CQC's inspection programme of Defence Medical Services: Annual report for Year 6 (2022/23)

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.

The focus of our approach continues to be the quality and safety of services, based on the things that are important to patients. This enables us to get to the heart of people's experiences.

In 2022/23, as in previous years, DMSR identified the medical facilities to be inspected. Of all the medical facilities, only a small number had not yet had an initial comprehensive inspection, so we were able to inspect the last 5 remaining medical facilities.

There are several differences between military general practice and NHS general practice, for example:

• DMS practice populations are much smaller than NHS practice
• providing services for families is far less common
• there is a greater focus on delivering occupational health throughout the DMS.

Staff see significantly higher numbers of patients with musculoskeletal injuries and fewer patients with chronic conditions.

First inspections in Year 6

We carried out 5 first comprehensive inspections of medical centres in Year 6. The overall ratings for each centre are determined by aggregating ratings for the 5 key questions.

• 3 were rated overall as good
• 2 were rated overall as requires improvement.

In Year 6, 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 the centre is led and managed. We found that all patients were able to access compassionate, effective and responsive care (figure 1).

Figure 1: First inspections of medical centres by key question and overall (Year 6)

Service	Safe	Effective	Caring	Responsive	Well-led	Overall
Bassingbourn Medical Centre	Good	Good	Good	Good	Good	Good
Kentigern House Medical Centre	Good	Good	Good	Good	Good	Good
Neptune Medical Centre	Good	Good	Good	Good	Good	Good
Maidstone Medical Centre	Requires improvement	Good	Good	Good	Requires improvement	Requires improvement
Winchester Medical Centre	Requires improvement	Good	Good	Good	Requires improvement	Requires improvement

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 Year 6, we re-inspected 9 medical centres to follow up previous concerns (figure 2). Of these:

• 5 received a second inspection
• 3 received a third inspection
• 1 received a fourth inspection.

Of the 9 services re-inspected, 6 demonstrated sufficient positive improvement to confirm that the quality of care had improved. Three medical centres had not been able to sufficiently address issues around safety, and one medical facility had ongoing concerns around effectiveness of treatment and leadership.

High Wycombe Medical Centre had improved the standard of care delivered to its patients and the environment in which its staff work. We highlighted outstanding leadership as a key factor in achieving this turnaround.

Brawdy Medical Centre was inspected for the fourth time and has improved as far as it can, given significant recruitment challenges due to its geographical position.

Figure 2: Re-inspections of medical centres by key question and overall (Year 6)

Bramcote Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	RI	RI	Good	Good	Good	RI
2nd	RI	Good	Good	Good	Good	Good
3rd	Good	X	X	X	X	Good

Brawdy Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	Inadequate	Inadequate	Good	RI	Inadequate	Inadequate
2nd	RI	RI	Good	Good	RI	RI
3rd	RI	Good	Good	Good	Good	Good
4th	RI	X	X	X	X	Good

High Wycombe Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	Inadequate	Inadequate	Good	RI	RI	Inadequate
2nd	RI	RI	Good	RI	RI	RI
3rd	Good	Good	Good	Good	Outstanding	Good

Kinloss Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	RI	Good	Good	Good	RI	RI
2nd	Good	Good	Good	Good	RI	Good

Lyneham Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	RI	Good	Good	Outstanding	Good	Good
2nd	Good	X	X	X	X	Good

Nelson Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	Inadequate	Inadequate	Good	Good	RI	Inadequate
2nd	Inadequate	RI	Good	Good	RI	RI

Newcastle Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	Inadequate	RI	Good	Good	Inadequate	Inadequate
2nd	RI	Good	Good	Good	RI	RI
3rd	Good	Good	Good	Good	RI	Good

Thorney Island Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	RI	RI	Good	Good	RI	RI
2nd	Good	Good	Good	Good	Good	Good

Waddington Medical Centre

	Safe	Effective	Caring	Responsive	Well-led	Overall
1st	Inadequate	RI	Good	Good	RI	RI
2nd	RI	Good	Good	Good	Good	Good

Safe key question

In Year 6, we found concerns around safety at 2 medical centres inspected for the first time and at 3 medical centres to follow up a previous inspection. As in previous years, there continues to be a clear link between a lower rating for leadership (the well-led key question) and a lower rating for safety.

We saw some improvements from the previous 5 years, but there are some common areas that still need to improve across medical centres.

Safe: Areas needing continued improvement

Safe levels of staffing

Across the 6 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 Navy, Army or RAF tasks. This, together with the lack of available civilian and locum staff, means that some services struggle to deliver continuity of service. In year 6, we continued to see medical centre teams that struggle with significant workforce shortages.

However, we note that regional teams and networks are often using innovative approaches to mitigate these risks.

Information systems

As in previous years, DPHC's information system cannot 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, and in previous annual reports, 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
• agreed standards and DPHC-wide policy for staff to work to
• comprehensive audit programme to ensure overall improvements in coding

• clinical diagnoses can be unclear and hidden within numerous screens, sometimes resulting in insufficient summarisation
• services use multiple clinical templates written in isolation from policy, which results in an inconsistent approach, problems with coding and gaps in reviews for some patients.

In 2022/23, DPHC has carried out positive work to implement a comprehensive suite of clinical searches. This has enabled medical teams to quantify and provide evidence around the safety, quality and effectiveness of care.

However, there are continued specific issues around the interface between clinical recording systems, including between:

• the Defence Medical Information Capability Programme (DMICP)
• DMICP Fixed
• Fixed Overseas
• Maritime
• DMICP Deployed.

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.

Firewall restrictions also cause problems for medical centre staff:

• They do not have 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.
• Staff cannot receive electronic discharge letters.
• When patients leave military service, staff cannot easily transfer records to NHS services.

In Year 6, 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

By effective, we mean that people's care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. An effective medical centre routinely reviews the effectiveness and appropriateness of its care as part of quality improvement. When care and support is effective, people have their needs assessed and their care and treatment is delivered in line with current legislation, standards and evidence-based guidance.

In our year 6 inspection work, we found that almost all medical centres we visited were providing effective care to their patients. Many factors contributed to this, including for example:

• providing training for staff that is relevant to their role
• inviting eligible patients for health screening
• having an effective recall of patients diagnosed with a long-term condition and maintaining accurate registers
• addressing backlogs in assessments and summarising clinical records
• regularly auditing clinical notes
• using the DMICP patient records system to facilitate clinical searches, assure recall programmes and monitor performance
• having a rolling programme of work to continuously improve patient outcomes.

Well-led key question

We looked at governance arrangements, culture, leadership capacity, vision and strategy, managing risks, issues and performance, and continuous improvement under this key question. Poor performance under the well-led key question affects all areas – particularly the safety and effectiveness of care and treatment.

For the well-led key question, of the 5 medical centres inspected for the first time:

• 3 were rated as good
• 2 were rated as requires improvement

Of those being re-inspected, we focused on leadership at 6 centres:

• 1 was re-rated as outstanding
• 2 were re-rated as good
• 3 were re-rated as requires improvement

Medical centres rated as outstanding foster a culture where challenge and transparency allowed teams to fulfil their duty of candour. Outstanding leadership focuses not only on the decisions and work carried out in a medical centre – it encourages and enables partnership working with internal and external stakeholders to deliver meaningful improvements for patients. In outstanding medical centres:

• staff have the capacity, experience and skillset to lead
• teams are resilient
• deputies are able to support during periods of high demand or when key staff are deployed.

We always look for examples of outstanding leadership to share with other services so that they can adapt and implement changes to improve.

Well-led: Areas needing continued improvement

Five medical centres were rated as requires improvement for the well-led key question in Year 6. We will re-inspect these services in Year 7 to ensure that they have delivered improvements.

We identified the following key areas for improvement and continue to make recommendations to Defence through DMSR to encourage improvement.

Leadership capacity

Professional isolation and lack of resilience continues to be an issue at some practices. Small practice teams sometimes find it difficult to implement and maintain strong governance systems to deliver safe and effective care continuously. These teams are also disproportionately affected by gaps in staffing. In Year 6, we still found concerns with some practices that had insufficient GP hours to provide a good level of clinical oversight and leadership. Staffing shortages meant they could not ensure that all lead roles were covered effectively, resulting in under-developed clinical improvement work, particularly clinical audit.

We still find that the medical centres that collaborate, affiliate, and share resources are more resilient to overcome challenges and are more likely to deliver consistently good care.

Effective practice management

The role of the practice manager is essential to:

• a good track record for safety
• safe information practices
• maintaining a learning culture
• ongoing delivery of quality care.

We have noted a difference in the routes that staff might follow before they manage a DPHC medical facility and the differing levels of support and training available to them.

RAF practice managers generally follow a career pathway to practice management. They often work in medical centres throughout their career, and they are trained and developed into the role over several years. However, Army and Navy personnel can be placed in a practice manager role without any previous experience of working in a medical centre and without any training. The role of the Army practice manager can be particularly broad, and the post holder might find themselves taking on a large range of roles and responsibilities that they have no previous experience in.

Civilian practice managers may be recruited to the role without any experience in medical services or the Ministry of Defence. Without mentorship and support, the learning curve can prove too steep.

There is scope to standardise the role of practice manager across the Forces, to agree generic terms of refence across Defence and to build a recognised career pathway for practice managers to pursue. To do this, DMS should:

• implement consistent policies and standing operating procedures for practice managers to adopt across DPHC Medical, which should be reviewed and updated consistently
• provide mentorship for deputy and junior practice managers
• ensure all practice managers attend a well-structured training course focusing on the practical delivery of the day job
• ensure there is consistent access to external qualifications in health and social care leadership and management, and health and safety qualifications.

Good governance

Governance systems are not always effective and do not support practices to deliver consistently high-quality services. We identified the following common issues in Year 6:

• Practices do not always understand and monitor their own performance.
• Staff are not always following central policy and procedures, sometimes leading to inconsistent care.
• There are not always planned improvement programmes focused around delivering meaningful and improved outcomes for patients.
• The arrangements to identify, record, and manage risks and issues, and implement mitigating actions, are sometimes ineffective.