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We have had some valuable reports on this subject, including those from Sir William Utting and Norman Warner. We have acted on them; we have been supported in our efforts by the Association of Directors of Social Services. We know that, over the past 15 years or so, there has been a significant reduction in the number of children in residential care. Many of those who remain are older than such children used to be, and resident children with emotional difficulties and disturbed behaviour live together in greater concentrations than before.

I do not underestimate the difficulties faced by staff in providing the right care for these children. Many come from disadvantaged backgrounds; many have experienced multiple placements; many have been physically or emotionally abused. Whatever we might aspire to, children's homes can never be replicas of family homes. It is therefore important that they be managed so as to ensure they play a positive part in meeting the needs of vulnerable children. Successive reports have commented on the good work being undertaken by dedicated and committed staff, but they also point to many examples of poor or inattentive management: too many unqualified staff left inadequately trained, supervised and managed to deal with difficult children. That is why we set up the residential child care support force, under the leadership of Adrianne Jones. It has been encouraging to see the response of local authorities, which welcome the help given them by the support force to improve the management and quality of their residential child care services.

The support force has developed a substantial agenda. It includes looking at the effectiveness of pre-placement assessments, developing a strategic planning framework for local authorities to use on their own or in collaboration with other authorities, developing effective relationships between education and social services departments, and looking at models of staff management and supervision.

I am well aware that the main effort towards and responsibility for achieving change in residential child care lies with the purchasers, the planners and the providers. For our part, we have promoted the residential child care initiative, which has thus far enabled about 400 senior officers from the local authority residential child care sector to study for a diploma in social work.

To help to combat the often negative image of residential child care, in collaboration with other agencies such as Barnardo's we have developed communications strategies designed to increase understanding and recognition of the positive contribution that residential child care makes to certain groups of young people. In 1993, our social services inspectorate published "Corporate Parents", a report of inspections of child care services in 11 local authorities. It described a high incidence of children's absence without authority--a point that we heard several times today--from the homes visited. Although all homes had procedures to be followed in the case of absence of a child, there was little in the way of good practice guidance.

Furthermore, in very few authorities were there management monitoring systems to establish the number of absent children, the pattern of absence or the reasons for their running away. The report accordingly recommended that local authorities establish monitoring systems. A forthcoming set of standards for residential child care services, prepared by the SSI, will stress the need for children who run away to be offered a chance to

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speak to a person independent of the home. The home should also have positive practices for receiving a returning child, so that he or she will be encouraged to remain.

None of these initiatives can necessarily produce immediate results, but I wanted to show my hon. Friend that the Government take this subject seriously. If children are to receive the necessary care, affection and discipline in children's homes, it is important that these initiatives succeed. If they do not, what we have described here today is unlikely to improve. That would not be acceptable to my hon. Friend or me, or--most importantly--to the children or their families and to those in the neighbourhoods in which they live. My hon. Friend the Member for Hallam, and my hon. Friend the Member for Erewash (Mrs. Knight), who has been listening intently and who knows Sheffield well, may not be completely satisfied by what they have heard me say today. I hope, however, that I have been able to convince him that I take his concerns seriously; and that, to the extent to which it is in the gift of the Department to do so, I have been able to reassure my hon. Friend that we shall look carefully at the child care regime at the open children's home in Dore, and at the proposals and procedures for secure accommodation, if it is offered. If planning permission for a secure unit at Limb lane is granted, we shall ensure that it is designed with the protection of the residents, both internal and local, fully in mind.

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Casualty Services (South London)

12.24 pm

Mr. John Fraser (Norwood): I am grateful for the opportunity to raise the subject of casualty services in south London. I am chiefly concerned about the services provided at King's College hospital in Denmark Hill. I am also concerned about how current proposals for other hospitals are likely to impact on that hospital.

The other proposals that I have mentioned are, first, the closure of the accident and emergency service at Greenwich general hospital. Secondly, there is the closure of the A and E service at Brook general hospital--both services are to be transferred to the military hospital at Woolwich. Thirdly, there is the absolute closure of the A and E service at Guy's hospital, which currently takes about 60,000 emergency cases a year.

There are already some restrictions on access to casualty services at Guy's. Restricting admissions from GPs there is already beginning to have an impact on the casualty services of other hospitals of south London, not least King's College.

Hospitals nowadays have to make two judgments. They have to make a financial judgment about the work for which they will tender as well as a medical judgment about the work that they are capable of performing. I am afraid that sometimes the financial drive to gain part of the market in health services may throw into doubt the medical judgments that are made.

To give some idea of the flavour of the problem, I offer a summary of an independent report, recently published in summary in the South London Press on 16 December. We learn that serious doubt has been cast on plans to axe the major casualty department at Guy's. The report says that the overspill of patients from the closure of the unit at Guy's could prove too much for the neighbouring St. Thomas's hospital at Waterloo, according to an independent study by top consultants KPMG Peat Marwick. The report goes on to say that the NHS has little experience of closures of such a large unit; Guy's serves about 60,000 patients a year. The report describes how the displacement of patients, combined with the probable move of services from the other two hospitals I have mentioned, is likely to push St. Thomas's above the 100,000-a-year patient limit.

I shall now discuss King's College hospital. The report, which was commissioned by the Save Guy's Campaign, but which is nevertheless wholly independent, expresses anxiety about whether King's College hospital and Lewisham hospital would be able to cope with increased numbers of patients. King's College hospital is my main concern, although I shall mention others in south London in passing. King's takes about 70,000 accident and emergency cases a year, of which 14,000 involve what are called accidents at home, at work or at leisure--there appear to be a large number of leisure accidents--and about 1,600 result from road accidents. I say to the Minister that there is strong evidence that King's College hospital is unable to cope with the number of accident and emergency cases that it receives at the moment, let alone with any increment that would result from the closure of Guy's casualty department or closures further afield. Why do I say that? The present building is not reassuring. I do not pretend to quote exactly, but I think that it was described by John Pilger as being rather like a

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front line in a war zone. It is outdated and cramped, and a poor relation of the advanced services that are provided at King's College hospital. In its present condition, its physical facilities compare poorly with those at Guy's or St. Thomas's or St. George's--another hospital in south London. I appreciate that it is being rebuilt at the moment, that it is improving, and that most patients are "triaged", or analysed, by a nurse within five minutes of arriving. I think that it is up to almost 100 per cent. However, being analysed by a nurse within five minutes of arrival at hospital is not the same thing as being treated.

I do not want to denigrate the hospital or to detract from the efforts of the staff there, but I remain worried about its ability to cope with its present volume of work, let alone the increase that might come about as a result of the closure of Guy's. I do not think that it is capable of withstanding the pressures that might accrue from any further closures.

As a starting point for making that judgment, let me quote, not from the Peat Marwick report, but from a report that was published by the Minister's Department in 1992, when there was an inquiry into casualty services at King's College hospital following tragic cases, some of which involved my constituents. The report first recognises--as I do--that the accident and emergency department at King's is being rebuilt, but it says:

"Rehousing the department is necessary but not sufficient. If King's College Hospital do not alter the circumstances in which the accident and emergency department has to operate, staff will find it difficult to provide a good quality service and patients will still be at risk. The accident and emergency department staff have much to do to prepare for the difficulties they face as the department is being refashioned around them and for the challenge of functioning efficiently in the new environment. Preparation should start soon; it should include a rigorous review of operational policies, medical and nursing records, manuals, procedures"

and so on.

I think that the crucial paragraph in the summary of the report describes the conditions in casualty in 1992. On the subject of management decisions, the report says:

"we think that they ought to have been taken sooner. It ought not to have been necessary to set up an external inquiry to ensure that the hospital and the health authority took action. All clinicians and managers at King's ought to have seen as their concern the unacceptable conditions for patients in the accident and emergency department. The Community Health Council's record of complaints received from patients highlights the distress and dismay of patients and relatives who have encountered these conditions.

The failure to grapple with those problems is a failure of the whole organisation.

Experience has shown that at King's it will require unremittingly determined management to make sure that these problems do not recur."

That was 1992, and it is beyond question that there was anxiety then. However, two years later, one is entitled to examine the performance and to acknowledge that there has been an improvement, but to say that shortcomings remain in that performance, which call into question putting any extra pressure on that hospital until it is able to cope with its existing problems.

To describe what I regard as continuing inadequacies, I first draw from a publication called "Casualty Watch", which is published by Southwark community health council. It takes half a day, one day a month, and considers how long it takes people to be treated in the accident and emergency department at King's. The day chosen for most of the following material is 28 November.

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A 93-year-old woman waited eight hours, 24 minutes in casualty following an epileptic fit before a decision was made to admit. That is far too long.

On the same day, a man of 53 waited six and a half hours in casualty with a collapsed lung. I know something about that condition because 32 years ago I went to the same hospital group with a collapsed lung. That was before the days of high technology and concentration, when Dulwich hospital was open, and I was admitted to a ward almost immediately. I think that that was the last time that I was treated as an in-patient in a hospital. For a man of 53 with a collapsed lung, six and a half hours is far too long to have to wait.

To show that there are pressures elsewhere in the system, on the same day a patient waited six hours for admission to St. Thomas's hospital. I saw some figures yesterday, 19 December, showing that another patient had to wait six and a half hours in Guy's. If Guy's is closed and pressure is put on other hospitals which already have long waiting periods, what will be the consequence?

Some people say that if Guy's is closed patients can be sent north of the river. That means sending them in an ambulance through the Rotherhithe tunnel where a blockage could result in an equal period of waiting.

I have mentioned "Casualty Watch", but I am bound to cite some individual cases, not least because a number of constituents have asked me to raise them in the debate.

I start with the case of Miss Maloney, the correspondence about which arose in February 1993. Miss Maloney was brought to King's College hospital on 1 February 1993 suffering from injuries sustained in a fall outside her warden-controlled flat. She first attended the casualty department at 9.20 am. She had suffered a number of small strokes and had high blood pressure problems. In the afternoon, it was decided that she was fit to go home. In a letter to me a relative of hers says:

"She was very unsteady on her feet and we had to get a taxi as no other means of transport was offered".

Miss Maloney returned to her warden-controlled accommodation, but the warden was extremely alarmed at her condition and telephoned the general practitioner who telephoned the casualty department requesting an ambulance immediately to return her to the casualty department at King's College, having first established that a bed would be available.

Miss Maloney arrived at the hospital at 6.15 pm, but no doctor examined her until 9.30 pm. Her son arrived and stayed until 4 am. In the same letter her relative says:

"I apologise for the lengthy description of events, but feel that two pages of writing is not too much to read compared with a 79 year old lady spending approx. 29 hours on a hospital trolley." I come next to the case of Mr. Moffatt. I shall not go into any great detail, but simply quote what the hospital said about his case:

"It is quite unacceptable that patients should be kept waiting for admission in the Accident and Emergency Department for 22 hours but it has got nothing to do with the cutting back of hospitals, or for that matter closing wards . . . In fact we . . . have opened more than 30 beds in the last few weeks to try to deal with the unprecedented increase in emergency cases that have been coming through our doors."

That is all very well, but there is no mention of how many beds have been closed before those 30 beds were opened. To be fair, the hospital goes on to blame the local

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authority for the time that it takes to take patients out of care at King's College hospital, particularly when they are elderly. It is often argued that the problem with accident and emergency services is that under community care the local authority does not take patients out of hospital quickly enough. But there are dangers in getting patients out of hospital as soon as possible. An example of that was given in an article in the South London Press on 16 December. It reads:

"Last Friday the South London Press highlighted the case of bedridden Lilian West (84) who died alone in her Herne Hill home without support. She had been released from hospital two days earlier and taken home by ambulance without a message reaching Southwark social services."

I am not talking about Lambeth council.

"Mrs. West was found dead by her doctor on November 25. She had died from bronchial pneumonia."

A great deal of care needs to be taken to ensure that people who leave hospital under those circumstances, particularly the elderly, will go to a safe environment and will not have to come back very quickly, as happened in the previous case.

There is yet another case. I quote now from a letter from King's College hospital. It reads:

"I would like to begin by offering my condolences on the loss of your daughter and sincere apologies for the distress both you and your daughter were caused by the lengthy wait for admission to a hospital bed from the Accident and Emergency Department." That was February 1994. Again, I do not want to quote too much, but just give a flavour. The hospital--not the relatives--says:

"She left the Accident and Emergency Department for the ward at 12.00 noon on 5 January, ten and a half hours after a decision to admit her had been taken and 16 hours after her arrival in the Department. I can only apologise for what is an unacceptable delay." I come to yet another case, a Mrs. Harmer. A constituent who wrote to me said:

"On the day of her admission she was given reasonably prompt care and attention by the medical staff in the Accident and Emergency Unit and I left her later that day having been assured that she would be admitted to a ward by the evening. On telephoning . . . at 9.00 pm I was shocked to receive the news that she was still in the Emergency Unit and, in fact, she remained there until the early afternoon of the next day. She had, therefore, spent a total of 27 hours on a hospital trolley bed in the Accident and Emergency Unit which was, for most of that time, extremely busy and cramped"--

as anybody visiting the department at King's College hospital would know--

"and where her own health was put at further risk by the stress of such an environment and the physical discomfort she suffered." In response the hospital said that it was its standard

"to admit patients"--

to the wards--

"within 4 hours . . . In your mother's case a decision to admit was made at 18.30."

It said that the

"Accident Department treated 201 patients of whom 41 required admission one of the highest numbers admitted during the month of January."

That was January 1994. It goes on to say:

"Again I am sorry that Mrs. Harmer waited such an excessive length of time in the Accident Department."

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I am afraid that the list just goes on and on. There is the case of Mrs. Crowley. She had been taken to hospital after being mugged. She was discharged back to her own home. There is some disagreement about the medical judgment, but her GP felt that she should not have been sent home. I shall now quote from the rather sad paragraph of the letter from the hospital:

"However, the GP subsequently wrote to the hospital on 20 January, to confirm that he wished Mrs. Crowley to be readmitted to hospital as it was proving difficult to manage her at home. She was admitted on 21 January and, as you know, sadly died on 4 February from acute peritonitis and a ruptured bowel."

That is a case of "Let us vacate the hospital bed", and shows a difference in judgment between the accident and emergency department and the local GP.

I was talking yesterday to my local community health council. It gave me further examples, all arising in 1994. In January 1994, a 90-year-old woman was received at King's College hospital. She had fallen at home, injuring her hip, and was admitted at 10.10 at night, where she remained on a trolley until 5.30 pm on 27 January 1994--a period of 21 hours--having received minimal care and a small amount of painkillers.

The patient has asked for confidentiality, so I will not, therefore, quote the name. I raised the matter with the hospital and with the South East London health authority. Its comment is somewhat surprising. It said:

"Whilst I would not wish to underestimate the seriousness of the situation at King's it is worth noting that other local providers such as Lewisham, other parts of London and our Region, indeed in England as a whole, are undergoing similar pressures about which we know very little."

I do not find it reassuring to be told by the health authority that such problems exist not only at King's College hospital but all over the country and that the reason for them is not understood. The letter continues:

"We are trying to piece this together so that we can make sense of the whole."

Let us remember that this is in the context of a proposal to close a major casualty department. It states:

"I am determined that we get to the bottom of what is happening so that the proper arrangements to guarantee our residents a decent service can be made."

I am not reassured by that.

The Minister may be aware of an unfortunate incident that occurred in June this year. The London Evening Standard reported:

"The Department of Health has furiously denied yesterday's story in the Evening Standard about how a war veteran was left dying on a trolley at a London teaching hospital until his family offered to pay for a private bed."

There was some dispute about whether the family was required to pay, but the incident nevertheless reveals a lamentable state of affairs.

I have details of yet another case of a woman left on a trolley from lunchtime on 17 March of this year until 7 pm the following day. Most of the cases that I have mentioned involve constituents who have come to my advice surgeries. I have not trawled through such cases in order to tell horror stories, but I suggest that the catalogue of incidents must prove that the hospital is not yet ready to have further pressures placed on it.

I acknowledge that King's College hospital is aware of its failings. I know that its buildings are inadequate and that that is not the hospital's fault because it inherited them. The hospital is doing what it can and is building a new accident department, but it would be dangerous to

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close Guy's and Greenwich hospitals until King's College hospital is up to standard. It has not yet learnt to live with what is from time to time a deficient ambulance service and a community care service that leaves much to be desired.

Most people go to hospital only as a result of an accident or an emergency. They are entitled to an ambulance service that is quick and reliable, which is not always the case in London. They are also entitled to prompt, reliable and effective treatment and to be discharged into secure surroundings, especially if they are elderly or mentally distressed. In the present circumstances, those rights will be abrogated or put at severe risk until there is an improvement in services at the casualty department at King's College hospital. Until there is an improvement in the ability of other casualty departments in south London to cope, it would be wrong to proceed with the present proposals. The Minister needs to tackle the problems that I have outlined. I wish the hospital well. I want it to succeed, but I have a duty to my constituents to express their concerns. 12.47 pm

The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville): I congratulate the hon. Member for Norwood (Mr. Fraser)on raising a matter of great importance to his constituents and those of surrounding areas in south-east London. I thank him for the constructive way in which he outlined the problems and must apologise for the disturbance caused when a pair of crutches belonging to a Government Whip which had been placed on the Table--not for the debate but for other purposes--fell off. That perhaps serves to remind us that even the Whips Office is vulnerable to the type of accidents that we are debating.

I am certainly aware of the difficulties that existed and which, according to the hon. Gentleman's evidence, continue to occur from time to time at King's College hospital's accident and emergency department. One of the first things that I had to do as a Minister in 1992 on a trip around the regions was to go to a studio in the midlands to discuss the tragic case of a lady who had died following a wait on a trolley at King's. As the hon. Gentleman acknowledged, efforts have been made since then to try to ensure that the A and E department at King's is able to deal with the enormous demands placed on it by the local population and the way in which health is dealt with in London. I say that advisedly; we are all aware that because of the weaknesses in primary care that have grown up in London there is enormous pressure on accident and emergency departments. The hon. Gentleman knows that there is an £8 million building programme in progress at King's. It has been difficult to advance that as quickly as we would have liked, for the simple reason that it has to take place around the existing department, so that people are sitting in what may sometimes seem to be a building site. There have been great attempts to ensure that the quality of care is kept up, despite those difficulties, but the new facilities will not be ready as soon as we would wish.

Apart from that investment there have also been considerable efforts to prevent problems such as trolley waits occurring unnecessarily. This year the demand for emergency admissions at King's has increased by more than 10 per cent. in terms of numbers of attendances, and I shall return to that subject later. However, the hospital

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now believes that, thanks to the efforts of the clinical staff and of management, it is now constantly achieving about 85 per cent. of admissions within four hours of the decision to admit.

The overall performance on discharge has improved too, with increases in day care and day work. That has enabled King's to reduce lengths of stay in hospital by 10 per cent., and occupancy to 90 per cent. Many of the cases that the hon. Gentleman cited are indeed shocking and should not have occurred. Efforts will continue to be made to avoid such long trolley waits in future; it is fair to say that such problems are probably more severe at King's than at any other hospital in the country.

The hon. Gentleman mentioned a letter that he had received from the health authority referring him to the overall problems caused by increases in demand for accident and emergency services and admissions to hospital. All around the country, especially last winter and in recent months, there have been sharp rises in the numbers of emergency admissions; it is not known for sure what the causes are.

There may be some social or demographic factors, or the increase may have something to do with asthma or bronchitis--last winter the onset of 'flu was certainly a big factor. However, it is not 100 per cent. known what has caused the increase in emergency admissions all over the country. Much work is being done to establish the causes so that, for the reasons that the hon. Gentleman gave, we can plan. We need to know what is likely to be the future demand on A and E departments.

The hon. Gentleman mentioned problems on discharge. Certainly there have been instances, many in London, of insufficient co-ordination between hospitals and social services departments so that people have not been properly looked after when they got home. I have to tell the hon. Gentleman that all those instances are avoidable; they do not necessarily arise from questions of resources, whatever anyone may say. What matters is achieving good organisation in social services and in the hospitals so that the two work closely together. No one should be discharged from hospital without adequate provision being made for them when they get home, and I am sorry to hear about some of the cases that the hon. Gentleman has described.

There are bound to be changes in A and E provision both in London and in the rest of the country. It is increasingly being recognised that A and E departments are high-tech, in the sense that they need all the best equipment, and to have all the clinical specialties concentrated within them, so that as much as possible can be done for the seriously ill people who arrive there.

The hon. Gentleman may be aware of the trauma centre at Stoke, which is still experimental in the sense that it is a pilot project. There is round- the-clock consultant cover. It appears from studies that dozens and possibly hundreds of lives have been saved by taking people to that centre rather than to local district hospitals where a team can be assembled which can ensure that very seriously ill people and particularly trauma cases from serious accidents can benefit from all the necessary facilities together and ready. Paramedics call forward by radio to alert crash teams. That is likely to be a feature of the future. We must be aware that it will entail concentration of accident and emergency facilities in some hospitals.

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The hon. Gentleman rightly issued a warning that proposed closures of accident and emergency units elsewhere might put too much pressure on, for example, St. Thomas's and King's. We shall watch that closely. I give the hon. Gentleman an assurance, which has been given before, that closures will not take place until adequate provision has been made elsewhere. In London that is a case of not only the considerable investment that is being made in improved accident and emergency facilities at King's, Lewisham and St. Thomas's, to name but three, but desperately needed improvements in primary care so that more of the people who attend accident and emergency units inappropriately either go to doctors or attend minor injury units elsewhere.

It has been stated that perhaps up to 25 per cent. of all who attend large units such as King's could probably be better treated elsewhere. That is not to blame the public but to point out that we are not using resources efficiently and that we must make other facilities available. I have heard from London ambulance personnel--those who are in the front line driving ambulances-- that the figure may be even higher than 25 per cent. in London and that we need to do a great deal to ensure that people do not attend accident and emergency units inappropriately. The result of their doing so is unacceptable delays. We need to get on with the large investment that is being made in primary care in the London area.

I conclude by reassuring the hon. Gentleman that we will not close accident and emergency units without making adequate provision. We shall continue to ensure that those who need better primary care and facilities other than accident and emergency units have those services provided. I thank the hon. Gentleman for bringing the cases that he raised in the debate to my attention. If he wishes to give me others in which he would like the names to be kept confidential, I should be happy to look into them.

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Gulf War Syndrome

12.58 pm

Mrs. Edwina Currie (Derbyshire, South): "My son is sick," she said, "please can you help me." The woman opposite me in my advice bureau, a middle-aged mother like myself, was clearly very worried. Her son, she explained, was a professional soldier who was still serving. He had a distinguished career behind him and had several years before retirement. He had served in all the trouble spots, including Northern Ireland, but since he had returned from Operation Granby in the Gulf he had not been well. In deference to her wishes, his identity is confidential. There are several similar families in my area. Their efforts are being co-ordinated by a former soldier, Terry Walker, of Littleover in Derby. Terry is unwell, but has been unable to obtain an accurate diagnosis or explanation.

We talked about the issue on Remembrance Sunday around my kitchen table at home. The families convinced me that Gulf war syndrome, as it has been dubbed, is genuine. If that is right, the way in which the Gulf veterans complaining of it have been dealt with so far is a national disgrace.

I shall rehearse a few facts that, I hope, my hon. Friend the Minister of State for the Armed Forces will accept. The forces sent to the Gulf were facing an enemy known to be equipped with chemical and biological weapons, and not averse to using them. It was essential to protect the troops as effectively as possible. Everything that occurred was carried out with the best motives--there is no argument about that--but good motives are not a substitute for good practice.

What appears to have happened? First, the troops were given an astonishing range of injections, which included two types of anthrax, plague, pertussis, polio, cholera, botulism, typhoid, hepatitis and yellow fever: nine within four days. I understand that the Minister has since admitted that they were also given injections against meningitis and tetanus, which brings the total to 11.

Several of the injections were given jointly. The pertussis vaccine was given to enhance the effectiveness of the plague vaccine. One soldier counted 27 injections before leaving England. There was no choice in the matter. Richard Turnbull, ex-RAF, told the Channel 4 "Critical Eye" programme, broadcast on 13 October this year, that station routine orders were issued stating that disciplinary action would be taken against any refusers.

It is not unusual to give vaccines conjointly, but by any standards this was an untried cocktail. In response to one of the many parliamentary questions that I tabled to the Minister asking what independent research he had commissioned into the possible after-effects of inoculation against the various diseases, he said: "None. All known vaccine interactions are published in standard medical text books and the British national formulary."

My hon. Friend the Minister should try reading the British National Formulary--it lists only three vaccines: influenza, rabies and typhoid, which are all shown as interacting with certain drugs, including treatment for asthma and anti-malaria tablets. Most of the concern in the BNF is that the vaccine may be rendered useless if other drugs are in use--it is not looking particularly at the exacerbation of side-effects.

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According to the BNF, the anthrax vaccine is supposed to be administered by four injections with intervals of three weeks between the first, second and third injections and six months until the fourth. That is not the pattern that many war veterans

report--everything was done with far greater haste. In any case, the plague vaccine was not licensed for widespread use in that way. It was available only on a named doctor-named patient basis, as were the nerve agent pre- treatment set tablets. It is no wonder that neither treatment is in the BNF --like thalidomide, the products were regarded as too dangerous for general use.

The nerve agent pre-treatment set--a chemical whose correct title is pyridostygmine bromide, a carbonate closely related to

organo-phosphorus compounds--had to be taken every eight hours for the whole time that someone was in the Gulf. It was not licensed for general use at the time and still is not. It appears to have been thoroughly nasty stuff and is the main target of complaints in the United States of America. It caused violent side- reactions and many subjects quickly stopped taking it.

Therefore, we have two aspects--injections and NAPS--but there are more possible contributory factors. Other organo-phosphorus compounds were in common use, including malathion as a delouser, and a product called DEET-- diethyltoluamide--which is used against sandflies. My hon. Friend the Minister may well tell me that malathion is found in head lice shampoo, but one is not supposed to breathe it in. Various chemicals were used against rotting animal corpses and garbage, which can themselves give rise to infections.

There was widespread atmospheric pollution due to the burning of oil wells, to which many soldiers were exposed for months on end. We in Derbyshire know that, among the products of incomplete combustion of hydrocarbons is the killer chemical, dioxin. There was at least one possible chemical attack on 20 January 1991, witnessed by many of the troops, and perhaps more. American veterans have testified that some of the dead Iraqi soldiers that they brought in had few marks on their clothes, but badly blistered and burned flesh--the hallmarks of chemical attack, including by mustard gas. Not surprisingly, those who handled the contamination became sick themselves.

I add two other possible factors. First, however safe a single injection or exposure might be, in combination the results could be highly dangerous. The presence of minute quantities of certain compounds can make proteins more active and serious damage is therefore that much more likely. Secondly, there may also be susceptible individuals. I am an asthmatic. The gene that gives rise to asthma is quite common-- it is present in about one third of the British population. It also causes hay fever, rhinitis, eczema and related conditions, all involving heightened reactions to outside stimuli.

I have a mild allergic reaction to certain things. My daughter had contra- indications for the pertussis vaccine and she did not have it. Anything can trigger the problems, particularly in a subject who is in stressful circumstances as these men and women were.

When I asked the Minister whether any links with asthma or hay fever had been investigated, he answered that individuals with a history of asthma

"could be susceptible to one of the protective measures, NAPS, the active constituent of which is pyridostigmine bromide".

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