to a model of continuous healthcare assurance.
- PRIMARY CARE
- Clinical governance < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Information technology < BIOTECHNOLOGY & BIOINFORMATICS
- Protocols & guidelines < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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- PRIMARY CARE
- Clinical governance < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Information technology < BIOTECHNOLOGY & BIOINFORMATICS
- Protocols & guidelines < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
Introduction
In planning for the deployment of five medical regiments to Op HERRICK 18 (the UK deployment to Afghanistan), two areas of risk were identified: the provision of Role 1 primary healthcare (PHC) by combat medical technicians (CMTs) and the visibility of deployed healthcare activity as the critical foundation to the governance and assurance process.
The Role 1 capability review by Hodgetts and Findlay reported in September 2012 that: ‘Combat Medical Technicians lack of experience in Primary Healthcare is a principal organisational risk that the Army has historically chosen to accept rather than mitigate by solving obstructions to improved clinical exposure in the Firm Base’.1 They also offered a possible solution regarding information management stating that: ‘A dynamically updated dashboard is an effective means of conveying risk across the Role 1 Network, by ‘Capability of Care’ for each Medical Treatment Facility and by competence for each individual medic. This is a model for future R1 Healthcare Governance’.1
This personal view looks forward into contingency, suggesting underlying themes and solutions to those issues articulated by Hodgetts and Findlay and still prevalent as Op HERRICK draws down.
The provision of Role 1 PHC by CMTs
Hodgetts and Findlay raise several areas of concern for the provision of Role 1 PHC by CMTs1 supported by the finding of Hawksley et al2 on Op HERRICK 10 that: ‘Initially a majority of medics were uncomfortable in dealing with primary healthcare issues. Many required supervision to examine patients and utilise protocols; after approximately one month all were confident with following these’. There is an urgency implied by Hawksley et al and Hodgetts and Findlay. They are suggesting that operational PHC by CMTs is an area of articulated risk, reinforced by operational experience, for which significant mitigation in the firm base has not been attempted. For Op HERRICK 18, the operational estimate process undertaken by the Role 1 medical regiment commanding officer, with the senior medical officer as his principal clinical advisor, had to attempt to address this issue as best as it could at the regimental level. To do otherwise would have not served the best interests of our patients.
PHC by CMTs is, conceptually, delivered through a protocol-based system, supported by training and clinical experience. It would be reasonable, therefore, to use this framework to suggest where the organisational risk articulated by Hodgetts and Findlay might be addressed.
Protocol delivered PHC
PHC has to be delivered by CMTs against a set of protocols. The concept of ‘blank sheet’ PHC delivery by CMTs is not within their current or likely future scope of practice, given their current level of training and clinical experience. Supported (ie, protocol driven) management of un-triaged PHC is probably the only defensible approach. It is absolutely critical as we move into contingency that these protocols are based on symptoms and not conditions. They have to be algorithmic in nature, taking the CMT from the presenting complaint (not presenting condition) to a reasonable and safe management plan and not necessarily diagnosis.
Evidence-based practice
The protocols used have to be evidence-based, and the evidence cited open to scrutiny. It is difficult to teach approaches to medical care where the underlying evidence base has not been forthcoming. The safe management of, for example, headache, is already medically well founded and deviation from widely accepted practice without compelling operational reasons is difficult to justify. Responsibility for provision of this evidence should be by working group and consensus across all those who deliver Role 1 care; continuous dialogue should be encouraged, with a rapid process of development and revision as management plans written by clinicians that are predictably undeliverable due to lack of equipment, training or operational reality are no management plans at all.
Firm base commitment to PHC training
Any CMT protocol has to support delivery of care in the firm base. When employed in firm base locations, Role 1 medical officers have a critical leadership role in addressing the ‘historical structural and attitudinal obstructions to Combat Medical Technician employment’.1 If we are to employ unsupervised CMTs, the protocols will have to be opened to external, independent review as the only way to assure that the unique level of care they provide is considered sufficiently safe by the wider medical community. There is opportunity here for leadership as NHS paramedics look to expand their remit into PHC.3 A partnership with the NHS, sharing our experience of remote, non-traditional PHC delivery could be a foundation to a ‘solution that supports Combat Medical Technician continuing clinical experience as central to Role 1 operational success, essential within the emerging structure and contractual framework of the joint Defence Primary Healthcare Service’.1
A dynamically updating dashboard capable of displaying risk across the Role 1 network
Op HERRICK 18 has seen the implementation of both components of the dashboard envisaged by Hodgetts and Findlay, namely, a ‘dynamically updated dashboard capable of conveying risk across the Role 1 network’ and ‘by competence for each individual medic’.1 The system uses the currently mandated Common Assurance Framework from the UK Permanent Joint Headquarters as the overall risk stratification tool. The 57 992 awarded marks from Role 1 validation are used as the dataset to support risk assessment by individual skill set in each theatre location. They are displayed ‘live’ on a geographical overlay of theatre by location.
The concept of a Role 1 dashboard implies a move away from a single point in time model towards continuous assurance. It is here that the danger lies in the recommendation of Hodgetts and Findlay. The risk of micro-management is significant and, if realised, would further distance service delivery, perhaps irrevocably, from the assurance process. Continuous assurance necessitates identifying and empowering the local leadership in each medical facility. There has to be a dialogue, a responsive framework that reflects the truly important markers and enablers of high quality care, by listening to those that deliver it. It requires an overt transfer of power, a conceptual change from circular arguments for quality (ie, an assurance framework is valid because the things it contains are in an assurance framework) and reinforcing inspectorate. There needs to be a genuine shift towards the lighter touch of guidance, assistance and partnership between those who deliver and those who seek to assure and govern.
Summary
Clinical planning at regimental level for Op HERRICK 18 was undertaken from May 12 and in this personal view I have expanded on the organisational risks in CMT delivery of PHC, offering a view as to where critical development work should be undertaken into contingency. This view has also noted that a Role 1 dashboard is deliverable on operations, but must be part of an organisational change in the approach to governance and assurance.
This personal view ends with an appeal. We must develop a culture of more timely Role 1 publications from operations across as wide a spectrum of Role 1 authors as possible. The planning for Op HERRICK 18 would have been greatly assisted by the data published in late 2012. While formal operational research is rightly managed centrally, for Role 1 the case review and reports of individual or collective experience can reliably inform future planning. To this end, contemporary publications should be encouraged across all aspects of Role 1 delivery. A report on managing medical supply chains by a medical support officer is as valid as a clinical case study. Building a published and more comprehensive evidence base will allow us to support our colleagues during the remainder of Op HERRICK and provide peer-reviewed evidence to inform policy into contingency.
Footnotes
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.