Chapter Three - Administration, coordination and information
3.1
Some of the
evidence provided to the Committee suggested that problems experienced by
current ADF personnel, reservists and veterans, arose from the lack of
effective electronic data collection and retrieval systems, incomplete links
between Defence and DVA, and what was seen as a shortage of adequate
information.
Data collection
3.2
In terms of
health information, Defence has stated that there are two records kept of
relevant information on injuries, illnesses and treatment, including that
arising from pre and post deployment assessments, and from the deployment
itself. These are the Unit Medical Record (UMR) and the Central Medical Record
(CMR).[271]
The
unit medical record is raised the minute that someone is formally inducted into
the ADF. It is intended to contain a record of the daytoday health care
delivered to the individual in their presentations for outpatient care. It also
contains any specialist referrals that may be made; the results of any investigations,
such as Xrays, pathology tests and those sorts of things; and copies of
routine health forms, such as the annual health assessment or the comprehensive
health promotion examination. It will contain copies of any other medical
examinations that may be donefor instance, pre overseas deployment, pre
promotion, pre change of category or pre engaging in specialist activities such
as parachuting or scuba diving. It will also have embedded in it the record of
vaccinations The medical record will also usually contain the results of the
annual fitness test.
The central medical record is a duplicate of the unit medical record, and
the only thing that it contains over and above the unit medical record is
copies of any documents that arise as a consequence of in-patient care. So, if
you are admitted to surgery for, let us say, an appendicectomy, the discharge
summary will be in the unit medical record to acknowledge that this has taken
place and whatever happened, but the actual detailed documentation such as the
nursing notes and the progress notes during the hospitalisation will go into
the central medical record.[272]
3.3
At present, such
files lack any information arising from injuries for which compensation is
claimed under SRCA,[273] although steps
are being taken to address this gap. The individual medical record may remain
with the individual, including when personnel are posted overseas (nondeployment
postings) so there is a certain level of responsibility on the individual to
ensure that new material on the individual file is copied and sent on to the
central file. Files for reservists are held by the reserve unit and activated
when the individual is involved in a full time service:
every time they have a health
interactiondental, medical or whatever it might bethat record is updated with
that information. If they in fact separate from the ADFin other words, no
longer have any affiliation with ustheir record is physically transferred to
the central medical records store. If nothing further happens, it sits there,
and that is it.[274]
3.4
One organisation
in particular believed that files were incomplete both because some
immunisations might have been recorded only in a WHO booklet and not in their
medical file, and some drugs were not recorded when their administration was a
command initiated action and not an exclusively health one.[275] As noted in Appendix 3, the attitude
to recording vaccinations has varied, and it is possible that some files are
incomplete or inaccurate in this respect.
3.5
Defence agrees
that there has been a limited capacity to provide an integrated file, as:
A members health profile is captured
through up to 14 disparate IT systems including medical and dental records,
psychological file, and compensation and rehabilitation data.[276]
HealthKEYS
3.6
As part of a
major overhaul of its data collection systems, the ADF is developing a tri
service approach which will seek to establish uniform processes and
information systems for the collection and collation of health information.[277] This system is called HealthKEYS,
and is expected to be rolled out over several years.[278] It is now the only corporate health
information management system approved to operate in the Defence Standard
Operating Environment. Nonetheless, although some other systems have been
decommissioned or will be, when replaced by HealthKEYS,[279]
the project itself will not be fully operative for some years, with the second
phase expected to be completed by 2009.[280]
3.7
A broad objective of HealthKEYS is to gather information which will help
to change and develop health services to meet needs:
for
those men and women who remain in the ADF the issue is clear, because gathering
the data and some of the analysis of that data is to assist us in the delivery
of health care to those people. So that reemphasises the point made that, at
the end of the day, the data can be used for different reasons. In our case,
whilst those men and women remain in uniform, clearly my interests are to
provide focused health care to those people which is appropriate; to identify
trends or areas of concern so that we can review current practices; and to try
to forecast future problems so that again we can make sure our strategies
moderate that.[281]
3.8
Healthkeys is not
unique to the ADF since it is a commercial clinical practice management system[282] with the potential to maintain
records, generate recalls, and collect event and pattern data on which more
detailed studies can be based. In terms of being a vital part of the ADF
deployable service, it is stated that the system will be deployed on larger
ships and in field hospitals and will interchange information with a number of
other Defence systems to reduce double keying of data.[283] This approach should help reduce
lost data through providing at least some of the records needed for individual
files and provide a better service through ready access to existing patient
information.
The
goal of the project we have in place at presentthe HealthKEYS projectis to
provide a single point data management system for the health record. That is its
stated goal. It is a three-phase project and we are only in phase one of the
project, which is essentially putting in the administrative bedrock on which
the rest of the clinical material will be built.[284]
3.9
A further advantage of HealthKEYS will be the capacity to link individual
data with event data sets in order to develop a picture of the individuals
exposure, including in deployments, to a range of environmental, chemical and
other substances:
We
will hopefully be in a position to inject into that data set, in real time, the
occupational and environmental threats to which they are exposed.[285]
3.10
Such links,
coupled with information on the individuals health status, should facilitate
the development of a better health profile, allowing rapid access to information
on likely exposures and therefore suggesting required treatment.
The
Americans had enormous problems following Gulf War I in terms of being able to
assess the threat exposure for their individuals, and they have put an enormous
amount of effort into trying to address that. They did so during the recent Iraq conflict, where they put on the ground health
assessment teams that were doing air, soil and water sampling in real time.
They were then linking that to the personnel records and to things such as geospatial
imagery to look at things like smoke and oil plumes, sandstorms and so on, so
that they could build an almost threedimensional data set[286]
3.11
It is also expected that the linking of sections of Defence will
facilitate the inclusion of data that will help provide a better profile of an
individuals health:
That
will facilitate us bringing psychological and mental health related issues into
the central health record. I think that is going to be an extremely important
part of our data manipulation.[287]
3.12
Such individual records would also have the benefit of being able to
provide better background information to veterans in the future when they may
wish to check exposures and link these to possible disorders:
They could work
out very specific hazard profiles for individuals, and that was important to be
able to reassure people.[288]
3.13
The Repatriation Commission also outlined the potential benefits of
HealthKEYS, including the capacity to provide, among other reports:
Regular
analysis of the health status of deployed veterans compared with serving
members who have not served overseas, as well as with the Australian population
Compilation of regular reports on the health status of veterans and serving
members for the purpose of informing policy development.[289]
The
longterm envisaged plan is that, for every deployment that goes overseas,
there will be a systematic collection of data and a program of ongoing
monitoring for things such as mortality and cancer incidence. We will vary that
standard approach according to the deployment. It probably would not be, for
example, so appropriate to have such a complete approach to a deployment like Bougainville, which was much less stressful than our
deployment to Afghanistan and Iraq. Within the overall framework of having an ongoing
process of monitoring the health of all groups of deployed, we will vary it to
make it appropriate to the type of deployment that is occurring.[290]
3.14
However, as at
early 2004, no individual data was on HealthKEYS:
At
this stage, no clinical components of the members medical record are electronic.
It is the intent of the HealthKEYS project to change that, but the entry of
clinical datain other words, the daytoday working clinical datawill not
come up until phase 2 of the project.[291]
3.15
It was also
stated that even currently serving personnel would not have existing
information scanned into the data base:
there is no viable way of migrating
the extant paper record into healthKEYS. For continuity of care purposes and
our archiving requirements, we will still need to keep that paper record.[292]
3.16
This must
necessarily limit the effectiveness or usefulness of any environmental
information relating to recent deployments since it would have nothing on an
individual against which to register. Some service organisation witnesses
expressed an interest in the operation of HealthKEYS,[293] but for the majority of their
current members it is likely to be of limited advantage. There still remains a
need, therefore, to obtain and retain as much information as possible on
environmental factors in deployments as this will be the background against
which many claims in the future are likely to be based.
3.17
This was noted in
one submission which, while acknowledging that there had been improvements in
relation to occupational health issues in a nondeployment context, believed
that the lack of integrated files could result in future problems:
there does not appear to be one agency
in the Department that links these [exposure records] with personnel records.[294]
3.18
It is to be hoped
that the greater awareness of occupational health and safety issues[295] and the capacity to link personnel
to other records[296] will also cover
these exposures. In the context of the anthrax issue, the capacity to evaluate
and monitor the health of those who received vaccinations,[297] must also be affected through the
absence of electronic information. While it may be that the fact of vaccination
is recorded as part of general deployment information, this will not provide
information on the individual or make possible connections with later illness.
Unless a separate detailed health review is undertaken for each deploymentand
it is suggested this will not be the caseonly future deployments will have
this level of detail.
EpiTrack
3.19
EpiTrack is an
electronic system into which event data can be entered, primarily in order to
track patterns of events such as injuries and disease, especially those related
to deployments.[298] It is a commercial
system which can be adapted to identify other event patterns.[299]
The EpiTrack system records the
principle reason for presentation at health facilities and the impact of such
attendances on manpower availability.
The key components of EpiTrack are
EVENT codes, which contain descriptors that are a mix of the causal event and
the diagnosis, with the causal event taking precedence
All ADF health units will conduct
health surveillance during deployments and field exercises. EpiTrack is also to
be used across the National Support Areas (NSA) to allow familiarity with use
when deployed.[300]
3.20
The system can
provide regular updates on the main causal factors of ill health and can
therefore inform those in command of the general health of their forces.[301] The extent to which this will allow
active intervention before disease or injury can limit mission accomplishment,[302] however, may be open to debate,
given that many people may have been injured or exposed to communicable disease
prior to patterns becoming obvious. However, this type of information does have
the potential to reduce health issues that may occur over a longer time period:
whilst
undoubtedly at some point in a costbenefit analysis you would factor in some
value for that better information available on claimsas a possible offset
saving or equally and in most cases, in fact, as a cost consequent on having
additional informationfar greater significance is attached to the possibility
of preventing the logical consequence of a disease train being set in motion by
that deployment. If, for example, it is possible to intervene on the basis of
information flowing from our health studiesfor example, by taking some sort of
preventative or prophylactic action in a way that might minimise the risk of
lung cancer developing downstreamthen we think that is a legitimate saving to
factor into our cost-benefit analysis.[303]
The interaction between HealthKEYS[304] and EpiTrack
3.21
The data provided
by HealthKEYS and EpiTrack has the potential to provide both systemic data on
broad trends and patterns, including occupational health and safety issues, and
on individuals who may also demonstrate patterns of injury or illness. Whether
information from EpiTrack will be available to DVA is not stated, but in terms
of DVAs current responsibilities concerning compensation such access would be
valuable. The identification of problem areas, in theory, would help to limit
compensation claims and the loss of personnel from preventable injuries.
Health reviews
3.22
The government
stated in 1999 that deployments would be subject to health reviews, and,
according to DVA, these would need to vary to reflect the nature and size of
the deployment.[305] Such reviews would
presumably use data obtained from the health assessment undertaken 3 months
after personnel returned from deployments as well as other data from HealthKEYS
and EpiTrack. However, the limited information available through HealthKEYS at
present suggests that detailed health reviews will only be available in the
future.
3.23
As is noted by
DVA, the value of studies depends on the objective, and the methodology needs
to suit this. The absence of information via current systems therefore does not
necessarily affect all reviews and research:
The recent deployments to the Solomon
Islands and Bougainville
would have little effect on cancer incidence statistics, assuming any would
ever be observed, until an appropriate latent period had elapsed Such
deployments could probably be more effectively studied by examining the effects
of social and psychological distress, involving techniques such as surveys and
small group interviews and monitoring mortality and cancer incidence over time.[306]
3.24
Nonetheless, an
overall picture of the health outcomes of deployments would require that
information of this type would need to be considered alongside the broad event
patterns provided by HealthKEYS.
DVA access to electronic information
3.25
Currently, DVA
does not have electronic access to HealthKEYS, although it is expected that in
time such access will be available.[307]
Defence is responsible for data entry and DVA is able to access this data if
required. The records of veterans, including reservists, are available only as
paper files, although in time some veterans records will be in electronic
format since they will have been entered when the individual was a current ADF
member. For the short to middle term, electronic data will not be available to
DVA on the majority of those making claims under the VEA. Similarly, those
making claims under the VEA will need to operate under the procedures currently
in placethat is, obtaining a paper record.[308]
3.26
The fact that
existing data on medical records will not be incorporated into HealthKEYS also
means that the records for currently serving personnel will be incompletesome
will remain as paper records because it is considered that entry of existing
data will create a slower result time:
firstly,
it would require someone scanning the information into an electronic format and
then putting it into a format that makes it readily accessible [and secondly]
the practical issues of bandwidth: as that record becomes bigger and bigger, it
becomes more difficultthe turnaround times become greater. So at this stage we
do not believe it is viable to put that in electronically.[309]
3.27
To some degree,
this problem could be overcome by the use of electronic tags which incorporate
exposure data and accurate medical record keeping.[310] Such tags may have been seen in the
past as too invasive and as a threat to privacy, but, with increasing capacity
to secure medical records, they may be extremely useful. DVA has undertaken
trials on smartcards with respect to services for veterans, and this may
provide some information on the security of data:
DVA has been involved in a trial with
the Brisbane Waters
Private Hospital
and an ICT firm called Smart Health Solutions as part of a NOIE IT Online
grant. The aim of the trial was to evaluate the functionality of smartcards in
providing authorisation to securely access patients online clinical
information and transmission of hospital discharge information.
DVAs component of the evaluation of
the trial was to conduct interviews and collate and analyse attitudinal and
perceptive feedback from veterans and health care providers. These findings are
of interest, and will report to, the HealthConnect projectthe proposed
national health information network to facilitate the safe collection, storage
and exchange of consumer health information between authorised healthcare
providers.[311]
3.28
DVA also noted
that smartcards are a further way of obtaining secure access to medical
records:
The
use of smartcards is one method that can be used to authenticate and access
computerised medical records. Computerised medical records can be authenticated
and accessed by other means such as a login and passphrase. Smartcards were
used in this trial as an authentication and access method for a range of
reasons including the generally accepted use of cards within the veteran
community (Gold & White DVA Treatment cards), and with the Australian
public (Medicare cards). Smartcards and their embedded chips can also be used
to strengthen the identification and/or authentication for authorised card
holders of that cardan important feature for ensuring security of computerised
medical records.
The outcomes of the trial will also
contribute to the body of studies that will inform the national HealthConnect project
in its role to develop a better connected health system for all Australians.
Use of smartcards and other technologies are being assessed in a number of
electronic health record implementations both within Australia
and overseas.[312]
Problems identified in relation to the collection of medical data
3.29
One of the main
issues identified by witnesses was the absence of systematic event recording,
especially of events which might be productive of later psychological problems.
There were at least two aspects to this, the failure to record and the limited
understanding of psychological factors relating to service such as
peacekeeping:
There are continuing difficulties with
Defences recording of critical incidents that may affect psychological well
being, and DVAs recognition of them in relation to compensation. There has
been substantial anecdotal evidence that many incidents, which form potential
stimuli for possible mental health problems have not been accurately reported
by Defence. The current systems major problem is its susceptibility to human
error.
In 2000, an International Force in East
Timor (INTERFET) veteran was involved in a combat incident. The veteran later
suffered a psychological condition, which can be linked to the stimuli of the
incident. The incident was not however recorded by Defence and the veterans
account was in contradiction to a DVA historians opinion that it never
occurred, and the veterans claim subsequently disallowed.[313]
3.30
The Australian
Peacekeepers & Peacemakers Association also believed that there was limited
understanding of the distinction between mental health issues experienced by
those undertaking warlike service, peacekeeping, and peacemaking operations.[314] While this may result in lack of
appropriate service provision, affected personnel may also consider their
experiences are less important if relevant events are not recorded. This is an
issue which would obviously also affect older veterans, for whom relevant
events are more distant and something they may have difficulty remembering.
Nonetheless, DVA notes that older veterans are also making claims in respect of
PTSD, although it is not clear how many of these are successful, or if others
are receiving treatment because they hold a Gold Card which does not require
health problems to be warrelated:
The number of PTSD claims by older
veterans has risen in recent years overtaking generalised anxiety as the most
common mental health disability approved for this group. Other mental health
problems may arise from a range of life experiences and adjustments relating to
retirement, loss and bereavement and physical or mental health degenerative
conditions related to ageing, such as dementia.[315]
3.31
DVA notes that
there are many factors involved in the development of psychological problems,
not all of them related to service. However, it does obtain information from
other sources on issues, even though this would not necessarily provide
information on precipitating events for individuals to making a claim:
DVAs picture of the mental health
state of young veterans continues to be improved by the following:
-
findings of the
Gulf War Study and the Pathways to Care Research Project;
-
presentation of
young veterans to the Vietnam Veterans Counselling Service;
-
closer liaison
with ADF on health issues such as mental health, alcohol and substance misuse;
-
participation in
and representation of the APPA in forums, such as the DVA National Younger
Veterans Consultative Group and the DVA Alcohol Management Health Promotion
Working Group;
-
the Transition Management
Service including the Defence Transition Pilot Scheme involving VVCS in
Townsville which is providing assistance to those exiting the ADF and will also
provide information about needs and ongoing assistance required by young
veterans; and
-
ACPMH collaboration
with the ADF on development of a postdeployment adjustment program from which
further knowledge will be gained about the needs of young veterans.[316]
3.32
DVA is also able
to obtain information from services required by veterans which can help identify
needs and ascertain if services are appropriate:
Through the structure of the Medical
Benefits Scheme a specific item number is used to identify the service accessed
by a veteran. This item number also specifies the fee payable to the service
provider. HIC collects this data which is transmitted to DVA on a daily basis.
Through DVAs Departmental Management Information System the data can be
manipulated to analyse usage and treatment trends.[317]
3.33
The limited
information which may be available on a veterans file can be enhanced,
although, again, much of this is unlikely to provide evidence of specific
causal factors. Additionally, there are limitations to the access of some data
on the grounds of privacy and data integrity,[318]
although data from research projects and AIHW will also help to identify needs:
The Department of Veterans Affairs
(DVA), however, does obtain data from the Australian Institute of Health and
Welfare on disorder prevalence in the community.
The prevalence of various disorders for
groups of veterans is being studied by DVA through research projects
commissioned by DVA that deal with specific conflicts, such as the Gulf and
Korean wars. DVA also conducts a Survey of Veterans, War Widow(er)s and their
carers every three years that collects data on selfreported disorders. The
last survey was conducted in 2003.[319]
3.34
In addition, with
the development of programs to address mental health and related issues, DVA
has provided training to staff which can aid them in assisting veterans:
-
State Offices
have conducted various customer service training sessions that encompasses
awareness of mental health issues;
-
training provided
to Departmental claims and assessment officers incorporates information of the
diagnostic criteria of a range of psychiatric and related conditions;
-
a resource
booklet available to staff and managers provides information and guidelines on
how to respond to clients who present with challenging behaviours including
mental health and related problems;
-
professional
staff of the VVCS have the opportunity for professional clinical development
through training and external supervision; and
-
The Mental Health
Policy Unit of DVA is formulating a strategy for improving mental health
literacy that will include a consideration of the needs of DVA staff.[320]
Effects of lack of data collection
3.35
The lack of data
collection in the past reflects the limitations of previous eras including
awareness of the fact that there may be long term outcomes of various events.
It also reflects the absence of information and technologies which increased
awareness of the effect of substances and had the capacity to measure these.
Referring to the Amberly deseal/reseal program, the ADF noted:
We should, in a
perfect world, have quite highfidelity data on the risk exposure for an
individual, but I put it to you that that is extraordinarily difficult.
3.36
Notwithstanding
these limitations, there have been some efforts to obtain information on levels
of exposure to substances in past events such as Hiroshima and Nagasaki and the series of bomb tests undertaken by various
countries at which both defence and civilian personnel were present. With
respect to Australian veterans, DVA has been involved in such measures,
including the use of dosimetry at Maralinga and other test sites:[321]
There
are some difficult elements associated with the estimation of dose which the
scientific advisory committee have suggested that we should look at, and in
relation to that work there is still some ambiguity about exactly how long that
work will take.[322]
3.37
Available
information on likely radiation exposure in Japan at the end of World War 2 has also been assessed:
In
the case of BCOF,[323] they said, We
accept fully that radiation causes these cancers; there is no doubt about that
at all. For our veterans who were in Nagasaki they will be covered by the RMAs statements of
principle and compensation will flow to them. But for our Hiroshima veterans, despite our best efforts, we cannot
get within several orders of magnitude enough exposure to allow compensation to
flow. The level of science was not just at the margin, it was really quite a
bit away. They did so looking at water, food, beer...
I
should also say that the BCOF veterans are a group of veterans that do actually
have some health problems that we need to carefully consider. There were quite
a lot of them exposed to mustard gas and quite a few of them were exposed to
psychological stresses, and we do very carefully make sure that all of our
statements of principle recognise BCOF service. Various infective agents which
are only found in southern Japan are put into the statements of principle to make
sure that the BCOF veterans are covered. But with respect to radiation,
although we have been together on a path of exploration for some years, Ken maintains there was enough radiation and our
best expert advice is that there was not enough radiation.[324]
3.38
Thus, there may
well be instances in which what might be called retrospective collection of
equivalent data will provide valuable information. Such technology as is now
available can use a range of data to recreate or model various events such as
exposures[325] (although this may not
always be to the satisfaction of veterans):[326]
Our
experience with Vietnam was that at the time we did not know that dioxin was going to be a
problem, but because we had pretty good unit records, in some cases it was
possible to go forth and construct a model of exposure. This was done in the royal
commission, and one of your previous committees also attempted to do that. You
can get a proxy model for exposure. It might also be important to keep things
like geographical information in addition to the medical information.[327]
3.39
The Repatriation
Commission has also outlined the processes it undertakes in respect of specific
events, although these will not necessarily assist every individual:
A
veteran who comes along with a compensation claim will say, I experienced a
murder, or, I saw atrocities, and that sort of information is not keptor is
very rarely kepton their central medical record. In fact, the usual thing is
for a veteran exposed to such a traumatic event not to tell anyone about it for
some time.
We
have a range of mechanisms in place for our people to go out and test the
veracity of those sorts of statements. They include looking at patrol records
and speaking to other members of the unit. There are a variety of mechanisms
that we use to train our people to work out whether or not something was the
case. There are obviously some cases where it is manifestly selfevident: if POW
J says he saw people being killed, it is evident that he did.in some
situations, particularly those involving, for example, naval deployments to
Vietnam, where whole ships companies may have been in the same spot at the
same timeand contained in a metal ship, in the mainwe have in the past made a
practice of seeking an expert historians advice. As you would be aware, that
has caused some ripples from time to time. But fundamentally it is our
responsibility to investigate each claim and, if it is a legitimate means of
inquiry, to ask a historian to assemble the ships logs and the facts and
compare the evidence introduced by the claimant against that. I think that is
fair enough.[328]
3.40
Some of the
processes which are now in place with deployments should overcome these
problems through personnel being asked to identify issues or events
experienced, prior to their return. This process will not necessarily provide
full details or recollections, nor may all personnel choose to provide this
information, but it is one means of identifying potential problems and working
to overcome these.
3.41
Other instances
of absence of information do not require such detailed assessment of the past,
although administration changes may be required in order to ensure that full
deployment event records are available. As was stated above, the practice of UN
hospitals retaining records[329] has
been a problem in the past, but should be overcome eventually if copies of
hospital information are provided or electronically mailed to a source such as
HealthKEYS or EpiTrack.
Nominal rolls
3.42
The nominal rolls
for various conflicts have been the source of some dissatisfaction among
veterans because the absence of these can delay research and the making of
claims. The nominal roll for the British nuclear tests, although suggested by
the 1985 Royal Commission, was not completed until fourteen years later.[330] There is still no BCOF roll, and one
is unlikely as there has not been any separate listing of Service personnel
during the period of service which would specifically define [members].[331]
3.43
Research on the
Korean War was delayed also because of the need to establish a nominal roll.
3.44
Ascertaining the
reasons for delay of such processes is difficult, but the main reasons are
likely to be the absence of relevant information and the lack of staff and
other resources. A further factor may be the absence of perceived needDVA
notes that Korean War veterans specific concerns were only established some
six years ago:
Until about six years ago, the Korean
War veteran community did not raise any specific need for such studies. When
the community raised this issue, Government responded promptly to their needs,
and began preliminary work, such as the construction of a Nominal Roll. Once
this was completed, the Cancer Incidence and Mortality studies were completed. [332]
3.45
However, the same
factors may also reflect an earlier more reactive than proactive approach both
to research and to the identification of needs of particular groups. While it
may be the case that Korean veterans have only recently raised issues, it could
also be said that the Vietnam experience much later almost forced the awareness of
many specific problems and development of services to meet these.[333] Applying the same principles to
other conflicts and undertaking relevant research is an appropriate task for
the department, and one that is now much more likely to initiate.
Better coordination and management through the Links project
The
program has been under way for some years, and it is motivated by two things.
One is that the Department of Defence and the Department of Veterans Affairs,
by working more closely together, can hopefully achieve more effective services
for serving personnel and veterans and more cost-effective services for the
taxpayer. It is also motivated by an understanding that, as the World War II
population passes on and Veterans Affairs scales down to some extent, it needs
to have a clear view about its future in the defence family, and that requires
ongoing attention.[334]
3.46
The current components
of the Links project include the Defence/DVA Medical Advisory Panel (MAP) which
has a review, coordination and assessment role in elation to health,
rehabilitation and compensation matters:
The Defence/DVA Medical Advisory Panel:
-
Coordinates the
examination of health issues emerging from Defence operations;
-
Assesses the
state and direction of research, identifies gaps and recommends joint
Defence/DVA research directions and priorities;
-
Reviews patterns
of injury, disease and compensation claims from current and retired members of
the Australian Defence Force to provide direction on appropriate joint
preventive health responses, including rehabilitation;
-
Reviews outcomes
of joint health care trials and health care provision arrangements;
-
Provides advice
on health monitoring and healthrelated data collection activities;
-
Reviews joint
Defence/DVA health training and education; and
-
Develops linkages
with organisations in the provision of military and veteran health.[335]
3.47
It also includes
the Transition Management project, which is to improve the transition from
military to civilian life for ADF members; the Mental Health Focus Group;[336] and Records Management which has as
an objective the more efficient management of data contained in personnel
files.[337]
3.48
These projects
have the capacity to streamline management and administration especially
through limitation of duplication, including of research, and facilitation of
greater awareness of DVA services by ADF members.
3.49
Some of the
duplication or ineffective management that currently exists arises from factors
beyond the control of either departmentfor example, the scattered information
that comprises ADF health records, and the tendency for former members to seek
records from DVA when they already have much of the available material. There
is also recognition that with improved information gathering, services can be
more proactive than reactive:
Threat
identification and investigation has shown that both of the organisations are
very highly motivated to adopt a much more proactive approach to health related
issues rather than the traditional reactive approach.[338].
3.50
DVA also has
links with other departments, such as the Department of Health and Ageing,[339] both in the management of projects
and in limiting duplication of research:
DVA has close links with the Department
of Health and Ageing though involvement in major research projects such as the
Coordinated Care Projects.
DVA operated a research grants program
up to the round that commenced in early 2004. This program is being phased out
in order to free up resources for more commissioned research. Individual grants extend over a three or four
year term.
The grants program was advertised
nationally, as a component of the NHMRC research grants program, and
applications were submitted in the first instance to the NHMRC for scientific
evaluation. This prevented duplication between the two agencies.[340]
Dissemination/discussion of information
Limited investigation of claims
3.51
The Regular
Defence Force Welfare Association advised that one particular problem for
claimants was a failure by DVA to identify any material lacking in a claim
prior to consideration:
The delegatealmost never identifies
deficiencies in the information supplied in support of the claim, and seeks to
have them rectifiedas he/she might, if genuinely investigating itand almost
never contacts the claimant or his/her representative to advise of any
problems that are likely to arise as a result of deficiencies in information
supplied.As a result, the onus is always on the claimant to supply whatever
information he/she imagines the delegate will need to consider the claim fully
and fairly.[341]
3.52
This problem was
identified by the organisation as arising from a number of administrative
factors, including:
-
A lack of knowledge
and experience on the part of the primary decisionmakers
-
The general lack
of understanding of the circumstances of military service likely to have been
experienced by veterans.[342]
3.53
While the first
may be true, primary decision makers generally work to a guide as to key
factors which must be present, and this helps limit adverse effects of
inexperience. Nonetheless, it is possible that pressure to complete claims quickly
and a need to remain separate from the claimant may result in required
information not being asked for after the claim has been lodged.[343] DVA advises claimants that they
should get assistance in completing the form, and that staff may also help,
with Form D2582 (Claim for Disability Pension)[344] noting at the beginning:
You are strongly encouraged to seek the assistance of an
exservice organisation of your choice in lodging this claim. An exservice
organisation should be able to provide you with advice on how the factors
identified in the Statements of Principles may apply in your case.
Assistance from
Veterans Affairs
Veterans Affairs staff can also help you to
complete this form.
Note: It would be to your
advantage to have each condition you are claiming properly diagnosed prior to
completing this form. This will help to prevent delays in the time taken to
process your claim.
The Basis for decisions
The decision on whether your disabilities are
service-related is based on uptodate medical and scientific evidence. This
information is detailed in the Repatriation Medical Authoritys Statements of
Principles.
If your claim is for a condition not included in the
Statements of Principles, it will be determined based on the best scientific
and medical evidence available.[345]
3.54
The second factor
(lack of military experience on the part of the assessor) should not be
relevant, as the form is designed to elicit the required facts, many of which
are to be completed by a medical practitioner. The lack of military experience
may be more relevant for the RMA, although only one example has been explicitly
identified.[346] The Committee has
suggested that there should be some input from the ADF to address any such
concerns.
3.55
However, because
of the complexity of the RMA SOPs, and a not particularly user-friendly RMA
website, it is possible that claimants, ESOs and medical practitioners have
some difficulty in obtaining relevant information about causal factors. While
SOPs are necessarily written in terms of a specific disorder, the View by
Category[347] approach, and even the
alphabetical listing available, do not provide the claimant with a readily
understandable guide or indicate the relevance of particular causal factors.[348] As a preventive approach, it may be
useful to indicate what disorders have been linked to causal factors to alert
individuals to potential health problems.
3.56
Although the
United States DVA list of compensable disorders[349] may require less specific links to
service, the fact that it lists these disorders under specific conflicts must
assist claimants in determining if they are eligible. It is a good model which
could be adapted if only as a laypersons guide to the SOPs.
3.57
A third issue was
the extent to which claimants might be encouraged to apply for assistance
citing an approved illness if there was currently no SOP which recognised
their real disorder. The Regular Defence Force Welfare Association Inc. noted
that often claimants might try to secondguess what the assessor was looking
for, but distinguished this from fitting or adapting the facts about
the circumstances of a claimants service to fit the decision-makers
requirements.[350] In the specific
case provided in a submission, the claimant was clearly frustrated by the lack
of a formal recognition of disorders such as Gulf War syndrome or the effects
of multiple environmental and other exposures. A related frustration was the
belief that what he perceived as disorders with a physiological basis were
being transformed into psychiatric problems, and that departmental staff
encouraged veterans to apply citing a psychiatric disorder.
3.58
As noted above,[351] there remain difficulties with the
formal classification of some symptoms, but this in itself does not prevent the
Repatriation Commission being able to provide access to treatment. Where there
is a possibility that a veteran is experiencing PTSD there is no wrongdoing on
the part of the department in suggesting a claim be made under this, since the
claim will need to be supported by medical evidence and meet the SOP standards.
Updating
of RMA Standards of Principles
3.59
Some submissions
stated that the RMA was either not up to date or needed to review all present
medical standardsfor authenticity and relevance to the illnesses which Service
personnel may encounter during their overseas service.[352] However, the RMAs workload is
likely to be such that it is unable to meet all needs for revision, and it does
continually update SOPs. In addition, it receives advice on areas of need:
In terms of the RMAs determination of
its priority for the consideration of SOPs, DVA keeps the RMA informed on the
frequency with which medical conditions are the subject of claims under the
Veterans Entitlements Act.[353]
Distribution
and discussion of information
3.60
Notwithstanding
the publication of detailed bulletins and updates and good websites provided
both by Defence[354] and DVA, many of
the issues affecting veterans are perceived by them as not being discussed
openly or in detail:
The first recommendation of the Australian Gulf War Veterans Study 2003 was that:
There should be wide promotion of the
study findings to the veterans and service communities, the Departments of
Defence and Veterans Affairs, the Repatriation Commission
To date, some six months after the
release of the Study, there has been no Government Response as to how this
recommendation is to be implemented. We consider that some action is required
to target veterans and their providers in the dissemination of this knowledge
and that the mere placing [of] the report on some departmental website does not
go far enough in implementing such a recommendation. The fact that only two
hard copies of the report were provided to this Association and that additional
copies could only be obtained at some significant cost are indicative of a lack
of wide promotion.[355]
3.61
Other submissions
have noted that in some instances there has been little information provided
which could assist personnel to identify potential problems.
In the case of environmental exposures,
however, a notated list of possible exposures are recorded on the ADF members
file with little or no detail as to level of exposure or risk to health Although
deployment on specified operations preclude reporting to Comcare as the
regulator, Defence still has the requirement under the Act [Commonwealth
Employees Occupational Health and Safety Act] to raise and retain specified
records. In the main, the Federation does not believe this is occurring.
recent discussions by Federation staff
with East Timor veterans identified that many of them were unaware of many of
the chemicals and substances which were known by Defence to be present in the
area of operations. Although it is accepted that many of these hazards did not
become apparent until personnel were incountry, subsequent briefings and
information have not been forthcoming or adequately recorded for future reference.[356]
3.62
Another
submission referred to the anthrax vaccination controversy in stating that
Defence must be pro-active in providing accurate health information, and
that, because of greater community awareness of environmental hazards and
illnesses which may take a long time to develop or present as a cluster of
inexplicable symptoms, it is understandable that veterans are concerned that
they may be susceptible to a new or unexplained disease caused by their
exposure in a hazardous environment.[357]
3.63
Concern was also
expressed about the lack of aggregate data on earlier deployments:
when
men who have served in the various campaigns and deployments, going right back
to the Vietnam days, come to lodge claims for compensation or reviews of
entitlements arising out of matters which they think relate to their service
activities, they often come up against the almost impenetrable wall of privacy.
I do not say that is necessarily a bad thing, but it is a problem in the field
for people supporting their claim, because they cannot get access to extra or
comparative or aggregate information. So that is a problem, but you say it is
being attended to.[358]
3.64
Generally, these
issues suggest that there is concern about both a lack of pro-active strategy
which either advises of potential hazards in advance or as soon as these are
known, and the lack of recognition of various health problems that individuals
and groups attribute to deployments. Disorders, such as gulf war syndrome and,
previously, chronic fatigue syndrome may not be classified as a distinct
disorder,[359] with only some
symptoms being apparent. Although longerterm outcomes are measured, these
depend on all medical presentations from each deployment.[360] Not all injuries may have been
notified either during or immediately after deployments, and the significance
of these may not be understood:
It
is always difficult to determine what is a legitimate syndrome and what is an
imagined syndrome based upon legitimate feelings.[361]
3.65
In these
circumstances, it is the individual or group which is likely to be
disadvantaged because there is no formal acknowledgment of the illness even
though its effects may be substantial. This situation is understood by DVA,
with reference previously being made to the availability of treatment in some circumstances
for symptoms which are not yet a disease.
3.66
There are
numerous other instances of delays in awareness of health issues, such as the
recent investigation into the reseal/deseal of F1111s at Amberley. Bearing
in mind that there will be occasions when several years of assessment reveals
limited causal connection with illness, there may be room for a much more
pro-active strategy of information about health issues. Although there is good
information available on research projects, and DVA believes that many veterans
are aware of these,[362] perhaps more
effort is needed to advise of research that has been undertaken in Australia
and elsewhere on the range of concerns that currently serving members and
veterans have, to provide readily comprehensible data on these issues, and to
develop information strategies which include more personal contact. Although
DVA may believe its role will decline with the passing of World War 2 veterans,
there appears to be a demand from an informed audience for a continued level of
service.
3.67
Where there is
other physical evidence of injury, disease or exposure to events the individual
may need still to take the initiative in documenting this until such time as
processes are in place for institutionalised collection of data. It is also
possible that keeping veterans up to date on information about particular
issues may help allay some concerns. One example is exposure to depleted
uranium (du) which has caused some
concern, although evidence provided by the ADF indicates that exposure to this
in the 1st Gulf War was limited as Australian forces were primarily
naval where the risk of exposure was limited.[363]
3.68
Notwithstanding
the fact that neither Defence nor DVA see du
as likely to be a major problem in the future, it will continue to be a problem
for some if the reasons for this belief are not clear. The relevant ADF Health
Bulletin provides explanations,[364]
but it also notes some changes in the previous assessment made by the RMA which
considered du in the context of the
Balkans conflict:
in reaching its view, the Expert
Committee made various assumptions about background radiation levels in the
Balkans region. These assumptions may not have been entirely relevant to the
Gulf and Iraq
regions. It is no longer safe to assume that the risks to health are as low as
previously thought; however, the level of risk to Australian troops is still
likely to be low.[365]
3.69
For Australian
veterans, who do not appear to have experienced such levels of exposure, there
may be very limited risk. If this is the case, it may be useful to ensure that
a summary of US studies is made regularly available on the internet so that
individuals can assess their levels of exposure against those persons who are
the subject of study. As much the same information is available in the abovecited
Health Bulletin, this should not create excessive additional work and would
demonstrate the appropriate level of interest in the well being of those no
longer serving.[366]
3.70
The United
Kingdom Ministry of Defence also has substantial information on the Gulf War
and related issues, which outlines in detail the research being undertaken, the
discussion of various illnesses, and the situation with respect to claiming a
war pension for symptoms as opposed to a disorder.