Original paper J R Army Med Corps: first published as 10.1136/jramc-2016-000720 on 6 January 2017. Downloaded from Lessons from the organisation of the UK medical services deployed in support of Operation TELIC OPEN ACCESS (Iraq) and Operation HERRICK (Afghanistan) Martin C M Bricknell,1 M Nadin2 1Ministry of Defence, Director ABSTRACT Medical Policy and Operational This paper provides the definitive record of the UK Key messages Capability, Whitehall, London, UK Defence Medical Services (DMS) lessons from the organ- 2 isation of medical services in support of Operation (Op) Capability Directorate (Army), ▸ The Journal of the Royal Army Medical Corps Formerly Head of Medical TELIC (Iraq) and Op HERRICK (Afghanistan). The analysis has provided a longitudinal record of lessons Capability (Army), Andover, UK involved a detailed review of the published academic lit- for military medicine since first publication. erature, internal post-operational tour reports and post- ▸ This paper is an official statement of the Correspondence to tour interviews. The list of lessons was reviewed through organisational lessons from Operation (Op) Maj Gen Martin C Bricknell, three Military Judgement Panel cycles producing the Director Medical Policy and TELIC and Op HERRICK for the Defence Medical single synthesis ‘the golden thread’ and eight ‘silver Operational Capability, Ministry Services. of Defence, Whitehall, SW1A bullets’ as themes to institutionalise the learning to ▸ This paper lists the activities being undertaken 2HB London, UK; deliver the golden thread. One additional theme, men- to implement these lessons. martin@ bricknell. net toring indigenous healthcare systems and providers, Received 17 September 2016 emerged as a completely new capability requirement. Revised 5 November 2016 The DMS has established a programme of work to Accepted 8 November 2016 implement these lessons. Campaign Study published in March 2015; a Published Online First 6 January 2017 redacted version of this document was released to the public domain in January 2016 as a result of a Freedom of Information request.1 The Health INTRODUCTION Services Support element of the study was tasked copyright. This paper provides a summary of lessons from the directly to the Army Medical Directorate, but a organisation of medical services in support of Joint approach was adopted and the breadth of the Operation (Op) TELIC (Iraq) and Op HERRICK DMS were consulted and participated in the ana- (Afghanistan) covering the period from February lysis, including significant contributions through 2003 to November 2014. The achievement of the the Defence Consultant Advisors (DCAs) and best possible clinical outcomes for our patients was Professors, the medical staffs in the operational the product of synergy between the chain of headquarters and both Royal Navy and Royal Air command, medical organisation and excellent clin- Force Medical Services. While undertaken towards http://militaryhealth.bmj.com/ ical practice. This paper, by interpreting how the end of Op HERRICK, the analysis represented medical services were organised, complements the a culmination of organisational knowledge accrued clinical lessons that are the main feature of the mul- over the preceding decade. tiple academic publications by Defence Medical The analysis was initiated with a literature Services (DMS) clinicians. review, focused on Op HERRICK post-operational reports, Commanders’ post-operational interview SCOPE AND METHOD transcripts and articles published within peer- This paper is based on material already in the reviewed journals. Several hundred lessons and public domain, primarily scholarly articles already observations were assimilated and circulated for published in medical journals, however other gov- review by a DMS-wide audience that included the on September 24, 2021 by guest. Protected ernment publications have been cited, notably DCAs and Professors, who were requested to add those produced by Defence Statistics (Health). No their own lessons and observations. Further con- new primary research has been undertaken and solidation followed, leading to a Joint senior level thus the evidence set is affected by the relative Military Judgement Panel (MJP), which reviewed paucity of material on the DMS organisation in 240 lessons, identified the top third and consoli- Iraq compared with Afghanistan. The focus is on dated these into 23 lessons and themes. The 23 deployed medical services and does not capture the lessons were forwarded for consideration by a lessons from providing healthcare for wounded, selected panel of 40 Op HERRICK medical Subject sick or injured service personnel from these opera- Matter Experts (SME), who were individuals who tions after their return to the UK in the Role 4 held Op HERRICK assignments as a Commander pathway. Lessons published by other nations from Medical, Deployed Medical Director, Brigade within the military coalition in both theatres or Senior Medical Officer, Commanding Officer (CO) from the clinical care of Iraqi or Afghan casualties of the Bastion Role 3 Hospital or the medical regi- To cite: Bricknell MCM, are not considered. ment, DCAs, Defence Professors, CO of the Royal Nadin M. J R Army Med Corps This article is structured around the medical Centre for Defence Medicine, North Atlantic 2017;163:273–279. lessons at Chapter 4-2 of the Op HERRICK Treaty Organization (NATO) Medical Adviser and Bricknell MCM, Nadin M. J R Army Med Corps 2017;163:273–279. doi:10.1136/jramc-2016-000720 273 Original paper J R Army Med Corps: first published as 10.1136/jramc-2016-000720 on 6 January 2017. Downloaded from principal Joint and single Service Medical Staff Officers. These Birmingham. The NHS remains a key strategic partner for the senior individuals had all completed Op HERRICK-related Ministry of Defence (MOD) to maintain an appropriately pre- assignments and were requested to provide insights based on pared pool of military secondary healthcare (SHC) staff at readi- their own Op HERRICK experiences. Given the length of the ness to deploy on operations. campaign, many had undertaken multiple deployments on Op These clinical gains were underpinned by significant enhance- HERRICK and also undertaken assignments in direct support of ments in training, equipment and MEDEVAC. Such enhance- the operation. Thirty SMEs responded, producing 80 additional ments may not be available during the early stages of future insights and observations, bringing significant richness to the operations because of constraints on our ability to move medical data and permitting detailed triangulation of lessons and prac- mass; competing priorities for use of helicopters may restrict tices. The insights and observations were mapped against the 23 their availability for MEDEVAC and the current limited environ- lessons and taken forward for consideration by a senior six mental tolerance of some key clinical equipment. These member MJP. This panel reviewed the lessons and made further enhancements within a new theatre of operations will have to consolidation, resulting in the list contained herein that are be built incrementally as the capacity of the Joint Supply Chain definitive lessons of the DMS. allows and the theatre matures. Consequently, our clinical The principal insight is based on a narrative from the multi- research should be directed towards the following goals: tude of lessons, observations and insights that encapsulates the ▸ The development of miniaturised and ruggedised imaging UK military medical endeavour and development over 8 years. and laboratory capability that has better tactical transport- The MJP also identified nine themes that require actions or ability and environmental tolerance and reduces logistic drag, work to retain, institutionalise or support this narrative. Each and which may offer the use of imaging and laboratory individual theme has been amplified by reference to academic support forward of field hospitals. papers published in the public domain and the method for sub- ▸ The development of clinical interventions and protocols that sequent implementation of these lessons into changes to organ- enhance our ability to sustain patients more effectively isation or practice is summarised in italics. during prolonged field care if medical planning timelines cannot be met. THE NARRATIVE: THE SYNTHESIS OF LESSONS, The primary organisational lessons have been captured in the OBSERVATIONS AND INSIGHTS new concept—the Operational Patient Care Pathway. This has The standard of healthcare delivered on Op TELIC and Op been incorporated into medical doctrine, and the UK national HERRICK, and resultant patient outcomes, provides the base- medical doctrine has been merged with NATO medical doctrine line that the DMS aspire to deliver on future operations. This as a single publication.5 performance was the result of the Operational Patient Care copyright. Pathway (OPCP)2 being managed as a single and coherent MEDICAL STATISTICS AND WORKLOAD end-to-end healthcare system, from point of injury to the home Data are essential to the analysis of performance of any medical base (Role 4). There is robust clinical evidence of cumulative system. The military medical system is unique in that it operates improvement in the probability of survival of the UK military under single organisational direction and so it is possible to casualties3 and the trauma system was regarded as exemplary by direct the collection and collation of medical information from the Care Quality Commission.4 It is recognised