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No QOF, no problem? Life in a military medical centre

18 July 2007

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It is my pleasure to introduce our small rural military medical centre in Lancashire. My name is Kirsten Hamilton and I am … old enough! I am the practice administrator in the military medical centre, which I joined in 2003 as the first full-time civilian working there. At that time, the other civilians there were locum doctors, working as required, and a part-time physiotherapist.

Our surgery has changed a lot since then. Our current team consists of a medical officer (MO), who is the military GP, and a part-time civilian GP. They are supported by a practice nurse and a physio­therapist (who are both part-time), a full-time pharmacy technician, six military medics, and myself. The whole team rarely works within the same building, though – but more about that later.

How things have changed in military primary healthcare
Before 2000, medical centres belonged to regiments and were staffed by the military. If necessary, civilian care providers performed locum cover or physio­therapy. In 2000, the provision of healthcare changed when the Army Primary Health Care Services (APHCS) took over the medical centres.

APHCS is split into regions – our medical centre is in the Wales and West Midlands region. Two area managers cover this region – one looking after Wales, the other looking after medical centres from Birmingham to Carlisle (the area our surgery comes under). Our area manager has her office situated in our medical centre.

Physiotherapy is available at the centre, and has been since before 2000, provided by a civilian physiotherapist. The hours of service have increased – but in the field of physiotherapy, not much has changed.

Before the takeover by the APHCS, our surgery also had a dispensing facility, which was carried out by a designated corporal.

We still have the dispensing facility, although this arrangement has now changed to fall in line with national standards. A regional pharmacist is based centrally, and our pharmacy technician, Elaine, is responsible for all the dispensing within the practice. She also provides prepacks to out­lying centres that do not have their own dispensary. Furthermore, Elaine is involved in Buttercups training for the military medical staff.

With the establishment of my post, I have taken the administrative pressure off the medics, who are now able to concentrate on patient care. My main duties are ensuring that targets are met by setting up clinics and providing statistical information.

I also liaise between hospitals and patients (to keep “did not attend” rates low) and with the military hierarchy to ensure transportation needs are met. Furthermore, I look after the computer system, and deal with the administration of medical documentation, which needs to accompany soldiers on postings and discharges. I also carry out general office duties.

Practice provision
Our surgery cares for about 750 patients aged between 17 and 55 years, who are generally fit.  To maintain their health, regular medical checkups have to be attended, ranging from hearing tests to five-yearly medicals, as well as regular vaccinations. This is the area where targets now have to be met, which might compare to the Quality and Outcomes Framework (QOF). However, there is no monetary incentive linked to meeting high targets set by the APHCS.

Naturally, our practice also provides service personnel with acute and chronic illness care. In addition, the staff provides medical cover during regimental sport events, exercises and military training.

But that is not all. The medics work hard providing medical training to the regiment, so as to ensure that a great number of soldiers have first-aid training that is suited to dealing with injuries sustained on the battlefield.

This may be the greatest difference between a military and a civilian medical centre.  All our military members of staff can, and do, deploy on exercises and operational tours, which poses its own unique challenges.

Obviously, there is the geographical distance between the medical centre and facilities within it, and the exercise or operational area, which can be anywhere in the world. To aid care for soldiers, the deployed medical staff carry with them special laptops with a copy of the medical records. These are downloaded before a tour, and are uploaded upon the return of the unit.

Unfortunately, communication between different members of the medical centre’s staff can sometimes verge between difficult and impossible, since some will remain at the practice and others will be working out in the field. There are no email facilities, and contacting each other using a telephone can be difficult due to differences in time alone. Letters take too long to reach a destination abroad, and are not commonly used to transmit information. This is a challenge when a hospital appointment letter arrives for a deployed soldier, but procedures are in place to deal with this type of problem.

Another difference between military and civilian medical centres is access to Choose and Book. There are still some military hospitals to which soldiers can be referred, but our doctors can refer a  soldier to a local hospital if they so wish. There is no link to either the internet or the to provide us with the facility to use Choose and Book. Therefore obtaining a timely appointment for a soldier can be tricky.

While our medical centre needs to ensure the highest fitness of soldiers so that they are able to deploy at short notice, civilian hospitals do not have that pressure upon them, and only offer appointments to suit their needs. Having said that, there is very good cooperation between our medical centre and our local hospital, which has grown throughout the years, but it has not always been easy.

A similar problem arises when a soldier attends a civilian GP as a temporary patient. Usually, the sick leave the GP gives is longer than a military practice GP would give. This is due to the fact that if a soldier attends a military medical centre with an illness, the doctor decides which duties the soldier is still fit for, and the soldier can carry on working in most cases, if only in a limited capacity.

A further problem is the communication between the NHS and the military medical centre. If the Army is not told that a soldier has been given sick leave, the unit can post that soldier “Absent Without Leave” (AWOL), meaning the soldier can then be arrested. There are also problems with continuity of care, as civilian doctors often do not inform the military GP of any treatment, as civilian practices may not be familiar with military regulations.

In summary, it would be fair to say that although we are not dependent on meeting QOF requirements to ensure financial security, we still have to meet a number of targets, which are to be achieved and reported upon every quarter to ensure that the maximum number of soldiers are fit and prepared to deploy to ensure the least number of lives are lost in a war.

Nevertheless, it is not easy to meet those targets when staff and patients are deployed; nor is it always easy to establish good communication links with NHS providers, or even between all members of staff – especially when more than half are somewhere on a battlefield or in a jungle on exercise.

However, those challenges are the ones the team thrives upon. And ultimately, as they say in the advertisements, “the team works”.