The challenge of starting an international air charter company is not to be undertaken lightly, and one that pilot Malcolm Humphries, and his wife Lisa, overcame with aplomb. The duo founded Capital in 1991, starting with just one aircraft and working from a home office. Discussing the challenges of being a working mother, Lisa tells a story about having a (very weighty!) mobile phone back in the day, pushing the pram with one hand and doing quotes for flights with the other – nothing like multitasking to keep the mind active!
Gradually, over the years, more contracts were won and the company grew, mainly operating shuttle flights for corporate companies, and offering the aircraft to medical companies who would provide the medics to fly, VIP executive flights and cargo contracts.
In 2011, the team decided to focus directly on the air ambulance market, which was when it established a fully staffed medical department, with dedicated aircraft operating solely as air ambulances. In 2015, Sir Peter Rigby became the major shareholder in Capital, and this investment enabled the company to become a global operator with a worldwide Air Operator Certificate with Learjets for the longer-range taskings, and King Airs for the more local European repatriations.
Fleet renewal is a vital but expensive part of operating an air ambulance company. Lisa told AirMed&Rescue: “We are constantly upgrading our aircraft with engines, props and avionics to meet European Aviation Safety Agency requirements. As the types of aircraft we operate are still in production we do not find this to be an issue, as parts are easily obtained when required.”
When Dr Martin first joined the company in January 2012, it was on a part-time basis while he continued his work as a consultant anaesthetist and intensivist in the National Health Service (NHS). In December 2013, his role progressed to full-time Medical Director at Capital while he remained part-time at the NHS. “That first year was very hard work,” he told AirMed&Rescue. “There was so much to do in setting everything up from scratch. Everything imaginable was needed – it was like building a whole new company. I started with creating plans, business cases and project timelines, recruiting criteria, Gantt charts and business documents, and was very soon purchasing medical equipment, setting up a pharmacy, creating a medical department containing a bespoke store room, a despatch room, training facilities and the medical ops and management offices.” Next on the ‘to-do’ list was the establishment of protocols, policies and general rules for the way in which the service would be operated, along with guidelines for managing medical operations, as well as how these would interface with flight operations.
The first ‘live’ mission was postponed until June 2012 so that all the systems could be tested with some preliminary flights and, by the end of the year, 110 missions had been completed successfully with no complications or significant problems. Dr Martin said: “That was quite a feat for a new air ambulance company and it was recognised as such. Some new set-up services take five years to reach that target!”
Next on the list of challenges was internationally recognised accreditation of the air ambulance service. EURAMI (the European Aero Medical Institute) usually doesn’t let companies that have been operating for less than two years apply for accreditation, but made an exception in Capital’s case due to previous experience in both its aviation and medical sectors. Dr Martin commented: “The activity that followed to ensure we passed all the required standards has now become a hectic blur of memory and there were times when I regretted trying to run before we’d even established a fast walk, but it was well worth it. We sailed through the audit inspection and won our first EURAMI accreditation outright, to the amazement of our customers and competitors alike.”
He went on to say: “Ever since then, the workload has increased, our capabilities have grown, our equipment catalogue has improved and increased to match our workload, we have met governance challenges face-on and set up reliable and robust systems for quality management, risk assessment, clinical oversight, safety in practice, medicines management and human resources (medical staffing), to name but a few. This, of course, has been a continuous and ongoing process and long will it be so.”
Dr Martin’s medical director role has been extended to include business processes, marketing, and networking, using decades of past friendships and relationships to push the company forward and attract new customers, as well as encourage and attract new recruits. “I continue to write aeromedical scientific papers and to run my CCAT aeromedical transport courses,” he added, with the side benefit of this being that many of Capital’s current staff have actually been recruited by virtue of being one of his students.
At Capital, every member of the medical team (full-time and part-time) is trained to look at each aeromedical transport case in exactly the same critical way. Dr Martin teaches risk assessment and harm reduction at every stage of the training, from basic physiology, through environmental stress, to clinical considerations. “In this way,” he explained, “all my staff, whether they are office based or flight medical crew, understand the concepts that underpin the decision-making process in terms of the logistic and clinical aspects of each case. Using policies and other guidance materials, I have provided a framework of information that accelerates the risk assessment for patients with common conditions and straightforward logistics.” By doing this, it means that staff don’t need to contact the medical director for every single case that comes their way, which, given the case load, would certainly end up as an onerous task. Capital undertakes around 1,000 aeromedical transport missions a year and advises on many more, and risk assessments for the majority of cases are routine and generic. These are dealt with by Flight Nurse Co-ordinators, who write each individual pre-mission briefing.
“On the other hand,” added Dr Martin, “I have defined complex cases that may be significant in terms of the patient’s clinical condition, age, the logistics of the transfer and any social, financial or any other important issues that may impact the safety, efficacy or efficiency of the transfer. My staff therefore seek my advice only when there is a dilemma that results in the case being defined as complex.”
The most serious and significant cases that are identified as ‘high risk’ will have a complete and formal risk assessment, analysis and management plan, drawn up by utilising Capital’s in-house Risk Policy. These documents are used to establish the staffing, kitting and conduct of high-risk missions so that potential problems are identified prior to the mission, and all possible steps are taken to ameliorate, mitigate, reduce or remove the risks identified. “If nothing else, this process focuses the mind on what might potentially happen, and highlights the importance of close monitoring and ‘monitoring with intention’ to exclude latent factors that threaten the patient or, indeed, the mission,” said Dr Martin.
Operating a critical-care fixed-wing air ambulance service that caters for all age ranges and all types of patients is a very complex task that demands hour-by-hour and minute-by-minute attention to detail, almost forensic gathering of information, and the ability to pull together a clinical and logistical plan that properly analyses and manages known and anticipated risks, while also building in enough reserve capability to cover the latent unexpected unknowns that lay waiting to be exposed.
an entire mission can be sabotaged simply by the reticence of one individual to tell the entire truth about a patient’s clinical stability
“This is especially true,” said Dr Martin, “when we aren’t given enough information about our patient. This can be for a number of different reasons and happens so often that I consider it to be the number one risk in itself! Indeed, an entire mission can be sabotaged simply by the reticence of one individual to tell the entire truth about a patient’s clinical stability,
or through the inexperience, indolence or apathy of an individual or organisation in unravelling the medical history and probing when the facts don’t quite add up. This is frustrating and, at Capital, we much prefer to seek and interrogate medical reports ourselves, rather than rely on third parties.”
This is, of course, all part of the process of case handling, where clinical and logistic problems are examined, analysed and solved together, for every individual case. To help, Capital trains all of its medical staff and medical operations team about cultural, religious and geographical differences, as well as in the key differences in healthcare delivery and law in various parts of the globe. End-of-life care is an example of how customs and laws vary dramatically between regions. For instance, DNACPR orders are not legal in some parts of the Middle East. Over the years, the company has collected information concerning pretty much every aspect of patient transport and repatriation all around the globe. Such intelligence and corporate memory is often extremely valuable when planning patient transfer missions. There are many reasons why communication and understanding can break down during case handling conversations, and language itself is a key factor; therefore, the language capabilities of a team working in a company that carried out its missions all over the world is another key aspect of successful case management. Capital employs a diverse population of healthcare professionals from 16 countries, making it rare for there to be a need for external interpreters.
Onwards and upwards
In recent years, Capital has seen passed milestones including the introduction of jets to the fleet, the creation of a neonatal transfer service, establishment of ECMO, IABP and paediatric intensive care capabilities, the start of worldwide operations, level three (critical care) capability in commercial airliners, establishing partnerships with operators in other continents, and some nearby partners with larger and more long-range aircraft. It has also been through two tough EURAMI inspections and two equally complex Care Quality Commission inspections, as well as helping colleagues with CAA and ISO9001 audits. “All of these processes,” said Humphries, “are now ingrained in our management systems and frameworks to make matters much easier in years to come.”