CQC's inspection programme of Defence Medical Services: Annual report for 2023/24 (Year 7)

Summary of activity in 2023/24

This report sets out our findings about the quality of care in Defence Medical Services (DMS) from our inspections in 2023/24 – Year 7 of this programme.

During the year, we carried out 37 first comprehensive inspections of:

• 23 medical centres (including primary care rehabilitation facilities with expertise input from DMS physiotherapy and exercise rehabilitation specialist advisors)
• 14 dental centres.

We also continued assessments, led by DMSR, of unique military healthcare services. These included:

• Royal Air Force Health Directorate (RAFHD) – Air Command
• Royal Fleet Auxiliary (follow up)
• MOD A Block (MAB) Medical Headquarters
• HMS Queen Elizabeth Dental Centre
• HMS Queen Elizabeth Medical Centre
• Falklands: Pre-Hospital Emergency Care.

We did not apply ratings or publish recommendations and reports for these inspections as the reviews were led and owned by DMSR.

We also carried out 10 follow-up inspections to ensure that services have resolved the concerns we found on initial inspections. We re-inspected:

• 4 medical centres (including primary care rehabilitation facilities with input from DMS physiotherapy and exercise rehabilitation specialist advisors)
• 3 dental centres
• 1 pre-hospital emergency care (PHEC) service
• 1 regional rehabilitation unit
• 1 military department of community mental health.

Most services have been able to deliver some improvements, although there are still barriers to improvement in some areas, specifically:

• insufficient leadership capacity
• lack of a clinical information system to provide a comprehensive set of performance indicators
• poor infrastructure
• gaps in training and healthcare governance work.

In our inspection reports, we continued to highlight exemplary practice to encourage other services to learn from it and to adapt what is relevant to use in their own improvement journey.

Along with the Defence Medical Services Regulator (DMSR), CQC is committed to ensuring that armed forces personnel and their families can access the same high-quality care as the rest of society.

We commend military and civilian personnel for their continued hard work and commitment to delivering high-quality, safe and effective care.

All inspection reports for DMS medical facilities are available on our website: www.cqc.org.uk/DMS.

Key findings from inspections in 2023/24

Dental services

For our inspections of DMS dental services, rather than give a rating, we judge whether the service is meeting standards and we make recommendations in the inspection report.

DMSR asked CQC to carry out first comprehensive inspections at 14 dental centres. Of these, 10 were meeting the regulations for all 5 key questions (Figure 1).

Figure 1: Inspections of dental centres in Year 7

As in previous years, common shortfalls were due to:

Building infrastructure and maintenance: Poorly designed and maintained buildings were unable to achieve ‘best practice’ as detailed in guidelines relating to decontamination in primary care dental practices, and the control of infections and related guidance. Although some dental teams had placed the risk on their risk registers, escalated the risk appropriately and submitted statements of need for remedial work, funding had not always been approved and so improvements had not been delivered.

Water safety: Failure by the contractor or station to provide clear information and resolve risks relating to routine water safety checks and the cleaning contract to minimise the risk of Legionella in the water system. This requires action to secure a system-wide solution.

Improvement on re-inspection

We re-inspected the safe key question at 3 dental centres in 2023/24 to follow up our previous recommendations.

• Brawdy Dental Centre: all standards met
• Halton Dental Centre: all standards met
• Blandford Dental Centre: not all standards met

Concerns initially identified at Halton and Brawdy Dental Centres had been addressed through legionella risk assessments, which gave assurance to the dental team of a safe water supply, and through upgrades to the building with improved accessibility.

Blandford Dental Centre had secured some improvements following the initial inspection, but still needed improvement relating to its water supply.

Medical centres

All military personnel, some dependants, and some civilian staff are entitled to use the services of a military GP practice. Unlike most NHS patients, military staff do not have the right to register with a GP practice of their choice but must register at the location where they are assigned.

In 2023/24, as in previous years, DMSR identified the medical facilities to be inspected. This included several overseas medical centres and a newly established group practice.

Summary of findings

The overall ratings for each medical centre are determined by aggregating ratings for the 5 key questions. Figure 2 lists the 23 first comprehensive inspections of medical centres in 2023/24. Of these:

• 2 were rated overall as outstanding
• 17 were rated overall as good
• 3 were rated overall as requires improvement
• 1 was rated overall as inadequate

As we have found in every year of the programme, problems are more often related to the centre’s approach to safety and how well it is led and managed (relating to the safe and the well-led key questions). We found that most patients were able to access compassionate care. There were concerns around the effectiveness of care delivered at 5 medical centres and we found a specific issue around the responsiveness of care across centres in Cyprus.

Figure 2: First comprehensive inspections of medical centres in 2023/24

Improvement on re-inspection

Where we identify shortfalls in the quality of care, we return to re-inspect to ensure the service has made sufficient improvement. In 2023/24, we re-inspected 5 medical centres, including the pre-hospital emergency centre in Cyprus.

Of these, one medical centre was re-inspected for the 4th time and one for the 5th time. All these services except one demonstrated sufficient positive improvement to confirm that the quality of care had improved.

Maintaining quality

As we had already inspected all firm base medical centres at least once, DMSR requested that we return to a selection of medical centres, identified using its own risk-based approach, where the last rating was either good or outstanding. This was to review whether standards had been successfully maintained.

Following a comprehensive re-inspection of these 16 medical centres:

• 2 were rated as outstanding
• 12 were rated as good
• 2 were rated as requires improvement.

We found that 6 had maintained all key question and overall ratings as good, but there was a mixed picture of improvement and deterioration in quality and ratings at others.

Safe key question

As in previous years, there continues to be a clear link between a lower rating for leadership (well-led) and a lower rating for safety.

We recognised some improvements from the previous 6 years, although there are some common areas that still need to improve across medical centres.

Safe levels of staffing

Across the 7 years of this programme, we have consistently identified concerns around shortages in the workforce and the resulting challenges in delivering safe and effective care. Services with poorer ratings tend to have more vacancies and posts that have not been covered by locums.

Healthcare teams face gaps in staffing when military healthcare staff are deployed, sometimes at short notice, on operational duty and Royal Navy, Army or Royal Air Force tasks. This, together with the lack of available civilian and locum staff, means that some services struggle to deliver continuity of service. In year 7, we continued to see medical centre teams that struggle with unsafe workforce shortages.

Information systems

As in previous years, Defence Primary Health Care does not have an information system that can provide a comprehensive set of performance indicators across its medical services, as recommended in guidance from the National Institute for Health and Care Excellence (NICE).

Across this inspection programme, we have highlighted concerns with the completeness and accuracy of patient records at some services. We have found that the accuracy of Read coding is variable, as there is no:

• agreed listing of the codes that should be used
• DPHC-wide policy for staff to work to or agreed standards
• comprehensive audit programme to ensure overall improvements in coding.

However, in 2024 DPHC has made a comprehensive suite of clinical searches available to medical teams enabling them to quantify and provide evidence around the safety, quality and effectiveness of care.

There are continued specific issues around the interface between clinical recording systems. Maintaining accountable oversight of patients who are deployed is challenging when they move between several versions of the clinical recording system – particularly patients with a chronic condition.

Other issues include:

• No access to Integrated Clinical Environment (ICE) order communications software. This supports multiple diagnostic specialities including pathology, radiology, cardiology and endoscopy. Pathology and radiology results are therefore not easily available to military medical centres, so they need to use ‘workarounds’, which introduce an additional level of risk.
• Inability to receive electronic discharge letters.
• Difficulty transferring records to NHS services when patients leave military service.

In Year 7, some practices continued to alert us to failures in IT networks and power. In some cases, these resulted in extended periods without access to the military patient records system. Where this has happened, in line with policy, clinical staff have only seen patients with urgent needs and delayed seeing patients at routine appointments until they could restore access to patient records. There are clear risks around delaying appointments and seeing patients without any access to their records.

Effective key question

Although 21 medical centres were providing effective care to their patients, 5 facilities had been unable to ensure that the service was effective. Common concerns identified included:

• a failure to formalise the training and support requirements for clinical staff who are required to deliver paediatric assessment and treatment
• omissions in inviting all eligible patients for health screening
• gaps in the review of patients diagnosed with a long-term condition
• gaps in training relevant to specific roles of staff
• no auditing of clinical notes
• staff being unable to use the DMICP patient records system to facilitate clinical searches, assure recall programmes and monitor performance
• no rolling programme of work to continuously improve patient outcomes
• lack of a structured process to ensure that clinicians come together to review clinical guidance and updates to enable evidence-based best practice in line with national guidance and Defence Primary Healthcare (DPHC) policy.

Caring key question

Compassionate care has a lasting impact on people’s experience of their medical centre. Practices rated as good or outstanding knew and understood their patients as individual people and were sensitive to their preferences and requirements. As well as observing how staff interact with patients, we base our judgements on patient feedback from comment cards, interviews with patients and data from the practice’s own patient surveys.

We found that all medical centres that we either inspected or re-inspected in 2023/24, except one, provided caring services to their patients. As has been the case every year to date, caring is once again the best performing key question. Medical centre teams proactively identify and support patients who are carers. For example, providing links with carers’ organisations and ensuring that the carer’s emotional and healthcare needs are met

The performance of one medical centre required improvement. This was because there was a need to investigate feedback received from patients about the consultation style of a clinician, to enable them to receive appropriate customer care training. Some staff and patients also raised a concern around whether the practice always ensured that information about them was confidential.

Responsive key question

Where we judged care to be good, medical centres understood the needs of their patient population. They had gathered feedback from patients and staff and used this knowledge to ensure that care was convenient and accessible. Responsive medical centres carried out equality access audits for their premises to ensure that all patients could use the facility comfortably and safely.

Responsive medical centres worked in close partnership with rehabilitation facilities to enable timely access to physiotherapy and exercise rehabilitation. They also worked with internal and external stakeholders to identify and meet the needs of personnel who were being medically discharged, and military veterans who were in the surrounding communities.

Where care fell short of being responsive, key concerns included:

• A failure to investigate and respond to patients’ complaints in a timely way.
• A need to engage with the patient population to get to the heart of their experiences, concerns, and requirements. There was a need for teams to work proactively with patients to resolve issues around communication, access to doctor appointments, convenient hours of provision, transport issues and ambulance access.
• Cancelling appointments when the patient is already in the waiting room in all but entirely unavoidable circumstances.
• A specific need to clarify and streamline communications between primary care clinicians, secondary care consultants and patients registered in medical centres in Cyprus.

Well-led key question

In this key question, we focused on leadership capacity, vision and strategy, risk and performance management, healthcare governance arrangements, culture and continuous improvement.

Of those being re-inspected to follow-up previous non-compliance, we focused on leadership at 3 centres, and all were re-rated as good.

The overall judgement across leadership in military general practice was largely positive. However, where we identified pockets of poor performance under the well-led key question this affected all areas – particularly the safety and effectiveness of care and treatment.

Areas for continued improvement

Two medical centres were rated as requires improvement for leadership and one was rated as inadequate in Year 7. We will re-inspect these services in Year 8 to ensure that they have delivered improvements.

Leadership capacity

Many medical centres rely on the Single Service (RAF/Army/Navy) to provide staff to fill key staff positions. Where this does not happen and there are gaps in staffing, this can be a significant barrier to clinical leadership capacity. At times, this can mean that either more junior staff are obliged to assume a level of accountability outside their rank and pay grade, or that clinical leaders work excessive hours in patient-facing roles often to the detriment of healthcare governance, staff appraisal and improvement work.

In overseas medical centres, staff are often called on to deliver services that extend well beyond the parameters of a standard medical centre. The out-of-hours and urgent care requirements overseas may require staff to work night and weekend shifts, and doctors may need to provide on-call cover that can be extensive at times. We have found a small number of medical facilities where the clinical working hours for some staff exceeded the safe working hours outlined in both the DIN (Defence Instruction and Notice) and the WTD (Working Time Directive 1998). This left no reasonable additional capacity for leadership and management of the service. Despite well-established links with the regional team, key staffing gaps and training requirements were issues that the regional team had been unable to resolve as they did not hold the levers to influence change.

Culture

We found some common themes around the cultures at medical centres that were facing challenges:

• Military medical facilities often work to a culture of ‘being proactive with what we have’. Staff may be aware of suboptimal resource, gaps in the workforce and inadequate infrastructure, but their commitment to deliver the mission is paramount, and so they continue to strive to deliver against the odds. Capacity concerns have often been escalated, but due to constraints around Single Service personnel, gaps in leadership capacity can be carried for an excessive length of time. This can put frontline staff in an impossible position as they have no levers to influence change to their predicament. At times, capacity constraints can mean that only key personnel attend practice team meetings, which means some staff are excluded from key learning from automated significant events reporting (ASER) review and healthcare governance initiatives.
• Some staff tell us they have escalated concerns about the challenges (sometimes on multiple occasions) but were unable to influence outcomes. In a number of these cases, staff had not achieved the resolution they hoped for, either because regional support was not available or because the issue was within the remit of another department. Blurred lines of accountability at a senior leadership level and unclear risk escalation pathways were barriers to improvement.
• On rare occasions we have found poor safety cultures where staff have either been unable to speak out or were not listened to when they did. Some staff tell us they have stopped raising concerns as they felt that nothing will be resolved. They have become disaffected in a system where they cannot influence the level of resource they require or the state of the infrastructure in which they work. Sometimes, local staff felt they were struggling in isolation to deliver against the odds. At a regional level, we sometimes found a lack of clarity about what regional teams could and should be delivering.

Effective practice management

As in previous years, we note that there is scope to standardise the role of the practice manager across the DMS, to agree generic terms of refence across DPHC and to build a recognised career pathway for practice managers to pursue.

However, in Year 7 (February 2024) DPHC ran its first ‘Joint Practice Managers’ course. This was provided in 2 blocks, each lasting 2 weeks. Twenty-five practice managers attended the full course and 24 successfully achieved the required standard.

Risk management

Timely and effective risk management is central to ensuring that concerns are acknowledged, escalated if needed and ultimately mitigated by an accountable body. Pathways for the escalation of risks in primary care and subsequent ownership of risk at senior levels do not always deliver what is needed. Lines of accountability can be blurred, particularly where stakeholders external to DPHC hold the levers for change. For example, key staffing gaps in the Western Sovereign Base Area were clearly identified at a local level as a key risk, but escalation to the regional team, DPHC, Single Service and British Forces Cyprus (BFC) had not resolved the issues – rather issues had remained a concern for over 2 years.

Governance arrangements

While strong in some areas, governance systems are not always effective and do not support services to deliver consistently high-quality care. Barriers included:

• unclear lines of accountability where staff do not know the arrangements or have clear terms of reference for lead roles and deputies
• staff not always following standardised policy and procedure, either because they are unsure where to find it or they have localised policies that may contradict central policy
• no cyclical improvement programme focused around delivering meaningful and improved outcomes for patients
• services not understanding and monitoring their own performance.

We have noted examples of strong governance around learning from complaints and automated significant events reporting (ASERs) at a local service level. However, there is scope to widen this learning through both regional and national trend analysis. Similarly, there is potential to share good practice and innovation through regional healthcare governance meetings.

Pre-Hospital Emergency Care (PHEC)

We inspected the Pre-Hospital Emergency Care (PHEC) service for British Forces Cyprus for the first time in June 2022. As this was a pilot, the report was not published. We returned in October 2023 to follow up the concerns raised at the initial inspection and noted that although some improvements had been delivered, concerns remained in some critical areas.

We rated the service as:

• Safe: Requires improvement
• Effective: Good
• Caring: Good
• Responsive: Good
• Well-led: Requires improvement
• Overall rating: Requires improvement

Several improvements had been implemented since June 2022:

• Patients could now access an emergency care service that was delivered (although not yet led) by paramedics with the right skills, qualifications and experience. Doctors were no longer working excessively long hours to provide PHEC cover in addition to out-of-hours duties.
• A working group had taken positive steps to address the complications faced in Cyprus when treating patients experiencing a mental health crisis. This has involved work towards amending section 12 of the Armed Forces Act 2006, which currently provides the framework for detention of persons in overseas service hospitals. Once amended and brought into force, secondary legislation would follow to deal with the process of detention and the process for appealing against detention of individuals on mental health grounds overseas.
• Integrated teams worked across Akrotiri, Episkopi and Dhekalia, facilitating mutual support networks between PHEC and primary care service delivery. PHEC paramedics working alongside primary care teams offered opportunities for shared learning, training and support for out-of-hours services.
• The service had re-established lines of communication with the fire service and Sovereign Base Area (SBA) police. Activities such as major incident planning were done as a collaboration. Work was also underway to improve working alongside the Republic of Cyprus ambulance service (ROCAS).

We identified several key areas that required improvements:

• There was a need to establish a clear service level agreement and set of key performance indicators to move beyond the historic ‘Treaty of Establishment’. This simply states the requirement as to ‘provide emergency services.’ There was also a general need to have standard operating procedures, memoranda of understanding and terms of reference to clearly define what is expected of the service and those working to deliver it. This should include the planned response to a major accident that would require a co-ordinated response.
• Blurred lines of accountability at a senior leadership level and unclear risk escalation pathways continued to pose risks to the safe delivery of the service.
• There is a need to have sufficient arrangements to protect staff when attending the scene of an accident or incident. The risk of loss of life must be mitigated when attending road traffic accidents but there were gaps in organisational learning. We saw that reporting of several automated significant events (ASERs), specifically around scene safety, were not delivering improvement.
• There was an ongoing need to improve the speed and accuracy with which PHEC staff located patients who needed a 112 response.
• Similarly, there was scope to consider and implement ways to improve the handover of clinical information to secondary care and to improve the accuracy of clinical information by digitalising the upload of clinical records back into DMICP.

Read the re-inspection report for British Forces Cyprus (December 2023).

Regional rehabilitation units

Regional rehabilitation units (RRUs) are provided by the Defence Primary Healthcare (DPHC) Unit. They deliver intermediate rehabilitation within the Defence Medical Rehabilitation Programme (DMRP).

During 2023/24, we followed up the inspection of RRU Northern Ireland, focusing on leadership under the well-led key question, and found that the required improvements had been made. This meant that RRU Northern Ireland is now rated as good for all key questions and as good overall.

At our initial inspection, we identified that there was scope to improve the leadership of the service under the well-led key question. At the re-inspection we found these improvements:

• The service had an overarching governance framework, which supported the delivery of the strategy and good quality care. Key vacant posts had been filled and lines of accountability had been clarified. Quality, performance and risks were understood and managed.
• Managers worked hard to run the service and ensure that patients’ needs were met. Accountability for healthcare governance had been made clear. All staff prioritised safe, high-quality and compassionate care and were working within their terms of reference.
• Staff supervision and peer review arrangements were appropriate. All staff groups now received regular formal peer supervision.

Defence community mental health services

The Defence Primary Healthcare (DPHC) Unit provides occupational mental health assessment, advice and treatment through a network of departments of community mental health (DCMHs), mental health teams and additional staff at deployed locations.

During 2023/24, we inspected one regional Network: The Defence Mental Health Network South East Region. The Network comprises 3 departments of community mental health (DCMHs): Aldershot, Portsmouth, and London. Since September 2021, the 3 services have increasingly worked together as a single point of access (SPA) to respond to initial referral requests, to assess patients and to offer treatment across the teams.

Our previous inspections of these services were:

• DCMH Aldershot in August 2019, rated as good overall
• DCMH London November 2021, rated as good overall
• DCMH Portsmouth, January 2023, rated as good overall, but requires improvement for the responsive key question because of delays in assessment and treatment.

At this time, the Defence Mental Health Network South East Region was working to deliver a single point of access and assessment for mental health care to address delays in assessment and treatment.

Our inspection covered the single point of access for defence military care in the region and aspects of the operational delivery of care from the DCMHs based at Aldershot, Portsmouth and London. We focused on the responsive key question, but also looked at aspects of the safe and well-led key questions to check improvements against our recommendations following the previous inspections.

We found that the South East Region Network and DCMHs had addressed all our previous recommendations and the network was rated as good for the safe, responsive and well-led key questions.

Teams were now delivering safe and effective care.

• Staff told us that morale had improved greatly following increased staffing and improvements to services. They had undertaken appropriate supervision and training, and they were positive about their role in delivering the service.
• We found clear and accountable leadership across the Network and with the single point of access (SPA) team. Staff we met were positive and told us that the team worked well together, and that leaders were approachable and supportive of their work.
• The team audited the clinical effectiveness of the service and used the information to inform changes to the operational model to drive continuous improvement and enhance patient care.
• The Network had developed a clearer operating model and referral pathway and had implemented safe systems and processes. This had ensured effective assessment and allocation of patients and clear oversight of clinical risk.
• Despite an increase in referrals and caseload, the team had met the response target for urgent and routine referrals and waiting lists for treatment had reduced.
• There was an overarching governance framework with effective systems and processes. This supported the delivery of the service and captured performance to ensure continuous learning. Potential risks that we found had been recorded in the risk logs and the common assurance framework. All risks identified included detailed mitigation and action plans.

Conclusion

Our inspections continue to highlight several internal factors that contribute to high-quality care, as well as factors that may inhibit it.

Clinical teams deliver complex services that span the care requirements of the individual patient as well as the occupational health care requirements of Defence. Military personnel and entitled dependants continue to receive prompt access to almost all services, and most have a very short wait to see a healthcare professional. Defence Medical Services benefits from a cohort of high calibre staff who are often willing to go the extra mile to ensure that patients receive personalised and compassionate care.

Across Defence Primary Healthcare, we have seen first-hand how sharing learning, best practice, innovation and resource across some services has improved the quality of care for military patients and their families, as well as delivering significant benefits for staff.

We re-inspected several services to follow up recommendations from previous inspections. Although some key areas still need to improve, most medical and dental centres re-inspected in Year 7 of this programme demonstrated sufficient organisational learning and positive improvement to confirm they had improved the quality of care.

However, several medical centres have ongoing areas that have contributed to poor quality care, including a poor culture, inconsistent application of policy and procedure, and insufficient leadership capacity.

Seven years into our programme we still have the same concern that Defence does not own a clinical information system that can provide a comprehensive set of performance indicators across its medical services. Inconsistent information management systems result in continued specific issues around the interface between clinical recording systems (including when patients deploy).

We again identified concerns around shortages in the workforce and the resulting challenges in delivering safe and effective care. We have also raised concerns when we see that medical staff are required to deliver care to children without the appropriate level of training to deliver this confidently and safely. It is important that they have the right level of training and the appropriate equipment to deliver this confidently and safely.

Many issues are beyond the immediate control of a specific service. For example:

• the challenges of designing and resourcing services overseas where medical teams are required to deliver out-of-hours cover and bespoke additional care – sometimes for patients who are not registered with them
• challenges for a small number of dental centres around issues with old infrastructure, where funding for building maintenance had not been approved and so staff were not able to deliver improvements.

Regardless of these continuing challenges, we commend military and civilian personnel for their continued hard work and commitment to delivering high-quality, safe and effective care.