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Abstract
The return to contingency after Operation HERRICK (2002–2014 Afghanistan conflict) has seen an emerging trend for small-scale rapidly developing expeditionary operations. The associated small, remote medical footprint for such operations, often within a coalition construct, reliant on host nation support is in direct conflict with the General Medical Council (GMC) guidelines for junior doctor supervision in an ‘approved practice setting’. If a General Duties Medical Officer (GDMO) is nominated to support future operations, the provision of assured patient care and supervision within GMC guidelines, while ensuring career progression and ongoing education, may prove a challenge. Recently published British Army Policy aims to provide a framework to meet these challenges. The authors’ first-hand experience in implementing this policy is explored further. The deployment of a remotely supervised GDMO, in line with British Army Policy, is both suitable and safe. This should assure quality medical care delivery during the era of Army Contingency Operations.
- MEDICAL EDUCATION & TRAINING
- PRIMARY CARE
- MEDICAL LAW
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Introduction
The concept of a General Duties Medical Officer (GDMO) has existed in the British Army for many years, aiming to introduce junior doctors to military medical practice. GDMOs have been deployed throughout recent conflicts, providing medical support across the echelons of care, supervised by senior military doctors within the area of operation. This afforded a local governance and supervision structure. The return to Contingency Operations1 and the need to maintain clinical supervision in an ‘approved practice setting’ make future GDMO deployments a challenge.2 We, therefore, must look forward and ask, ‘Can GDMO remote supervision allow suitable and safe future deployments during Contingency Operations in the Role 1 environment?’
A GDMO currently refers to a doctor who has completed a medical degree and Foundation Years (FY) 1 and 2. GDMOs are recruited either before completing a medical degree via cadetships or bursaries or during FY as Direct Entrants (DE). GDMOs may have prior military exposure, such as University Officer Training Corps or the British Army Reserve, and during their FY placements should have completed a General Practice (GP) and Emergency Medicine rotation, equipping them with necessary skills for their first GDMO posting. DE's prior experience may vary, as their medical training is dependent on their Foundation School, not the Defence Deanery.
Subsequently, military training is provided by the Professionally Qualified Officer (PQO) course at Royal Military Academy Sandhurst, and military medical training during the Army Medical Services (AMS) Entry Officers Course (EOC) and the Post Graduate Medical Officer (PGMO) course. GDMOs are then usually posted to Medical Regiments or occasionally to combat or combat support units in the UK, British Forces Germany or British Forces Cyprus as an assistant Regimental Medical Officer (aRMO). GDMO tour lengths of 27 months are typical before entering speciality training. Following training, the British Army uses GDMOs in ‘firm base’ medical centres, during Overseas Training Exercises and deployment in support of front-line operations. With variations in military and medical experience, supervision plans need to be individualised to person and task.
GDMO clinical supervision
By definition, GDMOs do not hold a Certificate of Completion of Training (CCT) in a speciality, and therefore, are not deemed to be independent medical practitioners by the General Medical Council (GMC). The governance of trainees at all stages has dramatically increased in recent years, with the focus being patient safety.3 Recognising that GDMOs do not fall into either the FY pathway or higher specialty training, the AMS and the GMC have been proactive in producing guidelines to aid in the management of GDMOs.
The AMS requires GDMOs to be supervised by a GDMO supervisor. The GDMO supervisor is a civilian or military doctor who has completed a CCT in GP and has undergone GDMO supervisor training. In November 2014, a new Director General Policy Letter (DGPL), DGPL 11/14,4 was published, the primary aim of which was to ensure that GDMOs in their first deployment are working within their capability and in a GMC ‘approved practice setting’2 ,5 taking into consideration the unique locations in which the military operates. This guidance provides a useful handrail to help the military chain of command understand the benefits and limitations of deploying a GDMO and to create a plan to mitigate these risks. Additional principles for the supervision of pre-CCTed doctor are derived from the GMC's Good Medical Practice.6 These two documents are a vital starting point to help advise on the suitability of a deployment. Box 1 shows the criteria that need to be met in order to mitigate remote GDMO deployment in concordance with the DGPL.
The requirements by the DGPL 11/14 for a GDMO in their first deployment
Completed 3 months minimum as a GDMO, which must include:
Satisfactory completion of 6-week medical centre placement.
Undertaking a deployment or medical exercise where they have shown that they can work under remote supervision.
The GDMO must be in date for battlefield ATLS.
The medical estimate and plan must be endorsed by the Competent Medical Authority , and the individual GDMO has been assessed by their Commanding Officer as being capable of fulfilling their part in the plan.
The GDMO has adequate remote support, which must include:
Access to 24 h theatre-specific, authoritative and current clinical advice for the management of presenting patients.
The Pan-Governmental Health Contract should be the preferred provider as it is already funded, and would be aligned to the referral and evacuation systems.
Alternate arrangements, for example, host nation/in-theatre services, may be considered if the Pan-Governmental Contract cannot meet the required standard of advice.
The GDMO must be given the name and contact details of the nominated primary care doctor(s) who will be giving the theatre-specific advice.
Maintenance of the existing supervisory relationship with the GDMO's current supervisor. This is to include regular (twice weekly minimum) discussion of all cases seen by the GDMO.
The GDMO must have assured access to reliable, secure communications.
‘Video with voice’ is the expected standard.
‘Voice only’ is acceptable if operational constraints dictate.
DGPL, Director General Policy Letter; GDMO, General Duties Medical Officer.
Current challenges
The material and physical cost of the British military responses in Iraq and Afghanistan have made lasting impacts on the British public. With increasing focus on clinical governance in all aspects of medical practice, accountability for negative outcomes and minor infringements need to be justifiable to a range of stakeholders, including the Service, the British public and the GMC. These changes have affected and influenced military medical training and the level of risk that is deemed acceptable. In recent years, the PQO course has been made longer to incorporate more basic military and generic officer skills. Following the experience of previous GDMOs, the PGMO course has changed with more emphasis on accountability and responsibility. The GDMO period is supervised and supported by the use of a reflective clinical portfolio, keeping development in line with NHS training. Despite all of these developments to GDMO training, supervised practice is tested to its limits if a GDMO deploys to a non-conventional clinical environment.
As the British Army returns to contingency operations, more small formations of soldiers are held at high readiness to deploy in a variety of roles. Deployments are likely to incorporate a front-line (NATO Role 17) Medical Officer (MO) to provide military primary healthcare and emergency medical care. This is often into dynamic situations, in isolated locations with a small logistic footprint. The MO may be required to provide supervision of other healthcare providers, such as Combat Medical Technicians and nurses, work alongside coalition forces and use host nation medical support. These factors pose significant risks for deploying GDMOs, and are compounded if direct supervision is not possible, such as non-deployable civilian GDMO supervisor, or if the deployment is small and only able to support one MO. A plan should be established to mitigate the perceived risk of remote GDMO supervision.
Practical implementation of remote supervision
It is important to emphasise to all parties that a GDMO is responsible for his/her actions as a licensed medical practitioner. Adherence to ongoing diligent medical practice supported by maintenance of the GDMO portfolio, use of appropriate guidelines and asking for help in a timely manner are essential. Despite a relative lack of military medical experience, a GDMO is likely to be well versed in current emergency care. The GDMO must commit to the twice-weekly supervisor meeting and discuss issues at the earliest opportunity with the remote supervisor.
Communications are vital as without reliable, secure means, any supervision plan is flawed. There are currently no medical standards of deployable communications. The means of communications will be dictated by the capability in theatre, but in expeditionary operations, these are often limited and are unlikely to support audio and visual communications. A hard copy of relevant contact numbers in case of emergency is vital.
The GDMO supervisor has a pivotal role in providing clinical supervision alongside sharing military experience with the GDMO in their first deployment. If the supervisor does not have operational experience, additional support regarding personnel management, policy queries, working with the chain of command and working alongside coalition partner forces may also be required. A pre-existing working relationship between the GDMO and the GDMO supervisor is advantageous as it mitigates some of the risk of remote supervision. DGPL 11/14 should be used as a guide for the GDMO supervisor to make recommendations as to the suitability for deploying a given GDMO, especially on behalf of a non-medical Commanding Officer.
The remote supervision plan requires the GDMO supervisor to have early engagement from the GDMO's Commanding Officer, Army Consultant Advisor in General Practice and Permanent Joint Head Quarters. The deployed chain of command need to understand the skills and limitations of the GDMO and how to appropriately use them. As deployments may impact GDMOs’ career progression, CAGP plays a vital role in agreeing to a deployment. In circumstances where there will be an impact on GMC standards, for example, revalidation, the Army Responsible Officer needs to be involved.
Suggested development
Currently, the sole predeployment medical course for the remote GDMO, over and above the EOC and PGMO, is battlefield ATLS. The management of road traffic injuries and of major medical incidents would be desirable skills for the deploying GDMO. These could be taught in a Major Incident Medical Management and Support course and the Pre-Hospital Emergency Care course.
As a guiding principle, only GDMOs in their second year who have had either aRMO, exercise or deployment experience should be deployable in a remotely supervised setting. The creation of a central register of GDMOs who have achieved the current standard, as assessed by their GDMO supervisor using the criteria of DGPL 11/14, should be created. Such a register would prevent a reactive response to a GDMO nomination either for deployment or posting to a high-readiness unit.
When a GDMO is deployed, it is highly desirable that the GDMO supervisor should visit early in the deployment to provide context for remote supervision; this visit should ideally be repeated at a later date to provide ongoing support. Where the GDMO supervisor is a civilian GP, this role would need to be reallocated, or the visit conducted by a suitable military GP.
While deployed, the GDMO may work alongside Coalition Nation medical teams, conduct host nation medical facility assessments or have to develop a Role 1 facility. The GDMO must understand medical recce methods and have an appreciation of Coalition Nations’ medical capability. Such areas could be comprehensively addressed in the PGMO course or form part of the competencies needed for deployment with remote supervision. A Role 1 validation exercise could identify areas requiring development prior to deploying.
Several components of the GDMO portfolio, such as Directly Observed Procedures and Clinical Observation Tool, are impossible for the remotely supervised GDMO to complete. Suggestions for development include the use of video to allow delayed indirect observation of practice; an offline, compatible version of the newly proposed online GDMO portfolio and an electronic offline battle box of reference material would aid remote supervision.
Conclusion
Army GDMOs can have a clinically assured, yet challenging Role 1 Operation experience in the era of Contingency Operations. The deployment of a remotely supervised GDMO should be assessed in line with DGPL 11/14 prior to nomination by the GDMO supervisor. When deployed, remote supervision, supported by secure, reliable and confidential communications, is vital alongside timely visits by a military medical representative, ideally the GDMO supervisor. The deployment of a remotely supervised GDMO, in line with British Army Policy, is both suitable and safe. The above will be key to maintaining quality medical care delivery by the AMS during the era of Army Contingency Operations.
Footnotes
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.