Extreme operations: a day in the life of NHS staff serving in Afghanistan

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Fantastic facilities, intensively trained staff and copious quantities of blood are all in a day’s work for NHS staff serving in Afghanistan. And the health service could gain more from their new skills. Nick Golding reports

The still of the airless desert day is broken as the helicopter carrying a wounded Estonian soldier comes in to land. Gunshot wounds to his leg and abdomen have been reported.

This barren, sweltering corner of Helmand province is far removed from a British town but, as the stretcher is hurried to the hospital through a cloud of dust, another episode of on-the-job training of NHS professionals is about to begin.

With frantic preparations getting under way in the emergency ward, Major Moira Kane, normally a matron at the George Eliot Hospital trust in Nuneaton, admits: “One of the first things I do - and maybe I shouldn’t - is look at the nationality. It’s only natural.”

She is one of the 80 per cent of staff at the field hospital of Camp Bastion, the sprawling military base closest to the centre of the British armed forces’ violent struggle, who work for the NHS. As military reservists, typically in Afghanistan for a six month stint, they gain an unparalleled opportunity to develop skills treating trauma injuries on a scale that can barely be imagined in a British hospital.

At the time of HSJ’s visit in May, the camp was home to 8,300 British soldiers, as well as a US force about to number 10,000. As operations intensify against the Taliban, the medical staff’s mental and physical capacity to withstand constant pressure to save lives is tested to the limit.

Extreme pressure

Overseeing the field hospital is Lieutenant Colonel Duncan Phimister, who arrived at the camp in April. He will manage a team of Territorial Army reservists from Birmingham for six months before he is due to retire from the forces after 29 years.

“The facility we have here is fantastic. The level of care we are able to guarantee is second to none,” he says. “We measure ourselves by unexpected survivors.”

The former deputy chief executive of George Eliot Hospital trust is well placed to comment on the benefits to the NHS of the active service of staff in a war zone.

“We’re able to provide a large pool of highly skilled staff. They are highly motivated. They weren’t pressed to come here - they volunteered,” he points out.

“The leadership skills training people get here would be really hard to replicate. We are used to managing under extreme pressure - when the pressure hits, it really is intense.

“I firmly believe that this is really good value for the NHS. The intensive training experience here in three months might be the same as they’d get in five or six years back home.”

But Lt Col Phimister appreciates that there are drawbacks to military service for trusts and reservists’ colleagues. Even before the economic downturn and the flu pandemic, some British hospitals experienced problems when specialist staff left for stints of military service.

While armed forces promise to fund cover, specialists are often hard to come by. While the number of staff serving in Afghanistan is a drop in the ocean compared with the NHS’s total workforce, it is accident and emergency, operating theatres and intensive care units which bear the brunt of deployments.

Lt Col Phimister explains that, when he was a deputy chief executive, he allowed four military reservist staff members from his accident and emergency department to go on service simultaneously, leaving those who remained hard pressed.

“I have to say that the nurse manager wasn’t very happy with me,” he admits. “They all volunteered again a year later but I wouldn’t let them all go at the same time. They are scarce resources in the NHS.

“We have worked hard with trusts and try to give them as much notice as possible. I was taking three intensive care staff out of one trust. The trust got in touch with me saying they would struggle to keep the unit open. In the end I took just one,” he says.

“I cannot think of a trust where the management is against the TA. Sometimes the line managers don’t know what we are on about, though.”

The benefits of the NHS employing reservists are something the Ministry of Defence wants to publicise. Its SaBRE (Supporting Britain’s Reservists and Employers) campaign aims to build better conditions, for both members of the Volunteer Reserve Forces and those who can experience difficulty when their colleagues leave for lengthy tours of duty overseas.

Lieutenant Colonel Graeme Cooke runs a warehouse providing Camp Bastion’s hospital with medical supplies. He is familiar with the problems encountered by reservists.

“There are problems dealing with bureaucracy - middle management doesn’t really buy into the benefits of being a reservist,” he says.

“I believe there’s a secret world of reservists back home. It’s treated like a silent side of your life. But we need to be more open about people being reservists. I’ve yet to meet a reservist who doesn’t think in terms of family and employer.”

Reservists in the army, navy and air force had previously been regarded as “weekend warriors” who received a quota of training but ended up with little experience of active service. That perception has now changed as Britain’s military resources have become stretched in recent years and increasing numbers of the 34,000-strong reservist force have found themselves sent to trouble spots including Iraq, Afghanistan and Kosovo.

As troops in Afghanistan suffer appalling injuries from roadside bombs with increasing regularity, reservists have not only had their work cut out but also discover opportunities to develop new treatments.

The Camp Bastion facility is spearheading new, aggressive ways of using blood products as severely wounded troops require great quantities of blood to stay alive. In one month, the hospital uses one third of all the O-negative blood, which can be given to anybody, donated in the UK. In the week before HSJ visited, one soldier had 50 units of blood pass through him.

The exceptionally well equipped operating theatre can be heated to 41C to help the injured avoid hypothermia. This seems somewhat ironic, considering the rest of the air-conditioned hospital feels a chilled refuge from the scorching heat outside.

Casualties’ treatment does not start with their arrival at the field hospital. In recent years, a greater emphasis has been placed on care on the battlefield, with all units supplied with tourniquets and Quikclot, which stems bleeding. Armed support groups will be sent out to attend injured servicemen in the field, although at least one officer told HSJ that the British were “not as gung-ho” as the Americans when it came to flying helicopters into battle to remove the injured. British policy emphasises the avoidance of unnecessary danger to support teams.

Not all of the recipients of NHS expertise are British - far from it. Most combat casualties are Afghan, from the country’s national police or army as well as civilians. Enemy forces are treated in Camp Bastion’s hospital, separated from allied troops by a screen and watched over by an armed guard.

Returning after injury

Hospitals run by the armed forces have an overwhelming specialty in emergency care and trauma injury, but few regular ward beds. At Kandahar base, several hundred miles to the east and the Royal Air Force’s logistical hub in Afghanistan, Commander Simon Carter of the joint force support headquarters explains why: “The aim is to get you fit to travel and then we get you home as soon as we can.”

Planes have been adapted to take servicemen and women back to the UK. Defence Medical Services has contracts with six NHS trusts with specialist units set up at Plymouth Hospitals trust, Frimley Park Hospital foundation trust, Peterborough and Stamford Hospitals foundation trust, Portsmouth Hospitals trust, South Tees Hospitals trust and University Hospital Birmingham foundation trust.

A concordat signed by the Department of Health and MoD in 2002 sets out co-operation between the armed forces and NHS. The MoD/DH Partnership Board meets three times a year to discuss enhanced co-operation, both on the quality of healthcare or treatment and on benefiting mutually from workforce development.

Speaking to HSJ in Kandahar, Christopher Long, chief executive of NHS Hull, who represents primary care trust commissioners on the board, says that the NHS has much to do both when it comes to supporting servicemen and getting the most out of reservists.

Mr Long, who served in Northern Ireland and the Gulf as he rose to become a captain in the Royal Regiment of Fusiliers before leaving the army in 1991, says: “I think the NHS treats reservists well but we aren’t sufficiently aware of the contribution they make.

“The thing that’s surprised me on this visit is the really effective integration of the Territorials in the ‘real’ army these days. They are held in high regard by their regular colleagues and make a significant contribution. I’ve been particularly struck by the levels of responsibility that some relatively junior reservists hold.”

Post-combat stress

Mr Long is particularly concerned that the NHS has had too little consideration for the needs of veterans and troops returning to Britain, especially when it comes to mental health support. Former servicemen have high rates of misuse of alcohol and drugs, which often obscure deeper underlying problems, he says.

“There’s a growing proportion of ex-servicemen in the prison population. Are we asking enough questions as to why they are there? What I’d like to understand better is whether there’s a link between recent service in Afghanistan and Iraq and how they have managed to settle back in civilian life after what in some cases will have been very harrowing experiences.”

NHS Hull two years ago introduced a policy of priority treatment for veterans showing signs of mental health problems, which has been taken up nationally. However, Mr Long warns: “I don’t believe that NHS practitioners are sufficiently aware of that policy and acting on it.”

Another key supporter of the SaBRE campaign is Nottingham University Hospitals trust chair Peter Barrett, who visited Iraq last year. He fears the NHS has missed a trick by failing to ask reservists about their wartime experiences, which means that many of the skills they pick up that could be useful to the NHS go to waste and their difficulties go unrecognised.

“Reservists are often reserved people. They don’t go shouting their mouths off about what they have seen and keep their heads down. Sometimes we have to encourage them to blow their own trumpet,” he says.

“They experience things that people wouldn’t normally experience. People are wasting their knowledge and their training.”

His trust has devised a welcome pack to support reservists returning to their job after deployment. A meeting will be held between those returning from deployment and the director of human resources at which their achievements are recognised. An annual dinner is held for all the trust’s reservists, many of whom had never previously had an opportunity to meet their military counterparts elsewhere in the trust.

Dr Barrett feels parts of the NHS have not been sufficiently sensitive to the needs of personnel mentally scarred by the grim realities of war.

“It’s true that some of their experiences have been fairly horrific and their decompression time is very short compared to the regulars. They are often expected to go back to work in a week or two after being released from mobilisation,” he says.

“We are happy to give them more. They can have as much time as they need to recover from trauma to return to work.”

The MoD’s Strategic Review of Reserves, which was released earlier this year, called for greater engagement from the armed forces with employers, warning that a lack of it meant the benefits medical reservists had gained were not fully appreciated.

Until this happens, those arriving at British hospitals could miss out on the expertise gained in the treatment of the Estonian soldier and so many others treated by NHS staff in war zones far from home.

Reservists: time commitments and workplace rights

The armed forces have 34,000 reservists, 86 per cent of them in the Territorial Army. The rest are split between the Royal Naval Reserve, Royal Marines Reserve and Royal Auxiliary Air Force. Half of reservists have been deployed on active service since 2003.

The largest contingent of medical reservists serves within the Royal Army Medical Corps, which has over 5,000 members in three general support regiments.

Training typically consists of one evening a week and 30 days a year, including weekends and 15 days’ continuous duty. Reservists receive further training after being mobilised.

Either the reservist or their employer can apply for mobilisation to be postponed or cancelled. Applications by employers are accepted in two thirds of cases, usually when it is felt the reservist’s absence would badly hit a business or organisation. The employer does not need the reservist’s agreement to apply.

Employers’ costs will be covered after mobilisation, including agency fees, advertising for cover, overtime payments and higher salary rates for temporary staff. Awards are usually capped at £110 a day.

Wages do not have to be paid by employers while the reservist is mobilised. The MoD will match the reservist’s civilian earnings up to a maximum of £200,000 and pay the employer’s pension contribution.

By law, the reservist must be reinstated to their former job. If this is impossible, for instance after a reorganisation, the employer must offer the “most favourable” alternative job possible. If the reservist would have been made redundant, this must be carried out on the same terms as had they not been mobilised.

Mobilised service usually lasts between six and 10 months. A reservist will not be mobilised for more than one year in five. Employers receive at least 28 days’ notice of mobilisation, except when a reservist reports to duty within hours after a terrorist attack or natural disaster. Reservists are entitled to post-operational leave.