The Independent Medical Expert Group (IMEG)
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The Independent Medical Expert Group (IMEG) Report and recommendations on medical and scientific aspects of the Armed Forces Compensation Scheme December 2017 From: Professor Sir Anthony Newman Taylor Chair Independent Medical Expert Group 6.A MOD Main Building Whitehall LONDON SW1A 2HB United Kingdom Telephone (MOD): +44 (0) 20 7218 9571 A Non-Departmental Public Body Facsimile(MOD): +44 (0) 20 7218 9473 Sponsored by the Ministry of Email: [email protected] Defence 5 December, 2017 Minister of State for Defence Personnel and Veterans Ministry of Defence Whitehall London SW1A 2HB Dear Minister, I have pleasure in submitting the Fourth Independent Medical Expert Group (IMEG) report. IMEG was set up in 2010 on the recommendation of Lord Boyce’s review of the Scheme and became a Non-Departmental Public Body (NDPB) in 2012. It continues to provide you with medical and scientific advice on the AFCS ensuring it reflects contemporary understanding and meets the needs of Service personnel. Topics for the Fourth report have been suggested by claimants and their supporters and a number of issues were referred for IMEG comment as a result of the 2016 Quinquennial Review (QQR) of the Scheme, published in February 2017. At this date from the end of hostilities in Afghanistan, claims in the scheme increasingly reflect injury and disorder sustained during sport, and adventure training. Since 2010, IMEG members have made visits to the Defence Medical Rehabilitation Centre (Headley Court), Hasler Company, and most recently to the Personnel Recovery Unit ((PRU) at Colchester). These have provided valuable insights into the priorities and perspectives of Service personnel. 1 The approach of IMEG to investigation of topics has been to identify and appraise the relevant evidence, reviewing the published peer-reviewed international literature as well as discussing topics with recognised military and civilian experts. For this report IMEG has considered the medical and scientific aspects of the MOD Radiation Policy Statement. Originally published in 2003, the present revision reflects the significant number of major revised reports published by the World Health Organisation (WHO) and the UN as well as by the Advisory Group on Ionising Radiation of the Health Protection Agency (now Public Health England) on the adverse health effects of ionising radiation. New work since 2003 includes further analyses of the Japanese atomic bomb survivors and a series of international studies on radiation workers. The new Policy Statement includes a list of radiogenic disorders including cancers as well as coronary artery disease, stroke and cataract. The largest single category of claimed disorders under AFCS are musculoskeletal disorders (MSK) including low back and neck pain. On investigation of these in most cases, there is no serious underlying pathology present but they can be very disabling. Aware of the confusion over the causes of non-specific back pain and how it should be treated, we have taken opportunity to include comment on the epidemiology of low back pain and its best practice clinical management. Other topics include hip pain and MSK disorders in recruits. Because of its size and importance Part 2 will consider pain and pain syndromes as well as diagnoses especially common in military populations such as shin splints, compartment syndrome, stress fracture. Traumatic brain injury (TBI), particularly mild TBI (mTBI), considered in the US, the signature injury of recent conflicts was referenced in the second (2013) IMEG report when the many gaps in understanding were noted. The then Minister asked us to keep the topic under review and, as appropriate, provide updates. This report includes the first of these. mTBI is not limited to conflict situations but is relevant to peace time activity including sporting accidents, adventure training, road traffic accidents. The resultant paper is very full and includes sections on audiovestibular and psychiatric effects. Opportunity was also taken to amend Table 6 brain injury descriptors. This was less about an increase in Tariff awards or new descriptors as clarification of existing descriptors. We concluded that although advances were being made in mTBI, there remain many unresolved issues. In particular there is yet no robust method of early identification of cases likely to develop persistent disabling symptoms. For the first time, this report includes two sections which we hope will be of particular interest to scheme medical advisers and decision-makers. These are the concept of “worsening” and some proposals for a medically sound understandable approach to “spanning” cases, cases where a person has served both before and after 6 April 2005 and eligible to claim under both schemes. The adoption of a balance of probabilities standard of proof in AFCS was not without controversy. Under the War Pensions Scheme (WPS) any disorder which first presents in service is likely to be accepted unless there is positive evidence that 2 there is no causal link to service. For epilepsy, and most cancers which sadly can arise in fit young people, that means war pensions entitlement will follow. For the AFCS lack of evidence of a causal link will mean rejection of the claim. This apparent discrepancy was raised with Lord Boyce in the 2010 AFCS Review and in response a category of “recognised diseases” was developed in AFCS. In successive reports we have looked at a range of disorders. In this report we considered ultraviolet light and skin cancers seeking evidence that ultraviolet exposure in AFCS service is consistently associated with an increase in frequency of the disorders and that there are circumstances where the risk is more than doubled. This makes it more likely than not that the case was due to a service cause. In that situation claims can be accepted as presumed due to service, without case specific investigation. The particular focus of the investigation was cutaneous malignant melanoma which is relatively common in working age adults in UK today. The evidence is that none of the established risk factors for skin melanoma is likely to be due to AFCS service. Claims will still be considered on their individual facts but are likely to be for rejection. We noted the publication in June 2017 of a short report from the Medical Research Council (MRC) Lifecourse Epidemiology Unit at Southampton recording an unexpectedly high proportion of deaths from multiple sclerosis among men whose last full-time occupation was in the UK Armed Forces. This was observed over the last three decades. No explanation is presently available but the only published military longitudinal study does not support the finding. We will continue to investigate. In 2016 a QQR of the scheme took place with report published in February 2017 when a number of issues were referred for IMEG comment. For the most part these were matters of clarification rather than proposals or recommendations for new or expanded approaches. Topics covered included infectious diseases and Zika virus, gender differences in award rates, a series of features of the scheme including permanence, interim awards, worsening and spanning. The team also asked for comment on medical aspects of an Exceptional Supplementary Award (ESA) and reflecting a key current concern for the military and wider communities, there were questions on mental health. In particular there were representations that the highest available award should be level 4, with a corresponding 100% Guaranteed Income Payment (GIP), paid from service termination or if a post service claim, from date of claim, for life. A GIP is a reduced earnings allowance paid to those with more serious disorders likely to have a direct adverse effect on civilian employability. IMEG looked closely at this issue for the 2013 report concluding then that for mental health disorders likely to be accepted as due to AFCS service, permanent complete incapacity for any kind of civilian work would be very unlikely, and so the highest award in the current scheme is at level 6 with a GIP based on 75% salary at service termination. There is currently much activity in mental health including in NHS UK enhanced service delivery arrangements, including for veterans, and revision of best practice treatment guidelines and classifications systems for mental health disorders. A new edition of the US classification, DSM V was published in 2014 and ICD 11 is due next year. It is already known that proposed diagnostic criteria for the same disorder are different in both classifications and from earlier editions of the same system. All this is subject to much senior clinician debate. We had the opportunity both to study 3 the literature and speak with some of the UK’s leading clinical experts and academics with an interest in traumatic psychological injury. As a result we propose a new Tariff 4 award. The descriptor is detailed and aims to reflect the rarity of circumstances where a higher award is appropriate. Reflecting the clinical evidence including the opinions of senior clinicians, we do not think level 4 awards, directly due to attributable mental health disorder, will be common. All IMEG members took part in our discussions and agreed the findings and recommendations. I believe these fairly reflect the contemporary evidence and are in line with scheme intentions. Since publication of the last report several members have left the group. I am sad to report the death of Lt Col Jerome Church OBE, who died suddenly in the US in July 2016. Jerome with his enormous expertise and experience, great humanity, unfailing good humour and sense of fairness made an enormous contribution to the group, as the representative of the charities. I am also indebted to Major Steve McCully RM, AFCS award recipient member who has left the Service and to Brigadier Hugh Williamson, HQ Surgeon General observer, who came to the end of his tour.