Audit of the MOD Gulf Veterans Medical Assessment Programme

The Gulf Veterans’ Medical Assessment Programme was audited by Gordon Mitchell and Dr Charles Shaw, King’s Fund Health Quality Service, on 18 December 1998. The purpose of the audit was:

1. To establish whether the unit is meeting the purpose for which it was established.

2. To identify opportunities for improving the effectiveness and/or efficiency of the way in which the unit is organised and delivering services.

3. To make recommendations for improvement.

This report is based on the audit of the GVMAP which was conducted using standards and criteria developed by the Health Quality Service. A copy of the standards and criteria was given to the service prior to the audit. The audit involved a review of documentation, interviews with staff and visits to the different areas within the service, including observing the assessment process. A telephone survey was also carried out to obtain feedback from users of the GVMAP service. The users comments were used to inform the audit.

This report reflects the audit findings. The executive summary outlines the main themes which were covered in the feedback given to the service at the end of the audit. The main body of the report sets out the audit findings and recommendations referenced to specific criteria. The report is written in action plan format and is intended to provide an agenda for ongoing development within the service.

A number of general themes can be identified:

• The enthusiasm and commitment of staff impressed the audit team. The service is well led by the head of GVMAP and everyone is clear about the purpose of the service. The organisational arrangements for the service are set out very clearly in the organisational chart. Individual terms of reference make clear the contribution of each post holder to the service. In spite of this, some personnel seemed uncertain about lines of accountability and the role of some individuals within the service, which needs to be clarified. The development of a system for monitoring workload and skill changes will provide useful data for this purpose.
  
• The referral patterns for the GVMAP are falling and numbers assessed have reached one fifth of previous peaks. This might reflect insufficient awareness or increased threshold for referral by GPs and Medical Officers or reduced prevalence of Gulf related problems. In addition there is a clear need to focus more attention on the analysis and use of the accumulated data and tracking changes to individual conditions over time. This would seem to indicate that the organisational arrangements should be reviewed to establish whether the present staff numbers and skill mix are appropriate.   Measurable objectives should also be developed to provide a basis for monitoring progress towards meeting the government’s key points and service aims.

• The lack of written documentation, particularly policies and procedures, makes it difficult to assess performance. The development of policies and procedures to cover all aspects of the organisation and delivery of services, including assessment procedures, will not only provide a basis for monitoring consistency but enable the effectiveness of the service to be reviewed at regular intervals. Written protocols for investigations and clinical interventions would enable their effectiveness to be evaluated with respect to research evidence and ineffective procedures to be withdrawn. Written information is also needed for patients and carers on assessment process, investigations, follow-up and how to express views about the service.

• The clinical assessment process appears to work well, although the provision of specialist advice requires further consideration. Clinical record keeping is of a high standard. The service would find it beneficial if this process and the health records were subjected to regular review, possibly as part of a clinical audit programme. The development of an integrated clinical and administrative database will help this process. Careful attention will need to be given to classification and coding, as well as the implications of establishing a database and capturing retrospective data and its analyses.

• The Ministry of Defence Health and Safety manual is an extremely useful document for guiding health and safety management. Unfortunately there is little evidence that staff understand their roles in this respect. Formal risk and control of substances hazardous to health assessments have not been carried out and no contact has been made with the local trust to establish where responsibilities begin and end. The role of the head of GVMAP in respect of health and safety and risk management should be clarified. All staff need to be trained to take responsibility for health and safety, risk and control of substances hazardous to health assessments. They also need to be trained in manual handling and lifting and fire procedures, to meet statutory requirements.

• The commitment to providing high quality service is evident but there are no agreed standards for monitoring and evaluating services. The development of a quality improvement plan and measurable standards would enable the quality of services to be monitored and areas needing improvement to be targeted. The extent to which patients could contribute to improvements through the provision of better information or the creation of user groups should also be investigated.

2. FINDINGS AND RECOMMENDATIONS