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DEFENCE MEDICAL REHABILITATION PROGRAMME (DMRP)
Introduction
1.
Defence Rehabilitation is delivered through a comprehensive and coordinated construct
known as the Defence Medical Rehabilitation Programme (DMRP). The DMRP is part of an overall
Defence strategy to maximise the number of Service personnel who are fit for operational
deployment whilst also honouring the Services duty of care to maximise the outcomes of those
wounded, injured or sick (WIS). The aim of the DMRP is to return Service personnel to operational
levels of fitness as soon as possible
1 – the “fitter quicker” principle – where this is not achievable
the aim is to attain the maximal level of physical, psychological and social health possible.
Directorate of Defence Rehabilitation
2.
The Directorate of Defence Rehabilitation is accountable to the Director of Healthcare
Delivery and Training through the Rehabilitation Executive Committee (REC). The Directorate is
responsible for policy and plans in support of the professional oversight and direction on all matters
associated with clinical development, implementation and audit of the DMRP.
3.
Defence Rehabilitation is a complex process demanding a Multi-Disciplinary Team (MDT)
approach. The core principles of military rehabilitation are:
a.
Early assessment.
b.
Use of the MDT.
c.
Active case management.
d.
Functional exercise-based rehabilitation.
e.
Rapid access to further specialist opinion.
f.
A focus on vocational outcome.
4.
In collaboration with PJHQ, SGD and the sS it is the responsibility of the Directorate to
uphold these principles and monitor clinical standards and effectiveness throughout the DMRP,
reporting to the REC.
5.
The DMRP extends across all aspects of military activity and is designed to be flexible to
meet the main effort. Although there is considerable cross over, for the purposes of this paper, the
activity will be split into two sections;
a.
Operations.
b.
Firm Base.
OPERATIONS
6.
Role 1. Rehabilitation specialists support Role 1 during Maritime, Land and Air operations.
a.
Maritime. The Forward Rehabilitation Team (Fwd Rehab Tm) is a deployed
physiotherapist and ERI asset on a sea going platform, working under the guidance of the
Principle Medical Officer (PMO). At present RFA Argus is the deployed platform for specialist
1 Often in collaboration with non medical PTIs.
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rehabilitation; however future platforms may be extended to Queen Elizabeth Class Aircraft
Carriers; this will be decided by theatre of operation and mission. The primary aim of the
Maritime Fwd Rehab Tm is to provide the Task Group (TG) with a primary rehabilitation
service and offer advice to the TG Commander, via the PMO, on the management and
onward referral of the TG’s injured personnel.
b.
Land. The Fwd Rehab Tm is manned with a physiotherapist and an ERI. It is a
mobile, peripatetic team that operates in the forward areas providing primary health care
support to Medical Regiments. The number of deployed Fwd Rehab Tm is dictated by the
configuration of deployed forces, theatre of operations and the mission. Their primary aim is
to provide MSK assessment and treatment in order to “keep the player on the pitch” and
provide expert case management and onward referral to the Force Medical Rehabilitation
Team as appropriate.
c.
Air. Air operational capability is delivered through either Expeditionary Air Wings
(EAW) or in support to operations as required by Defence. The EAW concept is to brigade
deployable forces in a readily identifiable structure which is able to rapidly field discrete units
of agile, scalable, interoperable and capable air power. Med Ops (HQ Air) generate the
manning requirement which is commensurate with the PAR and the initial operational needs.
To meet Future Force 2020 (FF20) requirements Air owned medical capabilities will be
configured to deliver against tasks up to and including 3 concurrent operations (simple,
complex and enduring) supporting discrete sS operations or as part of a combined effort in
conjunction with Maritime or Land components. There could, therefore, be up to 6 Role 1
Medical Treatment Facilities (MTFs) deployed at any one time, which depending on the PAR,
would be supported by up to 6 RAF physiotherapists and RAF ERIs deploying to support
each formation at its location.
7.
Role 22.
Rehabilitation specialists support Role 2 in both Land and Air operations.
a.
Land. The Force Medical Rehabilitation Team (FMRT) deploys as part of the Medical
Reception Station (MRS). It receives MSK patients from the Fwd Rehab Tms, and supports
Role 2 formations with MSK assessment and treatment. The team has a Multi-Disciplinary
Injury Assessment Clinic (MIAC) capability that will assess a patient’s suitability to remain in
theatre.
b.
Role 2(Air) MTF is to provide Damage Control Resuscitation (DCR) and Damage
Control Surgery (DCS) at an Air Point of Disembarkation (APOD) as a component of an AIR
Focussed Intervention or in support of a Complex Intervention conducted over extended
Lines of Communication, to meet the requirements of FF2020. There will be 2 x Role 2(Air),
with one formation in training and the other on a period of readiness. Each Formation will
deploy with 1 x RAF physiotherapist with respiratory, intensive care, MSK, trauma and ITU
skills.
8.
Role 33
. Role 3 medical facilities require physiotherapy support to cater for the High
Dependency and Intensive Therapy Unit and ward-based beds. In liaison with the FMRT, these
physios are also required to cover the MSK injuries that refer through the Emergency Medicine
department.
9.
Role 4. Role 4 severely WIS personnel rehabilitative care is delivered by the Royal Centre of
Defence Medicine (RCDM) and the Defence Medical Rehabilitation Centre (DMRC) which are both
Defence Medical Group assets. Patients returning from theatre are received at RCDM, where their
condition is stabilised, prior to onward transfer to DMRC to commence the Rehabilitative process.
10. The manning levels of all operational commitments can be found at Annex A.
2 Roles 1 and 2 are synonymous with Pre Hospital Care.
3 Role 3 is synonymous with Deployed Hospital Care.
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Operational Care Pathways
11. For injured Service personnel returning from operations defined care pathways have been
developed to ensure that patients receive the appropriate care and support on their return to the
UK. The operational care pathways vary dependant on injury severity;
a.
Mild to Moderate Injury. Annex B describes the operational care pathway for mild to
moderate MSK patients. This, in the majority, will involve the DMRT referring the patient to
their local RRU and the MIAC.
b.
Severely Injured. For those with injuries of a more complex nature, patients are aero-
medically evacuated to the Royal Centre of Defence Medicine (RCDM) Birmingham. Annex
C describes the operational care pathway for the more severely injured casualty. The
process is co-ordinated by the Defence Patient Tracking Cell and monitoring of the JTCCC.
Aeromedical Evacuation Procedures are detailed in Annex D.
FIRM BASE
12. Firm base DMRP activity is predominantly concerned with force generation and is delivered
through a tiered structure extending from Primary Care Rehabilitation Facilities (PCRF) at Units or
Stations, regionally at the Region Rehabilitation Units (RRUs) and nationally at the Defence
Medical Rehabilitation Centre (DMRC) and Royal Centre for Defence Medicine (RCDM).
DMRC
RCDM
Secondary
REGIONAL
REHABILITATION
UNITS
Intermediate
PRIMARY CARE
REHABILITATION
FACILITIES
Primary
Case Management
13. Successful medical rehabilitation relies upon effective case management. This should
ensure that each patient gets the right specialist opinion and treatment at the right place at the right
time to affect their early return to duty. Throughout the care pathway the clinical responsibility for
the patient remains with their Unit MO. It is the responsibility of the MO to ensure that the patient
is medically screened to determine whether they are fit to undertake exercise. Once a patient is
referred to the RRU/PCRF/DMRC, the Officer Commanding (OC)/Consultant (with input from the
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multi-disciplinary team) is responsible for the day to day management of the patient’s condition and
is required to effectively manage the following:
a.
Liaison with referring clinicians regarding the rehabilitation plan and/or discharge
summary.
b.
Liaison with the patient’s unit command (in conjunction with the referring doctor and
with the patient’s consent).
c.
Initiation and co-ordination of investigations, specialist opinion and treatment at
appropriate centres.
d.
Clinical Governance and quality of care requirements.
e.
Referral using the PT prescription cards to Unit PTIs for further conditioning.
Care Pathways
14. Table 2 details the rehabilitation referral guidelines. It summarises the clinical, service and
local factors that influence the patient referral and determine the most appropriate level of care.
The most common patient pathway would be referral to the PCRF then to the RRU and on to
DMRC as required. There will however be exceptions to this practice, for example a Unit Medical
Officers may specifically request input from DMRC if a patient’s condition warrants early specialist
opinion by referring the individual directly to DMRC and bypassing the PCRF and RRU. DMRC
may, likewise, refer patients directly to RRUs and PCRFs for ongoing therapy. Seriously injured
casualties may go directly to DMRC from RCDM or an NHS facility.
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Table 2 – Rehabilitation Referral Guidelines
PCRF
RRU
DMRC
Clinical
•
Minor injury with
•
Moderate Injury.
•
Moderate/severe injury.
expectation of return
•
Complex clinical problem.
to full duty within
•
Requires intensive
•
Factors
Requires nursing care
4/52.
rehabilitation (daily).
•
Inpatient treatment appropriate.
•
Failure to progress in RRU following two
•
Outpatient
•
Failure to respond to
admissions.
Treatment.
rehabilitation at PCRF
•
Requires specialist rehabilitation.
level.
•
Management advice.
•
PMES/P8 being considered.
•
Additional level of expertise
•
Consultant led, specialist clinical team required.
Service
•
Able to continue to
•
Unable to continue to work
•
Unable to continue work.
work, even in
in any capacity.
reduced capacity.
•
If return to work could be accelerated by more
Factors
•
Unable to continue to work
specialist rehabilitation.
•
Patient needs to
in specialist role (infantry,
remain local to
aircrew, PTI).
unit.
•
Temporary MES awarded.
Local
•
Appropriate level
•
No facility for local Rx
•
Requires protected time for rehabilitation.
of Rx available
available.
Factors
locally (Physio
Rx/ERI).
•
Requires protected time for
rehabilitation.
•
Social/domestic
situation makes
absence
unacceptable.
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Primary Care Rehabilitation Facilities
15. There are 151 PCRFs across Defence commanded by Defence Primary Healthcare (DPHC).
The PCRF delivers the rehabilitation required for specific units and formations. PCRFs are DPHC
assets, typically located within a medical centre, case managing and treating minor and some
moderate MSK injuries. PCRFs vary in provision from an establishment with a single part time
physiotherapist to locations with a large department with physiotherapy and exercise rehabilitation
facilities. The configuration of the facility will depend on:
a.
Service population at risk (PAR).
b.
The local military training activity and associated clinical needs.
c.
Unit tasking and operational commitments e.g. Special Forces.
d.
Local infrastructure.
e.
Patient return journey time being no greater than 1.5 hours.
f.
Local security restrictions on movement.
16. Annex E details establishment ratio of physiotherapy staff and Exercise Rehabilitation
Instructors (ERIs) to population at risk (PAR).
17. The PCRF will focus on the treatment of acute MSK injury combining physiotherapy and
exercise rehabilitation. Additionally, PCRFs will manage chronic conditions and receive referrals of
operational casualties via the Operational Care Pathway. PCRFs are to refer to RRUs and DMRC
depending on the clinical assessment and in accordance with best practice guidelines.
18. DPHC commands the PCRFs and is responsible for clinical delivery and healthcare
governance. The Operating guidelines for PCRFs can be found at Annex F.
19. The PCRF is the link between the CoC and the DMRP and must be represented on the
monthly Unit Health Committee. PCRF staff are responsible for providing the CO with
comprehensive updates personnel that are undergoing rehabilitation.
Regional Rehabilitation Units (RRUs)
20. The RRU is a Defence regional facility which provides medical opinion and delivers treatment
for patients with moderate musculoskeletal injuries. There are 15 RRUs across the UK and British
Forces Germany. RRUs deliver intermediate care and provide the main conduit to secondary care
rehabilitation
4. Each RRU will support a number of identified PCRFs. This support ranges from
the receipt of referrals through to providing advice with regards to clinical governance and delivery.
A comprehensive list of RRUs and the PCRFs that they support can be found at Annex G.
21. DPHC commands the RRUs and is responsible for clinical delivery and healthcare
governance. Annex H describes the core staffing and referral guidelines for an RRU.
22. The RRU provides co-ordinated clinical management to a tri-Service population within a
defined geographical region. The clinical services include;
a.
Multi-disciplinary Injury Assessment Clinic (MIAC). Clinical assessment at the
RRU is
delivered through the MIAC. This is a combined clinical assessment by a specialist
4 Insert definition of Secondary Care Rehabilitation
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GP trained in Sports and Exercise Medicine (SEM) to diploma level, a physiotherapist
(clinical specialist) and an ERI. The GP should ideally be an experienced military officer.
The MIAC is a critical element of clinical assessment and planning in the DMRP.
The MIAC
will, identify patient requirements and allocate appropriate early treatment based on clinical
need, operational issues and individual circumstances. The role of the MIAC is to determine:
(1)
An accurate diagnosis.
(2)
The need for further investigation.
(3)
An appropriate treatment plan, agreed with the patient.
(4)
The patient’s fitness for group-based exercise therapy.
(5)
The requirement for onward referral.
b.
All patients being referred to the RRU for the first time should be seen in a MIAC. This
is to ensure that there is an appropriate clinical plan for the patient and that the patient’s case
is being actively managed with interaction with relevant agencies.
c.
Injury Assessment Clinic (IAC). An IAC comprising of a physio and an ERI can be
used for the assessment of patients with a confirmed diagnosis or the review of those
returning after investigation or outpatient treatment where the management plan has already
been agreed at the MIAC.
d.
Onward Referral. The RRU provides the gateway to onward referral to secondary
care including:
(1)
DMRC Headley Court;
(2)
Fast Track orthopaedic surgery;
(3)
Other secondary care and opinion such as orthopaedic opinion, pain
management, etc.
e.
Clinical Investigations. The RRU provides the gateway to rapid access imaging.
RRUs also have access to on-site diagnostic Ultrasound scanning for immediate clinical
guidance.
f.
Residential Therapy. This is for patients whose condition necessitates a period of
intensive daily rehabilitation (such as post orthopaedic surgery), whose condition may be
exacerbated by travel or who cannot effectively perform their role or find protected time whilst
in full time employment. Patients may be admitted for 3 weeks into homogenous patient
groups for rehabilitation of specific conditions (eg back pain) or into general groups with a
range of differing injuries.
g.
Outpatient Rehabilitation. This is for patients who do not require an intensive period
of exercise based rehabilitation on a daily basis, who can effectively continue with their
employment and are within daily travelling distance. The patient’s occupational role may
inform this decision.
h.
Regional Podiatry Service (RPS). The aim of the RPS is to provide a clinical
biomechanical podiatry service to all entitled service personnel within the RRU catchment
area. The majority of patients with biomechanical problems are managed effectively within
Primary Healthcare (PHC) at the Primary Care Rehabilitation Facilities (PCRFs). Where this
management is unsuccessful or a Podiatrist/Biomechanical specialist opinion is required, the
RPS will provide a highly skilled and specialist lower limb biomechanical assessment and
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treatment, together with the provision of both off-the-shelf and custom made orthotics from
an MOD approved supplier, as required. The RPS is commanded by and accommodated at
the RRU. It consists of one PT/FT Band 7 podiatrist/physiotherapist (biomech) who will
deliver clinics at either the RRU or regionally through a peripatetic service. A full patient care
pathway and referral guidelines can be found at Annex I.
23. RRU Halton has the responsibility for overseas patients that fall outside Operations and
BFGHS. Annex J outlines the patient care pathway for this patient group who have varying
degrees of medical support.
DMRC Headley Court
24. DMRC Headley Court is a Role 4 Unit and a Defence Medical Group asset which sits at the
pinnacle of the DMRP. It provides multi-disciplinary medical rehabilitation for WIS patients with the
most complex needs including neurological and amputee services. A list of the specialists
employed at DMRC is found at Annex K. The Unit is split into five specialist, consultant led, multi-
disciplinary teams delivering residential inpatient support and outpatient clinics, these are;
a.
The Centre for Neurological Rehabilitation. The Neuro team delivers assessment
and residential rehabilitation for neurologically impaired patients including mild traumatic
brain injury (MTBI). The service delivers MIACs for Neuro rehabilitation, MTBI and Vestibular
impairments.
b.
The Centre for Complex Trauma Rehabilitation. The Complex trauma team
provides multidisciplinary assessment and rehabilitation of service personnel with complex
injuries including limb loss, spinal cord injury and multiple fractures. Included within the
treatment is the rehabilitation of physical, psychological, cognitive and social issues. The
complex trauma team has an on site limb fitting centre for the prescription and manufacture
of prosthetic limbs. The service also delivers outpatient services including; Complex Trauma
outpatients reviews, Burns and Plastics, Orthopaedic, Specialist Foot and Ankle Clinics.
Manning of complex trauma is established through set staffing ratios found at Annex A.
c.
The Centre for Spinal Rehabilitation. This team delivers inpatient residential
rehabilitation for patients with Spinal conditions. They run 4 inpatient groups including two
early spines (A and B that vary in functionality), Complex Early Spine Rehabilitation (CSER)
and the Ankylosing Spondylitis group (ASPIRE). In addition to the inpatient programme the
Spines team run an outpatient programme including; Spine MIACs, Inflammatory Arthritis
Clinics and Pain Nurse clinics.
d.
The Centre for Lower Limbs Rehabilitation. The team delivers residential inpatient
rehabilitation for patient with lower limb conditions. They run five inpatient groups;
(1)
Early Lower limbs (A) and (B). These 3-week courses provide early stage
functional Lower Limb rehabilitation utilising an MDT to promote optimal physical and
psycho-social recovery
(2)
Early Lower Limbs (C). This 3-week course provides very early stage functional
rehabilitation focussing on patients with low function and complex MSK injury, such as
chronic regional pain syndrome.
(3)
Hip and Groin Course. This short course focuses on physical rehabilitation of
Femoro-acetabular impingement, labral injury and post Arthroscopy.
(4)
Running Re-education. This short course focuses on physical rehabilitation of
Exertional Lower Leg Pain, and specifically gait adaptations that offload the lower leg
MSK structures.
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e.
The team also run specialist lower limb MIACS, the Elite Sports Injury Clinic and have
visiting orthopaedic clinics serving the outpatient community.
f.
The Centre for Specialist Rehabilitation. This team deliver inpatient residential
rehabilitation for Medical
5 and Upper limb patients. They also run the chronic pain
management group (COPE) and deliver outpatient clinics for peripheral nerve injury and pain
management alongside their regular MIACs.
25.
Clinical Services
a.
Rheumatology services including:
(1)
Defence Rheumatology Centre.
(2)
Rheumatology specialist nurse.
b.
Elite Services sports medicine clinic.
c.
Spinal surgery MDT Clinic.
d.
Vocational occupational therapy services.
e.
Prosthetic and orthotics services.
f.
Exertional lower leg pain clinic, including compartmental pressure testing.
g.
Plastic and reconstructive surgery clinic.
h.
Podiatry and rehabilitation workshops.
26. Indications for referral to DMRC from primary care might include:
a.
Consultant Rheumatology and Rehabilitation (R&R) opinion.
b.
Severe injury/polytrauma, including neurological trauma.
c.
Requirement for nursing care.
d.
Requirement for Occupational Therapy or Social Work input.
e.
Failure to rehabilitate at a local level.
f.
Requirement for specialist investigation such as:
(1)
Pressure studies.
(2)
Diagnostic ultrasound.
(3)
Functional testing.
g.
Rehabilitation Workshops / an engineering assessment.
5A group containing patients with complex multiple joint problems and chronic pain. Includes rehabilitation for conditions such as non-
freezing cold injury, chronic fatigue syndrome, rheumatological disorders and unexplained medical symptoms.
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Royal Centre for Defence Medicine (RCDM)
27. RCDM is a
Role 4
DMG unit associated and accommodated in the University of Birmingham
Hospitals Foundation Trust. It is a Level 1 specialist trauma centre with a key role in the acute and
elective management of complex and severely injured or ill personnel evacuated from operations
and overseas. It has 1200 acute beds with 100 Critical Care beds and 46 clinical specialities.
There is a military managed trauma ward, with welfare support and military provision for specialist
early rehabilitation with disciplines including; Critical Care, Trauma, Burns and Plastics, and
Trauma Hand surgery. The Aeromedical evacuation pathway to RCDM is outlined in Annexes B,C
and D.
28. RCDM also offers the main focus for operational physiotherapy training in Deployed Hospital
Care with a specialist clinical operational training team.
Patient Clinical Records
29. The Defence Medical Information Capability Programme (DMICP) is a system spanning
Primary, Intermediate and Secondary healthcare enabling the patient integrated Health Record
(iHR) to capture clinical information throughout the patient journey. There are variants of the
DMICP system, which include a deployed version, and local versions in Cyprus and Germany.
Additionally, there are templates within DMICP that are specific to each area of delivery. For
example within Defence Medical Rehabilitation there is the ‘Rehab Master Template’ (RMT). The
RMT is solely designated for Rehabilitation Doctors, Physiotherapists, Exercise Rehabilitation
Instructors and Podiatrist/Biomechanical Specialists. It is mandated that
all rehabilitation clinical
contacts should be recorded using the RMT which can be selected from the DMICP Template
dropdown menu within Consultation Mode (CM). DMICP records appointment, injury causation,
outcomes and discharge information. Within the RMT clinicians can also access the ‘Rehab
Examination Template’ for recording clinical assessment & the ‘Rehab Treatment Template’ for
recording all episodes of treatment intervention. The DMICP RMT SOPs are reviewed annually,
and there is a DMICP RMT User Group Committee who meet twice a year to develop the RMT and
make amendments were appropriate.
Patient Prescription Forms
30. The Patient Prescription Forms (PPF’s) are a standardised communication tools that enable
PCRFs and RRUs to record and prescribe the Physical Training (PT) capabilities of patients. The
PPF’s are only to be issued through DMICP and instructions on how to access, annotate, attach
and print/issue the forms is provided via the DDR website. The forms are to be used to their best
capacity by all rehabilitation staff when prescribing PT and transferring care of patients and
regardless of which sS is the rehabilitation provider; the PPF’s are mandated for the following:
a.
RN and RM Personnel. The PPF’s are to be used for all RN and RM personnel where
compulsory PT is part of their curriculum. This is to include the Royal Marine Band Service.
b.
Army Personnel. The PPF’s are to be used for all Army personnel.
c.
RAF Personnel. The PPF’s are to be used for RAF personnel where compulsory PT is
part of their curriculum.
Academic Department of Military Rehabilitation
31. The Academic Department of Military Rehabilitation (ADMR) reports directly to the Medical
Director through DDR. The role of this department is to design, deliver and coordinate research
activity throughout Defence Rehabilitation with the aim of developing an enhanced evidence base
which will inform best clinical practice.
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Summary 32. This document sets out the concept of operations for the Defence Medical Rehabilitation
Programme. The Programme aims to enable injured Service personnel to return to operationally
deployable levels of fitness as soon as possible, through the delivery of a comprehensive
rehabilitation service. In support of the moral component of fighting power, patients who will not
return to Service will be rehabilitated to the maximum physical and psychosocial level possible
before discharge.
33. The success of the DMRP will depend upon the implementation, organisation and
coordination of all elements of the plan, which should follow the principles that are outlined in this
paper.
Annexes:
A.
Operational Manning Levels for Rehabilitation Specialists.
B.
Operational Care Pathway – Mild to Moderate MSK Injured Personnel
C.
Operational Care Pathway – Severely Injured Personnel
D.
Patients with Musculoskeletal and neurological injures – Aeromedical evacuation procedures.
E.
Establishment ratio of PCRF clinical staff to Population at risk (PAR)
F.
Guidelines for the operating procedures for rehabilitation services at PCRFs.
G.
RRU Catchment Areas.
H.
RRU Core Staffing and Referral Guidelines.
I.
Regional Podiatry Service Referral Pathway and Referral Guidelines.
J.
Rehabilitative Care Pathway for Military Overseas Patients not in Operational Roles.
K.
Clinical Specialists at the Defence Medical Rehabilitation Centre.
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Annex A
OPERATIONAL MANNING LEVELS FOR MANNING LEVELS FOR
REHABILITATION SPECIALIST
Table 1. Force Medical Rehabilitation Team Manning
Ser
Role
Physiotherapists
ERI
(a)
(b)
(c)
(d)
1
1
1
1
2
2
3
1
4
3
1
0
Table 2. Hospital Physiotherapy Manning Ratios
Ser
Facility
Physio:Beds
(a)
(b)
(c)
1
ITU
1:5
2
HDU
1:6
3
Ward
1:25/30
Table 3. Expeditionary Air Wing Manning
Ser
Role
Physiotherapists
ERI
(a)
(b)
(c)
(d)
1
1 (PAR 800)
1
1
2
1(5) (PAR 2000)
2
1
3
Aeromedical staging
1
1
Unit (25 Beds)
4
2
1
0
Table 4. Role 4 - Defence Medical Rehabilitation Centre Complex Trauma Manning Ratios
Ser
Speciality
Staff : Patients Ratio
(a)
(b)
(c)
1
Consultant
1:20
2
Registrar
1:20
3
Physiotherapist
1:5
4
Occupational Therapist
1:10
5
Mental Health Nurse
1:20
6
Vocational OT
1:20
7
Social Worker
1:20
8
Exercise Rehabilitation Instructor
1:8
9
Clinical administrator
1:20
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Annex B
OPERATIONAL CARE PATHWAY – MILD TO MODERATE MSK INJURED
PERSONNEL
Patient
Return to duty in
theatre
Fwd Rehab Team
In Theatre
Provision
Force Medical
Rehabilitation Team
and Theatre Intensive
Rehabilitation Service
Royal Centre for
Defence Medicine
RCDM
Role 4
UK
Provision
Role 4
Defence Medical
Rehabilitation Centre
DMRC
Headley Court
Regional
Primary Care
Rehabilitation Unit
Rehabilitation Facility
RRU
PCRF
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Annex C
OPERATIONAL CARE PATHWAY – SEVERLEY INJURED PERSONNEL
Patient
In Theatre
Provision
Deployed Hospital
care
CASEVAC
Royal Centre for
Defence Medicine
RCDM
Role 4
UK
Provision
Role 4
Defence Medical
Appropriate NHS
Rehabilitation Centre
Specialist Provider
DMRC
Headley Court
Primary Care
Regional
Rehabilitation Facility
Rehabilitation Unit
PCRF
RRU
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Annex D
PATIENTS WITH MUSCULOSKELETAL AND NEUROLOGICAL INJURIES
– AEROMEDICAL EVACUATION PROCEDURES
Summary
1.
This directive sets out the arrangements for patients who suffer musculoskeletal and
neurological injuries while serving overseas (including operational deployments, exercise and
training) to ensure their appropriate and timely management. The principles also apply for Service
personnel based in BFG.
Introduction
2.
Musculoskeletal injury is a frequent cause of aeromedical evacuation from overseas. A high
proportion of these patients do not require acute hospital referral, being better suited to
management in a rehabilitation facility.
3.
The Defence Patient Tracking Cell (DPTC) based at DMS Whittington Barracks, Lichfield,
has a critical role in the process, providing timely co-ordination of case management for patients
with musculoskeletal conditions and those with more complex rehabilitation needs. DPTC has two
main roles:
a.
Tracking and Monitoring. The DPTC has established links with the Military Patient
Administration Cell (MPAC) and Aeromedical Evacuation Liaison Officer (AELO) at the Royal
Centre for Defence Medicine (RCDM). They also link with the Aeromedical Evacuation
Control Centre (AECC). The role of the DPTC is to provide the co-ordination, tracking and
monitoring of care pathways for patients from the point of aeromedical evacuation request
until the patient is discharged from specialist care. BFGHS will be responsible for co-
ordinating the management of those patients who are returned directly to BFG.
b.
Clinical. A consultant at DMRC provides a clinical opinion and advice on the proposed care
pathway.
Policy
4.
The arrangements for patients who suffer musculoskeletal injuries while overseas
are described below and are to be implemented with immediate effect.
Patient Pathway
5.
The aeromedical evacuation pathway for different clinical groups of patients with
musculoskeletal injury is as follows:
a.
Patients with complex musculoskeletal or neurological needs who require hospital care
are to be referred to RCDM.
b.
Patients with moderate/minor musculoskeletal injuries who have been assessed by the
DMRT, or an appropriate clinician, are to have a working diagnosis and a planned care
pathway. They are to be referred to the RRU that supports the patient's parent Unit. The
referring clinician is to ensure that the patient has:
(1)
An appointment with the MO at their parent unit within 24 hrs of discharge
from the Airhead.
(2)
A confirmed appointment at the RRU within 5 days of discharge from the
D-1 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Airhead.
6.
Annex G provides contact details for the RRUs.
7.
‘SG JMC DMG-DPTC Gp Mailbox’ is to be added to all Aeromed Signals 1 and 2 as an
action addressee.
8.
The appropriate RRU is to be included as an action addressee on both Aeromed
Signals 1 and 2 for those patients that are being referred directly to a RRU for onward care.
9.
Patients aeromedically evacuated back to RCDM are to have onward rehabilitation care
coordinated by the Rehabilitation Co-ordination Officer (RCO) at RCDM in close collaboration with
the Consultants at DMRC Headley Court.
10. On discharge from RCDM patients requiring onward rehabilitation are to have one of the
following:
a.
A MIAC appointment within 5 working days at an RRU;
b.
A MIAC/Admission date at DMRC Headley Court.
11. It is the responsibility of the referring agency to provide a referral FMed7 and all appropriate
clinical and administrative details (including xrays) which will ensure a safe and effective referral.
UK Airhead Procedures and Transport Responsibilities
12. The following transport procedures are to be followed for aeromedically evacuated
patients:
a.
RCDM. The Aeromedical Evacuation Control Centre (AECC) is to arrange
transport for patients to RCDM.
b.
DMRC. The AECC is to arrange transport for patients referred to the
DMRC Headley Court. T he patient’s parent unit is then responsible for any transport
requirements following assessment and treatment D - 3
c.
Discharge at Airhead. Discharge at airhead for those patients who have an RRU
Appointment. Patients referred to their appropriate RRUs will be considered to be
‘discharged airhead’ for MT purposes, and parent units will therefore retain the responsibility
for their onward movement.
Implemention
13. Further advice concerning this directive can be obtained from DACOS AvMed.
D-2 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Annex E
ESTABLISHMENT RATIO OF PCRF CLINICAL STAFF TO PAR
1.
The establishment of physiotherapists is subject to the Population at Risk (PAR). The ratio is
based on the Chartered Society of Physiotherapy (CSP) guidelines which state that one
physiotherapist should see;
a.
2 new patients per day. A new patient assessment is allocated up to 45 minutes.
b.
10 review patients per day. A review patient session is allocated 30 minutes.
2.
Musculoskeletal injury rates per PAR are dependent on the role of a given unit and the type
of physical activity undertaken. The physiotherapist allocation to PAR is shown in Table 1.
Table 1: Ratio of Physiotherapists to Population at Risk
Ratio Physiotherapist to PAR
Type of Unit
1:400
Phase 1 Training, Infantry Training & Special Forces
1:600
Phase 2 Training
1:800
Phase 3 Training & DS
1:1000
Garrison/Station with deploying personnel
1:1500
Civilians
3.
The Exercise Rehabilitation Instructor (ERI) requirement is shown at Table 2. This is
calculated on the total number of physiotherapists referring to the ERIs.
Table 2. ERI Staffing Ratios
Number of Physiotherapists
Number of ERIs
<1
Pro rata hours made up by the physiotherapist
1-2
1-2
3-4
2-3
4-6
3-4
4.
The patient throughput for ERIs is as follows:
a. ERIs will see 2 new patients a day. A new patient assessment is allocated 45 minutes.
b. ERIs will see 4 review patients a day. A review patient is allocated 20 minutes.
c. The remainder of a given day is clinical exercise delivery to groups and individuals.
The group therapy ratio is a maximum of 1:15 patients, subject to the mandatory risk
assessment. This may be reduced for complex patient groups.
JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Annex F
GUIDELINES FOR THE OPERATING PROCEDURES FOR REHABILITATION
SERVICES AT PCRFs
1.
PCRFs are expected to provide the immediate care for musculo-skeletal conditions. It is
recognised that the scale and availability of these facilities will vary depending on the Service
population, but rapid access is of proven benefit in reducing the delay in return to fitness and it is
essential that SMO/PMOs establish a mechanism within their medical centres to permit early
assessment of acute injuries. Referrals to the PCRF are made through the Medical Officer however
Units may opt for patient self referral subject to locally agreed SOPs and under the following
conditions;
a.
Agreement by the Chain of Command.
b.
Agreement by the medical Chain of Command
c.
All self referred individuals are to be referred to the MO if the problem is not resolved
within 10 working days.
2.
Access to a detailed assessment by an experienced MO and/or physiotherapist is to be within 2
working days of presentation. Two care pathways are then available;
a.
Management of the case locally. Appropriate treatment and rehabilitation to commence
within 5 working days with regular review. T he PCRF team should liaise closely with the primary
care MO at least every 10 working days to ensure that recovery is progressing satisfactorily and
to inform any decisions on Medical Employment Status (MES).
b.
Referral for assessment by the RRU or DMRC.
3.
The decision whether to manage the case in the PCRF will be dependent on a number of
criteria, but in particular the establishment of a firm diagnosis, the severity of the injury, the availability
of local physiotherapy and operational issues are key considerations. The use of the Best Practice
Guidelines (on DDRs intranet website) for common MSK presentations is paramount to guide
referrals. Expected return to fitness in one month should be used as a rough guide.
4.
On initial presentation, a comprehensive review of the patient’s occupational health status is to
be made and temporary downgrading completed when appropriate. Any patient referred to an RRU
should be awarded a Temporary Medical Employment Status TMES.
5.
Documentation. All cases are to be referred from the MO, documented on DMICP and are to
have an accompanying physiotherapy assessment recorded on the rehab master template. This will
include an initial assessment of fitness for role on presentation and appropriate regular assessments
of progress until return to full fitness. Referrals will require full clinical and occupational details
sufficient to safely inform a high standard of care. Referrals without sufficient detail may be returned.
This issue is of importance and is to be audited on a regular basis by DPHC.
JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
link to page 19
Annex G
RRU CATCHMENT AREAS
1
Aldergrove RRU, JHF FS Aldergrove BFPO 808. Tel: 9491 56117
Army
Ballykinler
Med Centre, Abercorn Bks, Ballykinler BFPO 805
Holywood
Palace Bks, Holywood BFPO 806
Lisburn
Theipval Bks, Lisburn BFPO 801
RAF
Aldergrove
Station Med Centre, RAF Aldergrove BFPO 808
2
Aldershot RRU, Canada House, Rawlinson Road, Aldershot, GU11 2LQ Tel: 94222 3184
Army
Abingdon
Dalton Bks, Abingdon, Oxon OX13 6JB
Aldershot
McNaughton House, Rawlinson Road, Aldershot,
Hampshire GU11 2LQ
Arborfield
MRS Arborfield Garrison, Arborfield, Reading,
Berkshire RG2 9NJ
Bordon
Combined Med Centre, Hampshire Road, Bordon,
Hants GU35 0HR
Deepcut
The Princess Royal Bks, Deepcut, Camberley,
Surrey GU16 6RW
Hermitage
Dennison Bks, Hermitage, Thatcham, Berks RG18
9TP
Hounslow
Cavalry Bks, Hounslow, Middlesex TW4 6EZ
London *
Wellington Barracks, Birdcage Walk, London SW1E 6HQ
Hyde Park Bks, Knightsbridge, London SW7 1SE+
Baird Health Centre, Gassiot House, St Thomas'
+ Hospital, Lambeth Palace Road, SE1 7EH
St Johns Wood Bks, Ordnance Hill, London NW8
6PT
Med Centre, Shooters Hill Road, Woolwich, London SE18
4LH+
Minley
Gibraltar Bks, Blackwater, Camberley, Surrey GU17 9LP
Pirbright
MRS Pirbright, Alexander Bks, Pirbright, Woking,
Surrey GU24 OQQ
Sandhurst
RMA Sandhurst, Camberley, Surrey GU15 4PQ
Thatcham
Dennison Bks, Hermitage, Thatcham, Berks RG18 9TP-
Twickenham
RMSM, Kneller Hall, Twickenham, Middlesex TW2
7DU
Winchester
Sir John Moore Bks, Andover Road, North
Winchester, Hants SO22 6NQ
Combermere Bks, Windsor, Berks SL4 3DN
Windsor
Victoria Bks, Windsor, Berks SL4 1HS
Victoria Bks, Windsor, Berks SL4 3DN
Woolwich
Royal Artillery Barracks, Repository Road, Woolwich.
SE18 4BE
RAF
Odiham
RAF Odiham, Hook, Hants RG29 1QT
Joint
Headley Court
DMRC, Epsom, Surrey KT18 6JW
3
Catterick RRU, Gough Road, Catterick Garrison, North Yorkshire, DL9 3EL Tel: 94731 3928
Army
Albermarle
Albermarle Bks, Nr Harlow Hill, Newcastle upon Tyne
NE15 0RF
Carlisle
Med Centre Defence Munitions, PO Box 1,
Carlisle,Cumbria CA6 5LX
Catterick
ITC, Vimy Bks, Catterick Garrison, North Yorks DL9 4PS
+ Seen at MIAC London with in-patient care at RRU Aldershot.
G-1 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
GMC, Horne Road, Catterick Garrison, North Yorks DL9
4DF
Dishforth
Dishforth Airfield, Thirsk, North Yorks YO7 3EZ
Harrogate
Army Foundation College, Unacke Bks, Harrogate,
N Yorks HG3 2SE
Leconfield
DST, Normandy Bks, Leconfield, Beverley, East
Yorks HU17 7LX
Ripon
Claro Bks, Ripon, North Yorks HG4 3RD
Topcliffe
Alanbrooke Bks, Topcliffe, Thirsk, North Yorks YO7 3EY
York
Imphal Bks, Fulford Road, York YO10 4AU
RAF
Boulmer
SMC, RAF Boulmer, Alnwick, Northumberland NE66 3JF
Fylingdales
SMC, RAF Fylingdales, Pickering, North Yorkshire
YO18 7NT
Leeming
SMC, RAF Leeming, Northallerton, North Yorks DL7 9NJ
Linton-on-Ouse
SMC, RAF Linton-On-Ouse, York YO6 2AJ
Staxton
SMC, RRH Staxton Wold, Staxton, Scarborough
Wold
YO12 4TJ
4
Colchester RRU, Building E04, Merville Barracks, Circular Road South, CO2 7UT Tel: 94660
7090
Army
Canterbury
Howe Bks, Canterbury, Kent CT1 1JU (Apr 14)
Chatham
Brompton Bks, Chatham, Kent ME4 4UG
Colchester
Ypres Road, Colchester, Essex CO2 7NL
Maidstone
Invicta Park Bks, Maidstone, Kent ME14 2NA
MCTC
MCTC, Berechurch Road, Colchester, Essex CO2
9NU
Folkestone
Sir John Moore Bks, Shorncliffe Garrison,
Folkestone, Kent CT20 3HE
Wattisham
Wattisham Airfield, Ipswich, Suffolk IP7 7RA
Wimbish
Carver Bks, Wimbish, Saffron Walden, Essex CB10 2YA
Woodbridge
Rock Barracks, Woodbridge, Suffolk, IP12 3TW
5
Cranwell RRU, Sleaford, Lincoln, NG34 8HB Tel: 95751 6382
Army
Chilwell
HQ Chilwell Station, Beston, Nottinghamshire NG9
5HA
RTMC, Chetwyn Bks, Beeston, Nottingham NG9
5HA
Grantham
Prince William of Gloucester Bks, Grantham, Lincs
NG31 7TJ
North Luffenham
St George's Bks, North Luffenham, LE15 8RL
RAF
Coningsby
SMC, RAF Coningsby, Lincs LN4 4SY
Cottesmore
SMC, RAF Cottesmore, Oakham, Leics LE15 7BL
Cranwell
SMC, RAF Cranwell, Sleaford, Lincs HG34 8HB
Digby
SMC, RAF Digby, Lincs LN4 3LH
Scampton
SMC, RAF Scampton, Sleaford, Lincs LN1 2TR
Waddington
SMC, RAF Waddington, Lincoln LN5 9NB
Wittering
SMC, RAF Wittering, Peterborogh, Cambs PE8 6HB
6
Edinburgh RRU, Mountain Division House, Redford Barracks, Colinton Road, Edinburgh EH13
0PP Tel: 94748 5599.
RN
Arbroath
RM Condor, Arbroath, Angus DD11 3SJ
Faslane
HMS Neptune, HMNB Clyde, Faslane, Helensburgh,
Dumbartonshire
GH4 8HL (CAPFASFLOT)
Prestwick
HMS Gannet, Greensite, Prestwick Airport, Monkton,
Ayrshire KA9 2RZ
Rosyth
HMS Caledonia, Hilton Road, Rosyth KY11 2XH
Army
Dreghorn
Dreghorn Bks, Redford Road, Edinburgh EH13 9QW
Edinburgh
Redford Bks, Colington Road, Edinburgh EH13 0PP
Fort George
Fort George, Ardesier, Inverness IV2 7TE
Glasgow
APC Glasgow, Kentigem House, 65 Brown St, Glasgow
G2 6EX
G-2 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Glencorse
Glencorse Bks, Penicuick, Midlothian EH26 0NP
Kinloss
39 Engr Regt Kinloss, Forres, Morayshire IV36 3UH
RAF
Boulmer
RAF Boulmer, Airwick, Northumberland, NE66 3JF
Leuchars
SMC, RAF Leuchars, St Andrews, Fife KY16 0JX
Lossiemouth
SMC, RAF Lossiemouth, Morayshire IV31 6SD
Spadeadam
SMC, RAF Spadeadam, Gisland, Carlisle, Cumbria
CA6 7AT
7
Gutersloh RRU, Princess Royal Barracks, Gutersloh, BFPO 47 Tel: 94873 2182
Army
Bielefeld
Med Centre, Catterick Bks, BFPO 39
Bruggen
Med Centre, Javelin Bks, BFPO 35
Detmold
Med Centre, BFPO 22
Gutersloh
Med Centre, Mansergh Bks, BFPO 113
Med Centre, Princess Royal Bks, BFPO 47
Herford
Med Centre, Hammersmith Bks, BFPO 15
Paderborn
Med Centre, Alanbrooke Bks, BFPO 22
Med Centre, Barker Bks, BFPO 22
Sennelager
John Farmer Centre, Talbot Bks, BFPO 16
MRS, Talbot Bks, BFPO 16
Wegberg
BFHC Wegberg, BFPO 40
8
Halton RRU, RAF Halton, Aylesbury, Bucks HP22 5PG Tel: 95237 6893
Army
Bicester
St George’s Bks, Arncott, Bicester, Oxon OX9 1PP
SMC, RAF Bentley Priory, The Common, Stanmore, Middx
HA7 3HH
RAF
Bentley Priory
SMC, RAF Benson, Oxon OX10 6AA
Benson
SMC, RAF Brize Norton, Carterton, Oxon OX18 3LX
Brize Norton
SMC, RAF Halton, Aylesbury, Bucks HP22 5PG
Halton
SMC, RAF High Wycombe, Bucks HP14 4UE
High Wycombe
SMC, RAF Lyneham, Chippenham, Wilts SN15 4PZ
Northolt
SMC, RAF Uxbridge, Middlesex UB10 0RZ
Joint
Northwood
JSU Northwood, Eastbury Park, Northwood,
Middlesex HA6 3HP
Overseas
British Forces
PCRF Akrotiri, Medical Centre, RAF Akrotiri, Cyprus,
Cyprus
BFPO 57.
PCRF Episkopi, Garrison Medical Centre, Episkopi,
Cyprus, BFPO 53.
Brunei
PCRF Dhekalia, Medical Centre, Dhekalia, Cyprus, BFPO
58.
Garrison Medical Centre, BFPO 11.
Gibraltar
Princess Royal Medical Centre, Devils Tower Camp,
Gibraltar, BFPO 52.
All Other
Excludes British Forces Germany and Operational
Overseas Bases
Theatres
G-3 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
9
Hohne RRU Haig Barracks, BFPO 30 94877 2182
Army
Dulmen
Med Centre, Tower Bks, BFPO 44
Fallingbostel
MRS Fallingbostel, Lumsden Bks, BFPO 38
Fallingbostel Physio Dept, MRS Fallingbostel, BFPO 38
Hohne
MRS, Haig Bks, BFPO 23
RAF
Brunssum
RHQ AFNORTH, Brunssum, Netherlands BFPO 28
10
Honington RRU Bury St Edmonds, Suffolk, IP31 1EE Tel: 95991 6996
Army
Swanton Morley
Robertson Bks, Swanton Morley, Norfolk NR20 4TX
RAF
Henlow
SMC, RAF Henlow, Bedfordshire SG16 6DN
Honington
SMC, RAF Honington, Bury St Edmunds, Suffolk
IP31 1EE
Marham
SMC, RAF Marham, Kings Lynn, Norfolk PE33 9NP
Wyton
SMC, RAF Wyton, Huntingdon, Cambs PE17 2EA
Joint
Chicksands
SMC, DISC Chicksands, Shefford, Beds, SG17 5PR
11
Cosford RRU, Albrighton, Wolverhampton WV7 3EX Tel: 95561 7152
Army
Bramcote
Gamecock Bks, Bramcote, Nuneaton CV11 6QN
Chester
Dale Bks, Liverpool Rd, Chester, Cheshire CH2 4BD
Donnington
DSDA Donnington, Telford, Shropshire TF2 8JT
Kineton
Malborough Bks, Temple Herewyke, Southam,
Warwick CV47 5UL
Preston
Fulwood Bks, Preston, Lancs, PR2 8AA
Weeton Bks, Kirkham, Preston Lancs PR4 3JQ
Ternhill
Clive Bks, Ternhill, Market ,Frayton,Shropshire, TF9 3QE
Lichfield
Whittington Bks, Lichfield, Staffs WS14 9PY
RAF
Cosford
DCAE DefeCAE, Albrighton, Wolverhampton, W Midlands
WV07 3EX
Shawbury
SMC, RAF Shawbury, Shrewsbury, Shropshire SY4 4DZ
Stafford
SMC, RAF Stafford, Beaconside, Staffs ST18 0AQ
Valley
SMC, RAF Valley, Holyhead, Anglesey LL65 3NY
Joint
BMF
MPAC, 1st Floor, K block, Selly Oak Hospital,
Raddleburn Road,B29 6JD,
12
St Athan RRU, East Camp, Medical Centre, MOD St Athan, Vale of Glamorgan CF62 4WA
Tel: 95421 7673
Army
Hereford
Sterling Lines, Hereford HR4 7DD
Brawdy
Cawdor Bks, Haverfordwest, Pemb SA62 6NN
Brecon
ITC Wales, Dering Lines, Brecon, Powys LD3 7RA
Chepstow
Beachley Bks, Chepstow NP16 7YG
RAF
St Athan
SMC, RAF St Athan, Barry, Glamorgan CF62 4WA
13
Plymouth RRU, Old Gym, HMS Drake, HM Naval Base, PlymouthPL2 2BG Tel: 9375 67126
RN
Chivenor
RM Barracks, Chivenor, Barnstaple, Devon EX31
4BL
Culdrose
HMS Seahawk/RNAS Culdrose, Helston, Cornwall
TR12 7RH
Dartmouth
BRNC, Dartmouth, S Devon TQ6 0HJ
Lympstone
CTC Lympstone, Nr Exmouth, Devon EX8 5AR
Plymouth
HMS Drake, Plymouth, Devon PL2 2BG
(including COMDEVFLOT)
G-4 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Bickleigh Bks, Shaugh Prior, Plymouth PL6 7AJ
Stonehouse Bks, Plymouth, Devon PL1 3JY
The Royal Citadel, Plymouth PL1 2PD
Taunton
Norton Manor Camp, Taunton, Somerset TA2 6PF
Torpoint
HMS Raleigh, Torpoint, Cornwall PL11 2PD
Yeovilton
HMS Heron, RNAS Yeovilton, Somerset BA22 8HT
Army
Oakhampton
Oakhampton Training Camp, Oakhampton, Devon
EX20 1QP
Penhale
Penhale Training Camp, Holywell Bay, Newquay,
Cornwall TR8 5PF
Fremington
Fremington Training Camp, Nr Barnstaple, Devon
EX31 3BJ
RAF
St Mawgan
SMC, RAF St Mawgan, Newquay, Cornwall TR8
14
Portsmouth RRU HMS Nelson, HM Naval Base, Portsmouth, PO1 3HH Tel: 9380 20847
RN
Poole
Hamworthy, Poole, Devon PL1 3JY
Portsmouth
Fort Blockhouse, Haslar Road, Gosport, Hants P012 2AA
HMS Collingwood, Newgate Lane, Fareham, Hants
PO14 1AS
HMS Excellent, Whale Island, Portsmouth, Hants
PO2 8ER
HMS Nelson, HMNB, Portsmouth, Hants PO1 3HH
(including COMPORFLOT)
HMS Sultan, Military Road, Gosport, Hants PO12
3BY
Army
Marchwood
McMullen Bks, Marchwood, Southampton, Hants
SO4 4ZG
Thorney Island
Baker Bks, Thorney Island, Emsworth, Hants PO10 8DH
Joint
Southwick Park
Defence College of Police & Personnel
Administration, Southwick Park, Fareham, Hants
PO17 6EA
15
Tidworth RRU, Jellalabad Barracks, TIDWORTH, Wiltshire, SP9 7DX Tel: 94321 2616
Army
Abbey Wood
Service Medicine, Abbey Wood, Bristol, BS43 8JH
Blandford
Med Centre, Blandford Garrison, Blandford Camp,
Dorset DT11 8RH
Bovington
Bovington Camp, Wareham, Dorset BH20 6JA
Bulford
Bulford Group Practice, Bengal Road, Bulford Camp,
Salisbury, Wilts SA4 9AD
Hullavington
Hullavington Bks, Chippenham, Wilts SN14 6BT
Larkhill
Larkhill Garrison, Willoughby road, Larkhill, Wilts
SP4 8QY
Middle Wallop
Middle Wallop, Stockbridge, Hants S020 8DY
South Cerney
Duke of Gloucester Bks, South Cerney, Gloucester
GL7 5RD
Tidworth
(QEMHC) Queen Elizabeth Memorial H C, St Michael’s
Avenue, Delhi Bks, Tidworth, Wiltshire SP9 7EA
Upavon
HQ AG, Trenchard Lines, Upavon, Wilts SN9 6BE
Warminster
WTC, Imber Road, Warminster, Wilts BA12 0DJ
Colerne
Azimghur Bks, Colerne, Chippenham, Wilts SN148OY
RAF
Boscombe Down
SMC, RAF Boscombe Down, Salisbury, Wilts SP4 0JF
JSU Corsham
SMC, JSU Corsham, Park Lane, Corsham, Wilts
SN13 9NR
Innsworth
RAF Innsworth, Gloucester GL3 1EZ
Joint
Shrivenham
Defence Academy, Shrivenham, Swindon, Wilts SN6
Hereford
Sterling Lines, Hereford HR4 7DD
G-5 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Annex H
RRU CORE STAFFING AND REFERRAL GUIDELINES
1.
OiC RRU. This critical post provides both the leadership for the RRU and the command and
control of physiotherapy and rehabilitation activity within the Region. The post holder will be an
OF3 physiotherapist who will have experienced a tour at DMRC, primary care and an operational
deployment. This pivotal role manages clinical delivery, governance, personnel and all associated
elements of RRU activity. The post holder will deliver a minimum of 20% clinical activity.
2.
2IC RRU. The 2IC of the RRU is an OF2 post that supports the OiC in the execution of their
duties and will conduct much of the internal audit of all aspects of the activity within the RRU. This
is a Physiotherapist role that requires a minimum of 50% patient clinical contact.
3.
Medical Officer (MO). May be GPs trained in sports and training injury medicine and hold a
diploma or an MSc in Sport and Exercise Medicine or doctors on the specialist register in Sport and
Exercise Medicine. They should also have a thorough knowledge of the occupational issues and
implications of musculoskeletal injury in Service personnel. The MO plays a central role in the
MIAC, both by contributing to the diagnostic process and patient case management. One MO
should be employed on a sessional basis to provide adequate clinical support and to ensure
continuity of care and case management. The actual sessions required will depend upon the local
demand but will usually be a minimum of 4 sessions per week.
4.
Civilian Physiotherapists. A minimum of 2 posts are required;
a.
One Band 7 (clinical specialist). Band 7 posts are established to provide specialised
clinical lead and Team leadership as required. They treat both inpatient group patients and
play an active role in the MIAC.
b.
One band 6 physiotherapist. The post provides physiotherapy for the inpatient groups.
5.
Exercise Rehabilitation Instructors. The ERIs are members of the sS PT Branches who
have undertaken the 6 month Joint Service Exercise Rehabilitation Instructor course at the Joint
Services School of Exercise Rehabilitation Instructors (JSSERI), DMRC. RRUs are manned with;
a.
One Warrant Officer/Flight Sergeant/Chief Petty Officer. This post is the lead
position for ERIs within RRUs. They will be experienced clinically, having been employed at
DMRC and/or an RRU previously and at least one PCRF. They will conduct clinical duties in
support of exercise interventions delivered to the groups and support the MIAC. The
WO2/FS/CPO ERI role will also include regional responsibilities to include the governance of
ERIs in PCRFs through their Regional Trade Specialist Advisor (RTSA) role.
b.
Two SNCO/Cpl ranked ERIs. One is employed supporting each group of 15 patients.
They deliver the exercise-based rehabilitation and are integrated members of the medical
rehabilitation team and on occasions support the MIAC.
6.
Podiatrist /Physiotherapist (Biomechanist). Each RRU will employ a Band 7 podiatrist or
a Band 7 physiotherapist (biomechanist) on a PT or FT basis (dependant on requirement). The
podiatrist will work out of the RRU and also have a regional role through delivering peripatetic
clinics.
7.
Consultant. The RRU will be assigned a visiting Consultant, who will be either a Consultant
in R&R or SEM. This consultant will lead twice yearly MDT visits to provide support for the RRU.
The RRU also has direct email access to the lead consultant providing support on matters such as
case management, access to specialists, clinical governance, and best practice initiatives.
H-1 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
link to page 25 link to page 25
8.
Administrative Support. Administrative support ensures the efficient and smooth running of
the rehabilitation Unit. Each RRU will have two E grade administrators. Duties would include
appointment and reception work, data collection and collation and administration of medical
records.
Referral to RRUs
9.
Referral Time Targets. RRUs are to conform to the Key Performance Indicators set by the
Rehabilitation Executive Committee (REC). When appropriate the FMed 7 and physiotherapy
assessment are to be faxed to the RRU to allow cases to be scrutinised before the appointment is
given. The performance of RRUs in achieving appointment targets will be audited. Direct referral
utilising DMICP must be used where available.
10.
Referral Documentation. All referrals to the MIAC are to be made on DMICP and are to
include a physiotherapy assessment and summary of patient. The referral is to include:
a.
The relevant detailed medical history
6, including the findings on examination and any
investigations already performed.
b.
The working diagnosis and previous investigations.
c.
Treatment to date, including physiotherapy or rehabilitation.
d.
Functional assessment in relation to fitness for task.
e.
Employment details.
f.
Medical Employment Standard.
7
11.
RRU Documentation. The RRUs are to maintain detailed records of the patient’s initial
assessment and their progress during therapy on DMICP. This is to include regular re-
assessment. RRUs should liaise closely with the referrer and the Unit MO to inform them of
progress and occupational issues.
12.
Audit. OiCs are to ensure that all assessments and treatments undertaken at the RRU are
appropriately documented. DPHC are responsible for ensuring that the SOPs are followed and
that throughput targets are being met. In addition, DPHC, in conjunction with Director of Defence
Rehabilitation (DDR) and his staff will conduct professional Healthcare Governance Assurance
Visits (HGAV) to ensure optimal working practices and that best practice is delivered to all groups
of patients.
Secondary Care Referral from RRU
13.
Orthopaedic Referral – Operative Intervention. As stated above, the RRU acts as a filter
for fast track orthopaedic referral. The RRUs will, wherever possible, refer to a specific
local/regional orthopaedic department. This will ensure that they are aware of the orthopaedic
consultant’s requirements with regard to pre-consultation investigations, however all RRU referrals
must be copied to referring MOs to ensure co-ordination of patient care. If a decision to operate is
confirmed then the RRUs should ensure that an appropriate pre-operative exercise programme is
provided.
6 RRU staff will not have access to PHC notes due to Caldicott protocols, therefore detailed notes are required to ensure optimum
patient care.
7 It is expected that all cases will have had their occupational health status considered.
H-2 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
14. For those patients requiring surgical intervention, the aim is that the patient will be offered
surgery within 6 weeks of the MIAC appointment if this is clinically appropriate. Units are to confirm
that the individual is available for admission and to inform their Chain of Command if
problems are encountered.
15. The RRU is to ensure that the individual has a planned post-operative rehabilitation
programme, even though the early phases of this programme may be carried out at PCRF level or
another RRU if the patient is sent home on sick leave. However, the referring RRU is to ensure
compliance with the programme and to ensure that monthly assessments of recovery are
performed. It is essential that the individual understands and agrees the importance of his/her
availability for this post operative rehabilitation.
16.
DMRC Consultant Referral. Whereas most musculoskeletal cases should be seen at the
PCRF/RRUs before referral to DMRC, patients can be referred directly to DMRC at the judgement
of the doctor or the MIAC team. Cases such as, neurological injury, complex trauma and
rheumatological cases should all be referred directly to DMRC. The aim is for patients to be seen
by a Consultant within 30 working days of a decision to refer being taken by the RRU MIAC/IAC.
The RRU is responsible for ensuring that the results of any pre-consultation investigations are
available at the time of the consultation.
17.
Secondary Care Referral Documentation. All referrals are to be made on DMICP / FMed 7
including a Physio report. It is the responsibility of the primary care practitioner to ensure that all
relevant past medical history, including drug, anaesthetic and allergic history, is made available to
the consultant at the time of consultation. The RRU will be responsible for arranging the
appointment. The primary care practitioner retains the responsibility for the patient, even though
the decision to refer is taken by the MIAC. A copy of the referral to secondary care is to be
forwarded to the primary care practitioner for inclusion on DMICP.
Discharge from rehabilitation
18. Discharge from any aspect of rehabilitation is to be recorded by the Primary Care practitioner
and the RRU (within the assessment documentation) on DMICP. A final assessment is to be
conducted that must state that:
a.
The patient has been returned to full fitness for task
or
b.
The patient has gained the maximum benefit possible from the rehabilitation
programme.
19.
Medical Employment Standard and Patient Data Transfer Requirements. The Primary
Care practitioner is to initiate appropriate medical boarding action, if necessary, once the patient is
discharged from rehabilitation to reflect the individual’s current employability based on advice
regarding their function provided by the RRU.
Overall audit of the process
20. It is essential that the selected care pathway is fully transparent for audit purposes with
accurate up to date entries in the DPTA. This requires good communication between PCRFs and
the RRUs to avoid duplication and double accounting. Regular audit of patients’ progress will be
conducted by the RRU and LS via the DPTA.
.
H-3 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Annex I
REGIONAL PODIATRY SERVICE REFERRAL PATHWAY
Injury caused or
aggravated by lower limb /
foot biomechanics
Corrected by
Complex Problems
simple footwear
advice?
- Significant bony abnormality.
Refer to Primary
- Prosthetic considerations
Care
Biomechanical problem
(when outside of scope of
No
Rehabilitation
identified whilst individual
PCRF)
Facility
is under RRU care
- Greater than 4cm leg length
discrepancy.
- Previous well managed
Is problem
treatment by RPS failed to
complex?
resolve problem.
No
Yes
Rx of injury
Footwear advice
Conditioning etc
Indirect care
resolves problem
RPS Treatment
Issue of-the-shelf
- Temporary orthotic prescription
orthoses with
fitting and review.
No
physio’s
alterations
- Exercise prescription (iaw current
PCRF care).
Off-the-shelf orthotic prescription,
fitting and review.
Orthoses resolve
- Bespoke orthotic prescription,
problem?
fitting and review (orthoses
delivered and fitted within 6 weeks.
Refer to Regional
Podiatry Service
No
(RPS) (FMed 7 to
RRU)
Yes
Too complex
Pt Assessed and
to manage
treated by RPS
at RPS
RPS intervention
resolves problem
Refer to DMRC
for biomechanical
Yes
No
assessment and
management
DMRC intervention
resolves problem?
Yes
No
Refer back to GP –
Biomechanical problem
biomechanical alteration
resolved
unsuccessful
I-1 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
REGIONAL PODIATRY SERVICE REFERRAL GUIDELINES
1.
Referral to the criteria to the RPS include;
a.
Any un-resolving lower limb biomechanical complaint that requires a Podiatry opinion.
b.
Poor tolerance of ‘Off-The-Shelf’ Orthotics with an expectation that a custom made
orthotic is required.
c.
Gait / Running Assessment.
d.
Specialist advice and provision of splints (eg ankle-foot orthoses).
e.
Patients with leg length discrepancies or congenital deformities that require footwear
adaptations. These can be sourced locally and invoices processed via SG Finance.
f.
Those personnel who may require bespoke/specialist footwear services will include:
(1)
Congenital deformity such as; Talipes equino varus, Metatarsus adductus,
Severe pes cavus or pes cavus leading to abnormal width or
depth
(2)
Those who have sustained severe foot deformity, scarring, pain and fixation
following trauma from RTAs or during operation (IED attack) for example.
(3)
Those who have severe foot deformity from an iatrogenic cause.
(4)
If normal footwear cannot accommodate an appliance such as a ankle foot
orthoses.
g.
Replacement of Custom Orthotic. Evidence should be shown of how all other
biomechanical factors have been addressed since the initial issue of custom made orthotics.
Custom orthotics are not to be repeatedly issued without patient re-evaluation.
2.
Dual Referrals. It is acceptable that PCRFs may refer to both MIAC and the RPS
simultaneously, if required. A separate FMed7 is to be completed for each, annotating that a dual
referral has occurred.
Onward Referral
3.
Second Opinion. Should a second opinion be required, the RPS podiatrist has two options:
a.
Refer to a Podiatrist at another RPS.
b.
Refer to DMRC Headley Court. These referrals should normally be reserved for
patients with complex injuries commensurate with multi-trauma or where a second opinion at
another RPS has proved unsuccessful.
4.
Secondary Care. Should a secondary care opinion be required the patient should be
referred either back to their primary health care facility for onward referral or to MIAC. Podiatrists
are not to refer directly to secondary care.
5.
DMRC Referral. Referral to DMRC Headley Court Podiatrists should only be made by the
RPS and not directly by Primary Care. Referrals are to be made by FMed7 and should include
evidence that the patient has been seen at both primary and intermediate level.
I-2 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
6.
Discharge. Once treatment is completed at the RPS, patients should be referred back to the
originating source with a completed FMed7.
I-3 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
link to page 30 link to page 30 link to page 30
Annex J
REHABILITATIVE CARE PATHWAY FOR MILITARY OVERSEAS
PATIENTS NOT IN OPERATIONAL ROLES OR STATIONED AS PART OF
BRITISH FORCES GERMANY
Introduction
1.
All UK military personnel based in overseas locations, are entitled to rehabilitative care in
accordance with the referral criteria detailed within the DMRP. This includes access to primary,
intermediate and specialist care rehabilitation, as would be expected of patients located within the
UK or Germany. This directive sets out the arrangements for patients who suffer musculo-skeletal
(MSK) and neurological injuries while serving overseas (not including operational deployments or
BFG based personnel), to ensure their appropriate and timely management.
Fundamental Principle
2.
The fundamental principle which must be applied when considering rehabilitative care for
overseas military patients:
Personnel based in overseas posts are not to be unduly prevented from accessing
appropriate rehabilitative care at all levels, and in a timely manner, due to their duty
location or specific role.
Entry to the Rehabilitation Care Pathway
3.
Entry to the rehabilitation care pathway for overseas patients can be achieved through a
number of methods, dependent upon the local facilities and medical frameworks available within
the country of origin. These are summarised in Figure 1 and detailed below.
a.
No unit medical officer locally. Where no military medical facility is accessible, the
senior ranking officer (or SNCO if no officer present) at the respective location has ultimate
responsibility for ensuring contact is made with the single Service point of contact (sS POC)
8.
The sS POC is to then either fund medical and rehabilitation care locally to the patient, or if
rehabilitation or potential orthopaedic surgical care is indicated, they are to ensure a FMed7
referral is sent to RRU Halton
9 for assessment and onward care as appropriate. If primary
medical care or medical surgical care is indicated the sS POC should follow direction as per
JSP 950 10-1-1.
b.
Unit medical officer present but no PCRF. Where no local rehabilitative care is
supplied within the unit formation, the unit medical officer is to either request funding for local
rehabilitative care from the sS POC or refer directly to RRU Halton for assessment and
onward care as appropriate.
c.
Unit medical officer and PCRF present. Where full primary medical and
rehabilitation care is available locally within the unit these are to be utilised as appropriate.
Where intermediate care is required, patients should be referred via FMed7
10 to RRU Halton.
RRU Halton 4.
Following assessment within a MIAC, patients onward care should be decided as per
guidance within the DMRP, with RRU Halton acting as the initial gatekeeper for the care pathway.
8 The roles, responsibilities and contact details of the sS POCs can be found withi
n JSP 950 10-1-1. The sS POC is normally
associated with a sS Medical Centre who will generate the required FMed7 referral.
9 RRU Halton is the default intermediate care facility for all overseas units excluding those within Operational Theatres or BFG.
10 FMed7 to have input from both medical officer and physiotherapist, as per UK based units.
J-1 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Where onward referral to another RRU or DMRC Headley Court has occurred the receiving unit
takes responsibility for the patient and must ensure the appropriateness of the onward care
pathway, including follow-up care post surgery if relevant. Where an RRU requests local PCRF
treatment, that RRU should retain oversight of the patients care pathway and must monitor their
progress appropriately, with review MIACs and onward referral or discharge as appropriate.
a.
Referrals. The following is to be noted with regards to referrals to RRU Halton:
(1)
Referrals are to be sent electronically on an FMed7 to the RRU admin list.
(2)
Faxed referrals are acceptable where there is no DMICP availability.
(3)
Where there is no PCRF available, FMed7 referrals to RRU Halton may be sent
directly by a medical officer, without a PCRF opinion within the referral.
5.
Ownership of the patient at all times remains with the medical centre at the patients duty unit,
or where none exists (as per para 3a), the sS POC.
Pre-habilitation
6.
In order to optimise patient care and ensure military medical rehabilitation protocols have
been adhered to with any necessary pre-habilitation processes in place, it would be expected that
prior to any onward referral for surgery, military primary care rehabilitation has been received by
the patient. Where no
military medical or rehabilitation input has been received from primary care
onwards, any overseas patient requiring orthopaedic surgery
must be referred and seen by RRU
Halton before surgery takes place (most likely in scenarios as per para 3a/b)
. Investigations
7.
Where possible, overseas medical centres are to obtain MRIs/Xrays prior to attendance at
RRU Halton, and in accordance with DDRs
clinical indications for MRIs. Discharge Process
8.
All overseas patients seen within the UK, are to be given a discharge report which is to be
entered onto their DMICP record or FMed4 as appropriate. It is the responsibility of the accepting
RRU or DMRC, to ensure this letter reaches the initial primary care referring location in a timely
manner.
Governance
9.
Locations that are not able to access all levels of the DMRP but have sourced a suitable
substitute locally, must ensure the following:
a.
Suitable governance structures and risk assessments are in place to ensure the
rehabilitative care delivered to UK military and entitled personnel, meets the standard
required had that patient been located within the UK.
b.
Rehabilitative care delivered conforms, as much as is practical, to the advice given
within the
DDR Best Practice Guidelines.
Travel, Subsistence and Accommodation
11. Travel to/from various care facilities and subsistence will not be paid by the medical centres
and guidance on travel and subsistence costs are to be met as per guidance withi
n JSP 752
Triservice Regulations for Expenses and Allowances.
J-2 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
10. Accommodation for patients attending a rehabilitation course or MIAC at an RRU or at
DMRC Headley Court, may be provided by the rehabilitation unit subject to availability.
Accommodation requirements outside these areas are the responsibility of the patient’s duty unit.
Figure 1. Rehabilitation Care Pathway – Overseas Patients (Non-Operational/BFG)
---------------------------------------------------------------------------------------------------------------------------
No Overseas
Unit Medical
Unit Medical
Unit Medical
Officer - No
Officer
Officer
PCRF
Overseas
Provision /
Unit
Funding of
PCRF
Locally
Sourced
Rehab
----------------------------------------------------------------------------------------------------------------------------
sS POC
RRU Halton
UK
MIAC/Treatment/
Investigations/Referral as
appropriate
PCRF
RRU
DMRC
Referral back to originating
medical facility/sS POC
J-3 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Figure 2. Rehabilitation and Surgical Care Pathway – Overseas Pateitns (Non-
operational/BFG)
No Overseas
Unit Medical
Unit Medical
Unit Medical
Officer - No
Officer
Officer
PCRF
Overseas
Provision /
Unit
Funding of
PCRF
Locally
Sourced
Rehab
----------------------------------------------------------------------------------------------------------------------------
sS POC
UK
RRU Halton
Secondary
Fast Track
MIAC/Treatment/
Care
Surgery
Investigations/Referral as
appropriate
PCRF
RRU
DMRC
Referral back to originating
medical facility/sS POC
-----------------------------------------------------------------------------------------------------------------------------
J-4 JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
Annex K
CLINICAL SPECIALITIES AT THE DEFENCE MEDICAL REHABILITATION
CENTRE
1.
DMRC contains a number of diverse clinical specialists that work together to provide Multi
Disciplinary care. These specialities include;
a.
Consultants (R&R, SEM, Neuro and Psychiatry).
b.
Physiotherapists.
c.
Occupational Therapists.
d.
Exercise Rehabilitation Instructors.
e.
Social Workers.
f.
Rehabilitation Nurses.
g.
Mental Health Nurses.
h.
Podiatrists.
i.
Psychologists.
j.
Speech and Language Therapists.
k.
Dieticians.
l.
Prosthetists.
m.
Orthotists.
n.
Prosthetic Technicians.
o.
Rehabilitation Assistants.
p.
Visiting Consultants including; Burns and Plastics, Orthopaedics, Peripheral Nerve Injury,
Urology, Neurology and Chronic pain.
JSP 950 Part 1 Lft 2-22-1 (V1.1 Dec 10)
