Presented by the Commander Major General István Szabó.
A reorganizational process has been going on in both the Hungarian civilian health care and the Hungarian Defence Forces (HDF) since 2011, and it has had a significant effect on military medicine. Adaptation to a newly launched national health policy, organizational fusions, changes in the leadership, establishment optimization, stabilization of financial management, the establishment of a new structure, and re-thinking and distribution of tasks have happened and are still going on in the military medicine, while the professional values and capabilities must be retained and corried over into the new structure unabridged. As a result of the reconstruction, the first and largest health institution of the Hungarian defence forces, the HDF Medical Centre was born. It is very special in having a double function: on the one hand to provide medical care for the civilian population, on the other hand to carry out military tasks in accordance with national and NATO requirements. The Commander of the Centre is Major General István Szabó, who informed us about the background of the establishment of the new organization, its main orientation and objectives.
The Necessity of Reorganizing the Hungarian Military Medicine
Before 15 November 2011, there used to be two main medical institutes in the Hungarian Defence Forces: the Central Military Hospital – State Medical Centre – and the HDF Dr. Radó György Military Medical Centre. The latter carried out specifically military medical tasks; while the State Medical Centre, as a hospital, provided a background for the military medical system, but its principal task was to ensure medical care for civilians.
The concurrent ensuring of military and civilian health care had to be made clear considering both the financial management and the command and control system.
In 2011, the Ministry of Defence made a decision to merge these two organizations. This is how the HDF Military Hospital was founded, as a new organizational element of the Hungarian forces, funded by the Minister of Ministry of Defence. It uniquely integrated the full spectrum of military medical capabilities from prevention to rehabilitation, and the tasks imposed on the medical centre by the macro-regions model of the civilian health care system.
In parallel, the Government of Hungary adopted a new national health strategy called the Semmelweis Plan, which defined the local and macro-regional health care in progressive levels, placing the so-called top hospitals on the uppermost level of the health care chain. HDF Military Hospital became the biggest and most important health institution of the capital’s north-east part and of the North Hungarian macro-region.
The number of the formerly about 3000 employees increased by 600, and the number of sites grew from seven to twelve.
The Centre has additional medical tasks on HDF level, including magisterial duties, aeromedical aptitude examination and research activities, and special research-and-development and medical force protection tasks.
The outpatient and inpatient care for mainly the MoD, the HDF, and the predecessor organizations (law enforcement organizations and railway employees, and those who are entitled based on the regional care system) shall be also ensured in the future.
On 1st February 2012, after the merging of the organizations and as a consequence of the double function – as it was not only hospital care anymore – and to meet further rationalization plans, the HDF Military Hospital was reorganized with the new name HDF Medical Centre.
Since 2012, the Centre has developed a rational financial management through several background checks of the civilian health care tasks, assessments of human resources and infrastructure, closing down premises, combining and relocating military medical tasks, and better use of income sources. The new structure and financial management perfectly suit the whole task system.
The Difficulties and Results of Integration and Rationalization
As a result of the assessment of external factors affecting the organization, decisions were made to rationalize the premises; and negotiations were started with the Department of Health, responsible for financing health care, about the improvement of the budget of the hereditarily under-funded health activities.
One of the main objectives of the reconstruction was to decrease infrastructure costs and to best use the synergies of the activities, through the rationalization of premises. As this reform, including the review of the peace establishment, is still under way, its economic effects cannot be fully quantified; but only eliminating the running costs of premises results in about 3-400 million HUF savings annually for the funding body.
The most important change for the military health system was the relocation of the Aptitude Examination Institute from Budapest to Kecskemét and the placement of its functions and personnel at different premises.
With regard to medical care, the most significant change in 2013 was the closing of the Patient Home of Veröce and rehousing the patients to the Szanatórium street premises in Budapest and other civilian institutes.
The premises in Szilágyi Erzsébet alley Budapest was vacated and the military labs and the NATO Centre of Excellence for Military Medicine moved from there to the headquarters at the beginning of 2014.
The final location of military laboratories is planned also in the headquarters, in the first quarter of 2015. The laboratory and epidemiology functions of the military health system are concentrated here. The last step of integration will take place when the building is renovated and the Public Health and Epidemiology Service also moves into the headquarters. The number of our sites will then decrease from 12 to 8.
The military health functions and tasks are funded through the budgetary allocations of the Ministry of Defence.
Unfortunately, the financial situation of the hospital part ensuring civilian health care is similar to that of other health care organizations of similar size and composition in the country. Regarding the funding of health care, the achievement of a funding level which corresponds to the area covered, the task system, and the progressive level would be desirable; however, implementing this falls outside the competence of the funding body, the Minister of Defence.
HDF Medical Centre (HDF MC) is one of the prominent health care organizations in Hungary, the 6th biggest entity of the Hungarian health care system. Only the university clinics and two large, integrated county-level health care providers exceed its size and complexity.
We should also note that the absence and the migration of professionals, typical of the whole Hungarian health care system, particularly affects our organization, considering that foreign institutions provide very advantageous offers for the highly qualified professionals (both military and civilian personnel) and for doctors in training educated here.
Seeking New Funds, Rationalization Tasks, New Development Opportunities
Exploring new funds is an indispensable tool for the development of the organization. The initiative to further expand the scope of reimbursable care at HDF MC will be a step forward in this area.
The troop medical offices will be connected with the medical system of HDF MC until the end of 2014, making troop health care and its administration more effective and smoother. The rationalization is a next step of the integration of areas, the placement into one location improving the efficiency of activities. Almost all military laboratory tasks will be performed in one single location, at the headquarters by the beginning of 2015.
The best solution for the infrastructural problems of HDF MC would be the moving of the two sites in Budapest into one common location. The investment plans have been developed; however, its financing is problematic.
Medical Material Supply
Medical material is supplied from two sources, depending on whether it is military or civilian medicine. The supply of medical material for military medicine is ensured from the budget of the MoD. The civilian medical material supply is provided from state sources.
Structure, Task System
The Centre is commanded by a military leader (non-medical), the Commander. The structure includes separate units: the civilian health care, military health care, the management and administration, and the economic management unit, the latter two support the two main pillars.
Both the hospital part and the military health care are managed by a medical person. The head of the hospital is the Medical Director in the rank of Brigadier General, the head of military health care is the Chief of Medical Service HDF, a Colonel. The Chief of Staff of the Centre, also a Colonel, is responsible for management and administration, while economic management is controlled by the Director of that unit, who is civilian.
Regarding the tasks imposed by NATO principles, the units of the Centre ensure medical force protection, training, evacuation, medical care, medical logistics, and research and development.
The task systems of the units are very complex, that is why the two main sectors, the medical and the military health care shall be presented separately.
The Tasks of the Military Hospital
Its main tasks and basic functions include: high-quality, efficient basic- and special health care, in the frame of military health care for the HDF and for those having special care entitlement, as well as the high-quality patient care for the entitled civilian acute, emergency and polytraumatised patients in the macro-region – based on the regional responsibility system.
We must mention specifically the people having special entitlement; as we have to provide outpatient- and inpatient special care for mainly the MoD, the HDF, and the predecessor organizations (law enforcement organizations and railway employees, and those who are entitled based on the regional care system), and also special military medical care tasks.
We provide service for the NATO unit stationed in Pápa, for international forces coming to Hungary for exercises, for specially protected people, as well as the NATO Centre of Excellence for Military Medicine.
Health care is ensured altogether on 7 sites; 3 in Budapest (2 active, 1 rehabilitative and chronic), 2 in Hévíz (locomotor rehabilitation), in Kecskemét (active) and in Balatonfüred (cardiology).
The Principles of the Structure, the Organization
Military medical organizations have to possess surgical capabilities (traumatology, thoracic, neurological, head and neck, oral, burns and reconstructive surgery) as well as the capability of mitigating, preventing, and healing specific physiological damages caused by chemical-, nuclear- and biological weapons. Emergency, anaesthesia-intensive- and infectious diseases care also plays an essential role here. We need top diagnostic, healing and rehabilitation units for these tasks. HDF Medical Centre possesses all of these.
The HDF Medical Centre is a priority hospital and the emergency centre of the North-Pest Region, and also the educational hospital of the Semmelweis University, and we have more than 200 classified doctors and university professors among our ranks. Full spectrum of health care on 7 sites, with 37 wards, on 2010 beds (prevention, outpatient- and inpatient care, and chronic medical care). Almost all care wards are classified as 3rd-level progressivity, with an area of responsibility of 1.5 million people in some professions. The hospital provides continuous on-duty and patient admission care.
The Professional Structure
With a few exceptions, we cover the whole spectrum of outpatient- and inpatient special care. We do not provide paediatric medicine, inpatient pulmonology, infectious disease and toxicology care. To make up for these professional shortages, the partner hospitals carry out these health care tasks, on the basis of the contracts signed with regional central hospitals.
Number of Patients
On the basis of CMI index, it is clear that – besides university clinics – the Military Hospital treats the most serious patients.
Aptitude tests, aptitude revision checks, and complementary special medical checks for the personnel of defence and law enforcement organizations.
The personnel belonging to the HDF Principal Specialists of the institution carry out the professional direction and further trainings of the health services of the defence and law enforcement organizations.
In the frames of continuous readiness, the hospital admits both sectors’ active personnel who have been injured in a foreign mission, on training or on other occasions.
The further special tasks are the following:
- Mission tasks (provide doctors and professional staff, training, repatriation, telemedicine, consultative professional assistance).
- Disaster health care (civilian and military tasks).
- Hospital background support for priority state-, army- and law enforcement events, exercises, and training tasks.
- Educational and clinical service for the NATO Centre of Excellence for Military Medicine.
- Medical care for protected person, state officials.
- Scientific research. 99 of the personnel possess a scientific degree (34 in progress), and 64 a teacher degree.
- All clinic wards of the hospital are accredited training locations of the Semmelweis University.
We started the planning and preparation of a special training method many years ago, with the aim to prepare our colleagues to deliver appropriate care individually or in teamwork even in extreme situations. For that purpose, we needed a training environment with the proper equipment which best simulates real situations. The pedagogically and professionally optimal design for that is the Clinical Demonstration Unit, which is the first such unit in Hungary in terms of size and equipment. Yearly 1000 civilian and military medical professionals are trained here.
The Tasks, Structure, Composition, and Capabilities of Military Health Care
The Defence Health Directorate of HDF Medical Centre performs the planning, organization, coordination, and elaboration tasks related to the medical support for HDF, and carries out the professional control of the medical elements of the HDF. The scope of its tasks includes force protection, medical care, medical evacuation, research and development, training and further training, as well as the provision of medical material and professional technical support.
It also has the tasks to provide basic and occupational health care for HDF personnel, ensure compliance with military, civilian, domestic and NATO/EU requirements and regulations, elaborate medical instructions and measures. It coordinates all the above tasks with the activities of HDF, in cooperation with the military organizations under the direct subordination of the Chief of Defence, with MoD organizations, with the National Medical Office, and with other national-level organizations.
Its capabilities include: basic health care (prevention, healing, rehabilitation), medical support for peace-, non-war and war activities, elimination of health-related effects of disasters, education, training, military medical research and development, occupational health care, general- and specific physical, psychological and health aptitude tests, public health and epidemiology support, and psychological support, as well as the full spectrum of prevention activities.
Regarding professional skills, it is made up of personnel having medical education or, due to the special tasks, non-medical professional education, who are capable to perform all tasks.
The Stucture and Composition of HDF Medical Service
The structure of HDF medical service includes central level and troop level. The central level is made up by medical personnel (doctors, professional staff) and other professionals with non-medical professional education (logistics, engineers). The two main pillars of the Medical Centre HDF are the Military Hospital and the Defence Health Directorate which is led by the Chief of Medical Service HDF, of course in close cooperation with the Medical Director in several areas.
The troop level medical service based on the Medical Centers of the units, their professional control and command is carried out by the Medical Chiefs.
The Main Tasks of HDF Medical Service
The priority for the central level is to plan, organize, and perform medical care (basic health care, outpatient- and inpatient special care) including prevention and rehabilitation, in times of peace, special legal order, and disasters. It also takes part in direct medical support. The priority task of the troop level medical care is to provide complete medical care for the Hungarian Defence Forces both in the home country and in operational areas. It ensures the maintaining of the personnel’s combat capability, and the health-related conditions for the completion of military operations.
The Structure and Tasks of the HDF Troop Medical Network
All military organizations (as organizational elements of the HDF) operate a medical centre to ensure basic health care (daily patient- and emergency care) for their military- and public servant personnel, which includes a medical station, the work of which is organized and controlled by the Medical Branch of HDF Joint Force Command.
The tasks of the troop medical organizations of HDF include planning, organization and control of medical care and prevention, emergency-, outpatient- and inpatient care, and medical recreation and rehabilitation. They plan, organize and control the screening, aptitude, and occupational health examinations, as well as the professional tasks of aero-medical, air search&rescue, air and land medical evacuation activities. It plans, organizes, performs, and controls special tasks in the fields of public health and epidemiology, occupational health and animal health, and issues normative measures if necessary.
Advantages and Disadvantages of the Established Structure and Operation
The fact that the health system of the Hungarian Defence Forces is made up by organizations which are built on each other in a strong, transparent, traceable subordination is an advantage. The medical staff of the different military organizations is able to carry out health support tasks of other military organizations. Its disadvantages include the shortage of doctors and nurses, the difficulties of personnel recruitment.
The Medical Involvement of HDF in Missions, International Experiences, Cooperation in Missions
Hungarian military medical professionals serve in the KFOR, EUFOR, ISAF, UNFICYP, MFO, and EUFOR RCA missions at the moment; 8 of them are doctors, who carry out support tasks in multinational health care institutions of different levels in cooperation with mainly German, American, French, Slovakian and Portuguese colleagues.
Besides the doctors who provide basic health care, mission tasks are carried out by surgeons, anaesthetists, internists, dermatologists, surgical assistants, intensive care nurses, anaesthetist assistants, psychologists, skilled workers, and ambulance drivers, on average 50 people.
Hungary permanently participates in the events and most important working group meetings of the Committee of the Chiefs of Military Medical Services (COMEDS) in NATO. Beside participation in foreign mission service, Hungarian military medical professionals can gain experience on a number of multinational exercises, among which the “Vigorous Warrior” is the most significant for the military medical profession.
Administrative Support for Professional Tasks
During merging and reforming the organizations, one principle of the reorganizations was the need to eliminate the superfluity of and rationalize the administrative elements supporting professional work. On the other hand, even though the reduction of non-professional parts is an imperative and emphasized expectation, these elements provide the necessary and indispensable support for the work of the main profile, and are an essential prerequisite for the success of the professional field. These background organizations are the “water-carriers” of the institute, about whom media speaks rarely; if they were absent, however, we would immediately feel that the continuous, smooth operation of the system was interrupted. The Centre has reached the optimal level of the composition and strength of these elements, and no further downsizing is advisable because that could possibly jeopardize day-to-day operation.
The Tasks of Departments and Sub-Departments
In general, the organization possesses all professional elements of different areas, which maintain contact with the superior levels of the areas, satisfy their information needs through daily working relationship, and, like a sensor, are able to follow the changes in professional fields, thereby supporting the Commander in decision-making mechanisms. This applies specifically to legal-, personnel- and labour affairs colleagues, who face this challenge daily.
We place a great emphasis on the introduction of possible technical developments and their applications in the field of command and control, of course. We have the necessary capabilities and capacities, which actively take part in the e-technological development of both professional medical areas and the administration, defining the special IT needs of the institute, supervising their introduction and operation.
There are expert sub-departments performing the quality assurance tasks; fire-, occupational-, and environmental protection tasks and checks; as well as state budgetary internal control. As a result of the previous reconstruction, the Centre became an organizational element of the Hungarian Defence Forces again. The adaptation of the consequently applicable regulations being new to many colleagues, and the elaboration and practising of the diversified task systems are the responsibility of the Operations and Training Department of the organization. It should be noted that the colleagues in this area also drive the organization of the Centre’s disaster management tasks, involving national-level responsibilities. Military training, which was partly pushed into the background and partly neglected in recent years, has stepped forward in the order of priorities of the Centre. Despite the human resources problems on the field of medical professionals, I think that the maintaining of a minimum military knowledge and basic practical skills is indispensable for a military organization, even though the main profile is entirely different.
Taking into consideration the range, size, and diversity of the scope of potential patients, also during the previous reconstruction, a so-called office for care entitlement issues was established within the Commander’s Office, whose responsibilities are to clarify the scope of patients, and administer and handle the submissions and certificates of entitlement by those people wishing the use the services of the institute on the basis of different laws and contracts. The employees working in this office have been in a difficult situation, as they had to create a new unit without any precedent background or relationships, in a frequently changing legal environment. This last year of operation proved that the decision was right, since – with continuous corrections in the system – the Commander now has a more clear picture in this regard.
The Medical Centre completed a demanding year at the end of April, when we submitted a report to the funding body, the Minister of Defence about the results achieved through the ordered rationalization tasks, the experience gained during those, and – taking the possibility of proposing – we highlighted further improvement opportunities. Beyond the fact that we have mostly performed the stipulated tasks, we know that we are hardly halfway to creating the optimal operating conditions of the organization. We must note that we have taken significant first steps which allow only “escaping ahead”, there is no turning back. Important infrastructural developments have been started at our main site, which is the top priority of the forthcoming period, as this is the basis for the success of our next steps planned in line with our reconstruction schedule, influencing people’s fate. Considering the above short, non-exhaustive situation assessment, you can possibly come to the – wrong – conclusion that our actions are motivated by the sources provided to us for the implementation thereof. As a matter of fact, it would have been irresponsible to even commence these tasks if the background had not been ensured; however, the ultimate objective of all our plans and actions is to keep together the professional staff forming the background of the organization and the available knowledge, in order to serve the – often similar – interests of the civilian and military medicine.