House of Commons - Defence

Select Committee on Defence Seventh Report

THE MEDICAL ASSESSMENT PROGRAMME

16. The Gulf Veterans' Medical Assessment Programme (MAP) was established in 1993 to examine UK veterans concerned that their health had been affected by their service in the Gulf. Since October 1997 it has operated from St Thomas's Hospital, London. The MAP does not provide treatment; it aims to give a diagnosis and recommend treatment or further investigation, and passes this information to a patient's general practitioner (GP) or medical officer. It also collects statistical information. Nearly three thousand patients had been seen by the MAP by the end of November 1999 and 28 were awaiting their first appointment. An average of four new patients approached the MAP each week during 1999.[41]

17. The MAP has had an unhappy history. Our predecessors' Report in 1995 identified a number of weaknesses in the way the MAP operated. The most serious were:

the failure of the MoD to publicise the MAP's existence, resulting in only 65 veterans being examined in the first year of operation;

the initial allocation of a single consultant for two days a week, which they regarded as 'hopelessly inadequate'; and

the failure to collect centrally the necessary data for an effective assessment of the scale and nature of the problem.[42]

Lt Gen Sir Peter Beale, the Surgeon General at the time MAP was set up, has commented in written evidence that—

Criticism of the time and manpower allocated initially to investigate such illnesses was ... completely unjustified

because very few patients came forward, despite radio and television appeals.[43]

18. Four of the key points on Gulf veterans' illnesses announced by the new government in July 1997 related to improvements in the MAP. These included:

new guidance to the Services and general practitioners to ensure veterans could take advantage of the MAP's services;

targets for new patients to be seen within 6 weeks of referral;

additional resources for the MAP database with a view to publishing detailed results of its findings in late 1997; and

a full audit of all aspects of patient care and of the service provided.[44]

MAP almost doubled the number of patients seen between July 1997 and the end of January this year.[45] The target for ensuring that new patients are seen within 6 weeks has been met consistently, but this was less of an achievement in 1999 when there was an average of 4 new patients a week, compared with 19 per week in 1997 and 12 per week in 1998.[46]

19. A paper on the clinical findings from the first 1,000 patients seen by the MAP was eventually published in the British Medical Journal in January 1999.[47] The 'key messages' from the paper were as follows—

Many Gulf war veterans present with a wide variety of symptoms

No single cause has been found to explain these symptoms

The variety and multiplicity of symptoms make it unlikely that any single cause will be found to underlie Gulf War illness

Some of the illnesses may be an example of a post-war syndrome

The MoD echoed the overall conclusion of the paper in its evidence to us—

We discuss epidemiological studies below (paras 66-70). We believe that the MoD has been remiss in not using the data available to the MAP to better advantage. Research should have been instituted before now, based on the MAP's findings, to ascertain the prevalence of illness amongst all Gulf veterans and to determine whether the symptoms demonstrated by patients seen at the MAP are representative. This has been a wasted opportunity and has contributed to the low opinion which users of the MAP have of its services.

Management Audit of MAP

20. A management audit of MAP was carried out by the King's Fund Health Quality Service in late 1998. The MoD explained that the audit took place later than planned because the post of head of the MAP remained unfilled for some time.[49] The purpose of the audit was—

to establish whether the unit was meeting the purpose for which it was established;

to identify opportunities for improving the effectiveness and/or efficiency of the way in which the unit was organised and delivering services; and

to make recommendations for improvement.[50]

The audit report was published in April 1999. It found that the service was 'well led by the head of GVMAP and everyone is clear about the purpose of the service' and 'the enthusiasm and commitment of staff impressed the audit team'.[51] The main areas where the report highlighted weaknesses were—

the lack of documentation on policy and procedures and of written protocols for investigations and clinical interventions;

lack of analysis and use of the accumulated data;

a need to focus on monitoring the progress of individuals; and

a need to review organisational arrangements, staff numbers and skill mix.

Amongst the report's recommendations were—

the provision of written information for patients and carers on the purpose of medical procedures, other sources of advice and assistance, and how to express their views on the service;

consideration to be given to setting up a patients' user group to give its views on aspects of the service and planned improvements;

the development of an integrated clinical and administrative database; and

the development of a quality improvement plan and measurable standards.[52]

A clinical audit of MAP has also been carried out, by the Royal College of Pathologists, and the MoD told us that 'the outcome of this will be reported shortly'.[53]

21. When the Minister gave evidence in April 1999 he told us that the MoD was hoping to act on the management audit report recommendations 'as quickly as possible'.[54] The MoD's response to the audit report's recommendations was finally published in December.[55] On the whole the response is positive and improvements to the service which have been put in place include—

all MAP procedures are now covered by written protocols which are reviewed regularly, and a management plan including targets and performance indicators is in place;

feedback from users of the MAP will now be obtained from a new satisfaction questionnaire, and the complaints procedure will be reviewed to bring it in line, as far as possible, with NHS practice;

a review of the appropriateness of clinical investigations offered by MAP is under way with a view to amending these annually in the light of emerging scientific and medical evidence;

the database has been updated;

the clinical work of the head of MAP and the second consultant physician will be externally assessed on an annual basis;

in addition to the MAP factsheet there will be a leaflet giving advice to users on making complaints about the service provided.

22. The MoD have said that 'all the recommendations are accepted'[56] but have also qualified this in saying that 'a very small number of issues remain outstanding'.[57] Recommendations relating to the provision of specific written information for family members and carers have not been adopted, although a post-assessment questionnaire will allow them to express their views and a freephone service will be set up. Nor does the MoD accept that a user group should be established as it believes it would be difficult to find a core group of users and to ensure that they were representative.[58] No additional steps will be taken to follow up patients' progress. The MoD has not taken up the audit report's recommendation that, where patients are referred for pathology tests or radiological examinations, information on such procedures should be provided by the MAP; the MoD believes such information should be provided by the NHS Trusts carrying out the tests.[59]

23. The Minister for the Armed Forces said in response to a Parliamentary Question in January—

Although we welcome the progress made in implementing the management audit recommendations, it remains to be seen whether this will have a noticeable effect on the services veterans receive from the MAP. We look forward to seeing evidence that the improvements put in place are having a significant effect on the way the MAP operates. We also hope that the results of the clinical audit will be published in the very near future.

Veterans' view of MAP

24. The long history of poor relations between veterans and the MAP has led to a situation where many veterans are dubious about the MAP's effectiveness in assisting them. When our predecessors reported on this subject in October 1995 they expressed some sympathy with the views of veterans on the problems with the service offered by the MAP. At that time veterans were waiting six or seven months for initial appointments. Some serving personnel were reluctant to report illness for fear of the possible effect on their Service careers. Our predecessors believed that reluctance to be assessed by the MAP 'may have been fostered by the constant denials of the existence of a syndrome on the part of the Department'[61] and veterans themselves, when giving oral evidence at the time, spoke of 'a hostile atmosphere' at the MAP.[62] The then Minister for the Armed Forces told us in 1997—

But the National Gulf Veterans and Families Association (NGVFA) told us in December 1999 that serving personnel are still not receiving appropriate treatment—

25. The MAP was initially located at the hospital at RAF Wroughton in Wiltshire because of the excellence of its facilities and its 'central location'. The problems of travelling to Wroughton for ill veterans was cited as a possible deterrent to attending for assessment.[65] In October 1997 the location was moved to St Thomas's Hospital in central London. But this has not solved the problems created by the need for veterans to travel to a single location. The Gulf Veterans' Association told us—

The MoD has already accepted the management audit team's recommendation that, for veterans who cannot travel to the MAP, arrangements will be made for a local consultant to undertake an assessment.[67] We accept that there is a difficulty in reconciling the need for a centre of excellence with the problems of travelling to London from the more distant parts of the United Kingdom. On balance, we believe it is important to centralise the expertise on Gulf illnesses in a single location and that London is the most appropriate location. We hope the MoD will consider providing additional assistance to Gulf veterans who have to travel long distances to the MAP.

PSYCHIATRIC ASSESSMENTS

26. Psychiatric assessments were introduced in spring 1994, initially for all MAP patients.[68] The number of veterans seeking such assessments then became too large for the resources available at Wroughton and the decision was therefore subsequently taken to restrict the availability to serving personnel. Mr Mike Tonnison, head of the Gulf Veterans' Illnesses Unit at the MoD, told us that psychiatric assessment had been reintroduced in response to veterans' requests, but this time on a regional basis, to ensure better access for those who may require repeat visits.[69] Under the new arrangements, veterans can be referred to a network of consultant psychiatrists with expertise in post traumatic stress disorder (PTSD). The cost of the initial assessment will be met by MAP but subsequent treatment will be the responsibility of the NHS.[70] As at the end of January, 245 personnel of the 2,934 patients seen by the MAP had a recorded diagnosis of PTSD.[71]

27. The veterans' representatives told us that they had pressed for psychiatric assessments in the past. Ideally, initial assessments should have been carried out by Combat Psychiatric Teams while personnel were still in the Gulf or during their return journey. There was now a reluctance amongst veterans to become involved with psychiatric assessments which might get them labelled as 'fruit loops'.[72] The head of the Gulf Veterans' Illnesses Unit confirmed that—

Dr Doug Rokke, who served as a health physicist with the US Army in the Gulf, told us of views expressed to him by veterans in the United States when asked to undergo stress assessments: 'When I go for medical care all they tell me is that it is in my head, that I am nuts'. Some veterans believe that a stress assessment is all that will be offered to them by the medical services and are therefore reluctant to take part.[74]

28. The MoD has given an undertaking that the new system for psychological assessments will be reviewed and audited 'early in 2000'.[75] We hope that this audit has been carried out and look forward to seeing the results in the government's response to this Report.

RECENT DEVELOPMENTS

29. The veterans' lack of confidence in the MAP has been exacerbated recently by confusion over the testing of a civilian veteran for evidence of contamination by depleted uranium (see paras 36-40), which was organised by the MAP. This in turn led the NGVFA to break off contact with the MoD.[76] The veterans do not see a future for a medical programme which is part of the MoD. Mr Shaun Rusling, Chairman of the Association, told us—

There have been serious inadequacies in the services MoD has provided to sick Gulf veterans, through the Medical Assessment Programme, over a number of years. It may now be time for the MoD thoroughly to review the way it provides medical assistance to Gulf veterans, taking full account of the views of veterans themselves, so as to provide a service which meets their needs and fulfils the MoD's obligations to them.

41 Ev p 88. The number of patients seen as at 25 November 1999 was 2,906. By 31 January 2000 this had increased to 2,934 (HC Deb., 17 March 2000 c 343w). Back

42 Eleventh Report, Session 1994-95, op cit, paras 10-28 Back

43 Ev p 109 Back

44 Gulf Veterans' Illnesses: A New Beginning, op cit, paras 8-19 Back

45 Minutes of Evidence, 29 July 1997, HC 222-i, Q 190; HC Deb., 17 March 2000, cc 343-344w Back

46 Ev p 88 Back

47 British Medical Journal, 30 January 1999, vol 318: Clinical findings for the first 1,000 Gulf war veterans in the Ministry of Defence's medical assessment programme, Coker et al Back

48 Ev p 2 Back

49 Ev p 2 Back

50 Health Quality Service, Gulf Veterans' Medical Assessment Programme, April 1999, Executive Summary Back

51 ibid Back

52 ibid Back