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Parliamentary Joint Committee on Foreign Affairs, Defence and Trade - 25/03/2013 - Care of Australian Defence Force personnel wounded and injured on operations

READE, Lieutenant Colonel Michael Charles, Professor of Military Medicine and Surgery, Joint Health Command, Australian Defence Force

[15:35]

CHAIR: Welcome. Although the subcommittee does not require you to give evidence on notice I should advise you that this hearing is a legal proceeding of the parliament and therefore has the same standing as proceedings of the respective houses. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attract parliamentary privilege. Do you wish to make an opening statement before we go to questions?

Lt Col. Reade : The most useful thing would be to give you a little bit of information about me and perhaps the scope of information which I can provide you. I am an intensive care physician—that is my clinical specialty. I was a reservist for more than 20 years before being appointed to this job, which is a full-time Defence position located at the University of Queensland and co-located with the Royal Brisbane and Women's Hospital. At the end of 2011, for the first time in many decades, the ADF stood up a full-time surgical team of clinicians who are based at the Royal Brisbane and Women's Hospital but are available for ADF deployments. My role is to work within that military surgical team and also to do academic work within the context of the University of Queensland. My specific brief, the way it is described in my contract, is to do research relevant to military trauma medicine and to guide the implementation of modern trauma care into the ADF.

I suppose that gives something of a frame of reference for what I might be able to contribute today. My role is very much in acute hospital medicine. I have done five operational deployments, most recently to Afghanistan in 2009. I have debriefed all of the medical teams that have worked in Afghanistan since, and I am due to deploy again later this year. I know something of the subacute and chronic rehabilitation facilities that the ADF either offers or facilitates, but that is not my particular area of expertise.

Dr JENSEN: Thank you very much for appearing here today. You were certainly very highly recommended in terms of giving evidence to the committee. Having deployed on operations in Afghanistan, how do you view our repatriation and recovery arrangements for our members, especially compared with some of our coalition partners?

Lt Col. Reade : Within the deployed environment they are essentially the same. We rely very heavily on the resources of now the United States but previously—

Dr Jensen interjecting

Lt Col. Reade : Indeed, at Kandahar airfield. The two military hospitals at Tarin Kowt are essentially American facilities now. Of course, when we were there one was run by the Dutch, but we were a more substantial part of that Dutch hospital than we are currently in Kandahar. So, in a sense, you are asking me to assess the quality of trauma care provided in those American facilities. My assessment, having read the weekly reports of individual cases coming back through the system, principally American cases being transferred back to the United States, but also having firsthand experience of looking after Australian soldiers who have come back through the Royal Brisbane Hospital—so, looking after patient care myself—is that the trauma care is excellent. It is a trauma system that has evolved dramatically in the last 12 or so years. I think it would be fair to say it was something in need of development at the start but that development has been very actively pursued. I think it is a more responsive trauma system that would be true in any civilian system anywhere in the world. Certainly that is my experience, and I have worked in the United States in civilian hospitals and the UK in civilian hospitals. It is responsive to the operational need, it is very well resourced and it is comprehensive in its care. It is very much focused on getting people out of the deployed environment quickly. The United States are able to repatriate their wounded servicemen within two to three days. I know it takes us a little longer because it is a more ad hoc sort of affair and, instead of having a regular aero medical evacuation team fly to Germany every week, we do it as needed and that needs time to stand up. But the provision of that care has also become excellent. Again, it was not initially. We would not have the facility, for example, at the outbreak of all of this to return a critically ill mechanically ventilated patient to Australia but we have now the airframes, we have got the medical equipment that is compatible with those airframes and we have got the trained and now experienced clinicians to do that. So it is really an outstanding medical system up until the point of return to Australia.

Dr JENSEN: In terms of the return to Australia, obviously you would have had a look at some of the ways that, for instance, some of our coalition partners go about things when they repatriate home. How do we compare in that regard and what lessons do you think we can learn from some of our coalition partners?

Lt Col. Reade : The big but unfortunate advantage they have over us is the numbers that they are dealing with. It is feasible for the British to consolidate all of their repatriated servicemen in Birmingham. In the United States they principally go to Walter Reed National Medical Center or San Antonio Military Medical Center. In that sense there is a critical mass of wounded service men and women that stimulates the development of clinical services in those sites. They have a policy by and large of having everyone come back to a single point. Reflecting on what Mr Jarrett said earlier, I think that is enormously beneficial for those servicemen to get to recuperate in a peer supported environment. I have had extensive discussions with the people who run Headley Court, the rehabilitation facility to which people are discharged from the service hospital in Birmingham in the UK. Of the many descriptions of what they do, I think the most telling was that when their soldiers, sailors and airmen rehabilitate they are at work, they are in a service environment and they are supported by their peers. So if you ask what we could learn, we could look to that as the standard of excellence. When people come back to Australia they by and large are returned to the hospital system in the state either next to their family or next to the unit from which they deployed. Therefore they are treated in isolation. Once they transition from acute to rehabilitation care, in terms of physical rehabilitation at least, they are often left in isolation, at least in the initial stages. I cannot see a better way of doing it with the number of casualties that we have—

Dr JENSEN: We have a lower number of casualties.

Lt Col. Reade : Exactly. If we were to improve the system, if the demand was there and if the resources were available to do it, I think having it all in the one place would be very telling. But I would add that military trauma medicine and surgery has evolved quite a lot in the last maybe five years, so the approach to the wounded soldier technically has become very different. I will give you a specific example of that. We are very concerned about infection, in particular invasive fungal infections from people who have been injured by improvised explosive devices with all sorts of contamination in their wounds. We are also concerned, with good clinical evidence, that to do a very extensive debridement, I suppose cleaning of that tissue and chopping away of muscle, at the initial wound surgery almost inevitably leads to more muscle loss, more tissue loss than was required, so people might end up with an above knee amputation as opposed to a below knee amputation.

So the approach that these hospitals in Afghanistan and in Germany are taking is to take the patient back to the operating theatre every 12 to 24 hours and to keep inspecting the wounds until they are sure all the infection has been cleared out. Whereas a more traditional approach—you might even say an Australian civilian approach—would be to do the initial wound surgery and then go back three or four days later and see what is going on and then maybe not do any more operations. Those are two conflicting approaches. One of my roles has been to do a bit of education of the civilian hospital system here to understand the way things are done in Afghanistan. For example, a chap who came back to the Royal Brisbane at the end of last year: the orthopaedic surgeons initially felt that it would be reasonable to take him to the operating theatre two or three days after he arrived. We pointed out that that was not the way things are done any more, he had been on a plane for 18 hours and they needed to take him to theatre immediately, which of course is what happened.

There are some technical improvements that we can make and that I would argue we are making in response to these changes in clinical practice.

Senator FAWCETT: Could you tell the committee where you think we are up to in terms of numbers of people available for deployment at the surgical and high-end skills nursing staff in the ADF—training pathways for them? You are obviously engaged in that. Can you tell us where that is at? Is it adequate in both capacity and scope? And where does the future lie with regular versus reserve staff?

Lt Col. Reade : I think, as an opening comment: we will always be very heavily reliant on reserve specialists, both medical and nursing. I cannot give you the absolute numbers—I am sure they are available—although the caveat to that is that there are a number of reservistswho remain on the books and who are perhaps less deployable than they were once when they signed up. Therefore, looking at a list of reservists does not necessarily give you a good idea of who would be available for a particular type of deployment. But, having said that, when there was a call for volunteers for these deployments this coming year to Kandahar they were quite substantially oversubscribed in every medical, surgical and nursing specialty. Again, I cannot give you the exact numbers. But I suppose that heartened me, that there was quite a depth of skilled and willing contributors to the process.

I think things evolved dramatically at the end of 2011 with the creation of this full-time military surgical team. There are five specialists: emergency, anaesthetics, intensive care and general surgery, but not yet orthopaedic surgery, employed at the Royal Brisbane Hospital and available for deployments. By the end of this year all of those people will have deployed to Kandahar. In parallel with that there is now a scheme whereby there is a full-time option to train in those acute procedural specialties for defence doctors. We had our first intake of those registrars at the start of 2012. My understanding is that that program is projected to continue to recruit trainees for the full-time component up to a steady state of around 20 to 30 full-time specialists. So those people will be in the full-time Defence Force and paid under its conditions of service and so on. But when they are not required for defence service they will work in a civilian hospital. Initially that might be the Royal Brisbane Hospital, but I know the intent is to spread that out over a number of hospitals around Australia.

I think that is a program that will sit very well next to our reliance on reserve specialists. Having been a reserve specialist for a very long time I know it is very difficult to down tools tomorrow and get on a plane for the purposes of the ADF, not through any lack of personal commitment but because of the impact it has on your patients who are you due to operate on tomorrow and on your colleagues who are going to have to stand in for you. So I think if you have a cohort of full-timers who understand, and whose hospitals understand, explicitly that they are going to disappear at a moment's notice—perhaps for a month or two—backed up by the reservists, who have had that notice to deploy, then that will substantially augment our capacity to provide medical and nursing staff in those deployed hospitals. So, if you like, we have sort of got by on the very good will of reservists for a long time; they have, at times—in the tsunami, for example—downed tools at a moment's notice. But this new system will put a lot less strain on individuals and therefore create a better capability.

Senator FAWCETT: I have two questions on that. Does that extend to other health professions in terms of critical care nurses? Also are the registrars bonded to the Defence Force? Does Defence create new opportunities with the respective colleges for these people, or are they taking places at the expense of other registrars who would have sought to get into a surgical program?

Lt Col. Reade : There are a few questions there that you might remind me of if I forget one or two of them. There are no extra training positions in the colleges. A number of the colleges have been very specific in saying that this is not a backdoor into specialist training, that an ADF trainee would have to compete on a level playing field with other trainees. So there is not going to be an extra surgeon in Australia because of this program, which is, I suppose, fair enough. You do not want a backdoor into training. You want an Australian Defence Force surgeon to be just as good as any other surgeon in the country and to have jumped over all of the same hoops.

Are they bonded? Yes, they will be. Their time during their registrar training will be training time as opposed to service in the same way that the ADF makes you incur a year of return of service obligation for each of those training years. That will be the plan. So someone might emerge having been trained for five years, with a five-year return of service obligation. Does it extend to the other critical specialties? You are absolutely right: critical care registered nurses are one of those and perioperative nurses would be the other—so scrub nurses and anaesthetic nurses. No: that full-time military surgical team model does not extend to them currently. The full-time ADF has already been relatively successful in recruiting perioperative and critical care registered nurses into its ranks. Again, I could not give you the exact number. I did a field exercise with the 2nd Health Battalion a couple of weekends ago, and there were more than sufficient critical care RNs. It was not true of the doctors. That, I suppose, is essentially because of the conditions of service for nurses compared to that of doctors in the ADF as it currently stands. So, no, there is no pressing need as currently perceived to extend that to the registered nurses.

I will say, though, that a lot of the critical care registered nurses and perioperative nurses in the full-time ADF feel as though they are clinically deskilled in their full-time military positions where they are often not performing any clinical roles. The move that we have taken to address that is to allow them long-term placement of a month or two or three within a civilian hospital every year to keep their clinical qualifications up at the same time as they progress through their military career. So things are moving there, too, but in a different way perhaps.

Senator FAWCETT: My last question in this area is that obviously people like those from Aspen Medical have been filling in for long-term placements in East Timor as well as doing some training roles et cetera. Where do you see the mix of that privately provided specialist health care versus reserve or full-time health care into the future?

Lt Col. Reade : You are right that Aspen have filled a critical gap in our capability in those low-level operations in the Solomon Islands and East Timor. It is my perception, having been there and seen firsthand and also having debriefed the teams, that it would be very expensive to train a contract health practitioner to the required level to go to Afghanistan and deal with that high-level, high-intensity everyday trauma that is being seen there. I think it is really only for Defence, for its own doctors—and even then sometimes it struggles to provide sufficient training for those people to go and work in that environment; plus, all the required force protection measures and so on would be difficult to expect of a civilian in that environment.

So, certainly in the current construct, I can see a role for Aspen in those low-level sorts of operations, but I would reflect that a number of the people who have gone and worked for Aspen have been defence reservists, and it is only because Aspen has paid them very, very considerably more to go and work as a contract health practitioner than the reserve might have been offering for them to go and work as a reservist in that environment that Aspen has taken over. I suppose as a reservist that always disappointed me a bit. Perhaps if the conditions of service for reservists could be made—and this is not our personal plea; it has nothing do with me—a little bit closer to the market value, which Aspen is paying, we might again have service doctors deployed in those low-level operations as well.

Mr SLIPPER: David has actually taken question after question that I was going to ask. To go back to these training places for specialists, are you saying that, if you siphon off some of these trainee specialists—registrars—that will mean that in the civilian area in Australia we will have fewer qualified in those specialities?

Lt Col. Reade : I can see how you would construe what I have said as meaning that, so let me address that. Defence does not have enough work for those specialists in the garrison environment in the domestic environment. We do not have any service hospitals for them to work in. So, when they are not operationally deployed, the expectation is that they would work in a public hospital—admittedly, paid for by Defence—providing care for everyone, Defence patients and civilian patients. So in a sense you could argue that by doing this Defence would be augmenting the civilian system rather than detracting from it.

Mr SLIPPER: Presumably most specialists do not want to be employed for the rest of their lives. They might spend a bit of time—sometimes necessarily, sometimes for other reasons—in the public system. So the specialists that you are training would be bonded to the military for a period and then they would be able to leave and enter private practice, would they?

Lt Col. Reade : I suppose the hope is that, at the end of that five- or six-year bonded period, they would transition to the reserve. So they would still be useful to Defence—and, indeed, they would be very experienced Defence members by that point—but they would be able to go and have their private practice if that is what they wanted to do. It is a bit specialty-specific, so most surgeons describe exactly the career pathway that you have outlined; most emergency physicians, for example, do not. There are very few emergency medicine consultant jobs in private hospitals. Emergency physicians tend not to have a private practice and so remain in the public system. Therefore, you could imagine a Defence doctor who had been through that system seeing no particular need to get out of it at the end of that six years, other than from the point of view of, I suppose, life flexibility—wanting to move and live somewhere else.

Mr SLIPPER: I have listened to your plea for more appropriate, shall we say, monetary compensation for reservists, who are sometimes, presumably, in private practice and called into the military. Would you say that most of them do it for altruistic reasons? It would seem to me that, if I were a medical specialist and I had a big list of patients—a really busy practice where people had to wait three months to see me—it would be enormously costly for me to drop tools and go to the military for six months, one month or two months. If that is the case then, given the fact that most people are not driven by altruism, how is it that you manage to get enough of these doctors?

Lt Col. Reade : I think the answer to your question is: you are right; they are driven by altruism. There is a surgeon, I think he is an orthopaedic surgeon, in Sydney who jokes that the most expensive bit of jewellery in his house is not anything owned by his wife; it is his Australian Active Service Medal because of the money it costs him on an overseas deployment to go and earn it, despite the fact that of course he had been paid at what might be considered relatively good medical officer rates—and, indeed, had benefited from the Employer Support Payment, which is supposed to cover some of your practice costs while you are away. So that is very individual-dependent, I suppose. For someone in mainly public practice, you are not far away from breaking even by the time you add in a fraction of the Employer Support Payment to cover any part time private work. But you are right; anyone who has a substantial private component to their practice will always lose on an ADF deployment. So why do people do it? I think you are right; I think they do it because they think it is an important job and—

Mr Slipper: And then they enjoy it?

Lt Col. Reade : That is true. It is very fulfilling. You get to work with a team you would not normally get to work with. And you get to feel as though you are doing some good for the country, which of course is true. So, indeed, they enjoy it. But I actually do think there is a genuine sense of altruism amongst many of those people.

Senator IAN MACDONALD: I understood you to say that there was a permanent group of specialists now coming into the Defence Force for the first time?

Lt Col. Reade : Yes.

Senator IAN MACDONALD: I do not think you mentioned psychiatrists.

Lt Col. Reade : That is an excellent point. Correct—there is not. Indeed, I had an email from a psychiatry trainee only last week asking me whether I thought that there would be ever any role for a full-time Defence psychiatrist. I had to reply that that is not really my area or in my ability to answer. But it is certainly not on anyone's radar at the moment. Indeed, in the light of everything else—certainly the previous speaker and, I imagine, whatever else you have heard during this inquiry—that does seem to be something of a deficit.

There are psychiatrists in the reserve. I know two personally who have made an outstanding contribution to the development of policy, in particular the design of what is called the mental health on operations course, a course that all Defence doctors have to do before they deploy. It focuses on the warning signs of PTSD, how to conduct a debriefing after a critical incident, how to deal with post-traumatic stress and so on. That has been very much driven by those reserve psychiatrists. But of course they are individuals and they work for Defence at best a day a week, and usually, in that work, they do not work clinically. Far be it from me—it is not really up to me—to say whether there would be a role for a full-time Defence psychiatrist, but I can only say that I imagine there would be, and it is not part of our current plans.

Senator IAN MACDONALD: As you rightly say, from the evidence we are hearing, perhaps it is something that could be looked at. There was something else you mentioned in a slightly different context about paying the market value for reservist specialists. Is this group of permanent specialists remunerated at around market value?

Lt Col. Reade : The current group—and this includes me—are all employed, technically, still on reserve conditions of service. Salary is paid at a rate that is about equivalent to a Queensland Health staff specialist, so we are not disadvantaged. It is paid through either Queensland Health or the University of Queensland, in my case. But the trainees are certainly all paid as full-time Defence Force officers. Trainees within Queensland Health do not earn that much money, so they are not terribly disadvantaged by that system. But really the question is that the current team is a temporary arrangement, if you like. It is intended that it exist for five years and that it be replaced by these full-time trainees coming through—that all those people, including me, transition to a truly regular appointment. I understand that the case to pay them—us—at the market rate is currently before the DFRT. I am not aware of the results of that. But at the moment, no, there is no mechanism to pay market rate.

Senator IAN MACDONALD: Colonel, I guess that as a currently serving officer you may not be in a position to or want to answer this, but are you noticing within the medical profession in the broad any push-back from the recent changes, with the realignment of contracts, to the engagement of medical specialists to do Defence work?

Lt Col. Reade : Are you referring to the provision of garrison health care as a contracted solution?

Senator IAN MACDONALD: Yes.

Lt Col. Reade : Yes, there has been quite a bit of push-back from people who, I think, would themselves admit that if they continued in the new system they would suffer quite a drop of income. Of course, why wouldn't you push back if that were the case? I think all I can say is what I genuinely believe: the new system is designed to provide exactly the same service to Defence members—

Senator IAN MACDONALD: It is certainly designed to.

Lt Col. Reade : in a more governed way. By that I mean that, instead of having contracts or arrangements with hundreds of individual practitioners around the country and no centralised oversight of what they are doing, the results of what they are doing in terms of employability or even just clinical results, the really big advantage of this new system is that we will have that data to identify outliers—someone doing the wrong type of operation in a lot of people and getting a bad result. There has previously not been a good mechanism for identifying that, and this current system will help that.

Speaking as an individual I think people have to understand that healthcare is a market. They seem to understand that when they have relationships with private health insurers. Defence has always paid considerably more than most private health insurers for its treatment of defence members, maybe appropriately so. Now the offer has gone down, so it is more in line with what you might expect from a conventional healthcare reimbursement. That has, needless to say, upset some people, but it is the market.

Senator IAN MACDONALD: Okay. Thank you.

CHAIR: Any last, quick questions? Mr Slipper.

Mr SLIPPER: One of our earlier witnesses seemed to suggest that more psychiatric services in particular should be outsourced because ADF members would feel more comfortable talking to someone who was not in the military and subject to military discipline. There also seemed to be a suggestion that there was less confidentiality in going to a serving military medical officer because that serving military medical officer on occasion is required to report on the patient in a way that a private sector professional giving the same treatment would not. Is that (a) a fact and (b) a concern?

Lt Col. Reade : I think there are conflicting goods driving the answer to your question.

Mr SLIPPER: People are worried that if the stuff gets back to the military then it might impact on their future career prospects.

Lt Col. Reade : I understand. I start out by saying that, equally, I have heard of a particular soldier going to a private psychiatrist, saying he was having flashbacks to when the IED went off and having the chap say to him, 'What's an IED,' which of course destroyed their therapeutic relationship . So I think there are benefits in having a service psychiatrist, but of course there are potential detriments as well, and confidentiality is the one that you have rightly identified as being the most important.

What can I say to that? I gave a talk last week at an international conference about the concept of dual loyalties in military medicine. We often are required to make it explicitly clear to the patients we treat that we are treating them not only as a patient but also as an agent of the organisation in which we both serve—in the same way that an occupational physician for a mining company might treat someone but have a dual loyalty. Is that problematic? I do not think it is as problematic as it might seem to be. It is certainly not the case that the chain of command—that is, the soldier's boss—has full access to the medical chart; it is all medical-in-confidence. But you are correct in saying that the commander has the ability to ask the psychiatrist, or whoever the doctor is treating the patient, 'What's going on?' And he or she may feel entitled to a more detailed answer than they would get from a private health professional.

I do not recall an example of that being a problem. I accept that it is a theoretical problem. Therefore I think the answer is probably to have a mix of both systems: ideally, to have a knowledgeable service doctor to take charge of the patient's case: ideally, an occupational physician or a general practitioner who is used to dealing with this dual loyalty conflict; and then, given that we have no full-time psychiatrists—so the question of a service psychiatrist is a moot point—to refer them to a private psychiatrist. We could have the occupational implications of that psychiatric diagnosis discussed at a professional level between defence doctor and consulting psychiatrist, and then using that Defence doctor to filter that information back to the chain of command is probably the best we can do. Otherwise, it is just an intractable problem.

Senator IAN MACDONALD: That is something that was a bit of an issue six or 12 months ago, when soldiers were being charged with criminal activity through material that their medical specialists were required, under a change in the medical rules, to make known to the military police or whoever. When I asked about this sometime ago—it would have been at estimates six months ago—I thought General Hurley told me that that was under very close review and something was going to happen. I have not chased that up. Are you able to tell me what has happened there?

Lt Col. Reade : I am afraid I cannot. I just do not do outpatient medicine, unfortunately, so I would have to refer you back to the boss on that. I am afraid I do not know.

Senator IAN MACDONALD: Okay. Thanks.

CHAIR: Thank you for your attendance today. If you have been asked to provide any additional material, would you please forward it to the secretariat. You will be sent a copy of the transcript of your evidence, to which you may wish to make corrections of grammar and fact. Thank you again for your appearance today. Can I ask a member of the committee to move a motion authorising publication of today's evidence.

Mr SLIPPER: I move:

That the committee authorise publication of evidence given before it at today's public hearing.

Question agreed to.

CHAIR: Finally, I would like to thank Mr Freeman from Mates4Mates and the Family Recovery Centre for hosting us today and for your excellent hospitality. We appreciate the support that you provide to our wounded diggers, and we all look forward to having a look through your facilities after we adjourn. On that note, I formally declare today's meeting closed. The committee will reconvene at 8.45 am tomorrow at Enoggera.

Committee adjourned at 17:10