Defence Medical Services - NHS€¦ · The focus of the review 4 The Defence Medical Services 5 Key findings 6 The standards of care across the Defence Medical Services 6 Views of

Service review

Defence Medical ServicesA review of the clinical governance of theDefence Medical Services in the UK and overseas

Inspecting Informing Improving

© March 2009 Commission for Healthcare Audit and Inspection.

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© Commission for Healthcare Audit and Inspection 2009.

ISBN 978-1-84562-218-3

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Cover photographs © Crown copyright/MOD

The Healthcare Commission 2

Foreword 3

Summary 4

What the Healthcare Commission was requested to do 4The focus of the review 4The Defence Medical Services 5Key findings 6

The standards of care across the Defence Medical Services 6Views of those who use the services 12Areas of exemplary practice 13Areas of good practice in clinical governance 16

Main conclusions 17Recommendations 18Next steps 21

1. Introduction 22

2. Methodology 23

Approach 23Self-assessment 23Follow-up assessment visits 24

3. Details of findings 26

4. Conclusions 90

Appendix 1: Standards for Better Health 94

Appendix 2: Contributors to this review 100

Appendix 3: DMS organisational and governance structures 102

Appendix 4: List of DMS units visited 105

Acknowledgements 108

Bibliography 110

1Defence Medical Services

Contents

The Healthcare Commission

The Healthcare Commission works to promoteimprovements in the quality of healthcare andpublic health in England and Wales.

In England, we assess and report on theperformance of healthcare organisations inthe NHS and independent sector, to ensurethat they are providing a high standard of care.We also encourage them to continually improvetheir services and the way they work.

In Wales, the Healthcare Commission’s roleis more limited. It relates mainly to nationalreviews that include Wales and to our yearlyreport on the state of healthcare.

The Healthcare Commission aims to:

• Safeguard patients and promote continuousimprovement in healthcare services forpatients, carers and the public.

• Promote the rights of everyone to have accessto healthcare services and the opportunity toimprove their health.

• Be independent, fair and open in our decisionmaking, and consultative about our processes.

On 1 April 2009, the Care Quality Commission,the new independent regulator of health,mental health and adult social care, will takeover the Healthcare Commission’s work inEngland. Healthcare Inspectorate Wales willbecome responsible for carrying out ouractivities relating to Wales.

2 Defence Medical Services

This report is the product of a fruitfulcollaboration between the Department of Healthand the Ministry of Defence, and between theHealthcare Commission and the Defence MedicalServices. It owes much to the leadership andcommitment of the Surgeon General, LieutenantGeneral Louis Lillywhite and his predecessor, thelate Surgeon Vice-Admiral Ian Jenkins. They tookthe view that it would be beneficial to the DefenceMedical Services if its services were exposedto the scrutiny that the Healthcare Commissionapplies to the performance of the NHS. TheHealthcare Commission, in line with its primarystatutory duty to encourage improvement in theprovision of health and healthcare, was pleasedto accept the invitation. The Defence MedicalServices provides care for about 250,000people – Service personnel and their families.All concerned felt it right that their healthcareshould be subject to the same scrutiny as thatof others in England.

In recognising the value of external appraisal,a significant step has been taken. While theHealthcare Commission will cease to operateafter 31 March, to be replaced by the Care QualityCommission, the principle of ensuring that theperformance and quality of the Defence MedicalServices are routinely assessed is now acceptedand embedded.

The picture that the report paints of the DefenceMedical Services is varied. There are areas ofoutstanding performance that the NHS couldprofitably learn from, not least the organisationand operation of trauma services. There areother areas where improvements need to bemade, for example, getting universal standardsin place across all services, and addressingmaintenance and cleanliness at some medicalunits providing services away from the front line.These needs for improvement are recognisedand it is pleasing that actions are already beingtaken to address them. It is important thatprogress is monitored and reported on regularly.

Professor Sir Ian KennedyChair


Foreword

What the Healthcare Commissionwas requested to do

In January 2008 the Surgeon General, Ministry ofDefence requested the Healthcare Commissionto undertake an independent review of the qualityof healthcare services provided by the DefenceMedical Services (DMS) in the UK and overseas.

We had not assessed the services provided bythe DMS before, as they were outside the scopeof the Health and Social Care Act (2003), whichprovides the legal framework within which theHealthcare Commission operates. However, theDMS was very keen to have an independentassessment of its services. The legislationrequired to bring the DMS within our regulatoryremit was laid before Parliament in June 2008.

“….a key issue is the lack of an externalregulator….. the DMS is very small and it canbe extremely difficult to keep up with bestpractice across the whole spectrum of medicalcare. An external regulator would help us toidentify where we are failing to adopt bestemerging practice….”Lieutenant General L P Lillywhite,Surgeon General

The review was based on Standards for BetterHealth, which were set by the Government andare used to assess the performance of the NHS.These standards focus on important patientsafety issues, on the quality of healthcareprovided and on how well services are focusedon the needs of patients. A list of the standardscan be found in appendix 1.

Some parts of the DMS had used these standardsfor internal review of the quality of care, but theyhad not been consistently applied across the threeServices. This review has, therefore, providedthe first opportunity to undertake a consistentreview process across all areas of DMS

healthcare provision within a specific timeframe.

This report provides the findings of our review,which was undertaken during 2008. It will outlinethe focus of the review, describe the DMS,report our key findings and make conclusionsand recommendations for development andimprovement. Our findings include areas ofexcellence and best practice, what we foundabout the standards of care across the DMS andthe views of some of those who use the services.

Appendix 2 gives a list of the key people involvedin the planning, management and delivery ofthe review.

The focus of the review

This was an ambitious and challengingreview. The scope of the DMS ranges fromroutine healthcare to healthcare provided inextraordinary locations and situations. Wetherefore needed to understand the context inwhich services were delivered and the particularchallenges this presented.

The overall aim of our review was to promoteimprovement in DMS services by identifyinggood practice and areas that need to improve.It also aimed to help the DMS to implementmore robust governance of the quality of thecare and treatment it provides.

The review was based on our current methodsfor assessing NHS and independent healthcareorganisations. DMS units were asked to carryout a self-assessment, which took the formof a declaration against compliance with theGovernment’s Standards for Better Health.We analysed their declarations and then visited53 units in the UK and overseas to check theircompliance against their self-assessments.


Summary


We selected these units as a representativesample of the services provided. We received 153declarations, which came from single units – forexample, rehabilitation units – and from hospitalsor regions representing several medical centres.

We also sought the views of those who use theservices, members of the armed forces, theirdependants and civilians who are entitled toreceive care and treatment from the DMS.

It was agreed that the findings of the reviewwould be made public and that the reportwould be available on the HealthcareCommission’s website.

The Defence Medical Services

The DMS is responsible for providing healthcareto approximately 258,000 people, includingService personnel serving in the UK andoverseas, those at sea, and family dependantsof Service personnel and entitled civilians.

The DMS encompasses all of the medical,dental, nursing, allied health professional,paramedical and support personnel, includingcivilian staff, employed by the Royal Navy, theBritish Army, the Royal Air Force and supportingunits. The DMS also provides some aspects ofhealthcare to other countries’ Service and civilianpersonnel overseas, in both permanent militarybases and in areas of conflict and war zones.

The range of services provided by the DMSincludes primary healthcare, dental care,hospital care, rehabilitation, occupationalmedicine, community mental healthcare andspecialist medical care. The DMS also provideshealthcare in a range of facilities, includingmedical and dental centres, regionalrehabilitation units and in field hospitals.

“….our patients and their families, whethermilitary or civilian, as well as militarycommanders, Ministers and the public,expect us to deliver healthcare, both inbarracks and on operations, which is of ahigh and continually improving standard….”Lieutenant General L P Lillywhite,Surgeon General

The Royal Naval Medical Service employs 1,522personnel who provide healthcare. Its workincludes providing comprehensive healthcare toshore establishments and on ships, submarinesand medical care to the Royal Marines.

The Army Medical Services employs 4,958personnel who provide healthcare. Thisincludes British Forces Germany HealthcareServices, medical regiments and field hospitals,primary and pre-hospital emergency care andTerritorial Army field hospitals.

The Royal Air Force Medical Services employs1,898 personnel who deliver primary, secondaryand intermediate care, including the aeromedicalevacuation service to the Armed Forces throughheadquarters Tactical Medical Wing and theAeromedical Evacuation Control Cell.

The Defence Dental Services employ 783personnel from the Royal Navy, the Army, theRoyal Air Force and the civil service. MilitaryDental Service personnel are employed andlocated all over the world and civilian employeeswork alongside military personnel in the UK,Cyprus and Germany.

“….we have a mixture of professionals fromthe three Services and a large percentage ofcivilians who form part of, and are considereda crucial part of our workforce….”Brigadier Pretsell, Director, Defence Dental Services

The DMS is responsible for ensuring that Servicepersonnel are ready and medically fit to go wherethey are required in the UK and throughout theworld – generally referred to as being ‘fit fortask’. This includes being ready to participate ininternational peacekeeping initiatives, respondto emergency situations – for example, floods,earthquakes or other environmental or naturaldisasters, both in the UK and overseas – or togo into areas of conflict or war zones.

The following services, not directly providedby the DMS, were not part of this review:

• The five Ministry of Defence hospital units inthe UK. They are embedded into NHS acutetrusts, and the host trusts provide the carefor Service personnel. These units are inPortsmouth, South Tees, Frimley Park,Plymouth and Peterborough.

• The Royal Centre for Defence Medicine(RCDM), which acts as a centre of excellencefor military medical research and receivesand treats military casualties from aroundthe world. This centre is on the same site asthe University Hospitals Birmingham NHSFoundation Trust. We assess all of theseservices as part of our annual health checkof all NHS trusts. They were therefore notpart of this review, except for theheadquarters element of the RCDM.

Also excluded from this review was care thatthe DMS commissions from the NHS and theindependent healthcare sector – for example,specialist diagnostic care and inpatient mentalhealthcare – as we already assess theseorganisations.

At the time of our review, the DMS wascommissioning inpatient mental health servicesfrom an independent healthcare organisation.

However, in November 2008 the Ministry ofDefence awarded a contract to a partnershipof seven NHS trusts to provide inpatientmental healthcare. The NHS trust leadingthis partnership is the South Staffordshire andShropshire Healthcare NHS Foundation Trust.The other six trusts involved in the partnershipare Cambridge and Peterborough NHSFoundation Trust, NHS Grampian, HampshirePartnership NHS Trust, LincolnshirePartnership NHS Foundation Trust, SomersetNHS Foundation Trust and Tees, and Esk andWear Valleys NHS Foundation Trust.

South Staffordshire and Shropshire HealthcareNHS Foundation Trust is also taking part inone of a number of pilot schemes in the UKto provide mental healthcare to veterans.

The organisational and governance structuresof the DMS are provided in appendix 3.

Key findings

Our review identified some areas of exceptionalgood practice and expertise. It also foundseveral areas where improvement is needed.Our findings are summarised under thefollowing headings:

• The standards of care across the DMS.

• Views of those who use the services.

• Areas of exemplary practice.

• Areas of good practice in clinical governance.

The standards of care across the DMS

Clinical care

Our review centred on the processes andprocedures within the DMS for ensuring the


Summary continued

delivery of safe and effective care and treatment,and whether these were focused on the needsof patients. This is called ‘clinical governance’.The review also considered how servicescontinually sought to promote and improvehealth and wellbeing.

Our review considered the quality of care andtreatment provided by the DMS overall and howwell services were complying with Governmentstandards for quality of care, the safety ofpatients, how services are managed, the trainingof staff and the facilities in which care is delivered.We found that services were provided by highlymotivated and caring teams of staff across allthree Services. There was a strong focus onpatients and an emphasis on providing accessibleservices in a number of diverse settings.

Following guidance on best practice

Planning and delivering treatment and careshould take into account any nationally agreedrecommendations for the use of existing ornew medicines and treatments and anyguidance on clinical procedures. Much of thisguidance is produced by the National Institutefor Health and Clinical Effectiveness (NICE).

The Defence Dental Services declared 100%compliance with this standard, while servicesprovided by the Royal Navy, the Army and theRoyal Air Force (RAF) declared much lowerlevels of compliance. Half of the Royal Navyunits declared non-compliance. Units thatcomplied had clear documented processes andplans for implementing recommendations onbest practice with regular monitoring in place.

We found that some staff were confused aboutthe difference between NICE guidance, whichevaluates the safety and effectiveness of clinicalprocedures where they are used for diagnosis

or treatment, and NICE technology appraisals,which are recommendations on the use of newand existing medicines and treatments.

Infection control, use of clinical devices anddisposal of clinical waste

These standards focus on ensuring thatworking practices prevent or reduce the riskof harm to patients and have a particularemphasis on hygiene and cleanliness.

Infection controlNearly 70% of the units’ self-assessmentsdeclared compliance with standards on infectioncontrol, with the exception of the Royal Navy,where over half declared non-compliance. Ourreview found that although some areas hadclear infection control policies and monitoringin place and had identified specific membersof staff to take overall responsibility for themanagement of infection control, this wasnot the case in half of the units visited in ourfollow-up visits. Cleaning contracts were alsofrequently stated to be inadequate.

Medical devicesOver 90% of the units’ self-assessments declaredcompliance with ensuring that all risks associatedwith obtaining and using medical devices wereminimised. We found that there were clear linesof accountability to ensure this in the units visited.

Reuseable medical devicesNearly 90% of the units’ self-assessmentsdeclared compliance with ensuring that reusablemedical devices were properly decontaminatedbefore being re-used and that risks associatedwith decontamination facilities and processeswere well managed. However, we found thatin some areas there was a lack of monitoringto assure that this standard was beingcomplied with.


Disposal of clinical waste Eighty-four per cent of units’ self-assessmentsdeclared compliance with ensuring that thereare systems in place to minimise risk to patients,staff and the general public by properlymanaging the segregation, handling, transportand disposal of waste. We found that some ofthe units visited had insufficient local monitoringof clinical waste and inappropriate segregationand transporting of waste.

Management of medicines

Services should have systems in place toensure that medicines are handled safelyand securely.

Eighty-two per cent of self-assessmentsdeclared compliance with ensuring clear lines ofaccountability for managing medicines, regularreview of the medicine stock, adherence toprescribing policy and appropriate managementof controlled drugs. In our visits, we found thatover half of the units’ compliance was impededby factors such as a lack of monitoring of thepolicy on the management of medicines,insufficient training for staff in dispensingmedicines, and inconsistencies and under-reporting of incidents relating to prescribingand dispensing medicines.

Management of medical records

Services should have a systematic andplanned approach to the management ofmedical records, and all records should becompleted appropriately, available whenrequired, maintained confidentially and storedsecurely at all times.

We found that the management of medicalrecords was an area that needed to improve.While clear policies and practices were in placeand staff were aware of the need to maintain

the confidentiality of personal information,we observed several breaches of informationsecurity. This included not ensuring that patientrecords were stored securely at all times.

We received some reports about difficulties inthe introduction of the electronic medical recordsystem – called the ‘Defence ManagementInformation Capability Programme’. Thisprogramme is intended to deliver an integratedelectronic healthcare record and improvethe way the DMS accesses and uses healthinformation. Despite initial difficulties, staff werepositive about the roll out of this programme.

Environment and amenities for care

All care and treatment should be provided inenvironments that promote the wellbeing ofpatients and staff and are designed for theeffective and safe delivery of care.

We found that some services were provided ineither purpose-built, well-equipped medicalcentres, or in suitably adapted older buildings.These units offered clean and appropriateclinical environments. Although a lot of thebuildings used to provide medical care wereold, these were still well maintained.

However, we also visited a number of medicalcentres, both in the UK and overseas, whereclinical services were provided in what weconsidered to be unacceptable conditions.These included very poor maintenance of thebuildings and inadequate facilities for clinicalstaff to work in. Our review found that someof the medical centres also had poor levelsof cleanliness. It was particularly concerningthat some of these centres had been scrutinisedthrough internal environmental audits. Thereview found internal audit reports highlightingareas of concern in terms of safety and


Summary continued

infection control with clear recommendations.However, there was little evidence ofrecommendations being taken forward.

One of the reasons given for not maintainingthese medical centres was because a ‘new build’was either planned or under consideration,but this was often several years away fromconstruction. We found the facilities in theseareas to be wholly unacceptable for patientsand for the staff providing health services, andreported our concerns to the DMS.

In response, the DMS took immediate action tobegin to address these concerns. Actions takenincluded drawing up detailed programmes ofrenovation and maintenance, repairing buildings,replacing equipment, upgrading existing facilities,ensuring that radiators had temperature controls,and ensuring that patients’ privacy wasmaintained – especially in changing facilities.The DMS also implemented a programmeof deep cleaning for areas where this wasidentified as a need. Actions were takenstraight away in some areas, with completiondates on all actions by the end of March 2009.The DMS stated that all of the issues raised hadbeen taken very seriously and were seen as anopportunity to demonstrate commitment toimproving standards for providing healthcare.

We found that in some areas in England, therewas a high concentration of medical centres inclose proximity to each other. We recommendthat the DMS undertake a review of the number,location and standards of accommodation ofthe medical centres and consider how toensure the best use of the resources available.

Clinical supervision

Clinical care and treatment should bedelivered under appropriate supervision andleadership for all staff.

We found that there was a high level of declaredcompliance against this standard. Our follow-up visits found that units were aware of wherethere were good supervisory arrangements inplace and where this needed to be improved.The GP training practices that we visited hadrobust clinical supervision for trainees.

We also found that professionally qualified clinicalstaff were able to update the clinical skills andtechniques that were relevant to their work andconsidered this to be an area of good practice.

Improving health

Services should be designed to promote, protectand improve the health of the people served.

Keeping Service personnel healthy is a keypriority for the DMS. We found some excellentinitiatives in place to promote healthy lifestylesand effective joint working with local NHS trustsin England. Health promotion activities focusedon DMS policy issues, such as smokingcessation, sexual health and programmesof health screening. Other areas includedinformation on managing specific conditions,such as diabetes and asthma and advice andsupport on alcohol misuse.

We found an area of particularly good practicewhen reviewing this standard in Army primarycare services. Regular health promotionthemes were set by the medical directorates, inpartnership with the single Service headquarters,and delivered in local medical centres. However,the themes were not always followed in eachmedical centre.


Safety of patients

Standards relating to patients’ safety areconcerned with ensuring that safety isenhanced and maintained and that activitiesare in place that prevent or reduce the risk ofharm to patients.

Child protection and safeguarding trainingWe reviewed the standard that ensures thatmedical services have processes in place foridentifying, reporting and taking action if thereare any actual or potential concerns about thesafety of a child. Children are defined as allthose under the age of 18, and this includesdependant children of Service personnel,cadets or trainees.

Our review found that some DMS staff wereunsure of the process for reporting any childprotection or safeguarding issues. Also ofparticular concern, in some areas, was a lackof recognition that those under the age of 18,particular those between the ages of 16 to 18should be defined as children. Children fromthe age of 16 can consent to medical treatmentbut are still legally defined as children.

While no specific concerns were found regardingthe practice of treating and safeguardingchildren, the lack of child protection trainingand the realisation of responsibilities for all staffworking both directly and indirectly with childrenwas a concern which should be addressed.

Use of ambulancesWe found an issue relating to the use ofambulances to transport patients – but in onearea only. Staff were concerned about thecontinued use of ambulances that had beenreported in an internal inspection as unsafeand needing urgent replacement. We raisedthis with senior officers during the review as

a matter of concern to the DMS because of thecontinuing risk to patients.

The DMS has stated that the ambulances, inthis one area, had been in use since 2002 andthat it was known that these vehicles presenteda safety risk to patients. A plan to modifyexisting vehicles and reduce the risk by midFebruary 2009 was put in place. New vehiclesare planned to be delivered in June or July 2009.The risk in using these vehicles has been knownfor a considerable time and their continued useprolongs the risk to patients’ safety. We considerthat this risk remains high and unacceptable.

Management of staff and services

Managerial leadership and accountabilityfocus on ensuring that the culture, systemsand working practices that ensure probity,quality improvement and patients’ safety arecentral to all activities concerned with clinicalcare and treatment.

Raising concernsWe found that DMS staff were generally confidentin raising concerns about any aspect of clinicalpractice and challenging discrimination andequality issues. There was a culture of trying toaddress and sort out any concerns, incidents orcomplaints at a local level. This had, however, ledto under-reporting of these within many services.Most staff who spoke to our assessors knew howto report issues or incidents through the chainof command or through the incident reportingprocesses. Some staff told us that there wassome reluctance to report concerns due to theculture and command structure, and that itmay affect career progression. Most of the unitswe visited had systems in place for reportingand managing any risk to healthcare delivery,collecting feedback from people who use thehealth services and reviewing clinical practice.


Summary continued

Training of staffWe found good practice in the access totraining given to all levels of staff. In particular,opportunities for clinical staff to update orextend their clinical skills and knowledge wereextensive. Other examples included access tohealth promotion courses for practice nurses.These included programmes to provide support,care and advice for people with asthma ordiabetes, or health promotion activities suchas weight loss clinics and advice and supporton giving up smoking.

“….the training that we are giving ourclinicians keeps them up to speed and hasseen our service improved over the years… the commitment that these people giveprovides an excellent service….”Colonel Pat John, Deputy Chief of StaffMedical at Permanent Joint HQ

Attendance at mandatory training was generallygood although not all areas declared 100%compliance with this standard. DMS staff insome areas reported that their high turnoverof staff made it more difficult to release stafffor essential training.

Medical assistantsThe DMS employs medical assistants withineach of the three Services, who have no primaryclinical qualification, but are trained in basicmedical care – for example, hearing or sighttesting, first aid and basic or advanced lifesupport skills. There is no exact equivalent rolein the NHS, although some of the RAF medicalassistants had undergone state registeredparamedic training through the NHS trainingscheme. The role of the medical assistant isinvaluable and variable. It includes extensiveadministrative and military duties, as wellas providing support to medical teams –

for example, on ships, in medical centresand rehabilitation units and in field hospitals.Medical assistants are often the first responderin emergency medical situations.

“….our medical assistants are the ‘bedrocks’ atsea…our challenge is to support them more….”Surgeon Commodore Tim Douglas-Riley,Director, Royal Naval Medical Service

Our assessment teams met many medicalassistants throughout the three Services andfound this extremely committed group of staffto be very enthusiastic about their roles, flexible,positive and motivated. They were appreciativeof, and valued access to, regular training anddevelopment of skills, but raised concerns abouta lack of clear pathways for career progression.They were particularly concerned that theirskills and competence, gained through trainingand experience, were not leading to formalqualifications, which would assist their careers,both within the DMS and at the end of theirmilitary contract or on retirement from theServices.

The role of medical assistants and theiraccess to qualifications needs to be reviewedand developed. The skills of these personnelcould be harnessed in the health service, whenthey leave the DMS. It would be appropriatefor the DMS to liaise with bodies such as NHSEmployers to see how the skills and experienceacquired by medical assistants can betransferred when they leave the Services.

“….we recognise the need for our medics tobe more qualified and we are endeavouringto provide our medical assistants with moreformal education….”Air Vice-Marshal Paul Evans, Director GeneralRoyal Air Force Medical Services


Monitoring performancePerformance requirements are set out inthe Defence Health Programme and thecomplementary single Service plans andstrategies. Services are required to monitorand achieve these within specific timeframes.Defence Dental Services declared low levelsof compliance on this, as did the Joint MedicalCommand, which is responsible for themanagement of all joint clinical care, medicaleducation and commissioning specialist careand treatment.

We found that the role of regional and service-specific headquarters was not always clearto staff working in the clinical services. Thisaffected what was being reported between theheadquarters and clinical units.

Regular monitoring of how individual staff wereperforming and what development and trainingneeds were required, known as staff appraisals,was clearly evident.

Collecting information and health statistics

In managing services, the DMS collects healthstatistics and information in areas of healthcaredelivery. Regular internal reviews and auditsacross services have also taken place.However, these were planned, implementedand processed differently by the Royal Navy,the Army, the Royal Air Force and the DefenceDental Services. This has led to:

• A lack of a comprehensive approach tomanaging and reviewing services.

• A lack of learning lessons between Services.

• The inability to capture and provide a clearcorporate overview of how well the DMS, asa whole, was achieving standards or meetingrequired levels of performance.

It had not been possible for the DMS to makecomparisons between areas of provision asinformation is not collected, analysed and storedcentrally to obtain a full and detailed picture ofthe performance of the DMS as a whole.

The Defence Medical Information CapabilityProgramme, which is currently being rolled outis planned to provide electronic patient recordsand a central database with comprehensivehealth information. The DMS anticipates thatthis will bring about a consistent approach toinformation gathering and will be used as partof the governance of healthcare delivery.

Views of those who use the services

A key part of our review was to ask for commentsfrom Service personnel, members of theirfamilies and civilians who work for the Ministryof Defence and are entitled, under their contractof employment, to some aspects of medicaltreatment and care. The review receivedcomments from 300 people.

Seventy per cent of respondents, who gavea relevant comment, had a positive opinion ofprimary care services, stating that services wereaccessible and that staff were professional andcompetent. Negative comments were mainlyabout administration processes, including lossof medical records, poor communication andlack of continuity of care – for example, changesin doctors and use of locum medical staff.

Over 80% of respondents, who gave a relevantcomment, had a positive opinion of dentalservices, but concerns were raised about longwaiting times for appointments. A quarter ofthe people who responded stated that therewas a difference between treatment given toService personnel and treatment given to their


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dependants. A particular concern was thatsome dependants felt they were not treatedas well as Service personnel and, at times,had difficulty getting dental care. The DMS hasstated that dependants are not, however, entitledto defence dental care in the UK.

Seventy-nine per cent of the 47 relevantcomments gave a positive opinion of hospitalcare, although waiting times were consideredtoo long. Concern was raised about the closureof military hospitals in favour of NHS andindependent acute healthcare providers,stating a preference for military hospitals.

All the comments we received aboutrehabilitation services were positive. Serviceswere described as “excellent” and “first class”,with praise for professional and supportive staff.

The DMS provides community mental healthservices and, although the number ofrespondents commenting on these serviceswas low by comparison with other services,experiences were positive or satisfactory –including good access to services. We receivedno negative comments.

Areas of exemplary practice

Our review found a number of areas of very goodpractice throughout the DMS. We identified goodpractice based on standards, clinical opinionand feedback from those who use the services.The following were considered to be examplesof areas where practice was exemplary.

Trauma management in military operations

overseas in war zones

An area of great importance for the armedservices and their dependants is how injuries

in areas of conflict and in war zones, or‘hostile areas’, are managed. Our reviewfound exceptional practice in this area. Themanagement of major injuries encompassesa range of issues:

• PreparationThere are two major protocols covering allaspects of trauma management in areas ofconflict or war zones. These are setting upa field hospital and the management ofcasualties. We found that these protocols werecomprehensive and detailed. They are valued bystaff and are used extensively to prepare fordeployment. Our assessment team observedpart of a medical preparatory exercise.

• TrainingAll members of the DMS, who have beennominated to be deployed to areas of conflict,participate in exercises, such as learning andpracticing trauma care and management.During the month’s training, staff fully rehearsethe setting up and use of a field hospital.Training includes two three-day intensivemodules on the management of major battleinjuries, in accordance with DMS protocols,which are observed and audited. Although thecomposition of the medical teams changeduring a tour of duty, the fact that all haverehearsed and have a sound understanding oftheir roles maintains the integrity and qualityof the service delivered.

We found that staff in front line units understoodtheir role in relation to trauma. The trainingreinforced and confirmed their core roles: tosave life, stabilise the condition of casualtiesand to transport them for further treatment.


• Medical Emergency Response /ImmediateResponse TeamsEmergency medical care in hostile areas isprovided by teams of dedicated, highly efficientand extremely competent teams of clinical andclinical-support staff. The Medical EmergencyResponse Teams (MERT) and the ImmediateResponse Teams (IRT), led by the Royal AirForce, provide an emergency response serviceto support medical teams in the care, treatmentand evacuation of personnel injured on thebattlefield. We found the commitment toensuring responsive, well-trained and well-equipped staff to provide emergency care andtreatment to members of the armed forces inhostile situations to be excellent and exemplarypractice. The MERT and IRT are doctors,paramedics, nurses and medical assistants,who are normally flown to the site of theinjured by helicopter. All staff have undergonespecialist emergency response trainingappropriate to their role and provide immediate,often lifesaving, treatment on the battlefieldunder the protection of a combat guard. Pre-hospital care is delivered on the groundand in-flight on board the helicopter.

Helicopters are equipped to carry and treatcasualties who are on stretchers or who areable to walk. The time from receiving a callto the team being airborne and on the wayto the casualty is a matter of minutes.Team working from the moment a call isreceived is of the highest level. Casualties canbe assessed and treated very quickly, whichmay be critical to their recovery. We found thestandards of response and care and treatmentfrom the medical and immediate responseteams, in extremely challenging situations,to be exemplary.

“….we have the difficulty of operating in austereenvironments and in remote locations… thisis a traditional feature of what we do and weare doing this very well. All the indicators showwe are achieving an enviable record of success,especially with trauma…”Major General Alan Hawley, Director General Army Medical Services

• Hospital careCasualties admitted to hospital take a journey ofcare that starts in the emergency department,where their condition is stabilised and their careplanned. The policies, protocols and guidelinesnecessary to manage the different pathways ofcare, X-ray, intensive or high-dependency careor repatriation, are in place. Staff were wellinformed and trained in their use.

Staff make a rigorous check of equipment every24 hours. All equipment was checked to be ingood working order. Staff in the emergencydepartment and intensive and high dependencycare areas worked closely together.

“….the results achieved in the managementof the injured soldier in the current conflictsare the best ever reported… this is a trulyremarkable achievement….”Mr John Black, President, The Royal College of Surgeons of England

• Aeromedical evacuationA unit known as the Tactical Medical Wing, basedat RAF Lyneham, is responsible for providingteams for the RAF’s aeromedical evacuationservice. The teams work in various conditions,recovering ill or wounded personnel fromacross the world. RAF aeromedical personnelalso provide in-flight care to wounded and illpersonnel who require transport to and between


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medical facilities, such as field hospitals. Theunit has a number of staff on stand-by, who areready to leave their homes or places of work andgo anywhere they are required, at short notice.The Critical Care Air Support Teams provideworldwide repatriation of the most criticallyill and injured members of the armed forces.

“….a major achievement is establishing anaeromedical evacuation system that deliversthe critically injured patient from the point ofwounding to hospital care in the UK, often inless than 24 hours….”Major General von Bertele, Commander, Joint Medical Command

Patients’ diaries

We found a very innovative programme thatinvolved all staff recording events in diaries forindividual patients. We were told that recoveringpatients have found the patients’ diaries veryhelpful, as they can fill in the time lost fromtheir memories, which can be so disruptive torecovery. This initiative has also helped grievingrelatives to identify better with the last days oftheir loved one’s life. It can also reassure themas to the quality and intensity of the care whichwas given.

Diary entries tended to focus on significantevents or milestones in a patient’s care andrecovery, such as improvements in wounds orsitting out of bed for the first time. Colleagueswho were visiting patients were also encouragedto write entries and to include news from thepatients’ parent unit, or anything the patientmight have an interest in. We think that thisinitiative could be shared widely with NHS andindependent healthcare intensive care and highdependency units.

Major Trauma Audit for Clinical Effectiveness

(MACE)

The Royal Centre for Defence Medicine, locatedin Birmingham, leads the Major Trauma Auditfor Clinical Effectiveness, or MACE audit. This isa systematic review of standards and processesof care, which examines all aspects of traumaassessment, immediate and ongoing treatmentand care and clinical outcomes. Clinical feedbackis conducted on a weekly basis throughteleconference meetings between the UK andthe field hospitals in areas of conflict and warzones. This is known as the Joint TheatreClinical Case Conference. Standards andclinical procedures were examined carefully,and all aspects of the treatment were carefullyrecorded. All clinical data from when a personis wounded, through to rehabilitation is collectedon the Joint Theatre Trauma Registry. This usesstandard codes for injuries so that performancecan be compared internationally.

There was close scrutiny of this systematicreview of standards from Birmingham so thatall the required information was completedaccurately. The audit had 68 key performanceindicators and was used to review, develop andcontinuously improve trauma care.

“….The College is very impressed with thehigh level of research being carried out bythe DMS, which contributes directly to thevery good service our troops are receiving….”Mr John Black, President, The Royal College of Surgeons of England

We found the Major Trauma Audit for ClinicalEffectiveness to be excellent, but consider thatit would benefit from an electronic upgrade toimprove recording.


We believe that the management of injuredService personnel is worthy of publicising,as there is much that could be learned by thetrauma services within the NHS. All aspectsof the management of the journey of care havebeen made as efficient as possible, including:

• The design and set-up of the field hospital,with logical and quick access to all servicesas and when they are required.

• Attention to training, with all aspects covered,including clear roles and practice sessions,which are recorded and analysed.

• Training of all personnel, but led by themedical assistants, in immediate treatmentof life threatening injuries, using tourniquetsand haemostatic packs (to reduce blood loss)and morphine.

• Immediate transportation of casualties fromthe front line to the hospital, with patientsbeing stabilised on the way by specialist staff.

• Stabilisation in hospital, with immediatesurgery to save life. This is supported bystate of the art techniques, including liberaluse of haemostatic factors and drugs.

• Transfer to intensive care and quickrepatriation to the UK.

• Comprehensive audit, using in-houseinformation systems coupled with robust data.

Rehabilitation services

The DMS provides intensive rehabilitation supportto Service personnel on both an inpatient basisand a regional outpatient basis. Inpatient care isprovided at Headley Court rehabilitation centre,where Service personnel with musculoskeletal,neurological or complex trauma injuries aretreated. Patients can be transferred directlyfrom hospital care, or referred to Headley Court

as part of the rehabilitation programme.Accommodation is available to families ofpatients. Headley Court is staffed by Service andcivilian personnel. Facilities and services includehydrotherapy, a gym, a social work department,physiotherapy, occupational therapy, remedialtherapy and a prosthetic department.

The service provides a number of regionalrehabilitation units across the UK and inGermany. Our review found that the care andtreatment in regional rehabilitation units wasexcellent, and was provided by highly motivatedand dedicated staff.

Areas of good practice in clinicalgovernance

Our review found a number of specific andeffective systems in place for ensuring thedelivery of safe and effective care and treatmentwithin the units we visited. The following areexamples of good practice in clinicalgovernance relating to specific standards:

Acting on safety alerts

Systems should be in place to ensure thatnotices relating to safe care of patients, alertsand other communications concerning safetywhich require action, are acted upon withinrequired timescales in order to protect patients.These were evident throughout the DMS. Thereview found a high level of compliance withthis standard in the units visited in follow-upassessment visits. Evidence for complianceincluded policy, processes and systems for actingon safety notices and alerts, were well embedded.There were clear lines of accountability andresponsibility for designated staff and effectivemonitoring systems in place.


Summary continued

Use of medical devices

All of the units providing healthcare need tokeep patients, staff and visitors safe by havingsystems to ensure that all risks associatedwith obtaining and using medical devices areminimised. Compliance with this standard wasassessed by us in six units, which were assessedas complying both in their self-declarationand on our follow-up. Good practice includedclear policies and processes being in place tomake sure that equipment was ready for usewhen required. We also found clear lines ofaccountability for procurement and competency-based training for staff in these units.

Continuous learning for clinical staff

Professionally qualified staff who are providingclinical care should continuously update relevantskills and techniques. We made follow-upassessments on this standard in 14 units.We found that appraisals of staff were wellembedded and linked to programmes fortraining and development. We also found thatstaff received good access to training and someunits worked in partnership with NHS trusts todevelop clinical skills.

Participating in clinical audit

Clinical staff should participate in regularclinical audits and reviews of clinical services.We found a number of clinical audits withsubsequent action plans, and examplesof resulting changes and improvementsin practice. Some of the units we visitedhad a designated person to take the leadin audit, and training, developing, managingand learning from audits was in place.

Main conclusions

The DMS is responsible for providing routinehealthcare, as well as care and treatmentdelivered in a range of different and challengingenvironments in the UK and abroad, and on land,at sea and on board aircraft. The challengesthat this breadth of services presents are metby teams of committed and dedicated staff.Our review found areas of excellence and areaswhere improvements need to be made to ensurethat Service personnel, their dependants andcivilians continue to receive safe healthcare.

Our review found a number of examples ofexemplary healthcare provision in the areasof trauma care and rehabilitation. The trainingprocesses leading to excellent traumamanagement are an area that the NHS couldlearn from in the delivery of emergency care.

We found many examples of very good practicein individual units across the Royal Navy, theArmy and the Royal Air Force. There were,however, variations across the DMS in theway that health services were monitored andreviewed. The way that information was reportedand statistics collected made it difficult for theDMS to get a corporate picture of how serviceswere achieving standards or meeting requiredlevels of performance. This highlighted the needfor a clear governance structure and system forthe whole of the DMS.

During the course of the review however, the DMSreviewed its governance arrangements and hasnow published a healthcare governance andassurance policy directive. This is aimedat developing common healthcare governanceand assurance processes throughout the DMS.


Our review found that staff working in clinicalservices did not always understand the roleof regional and service-specific headquarters,and there is a need for this to be clarified.

Our review highlighted areas that are inneed of attention, as well as areas in need ofdevelopment. The DMS responded immediatelyto areas of concern raised during the courseof the review, primarily about buildings and theinfrastructure within medical centres, and tookimmediate action to begin to address these.There is still work to do, however, to ensurethat services are safe and that all clinicalenvironments are suitable and ‘fit for purpose’.

Despite being a relatively small sample of peoplewho use the DMS, those people who gave uscomments or concerns on their experiences ofcare and treatment were generally positive andsatisfied about healthcare services. One issueraised, however, is a perceived difference in thelevel of service provided to different groups ofpeople covered by DMS – particularly Servicepersonnel versus dependants and other workers.It would be beneficial for the DMS to be clearabout entitlement to care and provision, includingwhere entitlement is limited to specific groupsof people.

The information from our review, itsrecommendations and conclusions shouldinform clinical governance structures andprocesses for the whole of the DMS, enableareas already identified as good practice todevelop further, and focus work on areas forimprovement and development.

The Healthcare Commission recommends thatthe DMS reflects on this experience of externalreview and consider how to ensure independentreview of its services in the future.

Recommendations

Clinical care

National guidance and best practice

The DMS should:

• Base all its care and treatment on bestpractice guidance and available directives.

• Review all relevant NICE technologyappraisals on new and existing medicinesand treatments, and guidance on clinicalprocedures to ensure that these are reflectedin DMS policy and guidance where relevant.

• More importantly, ensure that its currentpolicy and directives, which are already basedon best practice, are implemented andmonitored to ensure compliance.

Infection control, decontamination and clinicalwaste

The DMS should:

• Ensure that they have effective infectioncontrol and management plans and processesin place and that they have a named personto lead all aspects of the management ofinfection control. This should include detailedcleaning schedules and standards on hygieneto be maintained.

• Adhere to decontamination policy, proceduresand processes for the safe and effectivesegregation, handling and disposal of allclinical waste, as part of an infection controlgovernance plan.

Management of medicines

The DMS should:

• Review all its policies, processes and practiceson the management of medicines, due to thecomparatively high level of assessed non-


Summary continued

compliance that we found with all parts of thisstandard across all three Services.

Management of medical records

The DMS should:

• Keep all personal and confidential medicalinformation securely, whether in paper orelectronic form, to avoid unauthorised orinappropriate access, in line with DMS policyand government legislation. Although effectiveinformation governance is in place within someunits, this is not the case across the DMS.

• Give all staff advice and training on informationmanagement and governance, as part of theirinduction programmes.

Clinical environments

The DMS should:

• In partnership with those responsible forinfrastructure including Defence Estates andthe single Services, carry out a review of DMSfacilities in the UK and overseas to ensurethat they are all ‘fit for purpose’ for clinicalcare and for the safety of patients and staff.

• Set minimum standards for all healthcarefacilities, which can be used for regularmonitoring through environmental andinfection control audits. Action plans forall audits should specify named individualsaccountable for ensuring that actions areundertaken in a timely and appropriate manner.

• Ensure that clear lines of accountability forthe maintenance and infrastructure of allclinical environments are included in localgovernance plans.

• Undertake a review of the number, locationand standards of accommodation of allmedical centres and consider how to ensurethe best use of the resources available.

Clinical supervision

The DMS should:

• Provide all staff involved in the delivery ofcare and treatment with appropriate levelsof clinical supervision and clinical leadership.There are already a number of effectiveclinical supervisory frameworks and practices,and this good practice should be developed tocover the DMS.

Improving health

The DMS should:

• Develop a systematic and targeted approachto health promotion and disease prevention,building on current good initiatives andpartnerships with local NHS trusts. This shouldinclude assessments of local health needsand an evaluation of the impact of initiatives.

• Collate and analyse information on healthpromotion and disease prevention centrallyto promote sharing and learning across allof the DMS.

Safety of patients

Child protection and safeguarding training

The DMS should:

• Implement a programme of training inchild protection and safeguarding. The levelof training should be proportionate andappropriate to the position of staff, but mustinclude all clinical and non-clinical staff, andcontracted staff working in areas wherechildren are treated.

• Ensure that all its staff recognise that Servicepersonnel who are under 18 years of age arelegally still children. Healthcare staff need totreat them appropriately in relation to childprotection and safeguarding.


Use of ambulances

The DMS should:

• Maintain all its vehicles used for transportingpatients within agreed standards of safety.Where risks to the safety of patients areknown, these should be addressedimmediately. Where examination shows that vehicles should be replaced as a matterof urgency – or immediately, this needs to be acted upon.

Management of staff and services

Care and treatment available to non-Servicepersonnel

The DMS should:

• Make information available on all servicesin the UK and overseas that makes it clearwhich specific care and treatment is availableto Service personnel, and which is availableto their dependants and entitled civilians.

Experiences of the dependants of Servicepersonnel

The DMS should:

• Explore the concerns of those using services,especially dependants, about the difficultiesexperienced with the administration andbureaucracy of services.

Processes and structures relating to clinicalgovernance

The DMS should:

• Monitor the implementation of the newgovernance structure and arrangements andthe accountability and responsibilities forpersonnel with leading clinical governanceroles and responsibilities.

• Describe the responsibilities of headquarters,clinical units and individual staff so thatthere are clear definitions of their roles andresponsibilities for ensuring effective clinicalgovernance.

• Agree a governance plan that describeshow and what information will be collected,analysed and used to assist developmentand innovation.

The DMS has already recognised that this is anarea for improvement and is in the process ofeffecting changes to the clinical governanceprocesses and structures.

Mandatory training

The DMS should:

• Address the inconsistencies in attendance atmandatory training programmes to ensurethat all staff, military and civilian personnel,including students, attend mandatory trainingthat is relevant to their position and to theservice in which they are working.

• Ensure that it has monitoring systems inplace to record attendance at all requiredactivities for training and development, eitherbefore placement, posting or deployment orwithin an acceptable timeframe within theservice to which individuals are assigned.

The role of medical assistants

The DMS should:

• Review the role of medical assistants workingin the Royal Navy, the Army and the Royal AirForce, with a particular emphasis on theirrole in assisting the delivery of healthcareand treatment.


Summary continued

• Consider identifying appropriate qualificationsfor the role of medical assistant in all threeServices. This would help to ensure that theunderpinning knowledge, as well as thepractical application of clinical skills, isunderstood and competence formallyassessed and recognised.

Independent assessment and review

The DMS should:

• Reflect on the experience of our externalreview and consider how to find a way toensure independent review of its serviceson a regular basis in the future.

The Healthcare Commission would like tocommend the Surgeon General for being openand willing to have an independent review of theDMS and also for taking swift action on issuesthat arose during the course of the review. TheCommission believes that this has shown thevalue of independent assessment both for themanagement of the services and for the deliveryof clinical care.

The DMS has already engaged in earlydiscussions about ongoing external review andregulation with the new regulator for health,mental health and adult social care, the CareQuality Commission, which will take over thework of the Healthcare Commission, whichceases to exist after 31 March 2009. The CareQuality Commission will become operationalfrom 1 April 2009.

Next steps

This was a one-off review of the quality of theDMS undertaken by the Healthcare Commission.We have no jurisdiction to require any actionsto be taken. However, the findings of this reviewshould inform the development of care andtreatment provided by the DMS, influence futureplanning of services and provide a focus on theareas that need improvement.

The DMS has seen the report of the review andhas accepted its recommendations and begunto take action where needed.

We strongly recommend that the DMS drawsup a clear action plan to address all of therecommendations from this review. This needsto include a timetable for action, what outcomesare required, and to identify key personnelwho will be accountable for implementing,monitoring, reporting and ensuring that actionsare undertaken in a timely and effective way.


The Healthcare Commission had not assessedDefence Medical Services (DMS) before, asit was outside the scope of the Health andSocial Care Act (2003), which provides the legalframework we operate in. However, followingthe request from the Surgeon General for theHealthcare Commission to review the DMS,regulations were laid before Parliament tobring the DMS within our regulatory remit inJune 2008. We then adapted and applied themethodologies that we use to assess Englishhealthcare providers to assess the DMS.

The aims of our review were:

• To examine the clinical governance processesof the DMS by undertaking an independentassessment of the services provided toService personnel, their dependants andentitled civilians.

• To align the DMS with best practice inhealthcare assessment and regulationprocesses.

• To promote improvement in DMS provisionby identifying good practice and areas forimprovement.


1. Introduction

Approach

The Healthcare Commission adopted a similarapproach to that used used for the assessmentof NHS trusts’ performance against theStandards for Better Health, produced by theDepartment of Health in 2004.

This involved developing criteria for assessingeach standard. These criteria were presentedas elements. The elements provided furtherdetail on the standard and provided somedirection on how compliance with the standardmay be demonstrated. Each element includedthe key items of legislation and the Ministryof Defence or DMS policy that described theunderlying requirements. These have beenused to underpin the review. We developedthese criteria with representatives from theRoyal Navy, the Army and the Royal Air Force.

In addition, we reviewed how applicable eachof the standards was to each type of service –such as community mental health and primarycare. We identified some standards as notbeing applicable – for example standardsrelating to the provision of food, which onlyapply to inpatient settings or services whichhave overnight bedding down facilities.

We asked members of the armed forces, theirdependants and entitled civilians, who use theservices, for their comments on the quality ofthe healthcare services provided.

We also invited organisations that work with theDMS to submit comments. This was in line withcurrent methods of seeking commentariesfrom third parties in the assessment of NHStrusts in England.

We sought feedback in three distinct ways:

• Requesting comments from members of thearmed forces and their dependants, and alsocivilians who work for the Ministry of Defenceon a contractual basis or were entitled toemergency treatment in areas of conflictor war zones.

• Requesting comments from organisations inthe voluntary sector who work with currentand ex-Service personnel, for example,welfare services.

• Requesting comments from organisationsthat provide professional regulation, adviceand support to the DMS, for example, theRoyal Colleges.

We received just fewer than 500 commentsabout the healthcare provided by the DMS,primarily from members of the armed forces.

The overall aims of obtaining informationfrom those who use the service and relatedorganisations were to identify:

• Areas of good or excellent practice.

• Areas of concern.

Self-assessment

The first stage of the review involved a self-assessment by the DMS against the standards,based on the criteria developed. Although it hasbeen DMS policy for some time to comply withthe Standards for Better Health, each of thethree Services had previously chosen to do thisindependently and had their own systems forclinical governance. Most were using self-assessment questionnaires, followed up byinternal inspections. This was, however, thefirst time that all three Services had beenasked to complete the same self-assessment.


2. Methodology

We requested self-assessments of declarationsof compliance with the standards at unit level –for example, military hospitals and rehabilitationcentres – rather than a single declaration forthe whole of the DMS. Within Army provisionand for dental services, declarations weremade on a regional basis to cover severalhealth centres. This was for pragmatic reasons,recognising the lack of a common assurancesystem throughout the DMS. We received 153declarations in total.

One key difference from the assessment ofstandards in the NHS was that we asked DMSunits for evidence to support the declarationsfor each standard. This was to address, in part,the lack of external sources of informationavailable about performance in the DMSon which to cross-check and risk-assessdeclarations.

When NHS trusts submit their self-assessmentdeclarations of compliance against the Standardsfor Better Health, we can compare and analysethem against a considerable amount ofinformation. This allows us to target follow-upassessment visits to those trusts that areactually or potentially non-compliant. Thisinformation is drawn from the various sourcesthat trusts are required to submit informationto on their performance against targets andstandards. The DMS does not submit healthinformation to external bodies in the same wayas the NHS. There was therefore no informationon which to cross-check the individual units’self-declarations.

Each unit or region submitted their completedself-assessment to us electronically, or onpaper if internet access was not availableor not practicable.

Follow-up assessment visits

The second stage of our review consisted ofa series of assessment visits carried out byHealthcare Commission assessors, to checkthe accuracy of the self-assessments.

The overarching aims of these follow-upassessment visits were to:

• Provide a more detailed picture of performancethan could have been obtained by self-assessment alone.

• Assess the accuracy of the self-assessments.

• Compare effectiveness of clinical governanceprocesses across the DMS to identify areasof excellence as well as those areas whereimprovement is necessary.

We visited 53 units, which we selected on thebasis of a stratified sample, representativeof the different service types. Therefore, thelargest number of visits was to primary careservices, as these formed the majority ofservices provided by the DMS. We made fewervisits to community mental health and dentalservices, as there were fewer of these. A list ofthe DMS units visited is provided in appendix 4.

A team of assessors from the HealthcareCommission undertook these visits duringOctober and November 2008. Teams consistedof three to four experienced assessors andsenior clinical advisors. Each member of theassessment team went through a briefing andtraining programme to familiarise themselveswith DMS policies and procedures, gain anunderstanding of the context in which healthcareis provided by the DMS and understand thescope and diversity of service provision. Trainingand written guidance was also given on themethodology and assessment tools to be usedin the follow-up visits.


2. Methodology continued

Although all of the standards have been assessedduring our review, we did not assess everystandard on our visits. We chose the standardsfor the follow-up assessment visits in partnershipwith the DMS. They included all the safety andclinical effectiveness standards, as well as anumber of standards on governance, patientfocused services and public health.

We selected five standards for assessment oneach visit, according to the relevance for theservice being provided – for example, standardsrelating to health promotion were only chosen forfollow-up in primary care. Other considerationswere to provide as broad as possible anassessment of standards across provision toallow comparisons between the three Services.

Our approach for the assessment visits was totest compliance with the standards. This wasdifferent from our approach in the NHS whereinspections are used to test assurance systems.NHS trusts are required to continually providehealth statistics and information to nationalorganisations and central government. Thisinformation is used to cross-check declarations,risk-assess those at risk of non-complianceand target follow-up assessment. However, theDMS does not provide the same informationand therefore it was felt to be more appropriateand meaningful to check compliance.

We selected the standards for assessmentrandomly, and therefore there was a mixtureof standards where units had declared thatthey were compliant and some where theyhad declared that they were non-compliant.Again, this differed from our assessment of theNHS where inspection teams only follow-upstandards where a trust has declared to becompliant, but we have evidence to suggestthey were non-compliant.

We developed inspection guides for each of thestandards being assessed during our visits. Wealso developed questions for each of the elementsbeing assessed. This ensured consistencybetween the various assessment teams in thequestions they asked and the judgements thatthey made.

Our assessors had to establish whether anyassurance mechanism that was in place couldbe supported by evidence, through speaking tothe people in charge of the unit as well as theirstaff. In addition, we developed an observationtool. This enabled our assessment teams tocheck compliance with standards throughobservations within the different units andservice types.

As well as looking for evidence of complianceand non-compliance with the standards, ourassessors also looked for examples of goodor excellent practice.


The findings of the review are divided intotwo categories:

• The comments we received from peopleusing the services and comments fromorganisations working with the DefenceMedical Services (DMS).

• Information from units’ self-assessmentdeclarations and our follow-up visits toclinical areas.

Comments from people using theservices and organisations workingwith the DMS

The comments from people using the servicesand organisations working with the DMS arereported in two ways. Firstly, comments onspecific services as follows:

• Primary care

• Dental services

• Secondary care (hospital services)

• Rehabilitation services

• Community mental health services.

Secondly, key issues by role of respondentswho submitted comment as follows:

• Members of the armed forces.

• Entitled civilians.

• Family dependants.

• Professional bodies.

We received 485 pieces of feedback aboutthe healthcare services provided by the DMS.

We received comments from 215 members ofthe armed forces, 52 dependants, 20 entitledcivilians and 13 professional bodies.

Note: respondents could comment on more than onearea of healthcare.

We invited feedback from members of thearmed forces, their dependants and entitledcivilians about their experiences of care providedby the DMS. We also sought comments fromvoluntary organisations that work with currentor ex-Service personnel and from organisationsthat provide professional regulation, advice andsupport to the DMS on clinical issues. Therewere a number of options available for providingcomments on the services – by completing anon-line feedback form, writing to or emailingthe Healthcare Commission, or by telephoningour helpline. We used the Ministry of Defenceinternal communication systems to publicise this.


3. Details of findings

Primary care 213Dental services 128Secondary care (hospital care) 81Rehabilitation services 33Community mental health services 10Other 20Total 485

Number of commentaries by healthcare types

Member of the armed forces 215Entitled civilians 20Family dependants 52Professional bodies 13Total 300

Number of respondents by role

We received a total of 485 pieces of feedback inresponse to our appeal. Of these, the largestproportion of responses (215) was frommembers of the armed forces, with 52 fromdependants, 20 from entitled civilians and 13from professional bodies.

Commentary analysis by healthcare type

Primary care

We heard from 145 respondents who had anopinion on primary care services. Of these, morethan 70% were positive, with less than a thirdexpressing a negative (23%) or satisfactory(6%) view.

Comments from members of the armed forceswere 65% positive, from dependants 84%positive, from entitled civilians 89% positiveand from professional bodies 60% positive.

“In general terms I have found that access toprimary health has been either very good orexcellent. I have been able to get appointmentsin a timely manner and contact with healthprofessionals and support staff has been apositive experience.”Member of the armed forces

Attitudes of staff were reflected upon favourablyby 68% of the 38 respondents who commented onthis issue.

“The care I have received from the RN sick bayshave been excellent, delivered by helpful cheerfulstaff. What a contrast to my NHS experiences!”Member of the armed forces

“The service I received was excellent, I reallyfelt listened to and cared for and that allprocedures were followed up and thateverything was explained to me.”Family member

“Sometimes I feel as though I am not beingtreated as a ‘patient’ in the sense that I wouldbe in the NHS environment, and just seenas a soldier, when in fact the doctor-patientrelationship should supersede that of officer-soldier in these situations.”Member of the armed forces

Access to appointments drew a mixed responsefrom 62 respondents, with 53% of those whocommented on access being positive, and 47%being negative. It would appear this is an issuethat varies significantly by service and by location.

Administration and bureaucracy drew aconsistently negative response. Of therespondents who commented on it, 97%described negative experiences, although thenumber who commented was small overall –only 32 out of the 485 comments received.

“The care given by primary healthcare serviceshas been excellent. This is undermined,however, by the amount of repetitiveadministration and bureaucracy that hindersclinical staff from providing even better care.The introduction of a new IT programme hashelped but this is being hampered by thecontinued use of paper based records, etc.”Member of the armed forces

Communication and continuity of primary careboth received a number of negative comments.Sixty-two per cent of the 26 respondents whomentioned communication described it as poor,and 88% of the 24 who reflected on continuityof primary care felt it was poor.

“Usually pretty good. However, tends to be alarge turnover of locums and, sometimes givesome staff more time off than is sometimesnecessary. This turnover of staff also affectsmy wife who gets into a position of trust with


a doctor to find out that they have then movedon and so forth.”Member of the armed forces

“I have not been able to see the same doctorand have had different opinions to the sameailment. There does not appear to be enoughtime to see patients if you have more than oneproblem. I was asked if my second issue wasgoing to take long because there was a queueoutside. I felt I was being rushed when myhealthcare is important to me.”Member of the armed forces

“Having just retired after 37 years service I was,in essence, thrown in the streets medicallyspeaking. I was under treatment on my lastday of service but was cut off immediately. TheNHS still do not have any documentation onme. As a veteran the Service and governmentare not interested.”Veteran

“The healthcare that I have received has beenfirst class. All staff have been informative,helpful and friendly. Every time I have hadan appointment I have felt comfortable andextremely well looked after.”Entitled civilian

Dental services

More than 80% of the 77 comments that statedan opinion on defence dental care service werepositive, with the remainder being negative.Comments expressing an opinion on the DMSdental care service from members of the armedforces were 89% positive, from dependants 60%positive and from entitled civilians 75% positive.

“I have completed 26 years service andwould like to say that I’ve had excellenttreatment throughout this time and look

forward to another nine years.”Member of the armed forces

“I have no complaints as the service I havereceived has always been excellent and seemsto have improved over the last few years.”Member of the armed forces

Access to appointments and dental care wereconsidered a problem for 32% of the 37respondents who commented on this issue.

“Good service but long waits for appointments(dentist and hygienist) to carry out annualinspections and you keep getting remindersto tell you that you’re overdue!”Member of the armed forces

Differences in care for Service personnel anddependents were raised in 18% of respondentscommenting on dental services, declaringthat the dental services did not recognisedependants at all.

“Once again my treatment over the years fordental treatment has been second to none.It was disappointing though when treatmentfor my family members ceased a number ofyears ago and was dependent on the areayou are serving…the difficulty it is to finda NHS dentist to treat family members.”Member of the armed forces

Hospital care

Seventy-nine per cent of the 47 comments on theopinion of DMS hospital care were positive, withthe remainder either fair (4%) or negative (17%).

The major source of negative comment was theclosure of military hospitals in favour of NHSand independent healthcare providers. This wasraised by 17% of the people who commented onhospital care.


3. Details of findings continued

“The service provided for members of thearmed forces on return is inadequate, bringback a military hospital with nurses, doctorsand allied health practitioners who understandthe military ethos.”Entitled civilian

Waiting times and booking an appointment wascommented on by 20 out of 81 (25%) respondentswho submitted feedback regarding hospital care.Of these 20 comments, 12 (60%) were negative.

Rehabilitation services

All of the 19 respondents (100%) who submittedviews on DMS rehabilitation services providedpositive feedback.

Comments from members of the armed forceswere 100% positive, there were no responsesfrom dependants, 100% positive from entitledcivilians and no responses from professionalbodies.

“Post surgery (knee reconstruction), I’mnow under the care of Cranwell regionalrehabilitation unit and although it’s early daysyet (two weeks post operation) I’m really happywith the service that I’m receiving.”Member of the armed forces

“Headley Court provides outstandingrehabilitation facilities that use intensivemethods to produce outstanding results.After six months of almost no progress afterbreaking a shoulder, I was delighted with astartling breakthrough achieved at HeadleyCourt. More please.”Member of the armed forces

“I was referred to the regional rehabilitationunit and received excellent care throughoutthe care pathway.”Member of the armed forces

“My rehabilitation was first class. I was given allthe support to ensure that my muscles werebuilt up around my knee to support healing andI am now able to fully participate in all sports.”Member of the armed forces

“I had cause to utilise the Princess Maryhospital rehabilitation services and havereceived a first class service. The staff had agreat deal of understanding of rehabilitationtechniques to deal with complicated injuries.”Member of the armed forces

Community mental health services

Seven respondents expressed an opinion on thecommunity mental health services provided bythe DMS and of those 86% were positive and14% were fair. Comments expressing anopinion on the DMS hospital care service frommembers of the armed forces were 80%positive and 100% positive from dependants.There were no comments from entitled civiliansor the professional bodies.

“Mental health care is very effective withinthis area. They are quick to respond topatients’ needs.” Family member

Other feedback

An open feedback element was provided in thefeedback form, and of the seven people whochose to use it, 71% expressed a positive opinionof DMS services, with the remainder expressinga negative view.

“Deployed primary and secondary healthcareare the best in the world! What a shame thatwe can’t give our soldiers, sailors, airmenand their families treatment this efficientlyand enthusiastically at home!”Member of the armed forces


Information from unit self-assessmentsand follow-up visits

The following summarises the key findingsfrom the self-assessment declarations andinformation from the follow-up visits.

The DMS submitted 153 individual self-assessment declarations stating whether theirarea of healthcare services was compliant ornon-compliant with the standard. The unitswere asked to provide evidence used to assesscompliance. In the follow-up assessment visitsto a sample of services, we looked at evidenceof compliance and whether there wasagreement with the service’s declaration.

Service provision was categorised into thefollowing:

• Primary care/occupational medicine.

• Secondary care/hospital services.

• Regional rehabilitation units.

• Inpatient rehabilitation.

• Departments of community mental health.

• Defence dental services.

• Medical directorates within the single Serviceheadquarters.

• Regional medical headquarters.

The number of self-assessments submittedto us consisted of:

• 50 from Royal Navy units including the RoyalFleet Auxiliary.

• 26 from the British Army. These representedthe regions which the British Army serve andcontain a number of different healthcare units

within each region. Also included were fieldarmy medical formations and headquartersand the Territorial Army.

• 43 from Royal Air Force units including theRoyal Auxiliary Air Force.

• 12 from Defence Dental Service (DDS) unitswhich included the DDS headquarters andthe DDS regions where each region hasseveral dental centres.

• 19 from Permanent Joint Headquarters (UK)units. These included units deployed tooperations and the Permanent JointOperating Bases.

• 3 from Joint Medical Command units.

Standards and level of declared compliance

The following identifies the aims of eachof the standards and reports the percentageof declared compliance and non-compliance.This is followed by evidence collected from thefollow-up assessment visits to selected units.

The standards were grouped under thefollowing areas:

• Patient safety

• Clinical and cost effectiveness

• Governance

• Patient focus

• Accessible and responsive care

• Care environment and amenities

• Public health.



Patient safety

Patient safety is enhanced by the use ofhealthcare processes, working practices andsystemic activities that prevent or reduce therisk of harm to patients.

Standard C01a – incident reporting

Healthcare organisations protect patientsthrough systems that identify and learn fromall patient safety incidents and other reportableincidents, and make improvements in practicebased on local and national experience andinformation derived from the analysis of incidents.

• 138 out of 151 (91%) self-assessments thatwere applicable to complying with incidentreporting declared compliance.

Note: Self-assessments that selected commissioningas the type of healthcare provided were not applicablefor this standard (1%).

• Declared compliance on incident reporting washigh across all the services ranging from 88%of the Royal Navy units to 100% of DefenceDental Services and Joint Medical Commands.

This standard was assessed in 16 out of the 53units on follow-up visits by a review assessmentteam.

• The Healthcare Commission’s assessmentresulted in eight out of the 16 (50%) units’declarations of compliance being overturnedto non-compliance.


Royal British Royal Defence Head- JointNavy Army Air Dental quarters Medical

Force Services Command

88% 96% 91% 100% 94% 100%

Percentage of declared compliance

Key evidence presented by the DMS unitsfor compliance included the following:

• Clear overarching policy and processes in place.

• Positive incident reporting culture with staffactively encouraged and supported.

• Systems in place for the counting, aggregationand analysis for patterns and trends inincidents reported.

• Links with established clinical governancearrangements providing a platform for timelyaction planning and implementation uponfindings.

• Feedback mechanisms reaching all staff.

Key reasons for non-compliance includedthe following:

• High threshold for incident reporting excludingminor incidents and near misses.

• Cultural barriers to incident reporting,concern stated about rank.

• Cumbersome process stated by staff.

• Limited counting, aggregation and analysisof incident reports.

• Incident reports not constructively used todrive improvements in practice and services.

• Limited feedback mechanisms.

Comments and issues:

• Even in the presence of a clear overarchingpolicy and associated processes the thresholdfor incident reporting is variable. This canlead to inaccuracies in counting, aggregationand analysis for emerging patterns andtrends and lost opportunities for drivingimprovements in practice and services.



Standard C01a DMS unit Healthcare Commission declaration assessment

Royal Navy Dept community mental health Compliant CompliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantArmy department community mental health Compliant Not compliantRAF primary care Compliant Not compliantRAF primary care Compliant Not compliantRAF Tactical Medical Wing Compliant CompliantRAF community mental health Compliant Not compliantRAF primary care Compliant Not compliantRAF headquarters Compliant CompliantDental services headquarters Compliant CompliantJoint Medical Command Compliant CompliantSecondary care permanent base Compliant Compliant

Standard C01b – acting on safety alerts

Healthcare organisations protect patientsthrough systems that ensure that patient safetynotices, alerts and other communicationsconcerning patient safety which require actionare acted upon within required timescales.

• 133 out of 151 (88%) self-assessments thatwere applicable to complying with acting onsafety alerts declared compliance.


• All the British Army regions, Defence DentalServices, and the three Joint Medical Commandunits declared they were compliant withacting on safety alerts.


• The Healthcare Commission’s assessmentresulted in upholding 13 out of the 15 units’(87%) declarations of compliance.

• This is a significant finding indicating an areaof good practice.




76% 100% 91% 100% 94% 100%



• Policy, processes and systems for followingpatient safety notices and alerts from receiptto action.

• Named designated staff with clear lines ofresponsibility and accountability.

• Monitoring systems in place for ensuringcompliance with policy, process and actionstaken.



Standard C01b DMS unit Healthcare Commission declaration assessment

Royal Navy primary care Compliant CompliantRoyal Navy primary care Compliant CompliantRoyal Navy headquarters Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant Compliant Secondary care operations Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant CompliantArmy regional rehabilitation unit Compliant Not compliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantRAF primary care Compliant CompliantRAF primary care Compliant CompliantJoint primary care Compliant CompliantJoint Medical Command Compliant Not compliant

Standard C02 – safeguarding children

Healthcare organisations protect children byfollowing national child protection guidelineswithin their own activities and in their dealingswith other organisations.

• 111 out of 153 (73%) self-assessmentsdeclared compliance with safeguardingchildren standards.

• Declared compliance with safeguardingchildren standards was lower across theservices compared to other standards:• Three British Army regions declared non-

compliance with safeguarding childrenstandards.

• 17 Royal Navy units (34%) declared non-compliance with safeguarding childrenstandards.

• 13 Royal Air Force units (30%) declarednon-compliance with safeguardingchildren standards.

This standard was assessed in 8 out of 53 unitson follow-up visits by a review assessment team.

• The Healthcare Commission’s assessmentresulted in five out of the eight (62%) units’declarations of compliance being overturned tonon-compliance. One declared non-complianceand the assessment agreed with this. Thereforeacross the eight units there was a total of sixout of eight (75%) assessed as non-compliant.

• This is a significant finding and the evidenceused to declare compliance with this standardshould be reviewed.




66% 88% 70% 83% 68% 100%



• Arrangements in place for safeguardingchildren supported by current policy andprocesses.

• Named designated safeguarding lead personwith appropriate levels of training andexperience.

• Up-to-date safeguarding training provided forall staff.

• Good links with civilian partner organisations.

• Criminal Records Bureau checks up to datefor all staff with a programme of periodicrevalidation.


• Staff unaware of safeguarding policy andprocesses.

• Lack of designated safeguarding lead person.

• Lack of systems of audit or periodic reviewof child safeguarding processes.

• Limited or no evidence of joint working withcivilian partner agencies.

• Not all staff had current Criminal RecordsBureau checks and no system for periodicupdates.


• There was a lack of recognition, in someareas, that all those under 18 years old,including recruits, are defined as childrenunder current legislation.

• Safeguarding issues identified during thereview about clinical environment wereaddressed immediately by the DMS.



Standard C02 DMS unit Healthcare Commission declaration assessment

Royal Navy Primary Care Compliant Not compliantArmy headquarters Compliant CompliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Not compliant Not compliantRAF primary care Compliant Not compliantRAF primary care Compliant Not compliantRAF primary care Compliant Compliant

Standard C03 – NICE interventional proceduresguidance

Healthcare organisations protect patients byfollowing National Institute for Health andClinical Excellence (NICE) interventionalprocedures guidance.

Note: Standard only applicable to the self-assessmentsthat selected Defence Dental Services, secondary careand the tactical medical wing as the type of healthcarethey provide.

One out of the 22 healthcare services declareditself non-compliant with following NICEinterventional procedures guidance.

This standard was not assessed on follow-upvisits – assessed in self-declarations only.

Standard C04a – infection control

Healthcare organisations protect patientsthrough systems that ensure that the risk ofhealthcare acquired infection to patients isreduced, with particular emphasis on highstandards of hygiene and cleanliness, achievingyear-on-year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA).

• 106 out of 153 (69%) self-assessmentsdeclared compliance with infection control.

• Over half of the Royal Navy units declarednon-compliance with infection control.


• The Healthcare Commission’s assessmentresulted in five out of the 10 (50%) units’declarations of compliance being overturnedto non-compliance. Three units declarednon-compliance and the HealthcareCommission’s assessment agreed with this.The total number of units that were non-compliant was therefore eight out of 13 (62%).





1 unit 5 regions 1 unit 12 units 3 units 1 unit100% 100% 100% 100% 67% 100%




48% 81% 77% 92% 84% 67%



• Clear infection control policy and associatedprocesses in place readily available to all staff.

• Local and regional designated lead for infectioncontrol with clear roles and responsibilities.

• Competent infection control advice availableto staff both locally and regionally.

• Monitoring of compliance with the infectioncontrol policy.

• Infection control training provided to all clinicalstaff with a programme of update training.

• Ongoing infection control environmental riskassessments undertaken with evidence oftimely actions taken upon findings.

• Systematic infection control audits undertakenand reported through clinical governancearrangements with actions planned andtaken upon findings in a timely fashion.


• Lack of awareness by staff of the infectioncontrol policies and practices.

• No infection control designated lead.

• Lack of competent infection control advisorysources.

• Insufficient provision of infection controltraining.

• Lack of monitoring for compliance with theinfection control policy.

• Lack of systematic audit to informimprovements in policy and practice.


• There were repeated issues reported aboutthe scope of external cleaning contractsbeing insufficient to ensure adequateenvironmental cleaning standards on a day-to-day basis.



Standard C04a – Infection control systems DMS unit Healthcare Commission declaration assessment

Royal Navy primary care Not compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant CompliantRAF Tactical Wing Compliant CompliantRAF primary care Not compliant Not compliantDental services Compliant CompliantDental services Compliant Not compliantDental services Compliant Not compliantDental services Compliant Not compliantJoint primary care Compliant CompliantJoint primary care Compliant Not compliantSecondary care operations Compliant CompliantInpatient Rehabilitation Unit Not compliant Not compliant

Standard C04b – medical devices

Healthcare organisations keep patients, staffand visitors safe by having systems to ensurethat all risks associated with the acquisitionand use of medical devices are minimised.

• 134 out of 144 (93%) self-assessmentsdeclared compliance with ensuring that allrisks associated with the acquisition and useof medical devices are minimised.

Note: Self-assessments that selected commissioningand mental health as the types of healthcare providedwere not applicable for this standard (6%).

• All the British Army regions, Defence DentalServices, and the three Joint Medical Commandunits declared they were compliant withensuring that all risks associated with theacquisition and use of medical devices areminimised.

This standard was assessed in six out of the 53units on follow-up visits by a review assessmentteam.

• The Healthcare Commission’s assessmentagreed with all the units’ declaration ofcompliance.

• This is a significant finding and indicatesan area of good practice.


• Clearly stated policy and processes in placecovering all of the activities required toachieve optimum equipment readiness.

• Clear lines of named accountability andresponsibility for the procurement andoptimum integrity of all equipmentrequirements.

• Comprehensive competency-based trainingprovided to ensure the highest proficiencyin using and handing all equipment.

• Thorough training records maintained forall staff.


• Complete compliance was achieved by allunits assessed to a high standard.



Royal Navy regional rehabilitation unit Compliant CompliantArmy regional rehabilitation unit Compliant CompliantArmy regional rehabilitation unit Compliant CompliantRAF regional rehabilitation unit Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant Compliant



89% 100% 92% 100% 94% 100%


Standard C04c – decontamination

Healthcare organisations keep patients, staffand visitors safe by having systems to ensurethat all reusable medical devices are properlydecontaminated prior to use and that the risksassociated with decontamination facilities andprocesses are well managed.

• 133 out of 153 (87%) self-assessmentsdeclared compliance with ensuring reusablemedical devices are properly decontaminatedprior to use and that the risks associatedwith decontamination facilities and processesare well managed.

• Declared compliance ranged from 67% ofJoint Medical Commands to 100% of DefenceDental Services.

This standard was assessed in five out of the 53units on follow-up visits by a review assessmentteam.

• The Healthcare Commission’s assessmentresulted in three out of the five (60%) units’declarations of compliance being overturnedto non-compliance.

• This is a significant finding for the dentalservices and the evidence used to declarecompliance with this standard should bereviewed.


• Designated accountable and responsibleperson in place for decontamination withappropriate training and experience.

• Competency-based training available to allstaff reflecting current national guidance.

• Clear policies and processes fordecontamination with strict adherenceby all relevant staff.


• Lack of designated leadership andaccountability for guiding decontaminationactivities in line with national guidance andlocal policy.

• Lack of local monitoring for complianceagainst decontamination policies.

• Lack of systematic audit mechanisms orlinking arrangements in place to ensure thattimely actions are planned and taken uponfindings and disseminated to all relevant staff.

• Inadequate provision and routine use of fit-for-purpose protective equipment and clothing.



Standard C04c DMS unit Healthcare Commission declaration assessment

Dental services Compliant CompliantDental services Compliant Not compliantDental services Compliant Not compliantDental services Compliant Not compliantRoyal Navy primary care Compliant Compliant



84% 88% 93% 100% 79% 67%



Standard C04d – medicines management

Healthcare organisations keep patients, staffand visitors safe by having systems to ensurethat medicines are handled safely and securely.

• 112 out of 136 (82%) self-assessmentsdeclared compliance with ensuring thatmedicines are handled safely and securely.

Note: Self-assessments that selected commissioning,headquarters and mental health as the types of healthcareprovided were not applicable for this standard (11%).


• The Healthcare Commission’s assessmentresulted in seven out of the 13 (54%) units’declarations of compliance being overturnedto non-compliance.



• Clear lines of accountability covering allmedicines management activities.

• Reporting of incidents and near missesinvolving medicines with timely actionsplanned and taken upon findings.

• Monitoring against the medicines managementpolicy with actions planned and taken in atimely fashion upon findings.

• Systematic audit mechanisms in place that feedinto clinical governance arrangements so thatactions can be planned and taken in a timelyfashion and disseminated to all relevant staff.

• Established drugs formulary used to informstock control and prescribing activities.

• Systems in place for procuring medicinesfor exceptional prescribing.

• Competency-based medicines managementtraining with programmed updates forrelevant staff.

• Appropriate management of controlled drugsactivities under the guidance of a designatedaccountable officer.



76% 86% 84% 100% 94% 0%



• Lack of monitoring against the medicinesmanagement policy to ensure consistenciesin practice and safety.

• Lack of a systematic approach to local andregional audits of all medicine managementactivities and linking appropriate changesin practice requirements through clinicalgovernance arrangements.

• Insufficient competency-based medicinesmanagement training opportunities for allrelevant staff.

• Inadequate systems in place for checkingfor expired medications.

• Inconsistencies and under-reporting ofincidents and near misses involving medicines.This can compromise the potential for learningand the accuracy of counting and aggregating,and analysing the emerging patterns andtrend analysis that should be used to informevidence-based changes in policy and practice.

• Service specific or Joint Service Formularynot routinely used to inform stock controlor prescribing activities.


• Comparatively high levels of assessed non-compliance with all elements for this standardacross all three Services would indicate theneed for a review of all medicines managementpolicies, processes and practices to ensurethe safety of patients and staff.



Standard C04d DMS unit Healthcare Commission declaration assessment

Royal Navy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant CompliantArmy primary care Compliant CompliantRAF primary care Compliant Not compliantRAF Tactical Medical Wing Compliant CompliantSecondary care permanent base Compliant Not compliantSecondary care operations Compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant Not compliant

Standard C04e – waste management

Healthcare organisations keep patients, staffand visitors safe by having systems to ensurethat the prevention, segregation, handling,transport and disposal of waste is properlymanaged so as to minimise the risks to thehealth and safety of staff, patients, the publicand the safety of the environment.

• 128 out of 153 (84%) self-assessmentsdeclared compliance with ensuring thatwaste management systems were in place.


• The Healthcare Commission’s assessmentresulted in three out of the five (60%) units’declarations of compliance being overturnedto non-compliance.



• Periodic audit systems in place.

• Good levels of training provided for someclinical staff.


• Insufficient local monitoring for compliancewith the clinical waste policy.

• Insufficient local audit mechanisms in placeto ensure that clinical waste activities arelinked to clinical governance arrangements.

• Insufficient arrangements in place to ensurethat appropriate actions are planned and takenin a timely fashion as a result of audit findings.

• Inappropriate segregation of clinical andgeneral waste.

• Insufficient training provided to all staffcovering all clinical waste activities.

• Serious clinical waste disposal concernsnot cited on the risk register.


Standard C04e – Waste management systems DMS unit Healthcare Commission declaration assessment

Royal Navy primary care Not compliant Not compliantRoyal Navy headquarters Compliant CompliantSecondary care operations Compliant Not compliantJoint primary care Compliant CompliantJoint primary care Compliant Not compliant



74% 88% 88% 100% 84% 67%




Royal British Royal Defence Head- Joint Navy Army Air Force Dental quarters Medical

Services Command

Incident reporting 88% 96% 91% 100% 94% 100%Acting on safety alerts 76% 100% 91% 100% 94% 100%Safeguarding children 66% 88% 70% 83% 68% 100%Infection control 48% 81% 77% 92% 84% 67%Medical devices 89% 100% 92% 100% 94% 100%Decontamination 84% 88% 93% 100% 79% 67%Medicines management 76% 86% 84% 100% 94% 0%Waste management 74% 88% 88% 100% 84% 67%

Percentage of declared compliance with the safety standards overall

Clinical and cost effectiveness

Patients achieve healthcare benefits that meettheir individual needs through healthcaredecisions and services, based on whatassessed research evidence has shownprovides effective clinical outcomes.

Standard C05a – NICE technology appraisals

Healthcare organisations ensure that theyconform to National Institute for ClinicalExcellence (NICE) technology appraisals and,where it is available, take into account nationallyagreed guidance when planning and deliveringtreatment and care.

• 109 out of 153 (79%) self-assessmentsdeclared compliance with taking into accountnationally agreed guidance when planningand delivering treatment and care.

• Half of Royal Navy units declared non-compliance with taking account of nationallyagreed guidance when planning anddelivering treatment and care.

This standard was assessed in seven out ofthe 53 units on follow-up visits by a reviewassessment team.

• The Healthcare Commission’s assessmentresulted in one out of the five (60%) units’declarations of compliance being overturnedto non-compliance. Assessment agreed withtwo declarations of non-compliance. The totalnumber of units assessed as non-compliantwas therefore three out of seven (43%).




50% 77% 77% 100% 84% 100%



• Mechanisms for deciding whether a NICEtechnology appraisal (TA) is relevant to itsservices and, where appropriate, for makingan assessment of current local practiceagainst the appraisal.

• Policy – Department of Community MentalHealth Standing Orders via Chain ofCommand, Surgeon General Policy Letters

• Documented process for implementation.

• Plans for the implementation of eachrelevant TA.

• Relevant staff/teams notified about theactions required to implement the TA.

• Monthly business and team meetings.

• Examples given of implementation oftechnology appraisals.

• Audit activity and recent TAs affecting annualaudit programme.

• Quarterly reports.

• Monitoring through appraisals and one-to-one clinical supervision.


• No evidence to demonstrate monitoring ofcompliance with NICE technology appraisals.

• No formal audit or regional/national requestto undertake audit of compliance with NICEtechnology appraisals.

• No systems to ensure that staff had readNICE guidance and technology appraisals.


• Some confusion regarding the differencebetween NICE guidance and NICE technologyappraisals.



Standard C05a – NICE technology appraisals DMS unit Healthcare Commission declaration assessment

Royal Navy Dept of community mental health Not compliant Not compliantArmy Dept of community mental health Not compliant Not compliantRAF Dept of community mental health Compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantSecondary care operations Compliant CompliantJoint Medical Command headquarters Compliant Not compliant

Standard C05b – clinical supervision

Healthcare organisations ensure that clinicalcare and treatment are carried out undersupervision and leadership.

• 130 out of 153 (85%) self-assessmentsdeclared compliance with ensuring thatclinical care and treatment are carried outunder supervision and leadership.

• All Defence Dental Services declaredcompliance with ensuring that clinical careand treatment are carried out undersupervision and leadership.


• The Healthcare Commission’s assessmentresulted in five out of the 15 (33%) units’declarations of compliance being overturnedto non-compliance. Two units declared non-compliance which was agreed on assessment.The total number of units that were non-compliant was seven out of 17 (41%).




76% 81% 88% 100% 89% 67%



• Clinical supervision policy and clear supervisoryarrangements and frameworks in place.

• Supervisory structures and systems andmechanisms for review and feedback.

• Actions following feedback.

• GP training practices with robust clinicalsupervision for trainees.

• Job descriptions including clinicalsupervision responsibilities.

• Protected time for training (trade training).

• Systems in place to ensure continuity ofprofessional registration.


• Lack of understanding of what constitutes‘clinical’ supervision.

• Lack of clinical supervision framework.

• Not all clinical staff receiving supervision.

• There were no systems in place to ensurethe medical practitioners were provided withclinical supervision and appraisal throughtheir NHS contracts.

• There were no recording systems in placeto ensure that all clinical staff held currentregistrations with their respective professionalbodies.




Royal Navy primary care Compliant Not compliantRoyal Navy primary care Compliant CompliantRoyal Navy primary care Compliant CompliantRoyal Navy primary care Compliant CompliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantRAF primary care Compliant CompliantRAF primary care Compliant CompliantRAF primary care Not compliant Not compliantDental services Compliant Not compliantDental services Compliant CompliantArmy headquarters Compliant CompliantDental services headquarters Compliant CompliantArmy regional rehab unit Compliant Not compliantRoyal Navy headquarters Not compliant Not compliantSecondary care operations Compliant CompliantTactical Medical Wing Compliant Compliant

Standard C05c – continuous learning

Healthcare organisations ensure that clinicians(professionally qualified staff providing clinicalcare or defence medical services to patients)continuously update skills and techniquesrelevant to their clinical work.

• 133 out of 153 (87%) self-assessmentsdeclared compliance with ensuring thatclinicians continuously update skills andtechniques relevant to their clinical work.

• All headquarters and joint medical commandsdeclared compliance with ensuring thatclinicians continuously update skills andtechniques relevant to their clinical work.


• The Healthcare Commission’s assessmentagreed with 14 out of the 15 units’ (93%)declaration of compliance.





74% 92% 91% 92% 100% 100%



• Embedded formal appraisal systems linkedto training programmes.

• Funding available for training.

• Developmental training and inductionprogrammes.

• Audits in place, evidence of shared learning,feedback and evaluation provided.

• Training needs or gap analysis undertaken.


• Unclear as to percentage of staff who hadreceived appraisals and whether these weredocumented.

• Shortages of staff impacted on time for staffto be released for training.

• Inequalities in clinical training available andfunding for civilian staff.

• Peer appraisal not well set up.

Comments:

• Examples of joint working with NHS partnersto update clinical skills.




Army primary care Compliant CompliantArmy primary care Compliant CompliantRAF primary care Compliant CompliantRAF primary care Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant CompliantSecondary care permanent base Compliant Not compliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantDental services Compliant CompliantDental services Compliant CompliantArmy headquarters Compliant CompliantJoint medical command headquarters Compliant Compliant

Standard C05d – participating in clinical audit

Healthcare organisations ensure that cliniciansparticipate in regular clinical audit and reviewsof clinical services.

• 120 out of 153 (78%) self-assessmentsdeclared compliance with participatingin clinical audit.

• All Defence Dental Services and the JointMedical Commands declared compliancewith participating in clinical audit.


• The Healthcare Commission’s assessmentresulted in two out of the 13 (15%) units’declarations of compliance being overturnedto non-compliance and one unit’s declarationof non-compliance being overturned to becompliant.





64% 73% 88% 100% 84% 100%



• Clinical audit programmes with subsequentaction plans.

• Patient feedback.

• Staff able to cite examples of practice changeas a result of audit and feedback.

• Clinical audit featured as a standing agendaitem in meetings.

• Staff training in audit.

• Designated audit leads.

• Contributions to national data collections.


• Incomplete audit plan.

• Limited evidence to demonstrate learningfrom audit activity to improve services.

• Limited evidence to demonstrate theeffectiveness of clinical services throughevaluation, audit or research.



Standard C05d DMS unit Healthcare Commission declaration assessment

Royal Navy primary care Compliant CompliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantRAF primary care Compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantRAF regional rehab unit Not compliant CompliantRoyal Navy regional rehab unit Compliant CompliantArmy regional rehab unit Compliant CompliantRAF headquarters Compliant CompliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantSecondary care operations Compliant Compliant

Standard C06 – partnership working

Healthcare organisations cooperate with eachother and social care organisations to ensurethose patients’ individual needs are properlymanaged and met.

• 142 out of 153 (93%) self-assessmentsdeclared compliance with partnership working.

• Nine self-assessments declared non-compliance with partnership working.

This standard was not assessed on follow-upvisits – it was assessed in self-declarations only.

Although this standard was not assessedin follow-up visits, a number of effectivepartnership arrangements were noted duringthe review. These included the DMS working withlocal NHS primary care trusts in providing jointtraining opportunities to develop clinical skillsand health promotion activities. The DMS alsohas an effective working relationship with Guy’sand St Thomas’ NHS Foundation Trust whichcommissions secondary care in the Germanhealthcare system on behalf of the DMS.



Services Command

NICE technology appraisals 50% 77% 77% 100% 84% 100%Clinical supervision 76% 81% 88% 100% 89% 67%Continuous learning 74% 92% 91% 92% 100% 100%Participating in clinical audit 64% 73% 88% 100% 84% 100%Partnership working 88% 92% 93% 92% 95% 100%

Percentage of declared compliance by the DMS with standards in clinical and cost effectiveness



88% 92% 93% 92% 95% 100%


Governance

Managerial and clinical leadership andaccountability, as well as the organisation’sculture, systems and working practices,ensure that probity, quality assurance, qualityimprovement and patient safety are centralcomponents of all activities of the healthcareorganisation.

Standard C07ac – clinical and corporategovernance

Healthcare organisations apply the principlesof sound clinical and corporate governance andundertake systematic risk assessment and riskmanagement.

• 139 out of 153 (91%) self-assessments declaredcompliance with applying the principles ofsound clinical and corporate governance andundertake systematic risk assessment andrisk management.

• All Defence Dental Services, headquartersand Joint Medical Commands declaredcompliance with applying the principles ofsound clinical and corporate governance andundertaking systematic risk assessment andrisk management.


• The Healthcare Commission’s assessmentresulted in one out of the 18 (5%) units’declarations of compliance being overturnedto non-compliance and one out of the 18 (5%)unit’s declarations of not compliant beingoverturned to compliant.





88% 96% 84% 100% 100% 100%



• Allocated lead(s) for clinical governance.

• Clinical governance plans in place – regularmonitoring and updating.

• Clinical governance boards/committees/meetings in place.

• Regular clinical governance reporting.

• Processes in place – for example, auditprogrammes, risk registers and risk incidentreporting, patient satisfaction and feedbacksystems, and training.

• Clear clinical governance reporting structuresand specific responsibilities for individuals inlead roles.

• Staff awareness of responsibilities for clinicalgovernance.

• Evidence of improvements from riskassessment and management and incidentreporting.


• Clinical governance plans embryonic – beingplanned but not yet implemented.

• Systems in place for implementing clinicalgovernance – not yet actioned.

• Little evidence of risk assessment, reportingor monitoring.


Standard C07ac DMS unit Healthcare Commission declaration assessment

Royal Navy primary care Not compliant Not compliantRoyal Navy primary care Compliant Compliant Army primary care Compliant CompliantArmy headquarters Compliant CompliantRAF primary care Compliant Not compliantRAF primary care Not compliant Not compliantDental services headquarters Compliant CompliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantRAF headquarters Not compliant CompliantArmy regional rehab unit Compliant CompliantInpatient rehab unit Compliant CompliantRAF Tactical Medical Wing Compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant Compliant

Standard C07b – openness and honesty

Healthcare organisations actively support allemployees to promote openness, honesty,probity, accountability, and the economic,efficient and effective use of resources.

• 143 out of 153 (93%) self-assessmentsdeclared compliance with actively supportingall employees to promote openness, honesty,probity, accountability, and the economic,efficient and effective use of resources.

• All Defence Dental Services, headquartersand Joint Medical Commands declaredcompliance with actively supporting allemployees to promote openness, honesty,probity, accountability, and the economic,efficient and effective use of resources.


Standard C07e – promoting equality

Healthcare organisations challengediscrimination, promote equality and respecthuman rights.

• 144 out of 153 (94%) self-assessmentsdeclared compliance with challengingdiscrimination, promoting equality andrespecting human rights.

• Nine self-assessments (6%) declared non-compliance with promoting equality. AllJoint Medical Commands and headquartersdeclared compliance with challengingdiscrimination, promoting equality andrespecting human rights.

This standard was assessed in nine out of the 53units on follow-up visits by a review assessmentteam.

• The Healthcare Commission’s assessmentresulted in one out of the nine (11%) units’declarations of compliance being overturnedto non-compliance and one out of the nine(11%) units’ declarations of not compliantbeing overturned to compliant.






88% 96% 91% 100% 100% 100%

Percentage of declared compliance Royal British Royal Defence Head- JointNavy Army Air Dental quarters Medical


92% 92% 93% 92% 100% 100%



• Awareness of equality and diversity schemeand policies.

• Information given to staff which includedstandards for equality and diversity.

• Specific equality and diversity officers andadvisors.

• Examples given of actions taken to promoteequality.

• Examples given of policy changes to promoteequality.

• Awareness of how to report issues relatingto equality and diversity.

• Some statistical reporting.


• Low awareness of equality and diversitypolicies and issues.

• No equality and diversity monitoring in place.


• Some clinical facilities were not DDA compliant(Disability Discrimination Act – legislation topromote civil rights for disabled people andprotect disabled people from discrimination).

• Statistical reporting tended to be on age,gender and rank – little evidence of statisticson ethnicity and religion.


Standard C07e DMS unit Healthcare Commission declaration assessment

RAF primary care Compliant CompliantArmy primary care Compliant Not compliantRoyal Navy Dept of Community Mental Health Not compliant CompliantArmy Dept of Community Mental Health Compliant CompliantRAF Dept of Community Mental Health Compliant CompliantRoyal Navy headquarters Compliant CompliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantRAF headquarters Compliant Compliant

Standard C07f – existing performancerequirements

Healthcare organisations meet the existingperformance requirements as set out in theDefence Health Programme andcomplementary single Service plans.

• 119 out of 153 (78%) self-assessmentsdeclared compliance with meeting theexisting performance requirements as set outin the Defence Health Programme andcomplementary single Service plans.

• Four out of 12 Defence Dental Servicesdeclared compliance with meeting theexisting performance requirements as setout in the Defence Health Programme andcomplementary single Service plans.

• A fifth of Royal Navy units declared non-compliance with meeting the existingperformance requirements as set out inthe Defence Health Programme andcomplementary single Service plans. Oneout of three declarations from Joint MedicalCommand declared compliance with meetingexisting performance requirements.

This standard was not assessed on follow-upvisits – it was only assessed in self-declarations.

Standard C08a – whistle blowing

Healthcare organisations support their staffthrough having access to processes whichpermit them to raise, in confidence and withoutprejudicing their position, concerns over anyaspect of service delivery, treatment ormanagement that they consider to have adetrimental effect on patient care or on thedelivery of services.

• 130 out of 149 (87%) self-assessmentsdeclared compliance with supporting theirstaff through having access to processeswhich permit them to raise concerns.


• A quarter of the Royal Navy units declarednon-compliance with supporting their staffthrough having access to processes whichpermit them to raise concerns.

This standard was assessed in nine out of the 53units on follow-up visits by a review assessmentteam.

• The Healthcare Commission’s assessmentresulted in one out of the nine (11%) units’declarations of compliance being overturnedto non-compliance and one out of the nine(11%) units’ declarations of not compliantbeing overturned to compliant.





80% 81% 86% 33% 94% 33%




74% 96% 91% 100% 100% 100%



• Staff awareness of relevant policies andprocesses.

• Staff stated confidence in raising concerns.

• Examples of change resulting from reportingconcerns.

• Examples of reported concerns being wellmanaged.

• Army complaints commissioner.


• Lack of awareness of relevant policy andreporting processes.

• Stated under-reporting of concerns.


• ‘Rank’ was reported to be an actual orpotential barrier to reporting concerns.



Royal Navy primary care Compliant CompliantRoyal Navy primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant Not compliantArmy primary care Compliant CompliantRAF primary care Not compliant CompliantJoint primary care Compliant CompliantJoint medical command headquarters Compliant CompliantArmy headquarters Compliant Compliant

Standard C08b – personal developmentprogrammes

Healthcare organisations support their staffthrough organisational and personal developmentprogrammes which recognise the contributionand value of staff, and address, where appropriate,under-representation of minority groups.

• 131 out of 149 (88%) self-assessmentsdeclared compliance with having personaldevelopment programmes.


• All headquarters and Joint MedicalCommand self-assessments declaredcompliance with having personaldevelopment programmes.


Standard C09 – records management

Healthcare organisations have a systematicand planned approach to the managementof records to ensure that, from the momenta record is created until its ultimate disposal,the organisation maintains information so thatit serves the purpose it was collected for anddisposes of the information appropriately whenno longer required.

• 137 out of 153 (90%) self-assessmentsdeclared compliance with having an effectiverecords management system.

• A fifth of Royal Navy units declared non-compliance with having an effective recordsmanagement system.


• The Healthcare Commission’s assessmentresulted in nine out of the 15 (64%) units’declarations of compliance being overturnedto non-compliance.

• This is a significant finding and evidence usedto declare compliance with this standardshould be reviewed.





78% 84% 95% 92% 100% 100%




80% 92% 93% 100% 95% 100%



• Records management policy in place –staff aware and following policy.

• Lead for records management.

• Information for patients on access to recordsand data protection – for example, in patientinformation leaflets.

• Training on records management andinformation governance.

• Caldicott Guardian identified (CaldicottGuardians are senior members of staffwho have responsibility for protecting theconfidentiality of patients’ information andenabling appropriate information sharing).

• Audit of records undertaken and subsequentactions.


• No Caldicott Guardian identified.

• No records management or informationgovernance training.

• No clear systems in place for disposalof records.

• No awareness of records management policies.

• Patient information potentially accessible tounauthorised staff – breaches of informationconfidentiality security, for example, notesnot being stored securely.



Royal Navy primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant Not compliantRAF primary care Compliant Not compliantRAF primary care Compliant Not compliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantDefence Dental Services Compliant Not compliantSecondary care operations Compliant Not compliantSecondary care operations Compliant Not compliantSecondary care operations Compliant Not compliantRoyal Navy regional rehab unit Compliant Not compliantArmy regional rehab unit Compliant Not compliantRAF regional rehab unit Not compliant Not compliantArmy headquarters Compliant Compliant


• Some units providing secondary care feltunable to provide evidence against element 2 –‘records are completed appropriately and areavailable when required and disposed of in linewith single Service policies’ – as in barracksand not on operations. As all elements arerequired to be met the overall assessmentwas therefore not compliant.

• Some difficulties reported with the newelectronic patient record system, the DefenceManagement Information CapabilityProgramme, but generally positive aboutthe roll-out of programme.

Standard C10a – employment checks

Healthcare organisations undertake allappropriate employment checks and ensure thatall employed or contracted professionally qualifiedstaff are registered with the appropriate bodies.

• 136 out of 153 (89%) self-assessmentsdeclared compliance with employment checks.






82% 85% 95% 83% 95% 100%


Standard C10b – professional codes of practice

Healthcare organisations require that allemployed professionals abide by relevantpublished codes of professional practice.

• 141 out of 148 (95%) self-assessmentsdeclared compliance with the requirement thatall employed professionals abide by relevantpublished codes of professional practice.


• Seven (5%) self-assessments declared non-compliance with the requirement that allemployed professionals abide by relevantpublished codes of professional practice.

This standard was not assessed on follow-upvisits – it was only assessed in self-declarations.

Standard C11a – provision of training

Healthcare organisations ensure that staffconcerned with all aspects of the provision ofhealthcare are appropriately recruited, trainedand qualified for the work they undertake.

• 36 self-assessments (24%) declared that thisstandard was not applicable to their serviceor not applicable to their type of healthcareprovided.

• Of the 117 self-assessments that declared itwas applicable, 103 (88%) self-assessmentsdeclared they were compliant and 14 (12%)assessments declared they were non-compliant.


• The Healthcare Commission’s assessmentresulted in one out of the five (20%) units’declarations of non-compliance beingoverturned to compliance.




92% 92% 98% 92% 100% 100%




70% 95% 95% 92% 100% 100%



• Clear recruitment processes in place.

• Commissioning policy in place forrecruitment through agencies.

• Selected and limited recruitment agenciesused.

• Recruitment and training records in place.

• Registration and qualifications checkedby agency and rechecked locally.


• Some concerns were raised around thenumber of agency staff used. This wasconsidered a risk and on risk register –mitigation actions included using limitednumber of agencies.

• Reasons given for the use of agency staffincluded permanent staff being deployed.




Royal Navy primary care Not compliant CompliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantRAF headquarters Compliant CompliantInpatient rehab unit Compliant Compliant

Standard C11b – participation in mandatorytraining programmes

Healthcare organisations ensure that staffconcerned with all aspects of the provision ofhealthcare participate in mandatory trainingprogrammes.

• 118 out of 141 (84%) self-assessmentsdeclared compliance with participationin mandatory training programmes.

Note: Self-assessments that selected commissioningand headquarters as the types of healthcare providedwere not applicable for this standard (8%).

This standard was assessed in seven out ofthe 53 units on follow-up visits by a reviewassessment team.

• The Healthcare Commission’s assessmentresulted in one out of the seven (14%) units’declarations of compliance being overturnedto non-compliance.


• Induction programmes in place – areasincluded infection control, patient handling,information management, equipment careand clinically focused areas such as basiclife support.

• Training records held and attendancemonitoring in place.

• Responsibilities for training in jobdescriptions.


• High staff turnover and shortages of staffcausing difficulty to release staff for trainingcited as reasons for low mandatory traininguptake.

• No monitoring of attendance in place.



Royal Navy primary care Compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant Not compliantInpatient rehab unit Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant CompliantSecondary care operations Compliant Compliant



73% 95% 83% 92% 88% 100%


Standard C11c – professional development

Healthcare organisations ensure that staffconcerned with all aspects of the provision ofhealthcare participate in further professionaland occupational development commensuratewith their work throughout their working lives.

• 128 out of 149 (86%) self-assessmentsdeclared compliance with professionaldevelopment with staff.



Standard C12 – research governance

Healthcare organisations which either lead orparticipate in research have systems in placeto ensure that the principles and requirementsof the research governance framework areconsistently applied.

• 42 out of 48 (88%) self-assessments declaredcompliance with having systems in place toensure that the principles and requirementsof the research governance framework areconsistently applied. 105 (69%) self-assessments declared this standard as notapplicable.






76% 84% 95% 100% 89% 67%




Services Command

Clinical and corporate governance 88% 96% 84% 100% 100% 100%Openness and honesty 88% 96% 91% 100% 100% 100%Promoting equality 92% 92% 93% 92% 100% 100%Existing performance requirements 80% 81% 86% 33% 94% 33%Whistle blowing 74% 96% 91% 100% 100% 100%Personal development programmes 78% 84% 95% 92% 100% 100%Records management 80% 92% 93% 100% 95% 100%Employment checks 82% 85% 95% 83% 95% 100%Professional codes of practice 92% 92% 98% 92% 100% 100%Provision of training 70% 95% 95% 92% 100% 100%Participation in mandatory training programmes 73% 95% 83% 92% 88% 100%Professional development 76% 84% 95% 100% 89% 67%

Percentage of declared compliance by the DMS with standards on governance

Patient focus

Healthcare is provided in partnership withpatients, their carers and relatives, respectingtheir diverse needs, preferences and choices,and in partnership with other organisations(especially social care organisations) whoseservices impact on patient wellbeing.

Standard C13a – dignity and respect

Healthcare organisations have systems in placeto ensure that staff treat patients, their relativesand carers with dignity and respect.

• 147 out of 153 (96%) self-assessmentsdeclared compliance with ensuring that stafftreat patients, their relatives and carers withdignity and respect.

• Declaring compliance with ensuring that stafftreat patients, their relatives and carers withdignity and respect was high across all theservices. Four out of the six services alldeclared 100% compliance.


• The Healthcare Commission’s assessmentresulted in two out of the nine (22%) units’declarations of compliance being overturnedto non-compliance.





95% 100% 95% 100% 100% 100%



• Clear signage.

• Chaperone policy.

• Documented codes of conduct.

• Suggestion boxes, patient satisfactionquestionnaires.

• Induction training included expectedstandards of behaviour.

• Staff training.

• Complaints monitoring.

• Carers’ group meetings.

• Suitably designed environments.


• Concerns raised from patient feedback relatingto the absence of separate dedicated changingfacilities had not been adequately addressed.

• Patient dignity and respect was not beingpreserved during confidential discussions aboutindividual examinations and consultations.

• The sharing of changing facilities with visitingschool children presented a potentialsafeguarding risk that had not been fullyrecognised or addressed appropriately(subsequently addressed by the DMS whenraised by the Healthcare Commission).

• Patient privacy, dignity and confidentialitywere compromised by the layout of roomsin some facilities.


• A number of poorly designed and poorlymaintained buildings often compromisedthis standard.



Army primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant Not compliantCapital Ship Compliant CompliantRegional rehab unit Compliant Not compliantRegional rehab unit Compliant CompliantRegional rehab unit Compliant CompliantRegional rehab unit Compliant Compliant

Standard C13b – consent

Healthcare organisations have systems in placeto ensure that appropriate consent is obtainedwhen required, for all contacts with patientsand for the use of any confidential patientinformation.

• 139 out of 144 (97%) self-assessments declaredcompliance with ensuring that appropriateconsent is obtained when required, for allcontacts with patients and for the use of anyconfidential patient information.

Note: Self-assessments that selected headquartersas the type of healthcare provided were not applicablefor this standard (6%).

• Declaring compliance with ensuring thatappropriate consent is obtained when required,for all contacts with patients and for the useof any confidential patient information washigh across all the services. Ninety-seven percent declared compliance was the highestpercentage of compliance across all thestandards assessed.

This standard was assessed in three out ofthe 53 units on follow-up visits by a reviewassessment team.

• The Healthcare Commission’s assessmentagreed with all the units’ declaration ofcompliance.

• This is a significant finding and indicatesan area of good practice in departmentsof community mental health.


• Staff awareness of the need for consent to beobtained and of consent policies and SurgeonGeneral Policy Letters.

• Standing orders being followed.

• Patient information available and given topatients.

• Consent records.




Royal Navy Dept community mental health Compliant CompliantArmy Dept community mental health Compliant CompliantRAF Dept community mental health Compliant Compliant



96% 100% 90% 100% 100% 100%


Standard C13c – handling confidentialinformation

Healthcare organisations have systems in placeto ensure that staff treat patient informationconfidentially, except where authorised bylegislation to the contrary.

• 133 out 153 (87%) self-assessments declaredcompliance with ensuring that staff treatpatient information confidentially, exceptwhere authorised by legislation to the contrary.

This standard was assessed in three out ofthe 53 units on follow-up visits by a reviewassessment team.

• The Healthcare Commission’s assessmentresulted in one out of the three (33%) units’declaration of compliant being overturnedto not compliant.


• Caldicott Guardians in place.

• Standard operating procedures in place andfollowed.

• Secure management of records.

• Staff awareness.

• Training records of staff attending relevantinformation management programmes.


• No nominated Caldicott Guardian.



Joint primary care Compliant Not compliantRAF primary care Compliant CompliantRegional rehab unit Compliant Compliant



82% 96% 79% 100% 100% 67%


Standard C14a – complaints system

Healthcare organisations have systems in placeto ensure that patients, their relatives and carershave suitable and accessible information about,and clear access to, procedures to registerformal complaints and feedback on the qualityof services.

• 145 out of 153 (95%) self-assessmentsdeclared compliance with ensuring thatcomplaints systems are in place.

• All the Army regions that submitted self-assessments declared that they had systemsin place to ensure that patients, their relativesand carers have suitable and accessibleinformation about, and clear access to,procedures to register formal complaintsand feedback on the quality of services.


• The Healthcare Commission’s assessmentresulted in five out of the 11 (45%) units’declarations of compliance being overturnedto non-compliance.





90% 100% 98% 92% 95% 100%



• Complaints policies in place and staff awareof these.

• Patient information in various formats relevantto need patient population.

• Staff training on management of complaints.

• Complaints audit and evaluation andcomplaints database.

• Complaints discussed as standing agendaitems at meetings.

• Staff able to report changes to practice asa result of complaints.

• Advocacy services contacted and availableas required.


• Staff were not aware of any complaints policyor process or the arrangements for handlingor investigating formal complaints.

• Little evidence of ongoing monitoring oraudit of complaints or issues raised.

• Little evidence of information for patientson how to make a complaint, raise issuesor give positive feedback about the servicesor facilities.

• No independent advocacy arrangements inplace to assist patients, carers and relativesto access the complaints procedure.

• Verbal complaints were not generally recordedso that recurring issues aggregation andtrend analysis were not completed.

• Information in different languages was notavailable in places where many patients’,relatives’ and carers’ first language wasnot English.

• Complaints training not provided to staffat any level.



Royal Navy primary care Compliant Not compliantRoyal Navy primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantRAF primary care Compliant CompliantRAF primary care Compliant Not compliantDental services Compliant Not compliantDental services Compliant Compliant

Standard C14b – discrimination againstcomplainants

Healthcare organisations have systems in placeto ensure that patients, their relatives and carersare not discriminated against when complaintsare made.

• 142 out of 153 (93%) declared compliancewith having systems in place to ensure thatpatients, their relatives and carers are notdiscriminated against when complaintsare made.


Standard C14c – acting on complaints

Healthcare organisations have systems inplace to ensure that patients, their relativesand carers are assured that organisationsact appropriately on any concerns and, whereappropriate, make changes to ensureimprovements in service delivery.

• 140 out of 153 (92%) declared compliancewith acting on complaints.

This standard was assessed in eight out ofthe 53 units on follow-up visits by a reviewassessment team.

• The Healthcare Commission’s assessmentresulted in one out of the eight (13%) units’declarations of compliance being overturnedto non-compliance and one out of the eight(13%) units’ declarations of not compliantbeing overturned to compliant.





84% 96% 95% 100% 100% 100%

Percentage of declared complianceRoyal British Royal Defence Head- JointNavy Army Air Dental quarters Medical


90% 88% 93% 100% 95% 67%



• Complaints policies known and in place.

• Designated lead personnel for complaints.

• Timescales for responses met.

• Themed analysis of complaints.

• Examples of learning from complaints.

• Complaints included on risk registers.

• Staff able to give examples of changes topractice as a consequence of complaints.


• Headquarters not always informed ofcomplaints.


• There was variation between differentheadquarters’ role and function in themanagement of complaints.



Royal Navy Dept community mental health Compliant CompliantArmy Dept community mental health Not compliant CompliantRAF Dept community mental health Compliant CompliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantArmy headquarters Compliant CompliantDental services headquarters Compliant Not compliantRAF headquarters Compliant Compliant

Standard C15a – choice of food

Where food is provided, healthcare organisationshave systems in place to ensure that patients areprovided with a choice and that it is preparedsafely and provides a balanced diet.

• 35 DMS units declared this standard asapplicable.

• 32 self-assessments declared compliance(91%).

• Three self-assessments (9%) (two Armyprimary care, one Royal Navy primary care)declared non-compliance.

• Standard not applicable to 118 self-assessments.

• Of the three self-assessments that declarednon-compliance, commentary included thatthey declared non-compliant due to ongoingsurveys in each facility highlighting issueswith dietary services, no water provisionand difficulties for patients who require avegetarian or soft diet. It was stated thatthese issues had been raised through thechain of command.


Standard C15b – meeting patients’ dietaryrequirements

Where food is provided, healthcare organisationshave systems in place to ensure that patients’individual nutritional, personal and clinicaldietary requirements are met, including anynecessary help with feeding and access to food24 hours a day.

• 35 Defence Medical Services units declaredthis standard as applicable.

• 31 units declared compliance (89%).

• 4 units (11%) (one Army primary care service,one Royal Navy primary care service, oneRoyal Air Force primary care service, and oneHQ primary care) declared non-compliance.

• Standard not applicable to 118 self-assessments.

• Of the four self-assessments that declarednon-compliance, commentary included thatthey declared non-compliant because:• There was no provision to supply food at

a unit due to the pay as you dine system,but fluids were offered as required.

• There was no water provision facilities forpatient use.

• There were no arrangements for 24-hourfood provision.




Standard C16 – information for patients

Healthcare organisations make informationavailable to patients and the public on theirservices, provide patients with suitable andaccessible information on the care andtreatment they receive and, where appropriate,inform patients on what to expect duringtreatment, care and after care.

• 123 out of 143 (86%) self-assessmentsdeclared compliance with makinginformation available to patients.

Note: Self-assessments that selected headquartersas the type of healthcare provided were not applicablefor this standard (6%).

• All self-assessments from the British Army,Defence Dental Services, headquarters andJoint Medical Commands declared compliancewith making information available to patients.




Services Command

Dignity and respect 95% 100% 95% 100% 100% 100%Consent 96% 100% 90% 100% 100% 100%Handling confidential information 82% 96% 79% 100% 100% 67%Complaints system 90% 100% 98% 92% 95% 100%Discrimination against complainants 84% 96% 95% 100% 100% 100%Acting on complaints 90% 88% 93% 100% 95% 67%Information for patients 71% 100% 81% 100% 100% 100%

Percentage of declared compliance by the DMS with standards on patient focus



71% 100% 81% 100% 100% 100%


Accessible and responsive care

Patients receive services as promptly aspossible, have choice in access to services andtreatments, and do not experience unnecessarydelay at any stage of service delivery or thecare pathway.

Standard C17 – listening to views of patients

The views of patients, their carers and othersare sought and taken into account in designing,planning, delivering and improving healthcareservices.

• 145 out of 153 (95%) self-assessmentsdeclared compliance with listening to viewsof patients, carers and others.

• Nearly all self-assessments declaredcompliance with listening to views ofpatients, their carers and others.


Standard C18 – access to services

Healthcare organisations enable all membersof the population to access services equally andoffer choice in access to services and treatmentequitably.

• 132 out of 153 (86%) self-assessmentsdeclared compliance with enabling allmembers of the population to access servicesequally and offer choice in access to servicesand treatment equitably.

• Compared with the two other standards inthe patient focus domain, declarations ofcompliance with enabling all members of thepopulation to access services equally and offerchoice in access to services and treatmentequitably was lower.






92% 92% 95% 100% 100% 100%




82% 85% 86% 100% 89% 100%


Standard C19 – access in an emergency

Healthcare organisations ensure that patientswith emergency health needs are able to accesscare promptly and within nationally agreedtimescales, and all patients are able to accessservices within national expectations on accessto services.

• 145 out of 153 (95%) self-assessmentsdeclared compliance with ensuring thatpatients with emergency health needs areable to access care promptly and within agreedtimescales, and all patients are able to accessservices within national expectations onaccess to services.




Services Command

Listening to views of patients 92% 92% 95% 100% 100% 100%Access to services 82% 85% 86% 100% 89% 100%Access in an emergency 90% 96% 95% 100% 100% 100%

Percentage of declared compliance by the DMS with standards for accessible and responsive care



90% 96% 95% 100% 100% 100%


Care environment and amenities

Care is provided in environments that promotepatient and staff wellbeing and respect forpatients’ needs and preferences in that theyare designed for the effective and safe deliveryof treatment, care or a specific function,provide as much privacy as possible, are wellmaintained and are cleaned to optimise healthoutcomes for patients.

Core standard 20a – safe and secureenvironment

Healthcare services are provided in environmentswhich promote effective care and optimisehealth outcomes by being a safe and secureenvironment which protects patients, staff,visitors and their property, and the physicalassets of the organisation.

• 135 out of 148 (91%) self-assessments declaredcompliance with providing effective care in asafe and secure environment.(This standardwas applicable to all types of healthcareservice but five units did not declare).

• Declared compliance on providing effective carein a safe and secure environment was loweracross all the services compared with declaredcompliance on other standards. It rangedfrom 67% of the Joint Medical Commandsto 100% of Defence Dental Services.

This standard was assessed in all clinical units(except headquarters) on follow-up visits by areview assessment team using a specificallydesigned observation tool which looked at thefacilities and clinical environment.


• Relevant protocols in place and staff awareof contents.

• Designated lead for risk management.

• Fire safety training.

• Fire fighting equipment checks.

• Risk register regularly updated.

• Health and safety training.





83% 92% 98% 100% 95% 67%


Core standard 20b – private and confidentialenvironment

Healthcare services are provided in environmentswhich promote effective care and optimisehealth outcomes by being supportive of patientprivacy and confidentiality.

• 122 out of 153 (80%) self-assessmentsdeclared compliance with providing effectivecare in a safe and secure environment.Notably a fifth of self-assessments declarednon-compliance.

• Approximately a quarter of Royal Navy unitsand a third of British Army regions declarednon-compliance with providing effective carein a safe and secure environment.

This standard was assessed in all clinical units(except headquarters) on follow-up visits by areview assessment team using a specificallydesigned observation tool which looked at thefacilities and clinical environment.


• Well designed waiting and reception areas.

• Individual consulting rooms with lockabledoors and appropriate signage.

• Single sex washroom and toilet facilities.

• Single sex bedding down facilities whereappropriate.

• Designated areas for audiometry, ECG andoptometry.

• Health and safety audits.

• Quiet spaces available for confidentialconversations.

• Chaperone policy.


• Poor layout, cramped reception/waitingareas, poorly sited pharmacy hatches.

• Location of treatment and consultation facilitiesdid not promote confidentiality and privacy.


• In some units, risk assessments had beenundertaken with action plans to redesign andimprove the environment in terms of privacyand confidentiality.




76% 69% 86% 83% 89% 67%


Standard C21 – environment promoteseffective care

Healthcare services are provided in environmentswhich promote effective care and optimisehealth outcomes by being well designed andwell maintained with cleanliness levels inclinical and non-clinical areas that meet thenational specification for clean NHS premises.

• 105 out of 153 (69%) self-assessmentsdeclared compliance with providing servicesin environments which promote effective care

and optimise health outcomes by being welldesigned and well maintained premises.

• Providing services in environments thatpromote effective care was the standard withleast declared compliance as a whole andacross the services.

• 60% of the Royal Navy self-assessmentsdeclared compliance, which was the lowestamount of compliance. The Defence DentalServices declared the most amount ofcompliance with 92% of their self-assessments.

• Commentary from self-assessments thatdeclared non-compliance included thefollowing:



100%

90%

80%

70%

60%

50%Royal Navy Royal Air

ForceJoint Medical

CommandBritish Army Head

quartersDefence Dental

Services

Figure 1: Declared compliance with healthcare services providing an environment

that promotes effective care



60% 73% 63% 92% 89% 67%


“Our building is old but functional. It is not welldesigned for its purpose and maintenance ispoor as there are plans to build a new medicalcentre in 2012. We hope many issues will beaddressed at that time. The building is cleaneddaily by contract cleaners and kept tidy by theduty MA. We do not formally assess cleaningstandards.” Royal Navy, Primary Care

“….buildings that were not designed forpurpose and are in excess of 50 years old.”British Army, Primary Care

“The building is cleaned daily for two hours.The building is due to undergo a majorrefurbishment in the autumn to bring thebuilding up to standard. Once these workshave been completed, a new cleaning contractwill be in force and the building will have twofull-time domestic staff who will ensure thebuilding is cleaned thoroughly twice a dayand complies with infection control policy.” Royal Air Force, Primary Care




Royal Navy primary care Compliant CompliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant CompliantArmy primary care Compliant CompliantRAF primary care Not compliant Not compliantRAF primary care Not compliant CompliantJoint primary care Compliant CompliantJoint primary care Compliant CompliantArmy regional rehab unit Compliant Not compliantRoyal Navy regional rehab unit Not compliant Not compliantRAF regional rehab unit Not compliant Not compliantDental services Compliant CompliantDental services Compliant Not compliantDefence dental services Compliant Not compliantDental services headquarters Compliant Not compliantSecondary care permanent base Compliant Not compliant

• The Healthcare Commission’s assessmentresulted in nine out of the 15 (60%) units’declarations of compliance being overturnedto non-compliance. Three units declared non-compliance which the Healthcare Commissionagreed with. The total of non-complianceoverall was therefore 12 out of 19 (63%).One declaration of non-compliance wasoverturned to compliance.

• This is a significant finding and the evidenceused to declare compliance with thisstandard should be reviewed.


• Clean environment and fit-for-purposefacilities.

• Appropriate cleaning specification andcontract monitoring.

• Deep clean and on-call cleaningarrangements available.

• Quality monitoring of maintenance.

• Infection control training.

• Infection control audits.

• Disabled access and facilities (for example,toilets, lifts).

• Infection control, single use equipment anddecontamination policies.


• No local environmental risk assessmentsor environmental audit or monitoring.

• Poor standards of decoration.

• Remedial works not undertaken in a timelymanner.

• Poor standards of cleanliness.

• External maintenance and cleaning contractspoorly monitored.

• Units not DDA compliant (DisabilityDiscrimination Act – legislation to promotecivil rights for disabled people and protectdisabled people from discrimination).

• No hand wash sinks in clinical areas.

• No alcohol hand rubs in clinical areas.

• Non-adherence to COSHH principles (Control ofSubstances Hazardous to Health Regulations– intended to protect people from ill healthcaused by exposure to hazardous substances– for example chemicals, biological agentssuch as bacteria or parasites, gas).

• Poorly designed facilities compromisingpatient confidentiality.

• No dedicated sluice facilities.

• Condemned central heating boiler.

• Limited infection control training.

• Poor hand hygiene observed.

• Facilities not fit for purpose.

• No standards for environmental cleanliness.

• No risk register.


• There were several units that failed to complywith this standard. The main reasons were thatbuildings and estates were unfit for purpose,poor standards of cleanliness were observedand there was a lack of environmental riskassessment and contract monitoring. Insome cases, where risks and shortfalls inservice had been identified, little had beendone by way of resolution.





Services Command

Safe and secure environment 83% 92% 98% 100% 95% 67%Private and confidential environment 76% 69% 86% 83% 89% 67%Environment promotes effective care 60% 73% 63% 92% 89% 67%

Percentage of declared compliance by the DMS with standards for accessible and responsive care

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%Safe and secure

environmentPrivate and confidential

environmentEnvironment promotes

effective care

Royal Navy British Army Royal Air ForceDefence Dental Services Headquarters Joint Medical Command

Figure 2: Percentage of declared compliance with the standards in the care environment

and amenities domain across the services

Public health

Programmes and services are designed anddelivered in collaboration with all relevantorganisations and communities to promote,protect and improve the health of thepopulation served and reduce healthinequalities between different populationgroups and areas.

Standard C22a – local partnerships

Healthcare organisations promote, protectand demonstrably improve the health ofthe community served, and narrow healthinequalities by cooperating with each other,with local authorities and other organisationsand by making an appropriate and effectivecontribution to local partnership arrangements,including local strategic partnerships andcrime and disorder reduction partnerships.

• 135 out of 153 (88%) self-assessmentsdeclared compliance with this standard.

• Declared compliance with having localpartnerships was varied. The majority of self-assessments declared complianceranging from 82% of Royal Navy assessmentsto 100% of all three of the Joint MedicalCommand self-assessments.


Standard C22b – using the annual report of thelocal director of public health

Healthcare organisations promote, protectand demonstrably improve the health ofthe community served, and narrow healthinequalities by ensuring that the local directorof public health’s annual report informs theirpolicies and practices.

• 104 out of 145 (72%) self-assessmentsdeclared compliance with using the annualreport of the local director of public health.

Note: Eight self-assessments declared this standardas not applicable. These were three Royal Navy self-assessments, three Royal Air Force self-assessments,one British Army self-assessment and one DefenceDental Service self-assessment.

• Declared compliance with using the annualreport of the local director of public healthwas low compared to declared compliancewith other standards. Half of Royal Navy self-assessments declared non-complianceand just over a third of Royal Air Force self-assessments declared non-compliance.Only the Defence Dental Services and theJoint Medical Command declared all theirservices as compliant with using the annualreport of the local Director of Public Health.






82% 96% 86% 100% 89% 100%




47% 96% 70% 100% 84% 100%


Standard C23 – promotion of public healthprogrammes and national service frameworks

Healthcare organisations have systematicand managed disease prevention and healthpromotion programmes which meet therequirements of the national service frameworks(NSFs) and national plans with particularregard to reducing obesity through action onnutrition and exercise, smoking, substancemisuse and sexually transmitted infections.

• 137 out of 148 (93%) self-assessmentsdeclared compliance with the promotion ofpublic health programmes and NSF.

Note: Self-assessments that selected regional rehabilitationunits and tactical medical wing as the type of healthcareprovided were not applicable for this standard (3%).

• Over a third of the Royal Air Force self-assessments declared non-compliance withthe promotion of public health programmesand NSFs. The British Army, Defence DentalServices and Joint Medical Command declaredall their services as compliant with promotionof public health programmes and NSFs.


• The Healthcare Commission’s assessmentresulted in eight out of the 13 (62%) units’declarations of compliance being overturnedto non-compliance.





84% 100% 70% 100% 89% 100%



• Themed health promotion plan developedand implemented.

• Health needs assessment undertaken.

• Joint initiatives and shared learning withlocal NHS trusts.

• Patients’ information available – for example,lifestyle issues, disease management, healthscreening – information fairs and road shows.

• Individual and group sessions and clinics– for example, weight control, smokingcessation, sexual health and alcohol misuse –programmes developed in line with DMS policy.


• No local health needs analysis.

• Little evidence of health promotionprogrammes.

• No local health promotion plans.

• No evaluation of health promotion initiatives.

• Little or no sharing of information.


• Good practice – regular health promotionthemes set by Army primary care headquartersthat reflected national determinations,suggesting a strong emphasis on healthpromotion and preventative medicine – themesnot always followed through in local services.




Army primary care Compliant CompliantArmy primary care Compliant CompliantArmy primary care Compliant Compliant Army primary care Compliant Not compliant Army primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantArmy primary care Compliant Not compliantRAF primary care Compliant CompliantRAF primary care Compliant Not compliantDental services headquarters Compliant CompliantArmy headquarters Compliant Not compliant

Standard C24 – emergency planning

Healthcare organisations protect the public byhaving a planned, prepared and, where possible,practised response to incidents and emergencysituations, which could affect the provision ofnormal services.

• 130 out of 149 (87%) self-assessmentsdeclared compliance with this standard.

Note: Self-assessments that selected regionalrehabilitation units as the type of healthcare providedwere not applicable for this standard (3%).

• No area declared all their self-assessmentsas compliant with emergency planning.Declared compliance ranged from 38 out of48 Royal Navy self-assessments to 39 out of41 Royal Air Force self-assessments.




Services Command

Local partnerships 82% 96% 86% 100% 89% 100%Using the annual report of the local director of public health 47% 96% 70% 100% 84% 100%Promotion of public healthprogrammes and NSFs 84% 100% 70% 100% 89% 100%Emergency planning 79% 85% 95% 92% 95% 67%

Percentage of declared compliance by the DMS with standards in public health and health promotion



79% 85% 95% 92% 95% 67%


In inviting the Healthcare Commission toundertake an independent review of the qualityof care within the Defence Medical Services(DMS), it can be concluded that there was adesire for external scrutiny of the standards ofcare and treatment provided, to improve servicesand to identify areas of good clinical practice.

This has been a challenging and rewardingreview for the Healthcare Commission inundertaking healthcare assessment in an areanot previously assessed by us. We needed tounderstand the context in which the DMSoperated, the challenges it faced, and the diversityof the services it provided. The breadth andscope of these services provide a combinationof routine healthcare services and the deliveryof healthcare in extraordinary and very differentlocations and situations.

Our review found a number of examples ofexemplary healthcare provision in the areasof trauma care and rehabilitation. The trainingprocesses leading to excellent traumamanagement are an area that the NHS couldlearn from in the delivery of emergency care.

Although the number of Service personnel,dependants and entitled civilians commentingon their experiences of DMS was comparativelylow compared with the population served, therewas a high level of satisfaction expressed overall.Opinion of the primary care services and hospitalcare provided was high, particularly amongService personnel. Just over half of respondentsstated that appointments were easily madeor waiting times were short within primarycare. Feedback was very positive about therehabilitation and community mental healthservices, with no negative opinions submitted.Most respondents had a positive opinion of dentalcare but waiting times were considered too long.

The feedback we received suggests thatadministration and bureaucracy are negativefactors in the DMS, with 97% of respondentswho mentioned them experiencing problems.Comments regarding both poor communicationand a lack of continuity of care outweighed thenumber of positive comments in these areas.We also received negative comments aboutthe closure of military hospitals in favour ofNHS and independent healthcare providers.Some respondents stated that there was adistinct difference between the servicesprovided to Service personnel and thoseavailable to dependants.

Our review focused on the Standards for BetterHealth implemented in the NHS in 2004. Thesestandards have also been used by the DMS forinternally reviewing the quality of care. Thestandards, however, had not been consistentlyapplied across the DMS and this review hasprovided the first opportunity to implement thesame review process across all areas of DMShealthcare provision. This should be a startingpoint from which to work on the areas identifiedfor development and improvement and tofurther develop, share and learn from existinggood practice.

The DMS submitted 153 individual self-assessment declarations stating whether theirarea of healthcare services was compliant ornon-compliant with the Standards for BetterHealth. Some declarations covered regionalgroups of healthcare provision, for example,a number of medical centres. In our follow-upassessment visits to some of the services, welooked at evidence of compliance. The DMSneeds to consider how to collect data andinformation and how this can be used toinfluence and contribute to effectiveassessment in the future.


4. Conclusions

A high proportion of self-assessments declaredcompliance with standards relating directly toclinical care, such as taking account of nationallyagreed guidance when planning and deliveringtreatment and care. Our review found that theDMS had mechanisms in place for deciding onthe relevance of national advice, and documentedprocesses for implementation, monitoring andreview. We also found, in some areas, little orno evidence of national guidance being takeninto account, or systems being in place tomonitor best practice guidance.

There were high levels of compliance declaredwith ensuring that clinical care and treatmentwas carried out under supervision and leadership.Particularly good examples of clinicalsupervision for trainees were found in GPtraining practices. There were a number ofservices where there was a lack of evidence ofclear supervisory frameworks and practices.

Our review found that formal staff appraisalsystems were well embedded across all servicesand staff had good access to development andtraining. Professional clinical staff were ableto access opportunities to continuously updateskills and techniques relevant to their clinicalwork. The number of clinicians participating inregular audits and reviews of clinical serviceswas variable. Three-quarters of the unitsdeclared compliance in their self-assessmentof this standard, and some of the units wevisited had detailed clinical audit programmes,were able to cite examples of practice changeas a result of audits and had designated auditleads. Information from audits in some areascontributed to national data collections.

All Defence Dental Services, headquartersand Joint Medical Command units declaredcompliance with applying the principles ofsound clinical and corporate governance andundertaking systematic risk assessment andrisk management. There was a high level ofdeclared compliance from the three Services.Evidence to support this from follow-upassessment visits included audit programmes,risk registers and risk incident reporting, patientsatisfaction and feedback systems. The reviewalso found areas with clear clinical governancereporting structures and specific responsibilitiesfor individuals in lead roles.

We found that DMS staff were generally confidentto raise concerns about any aspect of clinicalpractice and to challenge discrimination andequality issues. There was a culture of trying toaddress and sort out any concerns, incidents orcomplaints at a local level. This had, however,led to under-reporting within many services.

Nine declarations out of the 153 submitted self-declared to be non-compliant with the standardrelating to promoting equality. Evidence fromfollow-up visits supporting compliance includedawareness of equality and diversity schemesand policies among staff, specific equality anddiversity officers and advisors and examples ofactions taken to promote equality. Our reviewfound that some services were not compliantwith requirements of the DisabilityDiscrimination Act.


Although 90% of self-assessments declaredcompliance with having effective recordsmanagement systems, in follow-up visits it wasfound that this was an area which needed to beimproved. Some records were not stored securelyand some units did not have a CaldicottGuardian appointed. A further area for attentionwas the management of medicines where areview of policy and practice is recommended.

Declared compliance with ensuring that stafftreat patients, their relatives and carers withdignity and respect was high across all theservices. Four out of the six services declared100% compliance. Ensuring that appropriateconsent is obtained when required, for allcontacts with patients and for the use of anyconfidential patient information was high acrossall the services. The percentage of declaredcompliance on this was the highest across allthe standards assessed. Follow-up visits foundthat staff were aware of the policy for, andprocess of, obtaining consent to treatment.

All the Army regions that submitted self-assessments declared that they had systemsin place to ensure that patients, their relativesand carers have suitable and accessibleinformation about, and clear access to,procedures to register formal complaints andfeedback on the quality of services. All otherareas declared over 90% compliance.

Thirty-five units declared that the standardregarding providing food was applicable to theirunits. The standard states that where food isprovided, healthcare organisations have systemsin place to ensure that patients are providedwith a choice and that it is prepared safely andprovides a balanced diet. Three of the self-assessments declared non-compliance, statingthat this was due to ongoing surveys in eachfacility highlighting issues with dietary services,no water provision and difficulties for patientsrequiring a vegetarian diet or staff and individualswith problems chewing or swallowing, whorequire a soft diet. It was stated that these issueshad been raised through the chain of command.

All self-assessments from the Army, DefenceDental Services, headquarters and Joint MedicalCommands declared compliance with makinginformation available to patients. Sixty-nine per cent of self-assessmentsdeclared compliance with providing servicesin environments which promote effectivecare and optimise health outcomes by havingwell-designed and well-maintained premises.Providing services in environments whichpromote effective care was the standard withthe least declared compliance as a whole andacross the services. Sixty per cent of the RoyalNavy self-assessments declared compliance,which was the lowest amount of compliance.The Defence Dental Services declared thehighest amount of compliance with 92% oftheir self-assessments compliant.


4. Conclusions continued

Our review found units providing services inpurpose built, well-equipped medical centresor in older buildings that had been suitablyadapted. These medical centres offered cleanand appropriate clinical environments. Althougha lot of the buildings used to provide medicalcare were old, these were still well maintained.The review also visited some medical centresboth in the UK and overseas where clinicalservices were provided in what the HealthcareCommission considered to be unacceptableconditions. These conditions included poormaintenance of the buildings and inadequateworking facilities for clinical staff. We foundthat some of the medical centres also had poorlevels of cleanliness. We have been formallyadvised of the immediate actions that havebeen taken and the plans put in place toaddress these urgent issues.

Eighty-eight per cent of self-assessmentsdeclared compliance with promoting, protectingand demonstrably improving the health ofthe community served, and narrowing healthinequalities by cooperating with each other andwith local authorities and other organisations.

Declared compliance with having localpartnerships was varied. The majority of self-assessments declared compliance rangingfrom 82% of Royal Navy assessments to 100%of all three of the Joint Medical Command self-assessments. Good practice in improvinghealth included themed health promotion plansbeing developed and implemented, health needsassessment being undertaken, joint initiativesand shared learning with local NHS trusts,patient information being available – forexample, lifestyle issues, disease managementand health screening. Other areas of goodpractice included individual and group sessionsand clinics being provided on issues such asweight control, smoking cessation, sexualhealth, and alcohol misuse, and these weredeveloped in line with DMS policy.

The information from our review, itsrecommendations and conclusions shouldinform clinical governance structures andprocesses for the whole of the DMS, enableareas already identified as good practice todevelop further, and focus work on areasfor improvement and development.

The Healthcare Commission recommendsthat the DMS reflects on this experience ofexternal review and considers how to ensureindependent review of its services in the future.


Standards for Better Health


Appendix 1

Domain outcome: patient safety is enhanced by the use of healthcare processes, workingpractices and systemic activities that prevent or reduce the risk of harm to patients.

Core standard C1

Healthcare organisations protect patients through systems that:a) Identify and learn from all patient safety incidents and other reportable incidents, and make

improvements in practice based on local and national experience and information derived fromthe analysis of incidents.

b)Ensure that patient safety notices, alerts and other communications concerning patient safetywhich require action are acted upon within required timescales.

Core standard C2

Healthcare organisations protect children by following national child protection guidelines withintheir own activities and in their dealings with other organisations.

Core standard C3

Healthcare organisations protect patients by following National Institute for Clinical Excellence(NICE) interventional procedures guidance.

Core standard C4

Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that:a)The risk of healthcare acquired infection to patients is reduced, with particular emphasis on

high standards of hygiene and cleanliness, achieving year-on-year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA).

b)All risks associated with the acquisition and use of medical devices are minimised.c) All reusable medical devices are properly decontaminated prior to use and that the risks

associated with decontamination facilities and processes are well managed.d)Medicines are handled safely and securely.e)The prevention, segregation, handling, transport and disposal of waste is properly managed

so as to minimise the risks to the health and safety of staff, patients, the public and the safetyof the environment.

First domain: safety


Domain outcome: managerial and clinical leadership and accountability, as well as the organisation’sculture, systems and working practices, ensure that probity, quality assurance, quality improvementand patient safety are central components of all activities of the healthcare organisation.

Core standard C7

Healthcare organisations:a)Apply the principles of sound clinical and corporate governance.b)Undertake systematic risk assessment and risk management.c) Actively support all employees to promote openness, honesty, probity, accountability, and the

economic, efficient and effective use of resources.d)Ensure financial management achieves economy, effectiveness, efficiency, probity and

accountability in the use of resources.e)Challenge discrimination, promote equality and respect human rights.f) Meet the existing performance requirements.

Third domain: governance

Domain outcome: patients achieve healthcare benefits that meet their individual needs throughhealthcare decisions and services, based on what assessed research evidence has shownprovides effective clinical outcomes.

Core standard C5

Healthcare organisations ensure that:a)They conform to National Institute for Clinical Excellence (NICE) technology appraisals and,

where it is available, take into account nationally agreed guidance when planning anddelivering treatment and care.

b)Clinical care and treatment are carried out under supervision and leadership.c) Clinicians* continuously update skills and techniques relevant to their clinical work.d)Clinicians participate in regular clinical audit and reviews of clinical services.* Professionally qualified staff providing clinical care or defence medical services to patients.

Core standard C6

Healthcare organisations cooperate with each other and social care organisations to ensure thatpatients’ individual needs are properly managed and met.

Second domain: clinical and cost effectiveness


Appendix 1 continued

Core standard C8

Healthcare organisations support their staff through:a)Having access to processes which permit them to raise, in confidence and without prejudicing

their position, concerns over any aspect of service delivery, treatment or management thatthey consider to have a detrimental effect on patient care or on the delivery of services.

b)Organisational and personal development programmes which recognise the contributionand value of staff, and address, where appropriate, under-representation of minority groups.

Core standard C9

Healthcare organisations have a systematic and planned approach to the management of recordsto ensure that, from the moment a record is created until its ultimate disposal, the organisationmaintains information so that it serves the purpose it was collected for and disposes of theinformation appropriately when no longer required.

Core standard C10

Healthcare organisations:a)Undertake all appropriate employment checks and ensure that all employed or contracted

professionally qualified staff are registered with the appropriate bodies.b)Require that all employed professionals abide by relevant published codes of professional practice.

Core standard C11

Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare:a)Are appropriately recruited, trained and qualified for the work they undertake.b)Participate in mandatory training programmes.c) Participate in further professional and occupational development commensurate with their

work throughout their working lives.

Core standard C12

Healthcare organisations which either lead or participate in research have systems in placeto ensure that the principles and requirements of the research governance framework areconsistently applied.

Third domain: governance (continued)


Domain outcome: healthcare is provided in partnership with patients, their carers and relatives,respecting their diverse needs, preferences and choices, and in partnership with otherorganisations (especially social care organisations) whose services impact on patient wellbeing.

Core standard C13

Healthcare organisations have systems in place to ensure that:a) Staff treat patients, their relatives and carers with dignity and respect.b)Appropriate consent is obtained when required, for all contacts with patients and for the use

of any confidential patient information.c) Staff treat patient information confidentially, except where authorised by legislation to the contrary.

Core standard C14

Healthcare organisations have systems in place to ensure that patients, their relatives and carers:a)Have suitable and accessible information about, and clear access to, procedures to register

formal complaints and feedback on the quality of services.b)Are not discriminated against when complaints are made.c) Are assured that organisations act appropriately on any concerns and, where appropriate,

make changes to ensure improvements in service delivery.

Core standard C15

Note: this standard is applicable only to healthcare organisations that routinely provide patients with food. Where food is provided, healthcare organisations have systems in place to ensure that:a)Patients are provided with a choice and that it is prepared safely and provides a balanced diet.b)Patients’ individual nutritional, personal and clinical dietary requirements are met, including

any necessary help with feeding and access to food 24 hours a day.

Core standard C16

Healthcare organisations make information available to patients and the public on their services,provide patients with suitable and accessible information on the care and treatment they receiveand, where appropriate, inform patients on what to expect during treatment, care and after care.

Fourth domain: patient focus



Domain outcome: patients receive services as promptly as possible, have choice in access toservices and treatments, and do not experience unnecessary delay at any stage of service deliveryor the care pathway.

Core standard C17

The views of patients, their carers and others are sought and taken into account in designing,planning, delivering and improving healthcare services.

Core standard C18

Healthcare organisations enable all members of the population to access services equally andoffer choice in access to services and treatment equitably.

Core standard C19

Healthcare organisations ensure that patients with emergency health needs are able to accesscare promptly and within nationally agreed timescales, and all patients are able to accessservices within national expectations on access to services.

Fifth domain: accessible and responsive care

Domain outcome: care is provided in environments that promote patient and staff wellbeing andrespect for patients’ needs and preferences in that they are designed for the effective and safedelivery of treatment, care or a specific function, provide as much privacy as possible, are wellmaintained and are cleaned to optimise health outcomes for patients.

Core standard C20

Healthcare services are provided in environments which promote effective care and optimisehealth outcomes by being:a)A safe and secure environment which protects patients, staff, visitors and their property,

and the physical assets of the organisation.b)Supportive of patient privacy and confidentiality.

Core standard C21

Healthcare services are provided in environments which promote effective care and optimisehealth outcomes by being well designed and well maintained with cleanliness levels in clinicaland non-clinical areas that meet the national specification for clean NHS premises.

Sixth domain: care environment and amenities


Domain outcome: programmes and services are designed and delivered in collaboration withall relevant organisations and communities to promote, protect and improve the health of thepopulation served and reduce health inequalities between different population groups and areas.

Core standard C22

Healthcare organisations promote, protect and demonstrably improve the health of thecommunity served, and narrow health inequalities by:a)Cooperating with each other and with local authorities and other organisations.b)Ensuring that the local Director of Public Health’s annual report informs their policies and

practices.c) Making an appropriate and effective contribution to local partnership arrangement including

local strategic partnerships and crime and disorder reduction partnerships.

Core standard C23

Healthcare organisations have systematic and managed disease prevention and health promotionprogrammes which meet the requirements of the national service frameworks (NSFs) and nationalplans with particular regard to reducing obesity through action on nutrition and exercise, smoking,substance misuse and sexually transmitted infections.

Preface:The elements are driven by the health improvement and health promotion requirements set outin NSFs and national plans with a particular focus on the following priority areas: • Encouraging sensible drinking of alcohol.• Encouraging people to stop smoking and providing a smoke free environment.• Promoting opportunities for healthy eating.• Increasing physical activity.• Reducing drug misuse.• Promoting sexual health.• Preventing unintentional injury.

Core standard C24

Healthcare organisations protect the public by having a planned, prepared and, where possible,practised response to incidents and emergency situations, which could affect the provision ofnormal services.

Seventh domain: public health

Contributors to this review

A number of individuals have contributed tothe research, development, management andimplementation of this review. In recognitionof their particular contribution, the HealthcareCommission would like to thank the followingpeople.

Reference Group

Kate Lobley, Head of Operations, ExecutiveTeam Sponsor and Healthcare CommissionProject Lead, Chair of the Reference Group (leftthe Healthcare Commission in October 2008)

• Ian Biggs – interim Head of Operations Group,Healthcare Commission

• Roxy Boyce – Head of Planning, Business andPerformance Management

• Maureen Burton – DMS Project Manager,Healthcare Commission

• Richard Clayton – Friarage Hospital Manager/Assistant Operational Services Director,South Tees Hospitals NHS Trust

• Professor Ann Close – National ClinicalAdvisor, Healthcare Commission

• Paul Farrimond – Director, Care ServicesImprovement Partnerships (CSIP) North East,Yorkshire and Humber, Regional DevelopmentCentre

• Wing Commander Mark Fleetwood –DMS/Healthcare Commission Liaison Officer

• Ray Greenwood – Chief Executive, St John andRed Cross Defence Medical Welfare Service

• Professor David Haslam – National ClinicalAdvisor, Healthcare Commission

• Kate Lawrence – Development Manager/Methodology Lead – Assessment & MethodsGroup, Healthcare Commission

• Robert Leader – Chief Executive, St Dunstan’s• Peter Mellor – Company Secretary

Portsmouth Hospitals• Andrew Morris – Chief Executive, Frimley

Park Hospital NHS Foundation Trust• Gary Needle – Head of Assessment and

Methods Group, Healthcare Commission• Brigadier Christopher Parker – Commandant

of the Royal Centre for Defence Medicine inBirmingham

Healthcare Commission Project Team

Maureen Burton Project Manager, Chair of Project Team

• David Chalder – Senior Legal Advisor• Roger Davidson – Head of External Affairs• Murray Devine – Safety Strategy Lead• Daniel Funge – Analyst• Marilyn Hansford – Lead Assessor • Kahlie Jensen – Business Coordinator • Kate Lawrence – Development Manager• Hayley Marle – Senior Analyst• Lorraine Moore – Area Manager • Neil Prime – Head of Analytical Support• Robert Taylor – Lead Assessor • Charlotte Trimm – Development Officer• Lynda Watts – Information Assurance

Programme Manager• Karen Wilson – Lead for Clinical Quality


Appendix 2

External clinical and managerial advisors

• Dr Ray Cross – Clinical Director ofCommunity Dental Services, CroydonPrimary Care Trust

• Mark Marshall – Associate Director ofStandards for Better Health, North EssexPartnership NHS Foundation Trust

• Dr Hugh Reeve – GP, Cumbria PartnershipNHS Foundation Trust/General MedicalCouncil assessor

• Dr Sarah Whiteman – GP, Milton KeynesPrimary Care Trust/General Medical Councilexaminer

Healthcare Commission senior clinicaladvisors

• Dr Nick Bishop – Senior Medical Advisor• Professor Ann Close – National Clinical Advisor• Dr Danny Keenan – National Clinical Advisor• Professor David Haslam – National Clinical

Advisor

Healthcare Commission assessors/internal advisors

• Erin Amato – Helpline Assistant Manager• Kouser Chaudry – Assessor SW region• Sue Fraser-Betts – Assessor Central region• Ricinda Dyer – Analyst• Rekha Elaswarapu – Lead for older people,

long term conditions team• Michele Golden – Assessor London &

SE region• Elaine Harper – Assessor Central region• Andrea O’Connell – Assessor London &

SE region• Lea Pickerill – Helpline Manager• Elizabeth Seale – Assessor Central region• Brian Silverwood – Assessor North region• Richard Wells – Analyst• Sandra Wilson – Assessor Central region• Jan Yates – Assessor North region


* Defence Medical Services Department is theheadquarters of the DMS under the combinedleadership of the Surgeon General and the DeputyChief of Defence Staff (Health).

** Joint Medical Command is responsible for themanagement and delivery of all joint clinical care,medical education and training and commissioningspecialist hospital diagnostic, care and treatmentincluding inpatient mental health care.

*** The Permanent Joint Headquarters is responsible forhealthcare provided in Gibraltar, Cyprus, the FalklandIslands, Diego Garcia and Ascension Island and forhealthcare provided in locations where the militaryservices are deployed throughout the world.Responsibility for healthcare standards in theselocations is exercised through the Surgeon General.

**** Royal Centre for Defence Medicine based inBirmingham is a dedicated training centre fordefence personnel with a focus on medical research.It also provides medical support in secondary andspecialist care for members of the armed forces andmedical support to military operational deployments.

DMS personnel provide healthcare in thefollowing roles:• Medical officers (primary and secondary

healthcare)• Dental officers• Medical support officers• Nurses (primary and secondary healthcare)• Allied health professionals• Medical assistants.


Appendix 3

The Surgeon General

The Deputy Chief of Defence Staff (Health)

Defence Medical Services Department*

Joint MedicalCommand**

Royal Centrefor Defence

Medicine****

Defence DentalServices

Royal NavalMedicalService

ArmyMedicalServices

Royal Air Force Medical

Services

Permanent Joint Headquarters***

Defence Medical Services organisational structure

Royal Naval Medical Service

The Royal Naval Medical Service is responsiblefor providing comprehensive healthcare onships, submarines and medical care to theRoyal Marines. It employs 1,522 personnelwho provide healthcare in the following areas.

Ashore

• 21 medical centres.

Afloat

• Capital ships• Frigates and destroyers• Submarines• Minor war vessels• Royal fleet auxiliary• Headquarters.

Operations

• First aid posts• Combat forward surgical groups• Primary Casualty Receiving Facility –

RFA Argus.


DMS Board

ChairDeputy Chief of

Defence Staff (Health)

DMS Executive Group

ChairAssistance Chief of


DMS Clinical Committee

ChairAssistance Chief of


Service Personnel Board

ChairDeputy Chief of

Defence Staff (Personnel)

Service PersonnelOperating Board

ChairDirector ServicesPersonnel Policy

Defence Health StrategySteering Group

Chair Assistance Chief of


DMS Assuranceand Governance

Group

ChairInspector General DMS

Department MOD

Defence Medical Services governance structure

Army Medical Services

The Army Medical Services employs 4,958personnel who provide healthcare in thefollowing locations:

Primary healthcare:• Army UK primary healthcare services:

• 7 regions• 66 medical centres• 15 medical reception stations• 70 primary care rehabilitation facilities• 7 regional rehabilitation facilities• 8 departments of community mental

health.• British Forces Germany Healthcare Services

– Germany.

Army operational healthcare is providedthrough the following:• Medical regiments, primary and pre-hospital

emergency care• Field hospitals• Territorial Army field hospitals.

Royal Air Force Medical Services

The Royal Air Force employs 1,898 personnelwho deliver primary, secondary and intermediatecare in the following locations:• 31 medical centres• 4 departments of community mental health• 3 regional rehabilitation units• 3 regional occupational medicine departments.

In addition, the RAF provides an aeromedicalevacuation service to the Armed Forces throughheadquarters Tactical Medical Wing and theAeromedical Evacuation Control Cell.

Defence Dental Services

The Defence Dental Services employ 783personnel from the Royal Navy, the Army, theRoyal Air Force and the civil service (clinicaland non-clinical civilian personnel employed bythe Ministry of Defence or the three Services).These personnel are trained dentists,therapists, hygienists, technicians and dentalnurses. Military Dental Service personnel areemployed and located all over the world andcivilian employees work alongside militarypersonnel in the UK, Cyprus and Germany.

There are eleven principal dental officersworking from regional delivery headquartersand there are 163 dental centres in total.




Appendix 4

List of DMS units visited by the Healthcare Commission

Service type Unit Location Country

Primary care

Primary care HMS Ark Royal Aircraft Carrier Portsmouth, Hampshire EnglandPrimary care HMS Gloucester (Type 42 Destroyer) Portsmouth, Hampshire EnglandPrimary care Royal Navy Medical Centre Portsmouth, Hampshire EnglandPrimary care Royal Navy Medical Centre Faslane, Dunbartonshire ScotlandPrimary care Commando Training Centre Lympstone, Devon England

Royal MarinesPrimary care Army Medical Centre York, Yorkshire EnglandPrimary care Army Medical Centre Dishforth, North Yorkshire EnglandPrimary care Army Medical Centre Wilton, Wiltshire EnglandPrimary care Army Medical Centre Bulford, Wiltshire EnglandPrimary care Army Medical Reception Station Catterick, North Yorkshire EnglandPrimary care Army Medical Reception Station Tidworth, Wiltshire EnglandPrimary care Army Medical Centre Rheindalen GermanyPrimary care Army Medical Centre Elmpt GermanyPrimary care Army Medical Centre Bielefeld GermanyPrimary care Army Medical Centre Princess Royal Barracks, Germany

GuterslohPrimary care PJHQ Medical Centre Sovereign Base Area, Akrotiri CyprusPrimary care PJHQ Medical Reception Station Sovereign Base Area, Dhekelia CyprusPrimary care Medical Centre (satellite unit ) Sovereign Base Area, Cyprus

Ayios NikolaosPrimary care Medical Centre Contingency Operating Base, Iraq

BasraPrimary care Military Transition Team Contingency Operating Base, Iraq

BasraPrimary care Royal Air Force Medical Centre Aldergrove Northern

IrelandPrimary care Royal Air Force Medical Centre Benson, Oxon EnglandPrimary care Royal Air Force Medical Centre Lyneham, Wiltshire EnglandPrimary care Royal Air Force Medical Centre High Wycombe, England

BuckinghamshirePrimary care Royal Air Force Medical Centre Halton, Buckinghamshire EnglandPrimary care Royal Air Force Medical Centre Kinloss, Forres Scotland




Dental care

Dental care Baird Dental Centre St Thomas’ Hospital, London EnglandDental care Northwood Dental Centre Northwood, London EnglandDental care Royal Air Force Dental Centre St Athan, Cardiff WalesDental care Royal Air Force Dental Centre Cosford, Shropshire EnglandSecondary/hospital care

Secondary/ No 34 Field Hospital Army York, Yorkshire Englandhospital care Regular UnitSecondary/ Territorial Army Cardiff Waleshospital care 203 (V) Field HospitalSecondary/ No 4 Medical Regiment Army Aldershot, Hampshire Englandhospital care Regular UnitSecondary/ The Princess Mary Hospital Akrotiri Cyprushospital careSecondary/ Field Hospital – from various units Contingency Operating Base, Iraqhospital care BasraRehabilitation

Rehabilitation Inpatient Rehabilitation Unit Headley Court, Epsom, Surrey EnglandRehabilitation Royal Navy Regional HMS Nelson, Portsmouth, England

Rehabilitation Unit WiltshireRehabilitation Army Regional Rehabilitation Unit Aldershot, Hampshire EnglandRehabilitation Army Regional Rehabilitation Unit Gütersloh GermanyRehabilitation Royal Air Force Regional Cranwell, Lincolnshire England

Rehabilitation UnitCommunitymental health

Community Royal Navy Department of Plymouth, Devon EnglandMental Health Community Mental HealthCommunity Army Department of Lisburn, Belfast Northern Mental Health Community Mental Health IrelandCommunity Royal Air Force Department of Cranwell, Lincolnshire EnglandMental Health Community Mental Health



Headquarters

Headquarters Navy Command Medical HQ Portsmouth, Hampshire EnglandHeadquarters British Forces Germany Wegberg Rheindalen Germany

Health Service HQHeadquarters Army Primary Health Care Service Camberley, Surrey EnglandHeadquarters Army Medical Directorate Camberley, Surrey EnglandHeadquarters Army Primary Health Care Service Tidworth Wiltshire England

Regional HeadquartersHeadquarters HQ 2 Medical Brigade, Army Strensall, Yorkshire EnglandHeadquarters Joint Medical Command Headquarters Gosport, Hampshire EnglandHeadquarters Directorate General RAF High Wycombe, England

Medical Services Air Command BuckinghamshireHeadquarters Defence Dental Services Headquarters Halton, Buckinghamshire EnglandMedical Headquarters Tactical Medical Wing Lyneham, Wiltshire EnglandheadquartersAdditional visits Observation and educational visits

Secondary/ Gilead Hospital Bielefeld Germanyacute careMedical training Army Medical Services Training Centre Strensall, York EnglandexerciseAcademic Royal Centre for Defence Medicine Birmingham EnglandDepartment ofEmergencyMedicineSubmariner Royal Navy Base Dunbartonshire Scotlandmedical care

Many individuals throughout the Ministryof Defence, Defence Medical Serviceshave contributed to the development andimplementation of this review. The HealthcareCommission would like to acknowledge theircommitment to making this review happen and totaking the necessary actions, following the review,to continually improve healthcare delivery.

In recognition of their particular contribution,the Healthcare Commission would like to thankthe following people:

• Lieutenant General Louis Lillywhite –Surgeon General MOD

• Surgeon Rear Admiral Lionel Jarvis –Assistant Chief of Defence Staff(Health),Defence Medical Services Department, MOD

• Surgeon Rear Admiral Philip Raffaelli –Director Strategic Change and InspectorGeneral, Defence Medical ServicesDepartment, MOD

• Major General Mike von Bertele –Commander Joint Medical Command

• Major General Alan Hawley – DirectorGeneral Army Medical Services

• Air Vice-Marshal Paul Evans – DirectorGeneral Royal Air Force Medical Services

• Surgeon Commodore Tim Douglas-Riley –Director Royal Naval Medical Service

• Brigadier Ian Pretsell – Director DefenceDental Services

• Captain Helen Allkins – Director NavyNursing Services

• Surgeon Captain Paul Hughes – HealthcareGovernance, Fleet Medical Division, Royal Navy

• Surgeon Captain Richard Johnston – AssistantDirector Performance Management, MOD

• Surgeon Captain Mark Weston – AssistantDirector Clinical Delivery, HQ Defence DentalServices

• Colonel Philip Bolton – Head HealthSurveillance, Defence Medical ServicesDepartment, MOD

• Colonel Timothy Hoggetts – DefenceProfessor of Emergency Medicine, RoyalCentre for Defence Medicine, Birmingham

• Colonel Pat John – Medical Operations,Permanent Joint Headquarters

• Group Captain Lucy Elphinstone – AssistantDirector Armed Forces Health, DefenceMedical Services Department, MOD

• Group Captain John Gaffney – AssistantDirector Performance Management, DefenceMedical Services Department, MOD

• Group Captain Jackie Gross – Deputy Chiefof Staff Healthcare Governance and DirectorPrincess Mary’s Royal Air Force Nursing Service

• Commander Nick Howes – ClinicalGovernance, Joint Medical Command

• Surgeon Commander Martin Randle –Healthcare Governance, Fleet Medical Division,Royal Navy

• Lieutenant Colonel Mo Holman – Healthcareand Audit, Army Medical Directorate

• Lieutenant Colonel Ross McCulloch –Healthcare and Audit, Army Medical Directorate


Acknowledgements


• Lieutenant Colonel Sarah Ramage – ClinicalDelivery, HQ Defence Dental Services

• Wing Commander Mark Fleetwood – DMS leadfor the Healthcare Commission Review MOD

• Wing Commander Helen Stewart – HealthcareGovernance, Royal Air Force Air Command

• Major Simon Rothwell – Clinical GovernanceLead, Operation Telic

• Squadron Leader Heather Clarke – HealthcareGovernance, Royal Air Force Air Command

• Squadron Leader Trevor Hopper – Assessmentand Audit, Directorate of Healthcare MOD

• Squadron Leader Andy Raper – MedicalOperations, Permanent Joint Headquarters

• Lieutenant Jacqueline Quant – HealthcareGovernance, Fleet Medical Division, Royal Navy

• Mr Pete Bennington, Programme Director,DMS Top Structures Study, Defence MedicalServices Department, MOD

• Miss Caroline Fox – Assistant Director ExternalDevelopment, Defence Medical ServicesDepartment, MOD

• Mr Jim Wilson – Senior Auditor, DefenceInternal Audit, MOD

Data Protection Act 1998

Human Rights Act 1998

Human Rights Act Scheme for Ministry ofDefence 2008-11

Joint Services Publication (JSP) 315 ServicesAccommodation Code Edition 3 July 1999

JSP 340 D/AMD/113/9 Joint Service Regulationsfor the management of medical, dental andveterinary materiel and equipment 2000

JSP 375 Health and safety handbook 4th EditionOctober 2001

JSP 536 Ethical conduct and scrutiny in MODresearch involving human participants

Ministry of Defence, Defence Medical ServicesDepartment (2008), DMSD/32/14/11, DefenceMedical Services Top Structures – Next Steps(TS-NS) Project Report, 16 January 2008

MOD Factsheet, 23 March 2007, Medical Supportto Personnel Injured or Sick on Operation:A defence Policy and Business news article

Surgeon General’s policy letter (SGPL) 01/03dated 7 January 2003 Ref D/SG/370/12/1, ClinicalGovernance in the Defence Medical Services

SGPL 02/04 dated 20 January 2004Ref D/DMSD/360/4 Smoking cessation guidelinesfor use by health professionals in the DefenceMedical Services

SGPL 18/04 dated 20 December 2004Ref DMSD/5/3 Quality assurance of clinicalgovernance on deployed operations

SGPL 05/05 dated 8 March 2005 Ref DMSD/366/1Minimum training standards for primary caredoctors working in the DMS

SGPL 10/05 dated 28 July 2005 Ref 276/2Clinical supervision for nurses

SGPL 12/05 dated 23 August 2005 Ref DMSD/5/1/2State regulation of allied health professionalsregulated by the Health Professionals Council

SGPL15/05 dated 20 September 2005Ref DMSD/5/1/1 Clinical governance policy forDepartments of Community Mental Health

SGPL 26/05 dated 13 February 2006Ref DMSD/5/1/1 The Defence Medical Servicespatient consent policy

SGPL 05/06 dated 24 February 2006Ref DMSD/13/5/2 Strategy for improving thesexual health of the Armed Forces

SGPL 14/06 dated 15 June 2006 Ref DMSD/5/2Defence Medical Services resuscitationstandards and training policy

SGPL 01/08 dated 29 February 2008Ref DMSD/20/10 The management of poorlyperforming doctors and dentists within theDefence Medical Services

SGPL 11/08 dated 18 April 2008Ref DMSD/02/09/01 The role of Defenceconsultant advisers and Defence professors

Statutory Instruments, 2008 No. 1181 PublicHealth, The Commission for Healthcare Auditand Inspection (Defence Medical Services)Regulations 2008

www.mod.uk/DefenceInternet

www.mod.uk/DefenceInternet/microsite/dms

www.opsi.gov.uk/

www.uhb.nhs.uk/Services/Rcdm/Home.aspx


Bibliography

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Documents

Defence Medical Services - NHS€¦ · The focus of the review 4 The Defence Medical Services 5 Key findings 6 The standards of care across the Defence Medical Services 6 Views of