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Health Matters
Four Year Report 2005-08
Gibraltar Health Authority
Index
1. PUBLIC HEALTH AND HEALTH PROMOTION
1.1. VITAL STATISTICS
1.1.1.
1.1.2.
1.1.3.
1.1.4.
1.2.
1.3.
1.4.
1.5.
1.5.1.
1.5.2.
1.5.3.
1.6.
Population
Births (See Tables 1.1 to 1.4 in the Appendix)
Life expectancy
Deaths (See Tables 1.5 to 1.10 in the Appendix)
Infectious diseases
INFECTION CONTROL
IMMUNISATION
HEALTH PROMOTION
No Smoking Day, March 2005
Diabetes Awareness Day, September 2005
Head Lice
Public Analyst Report
2
2
2
2
2
2
4
8
9
10
10
10
15
17
2. PRIMARY CARE SERVICES
20
2.1.
2.2.
Primary Care Centre
Dental Services
20
21
SECONDARY CARE SERVICES
23
3. 3.1.
3.2.
3.3.
3.4.
3.5.
3.6.
3.7.
3.8.
Ambulance Service
General Medicine
Paediatrics
Operating Theatre And Day Surgery
OPTHALMOLOGY SERVICES
ENT SERVICES
MENTAL HEALTH SERVICES
Palliative Care
23
23
24
27
27
30
31
32
4. DIAGNOSTIC SERVICES
34
4.1.
4.2.
Pathology Services
Diagnostic Imaging Services
34
35
5. THERAPY SERVICES
37
5.1.
5.2.
5.3.
5.4.
5.5.
Physiotherapy Services
Occupational Therapy
Speech And Language Therapy
Department Of Nutrition And Dietetics
Pharmacy
37
37
38
40
41
6. NURSING
43
7. EDUCATION
49
7.1.
School Of Health Studies
49
8. MANAGEMENT
51
8.1.
8.2.
8.3.
8.4.
8.5.
8.6.
8.7.
8.8.
8.9.
Bed management
Sponsored Patients
Patient Advice And Complaints Office
Human Resources
Medical Records And Reception
Catering
Information Management And Technology
Procurement And Supplies
Technical Services Department
51
51
52
53
54
55
55
57
58
9. FINANCE
60
Foreword by Minister for Heatlh Yvette del Agua
1. PUBLIC HEALTH AND HEALTH PROMOTION
comprehensive, easier to follow report, which will
allow the reader to obtain a better and more detailed
insight and analysis into the activity of our Health
Service.
Change is always unsettling, and the last 4 years
have brought about tremendous change to the
GHA in terms of the move to the new hospital, the
introduction of new medical services, new surgical
techniques, and new policies and procedures.
It takes enormous effort on everyone’s part to deliver
the many and varied services that this Government
has tasked the GHA with providing to a community
of our size, and to deliver them to the high standards
that this discerning community rightly expects. It is
indeed a huge moral and professional responsibility
to be entrusted with the health and sometimes the
lives of others.
And in our eagerness to deliver these improvements,
in the time-consuming and sometimes frenetic
routine of care delivery, in the desire to meet the
high expectations of our service users, it is very easy
to take those who deliver the services for granted,
the vast majority of whom are hard-working
and committed individuals. I therefore take this
opportunity to pay tribute to Management and Staff
for their cooperation and support throughout this
important transition period.
The period spanning this report has been an exciting
and challenging time for the Gibraltar Health
Authority. It covers the first 4 years of activity within
the new St Bernard’s Hospital.
The last Annual Report was published in 2005 and
covered the previous year’s activity. A decision was
taken at the time to delay further annual publications
and to produce a report covering a 4 year period.
In so doing, it gives us an opportunity to present
a consolidated report of the numerous changes
that have occurred since the new hospital opened.
Another determining factor in the decision to move
away from annual reports is that better perspectives
of trends can be gained by studying events over a
longer period taken together, bearing in mind also
that small numbers are easier to analyse when pooled
over a number of years.
The objective is to provide the public with a more
4
Looking towards the future, there are challenging
times ahead as the GHA gets ready to implement the
Government’s remaining manifesto commitments.
I am the first to acknowledge that the GHA is
not perfect, no medical facility in the world is.
Management is not perfect, the staff is not perfect
and I as Minister responsible am certainly far from
perfect. Our collective aspiration, however, is to work
together to bring about even more improvements
and advancements, on the part of all of us, and for
the benefit of all of us, because at the end of the day
we are all users and therefore beneficiaries of our
health service.
But even whilst we continue to work towards
that aim, I am confident that the majority of this
discerning community knows how to appreciate
and be thankful for what we have: a health service
which, as evidenced by the breadth and scope of this
report, compares extremely favourably to that of any
comparable community of our size.
5
The numbers of babies born in Gibraltar in the last four years
were 410 (2005), 365 (2006) 398 (2007) and 397 (2008)
1.1 VITAL STATISTICS
1.1.1 Population
The civilian population of Gibraltar has continued to
grow slowly but steadily in the last decade. The estimated
end-year population on 31 December 2008 was 29,286
according to the Government Statistics Office. Previous
estimates had been 28,779 (2005), 28,875 (2006) and
29,257 (2007), which together represent fairly modest
increases from year to year.
The overall increase since the last Census (2001) is around
6.4%. Most of the growth has been in the Gibraltarian
male population, particularly children and adult males. In
contrast there has been a small but significant decline in
the Non-British population.
1.1.2. Births
(See Tables 1.1 to 1.4 in the Appendix)
The numbers of babies born in Gibraltar in the last
four years were 410 (2005), 365 (2006) 398 (2007)
and 397 (2008).
In contrast to several large European countries, Gibraltar
has generally enjoyed relatively high birth rates.The Crude
Birth Rate for the last decade averages at 12.63, a figure
only bettered among 27 European nations by France and
Iceland. However, during this period, the overall trend
has been a gentle decline in the crude birth rates of the
resident population, from 2005 (14.25%), 2006 (13.1%)
and 2007 (12.6%) to 2008 (12.6%). The specific birth
rate for the Forces population, which is demographically
younger, tends to be around 20.
Male births predominated until 2002 but since then
the position has see-sawed. Curiously, females have
predominated in all even years, 2004 (52.9%), 2006 (51.2%)
and 2008 (53.1%), whereas males have predominated in
odd years 2003 (51.5%) and 2005 (52.7%), although in
2007, the sexes were exactly equal (50%).
The vast majority of births took place in hospital, with
only one home birth in 2008. On average, the resident
population accounted for around 92% of all births, the
balance being births in the Forces population. Two still
births occurred during the last four years, both in 2006.
The number of teenage girls becoming mothers each year
has hardly changed in recent years and continues to be
a matter for concern. The number of births in teenage
mothers continued to remain at the now familiar levels in
2005 (23) and 2006 (20), but rose sharply to 28 in 2007,
the highest in the last ten years, before returning in 2008
to 22. For many years, Gibraltar’s youngest mothers have
been aged 15 or more, but in 2004 and 2006, mothers
aged 14 appeared for the first time. Of the 93 teenage
pregnancies occurring in Gibraltar from 2004-2008, four
occurred in the Forces population, two (2005), one (2006)
and one (2007).
At the other end of the spectrum, women aged 40 years
or older gave birth to 14 (2005), 12 (2006) 10 (2007) and
9 (2008) babies respectively. However, during the five-year
period 1999-2003, the average age of the oldest mother
was 44, while during the five-year period 2004-2008, it
Cancers are the dominant cause of death in persons under 70, the occurrence being about
1.7 times more than in the general population.
was 46.8, suggesting a trend towards more older women
having babies.
The general health of babies born continues to be good
with only small proportions of babies born with birth
weights below 2500g. In 2005, there were 19 (4.6%) low
birth weight babies, rising to 21 (5.7%) in 2006 and to 30
(7.5%) in 2007, before falling to 23 (5.8%) in 2008. The
average weight was generally stable, around 3300 grams
(7lb 5oz), with nearly 30% of births falling within 5% of
this figure.
1.1.3 Life expectancy
Longevity in Gibraltar has generally been good
in recent years with the Census 2001 estimates
showing life expectancies of 78.5 years (males) and
83.3 years (females).
The mean age of death in the resident male population
was 72.4 years (2005), 74.9 years (2006), 74.6 years (2007)
and 73.7 (2008), while that of the female population was
81.7 years (2005), 79.6 years (2006), 82.7 years (2007) and
83.3 (2008).
The life expectancy at birth is generally very good
in Gibraltar. In 2005, one non-resident baby died of
extreme immaturity; in 2006, one resident infant died just
before his first birthday of congenital heart disease; and
in 2007, one resident baby died at 8 months from spinal
muscular atrophy. All three babies had conditions that were
incompatible with sustained life.
1.1.4 Deaths
(See Tables 1.5 to 1.10 in the Appendix)
There were 239 deaths in the resident population in
2005, giving a crude death rate of 8.3, roughly similar
to that of previous years. In 2006, 229 deaths occurred
in the resident population, representing a crude death
rate of 7.9, roughly similar to that of previous years.
However, in 2007, the number of deaths in the resident
population fell dramatically to 197 and then in 2008 to
194, giving a crude death rate of 6.5 for 2008, the lowest
in the last decade.
It is thus seen that the death rate is progressively declining and
the total number of deaths in each of the last two years has
been less than 200, a figure unprecedented for many years.
In addition to the above, the Registrar of Births and Deaths
also records the deaths of non-residents in Gibraltar, of
whom there were 13 (2005), 7 (2006), 7 (2007) and 4
(2008). These are usually tourists or seafarers.
“Premature deaths” is a loose term applied to deaths of
persons under the age of 70 on the logical assumption
that any person who dies at an age that is at least a full
10% below average life expectancy, should be regarded as
having died prematurely. It is usually good practice to pay
6
special attention to these deaths as they may give some
indication of avoidable mortality.
Of the 854 people who died during the period 20052008, there were 177 (20.6%) who did not live to see
their 70th birthday, a figure that society should regard as
a loss to society. However, the most striking feature of
this group is the gender contrast, with only 58 women
(12.5% of all women) dying before their 70th birthday, in
contrast to 119 men (30% of all men) failing to reach this
landmark. Put starkly, for every woman who dies young,
2.5 men die young. When the bar is lowered to 50 years,
the differences widen further. During the same period,
only 10 women died as against 32 men, giving a ratio of
3.2 men for every woman.
Similarly, throughout the 2005-2008 period, the gender
patterns for deaths in the over-70s too show the same
consistency. Typically, after the mid 60s, the death rate for
men rises sharply to peak in the late 70s, falling gradually
thereafter, with very few men still alive in the 90s. On
the other hand, the death rate for women does not rise
until the 70s, peaks in the late 80s and falls gradually in
the late 90s. Only 35 men reached the 90s, with only one
centenarian. In contrast 109 women reached the 90s, four
of whom lived up to be centenarians.
Over a ten year period, the number of deaths due to all
causes has declined each year by around 4.7% per annum.
While the decline in Cancers is modest, around 0.7% per
annum, that of Heart Disease has been more dramatic,
at around 4.2% per annum. Deaths due to Respiratory
diseases are actually increasing at the rate of 1.6% per
annum. Until 2005, Heart Disease had continued to
dominate as the principal cause of death, but following
steady reduction it has slipped below Cancer in recent
years. Cancers are the dominant cause of death in persons
under 70, the occurrence being about 1.7 times more than
in the general population. Deaths due to accidents are
more common amongst males.
Reviewing all cancer deaths over the last 8 years (200108), the top 5 cancers causing mortality are Lung, Colorectal, Breast, Prostate and Carcinomatosis.
Lung Cancer is so pre-eminent in this respect that its
deaths are almost double that of its nearest rival, Colorectal
cancer. Lung Cancer is the most frequent cause of death
from cancer in men. In 2005, there were 15 deaths from
lung cancer, the highest in the past five years, followed by
11 (2006), 8 (2007) and 7 (2008) deaths respectively from
this condition. Lung Cancer deserves special attention,
not only for its dominance in this respect, but also its
disproportionate effect on the young. In the four years
(2005-2008), 14 people under the age of 65 years died
prematurely from lung cancer alone, the youngest being
only 35 years old.The most common cause of cancer
mortality in women is Breast Cancer. Again it is double
that of its nearest rival in women, Colorectal cancer. It
is hoped that forthcoming initiatives to screen women
7
Lung Cancer is the most frequent cause of death from cancer in men.
systematically will reduce the mortality from breast cancer. Interestingly, lung cancers seem to be much less frequent as a
cause of death in women, but whether this will remain so with the worrying rise in female smoking remains to be seen.
Two cancers that appear to be rising are those of the oesophagus and pancreas - 16 and 14 deaths respectively over the same
period - both of which are strongly linked with long term alcohol consumption.
The large number of Colorectal Cancers deserves special mention. Many of these are familial and a significant number can
be picked up by selective screening. A screening programme is under consideration by the Authority.
Deaths from other causes remained within the usual ranges with two notable exceptions.
Between 2005-2008, there were 9 deaths from unnatural causes (including three poisonings, three drownings, a road accident
and a suicidal hanging). It should be cautioned that these figures can be slight underestimates as cases which are pending
Coroner’s inquests on the cause of death have not been included. While deaths from unnatural causes may occur in small
numbers, they have a profound impact on society as typically they tend to be in younger people.
The other notable exception was a rise in deaths from infectious diseases, with the number of persons dying in this way
remaining at the high first seen in 2004 and then quite steady, at 17 (2005), 14 (2006) and 17 (2007), before falling to 8
(2008). This is a matter for some reflection as the average number of persons dying from infections has almost doubled in
the last 5 years - from 8.2 (1999-2003) to 14.0 (2004-2008).The majority of these are very elderly people in their 80s dying
of septicaemia.
An interesting observation is that the number of persons who died with diabetes as a contributory cause has remained
significantly high, with 106 persons (14.2% of all deaths) in the four year period 2005-08. It is less popularly known that
Diabetes is a strong risk for heart attacks.The proportion of people with diabetes who die of heart disease is generally higher
than the rest of the population. During the same period, heart disease was responsible for the deaths of 39.6% of people
with diabetes compared to 23.8% in those who did not have diabetes. These are important observations. Having diabetes
greatly increases the risk of heart disease and premature death. Regular and optimal control of diabetes is vital in reducing
disease and death.
1.2 INFECTIOUS DISEASES
Laboratory confirmed infections (See Tables 1.11
to 1.13 in the Appendix)
In 2005, the total number of laboratory confirmed
infectious diseases was 206 compared to the previous year
(199). In 2006, this number was almost identical (205),
but in 2007, it increased to 249 and in 2008 to 291. In
perspective, these figures compare with the annual totals
of infectious diseases of around 240 seen throughout the
early 2000s, but some interesting shifts lie underneath.
The incidence of food-borne infections appears to be
changing dramatically over the years.
Salmonella infections have considerably fallen, from
129 (2003), to 90 (2004), 28 (2005), 22 (2006), 14
(2007) and 26 (2008). It is believed that this steep
decline is largely due to the popular switch to British
eggs purchased from Gibraltar supermarkets, sourced
from vaccinated chickens.
Campylobacter infections, on the other hand, have drifted
upwards, from 24 (2003) to 32 (2004) to 38 (2005) to
48 (2006), rising up to 67 (2007), before falling back
to 37 (2008). However, this is still lower than the levels
seen in the late 1990s (around 70-80 cases per annum).
Campylobacter infections occur because of poor food
hygiene, especially consuming undercooked chicken or
pork. There were no food-borne outbreaks between 2005
and 2008.
Rotavirus is responsible for an infection that causes
8
The most common cause of cancer mortality in women is Breast Cancer.
Having diabetes greatly increases the risk of
heart disease and premature death.
diarrhoeas in very small children. The numbers averaged
around 30 per year from 1998 to 2003. However Rotavirus
infections shot up to 50 (2005), dropped to 27 (2006) and
rose again to 55 (2007) before falling back to 29 (2008).
Although some of these rises are due to small outbreaks,
it is believed that more cases are being ascertained due to
greater awareness.
In mid-2006, for the first time, the laboratory began testing
for Mycoplasma an organism that produces pneumonialike infections and immediately reported 31 cases through
the autumn months. In 2007, there were 44 cases and in
2008 there were 92. Although all this seems alarming,
again, these figures probably do not represent the arrival
of a new disease, but the unmasking of an existing one.
Most of the infections have been mild, but some cases
have required critical care.
The incidence of bacterial meningitis has fallen
considerably since the introduction of the universal
childhood vaccination programme. There were only two
cases during 2005-2008, in small children who recovered
completely.There were 9 cases of tuberculosis in the same
period, all of whom were successfully treated without
spread to contacts.
Thus, certain interesting trends emerge. The fall in
Salmonella is matched by the rise in Campylobacter, while
the rest of the increase in infectious disease notifications is
almost wholly explained by the increases in Mycoplasma
and Rotavirus infections. Overall, there are no significant
shifts in any of the other major notifiable infections.
Measles Outbreak of 2008 (See Tables 1.15 and 1.16
in the Appendix)
From January 2008, the Infection Control Committee
was aware of a progressively increasing outbreak of
measles, mostly affecting young adults, in the Spanish
hinterland. However, despite careful monitoring for over
7 months, no cases were reported in Gibraltar, although
Spanish authorities notified Gibraltar separately of 5
cases who had local connections (such as employment)
and these were followed up locally. However, when three
local cases were reported in early August, matters changed
dramatically.
During the period 1st August 2008 to 28th November
2008 (120 days), the Public Health Department was
notified of 283 clinically diagnosed cases of measles. Prior
to this outbreak, not a single case of measles had been
notified for several years. Investigating nurses found that
in a number of cases, other family members had also been
affected without being reported and hence it is likely that
the true number of measles cases exceeded 300.
As it is certain that the Gibraltar outbreak was acquired in
the wake of the Spanish outbreak, the several months gap
is interesting and it is believed that Gibraltar’s good herd
immunity (due to widespread uptake of immunisation
and natural infection in childhood) probably had a major
part to play.
After a steady trickle initially at around 1-2 cases per day
for about 5 weeks, the outbreak accelerated averaging
around 5-6 notifications per day. A significant majority of
the cases (63%) occurred in the school-age group (5 years
to 19 years), the youngest case being 4 months old and
the oldest case 58. Only eight cases occurred in persons
over 40. However, attack rates were highest in infants.
Every single one of the 283 clinically diagnosed cases of
measles occurred in persons who are unimmunised or
were partly immunised.
Measles infection can be prevented by the MMR vaccine.A
public MMR vaccination programme was first introduced
in Gibraltar in 1989 offering a single dose at 18 months
to all children. In 2002, the age was brought down to
15 months and a second dose (pre-school booster) was
added. MMR uptakes had been anecdotally believed to
be good (in excess of 90%), but the scale of this outbreak
suggests that this might have been over-optimistic and
have revealed a need to establish more precise and reliable
figures through the use of computer records.
A rapid response process was put in place from the outset.
Every measles case was notified immediately by phone to
the Infection Control team by GPs, Emergency doctors
and hospital consultants. Infection Control nurses visited
every family within 24 hours, gave advice on isolation
precautions, identified contacts and took samples for testing.
Anybody at immediate risk was given MMR vaccination
or referred for medical assessment. This system worked
very well but depended heavily on the dedication of the
Infection Control Nurses.
A public MMR immunisation campaign was launched
from the second week to reach unimmunised children.
The lower age group was extended to include infants 6
months and older. This was a race against time and special
walk-in clinics were opened for vaccination. Despite
supply hitches, the campaign was successful, with over 500
vaccinations administered.
The outbreak ceased with the last case notified in late
November 2008.
There are some key issues that deserve further thought :
MMRVaccination is key to measles prevention.It seems very
likely that the disease spread widely through the large pool
of vulnerable children, who had remained unimmunised
in the early 2000s because of the unwarranted negative
image of MMR vaccination portrayed by the media. It
is also sometimes forgotten that there are some children
who cannot be immunised (allergy, certain diseases) who
depend for their protection, upon everyone else around
them being immune. Efforts should be continued to
promote vaccination.
The size of the outbreak suggests the need to revisit
assumptions of immunisation rates, uptake figures and
Salmonella infections have fallen 80% in five years
9
All 283 clinically diagnosed cases of measles occurred in persons
who are unimmunised or were partly immunised.
estimates of herd immunity. An audit of immunisations
is being launched, but until the immunisation system is
computerised, these efforts will remain limited.
The rapid and large-scale involvement of a crowded urban
population, alongside vaccine shortages and scarcity of
skilled staff, create complex and difficult situations that
need to be taken into account in emergency planning.
MacDonald Review of Infection Control
In October 2005, the Authority invited Sheila MacDonald,
infection control leader for Capital Health district in
Nova Scotia, Canada, to carry out an independent review
of infection control services in Gibraltar and advise on
improvements.
The resulting report showed that the overall quality of
infection control in the Authority was very good, with
principal weaknesses in the areas of shortage of skilled
infection control manpower and lack of infrastructure for
systematic surveillance. Some outdated practices in the use
of fumigation, room ventilation and table-top sterilisers
were identified. The standards of hygiene in the new
catering facility were judged to be exemplary, but those in
KGV hospital were poor.
The report had in excess of 50 recommendations, most of
which have now been implemented.
Multi-Resistant Staphylococcus Aureus
(MRSA) (See Table 1.14 in the Appendix)
MRSA (multi-resistant staphylococcus aureus) is a
bacterium that is a variant of the common bug that causes
boils and pimples. It achieves greater importance because
it is resistant to common antibiotics.
To keep matters in perspective, it must be emphasised that
the MRSA bacterium is no more harmful to ordinary
healthy people than its cousin that causes boils and pimples.
Problems can arise in people who have poor immune
systems, who are debilitated, who are very old or who are
very young, if they develop a major infection requiring
antibiotics in which case, only some strong antibiotics
work. This also matters with joint replacement surgery,
where hygiene has to be exceptionally high. This is why
hospitals, which have many patients in these categories,
are keen to keep the risk low, whereas fit people in the
community have little to fear. Indeed it is likely that
people outside the hospital do get everyday infections
from MRSA, of which they probably are not even aware.
In this context, sensationalisation by the media with terms
like “superbug” is unhelpful.
The incidence of MRSA infections rose steeply in 2004,
peaked in 2006 and slowly declined over the next two
years. The number of infections detected were 33 (2004),
28 (2005), 46 (2006), 36 (2007) and 23 (2008). The figure
for 2006 was the highest in St. Bernard’s Hospital’s recorded
history. The high levels of MRSA in the hospital aroused
10
much concern and every case is now routinely scrutinised.
For analytical purposes, MRSA cases detected in hospital
are grouped into four categories based on how the infection
was transmitted to the patient: (a) Imported: where the
person arrives at the hospital with MRSA infection
already established, which he (or she) has acquired from
outside Gibraltar; (b) Intrinsic: where the person arrives
at the hospital already carrying MRSA infection but
with no evidence of overseas contamination; (c) Hospital
Acquired: where the person did not have MRSA infection
or colonisation on arrival at hospital, but becomes infected
during his stay; and (d) Indeterminate: where the source
of the MRSA cannot be reliably ascertained. For control
purposes, record is also kept of those patients who have
the infection outside the hospital.
The figures are presented in the statistical table (1.14 in
the Appendix), but in essence
• a significant number of MRSA cases are imported from
Spain and the UK
• more people than before are carrying the bug and bringing
it with them into hospital the level of hospital acquired
infection has increased sharply.
• The number of MRSA cases arising among the Elderly
Care Agency residents is also increasing.
In 2005, the Infection Control Committee introduced the
following measures:
a) All patients admitted to Critical Care Unit to
be screened on arrival and if found to be carrying
MRSA, to be isolated and treated with special
antibiotics until clear.
b) All staff with history of recurrent previous MRSA
carriage to be screened regularly until clear.
c) All long term patients of over 6 months continuous
Hospital stay to be screened regularly.
d) All patients to be screened before transfer to the
Elderly Care Agency.
e) Essential clinical details of every isolate of MRSA
(whether true infection or contamination) to be
systematically recorded in a database to be designed and
built for this purpose.
f) More rigorous handwashing practices to be introduced
for use by staff, patients as well as visitors.
All these changes were superimposed on the measures
already in place, such as entry protocols for patients
coming in from overseas hospitals, environmental cleaning
policies, antibiotic prescribing policies, etc..
Pandemic Influenza
Influenza is a common and highly infectious disease
caused by a virus that transmits readily from person to
person through airborne droplets and tends to occur in
seasonal - mostly winter - epidemics. It affects people of
Always wash your hands
all ages, but is serious only for certain sections of society
- the very old, the very frail, people with chronic diseases
like diabetes, people with impaired immune systems and
people with multi-organ disorders. For most people it is
an unpleasant illness but one from which they recover
fully. The virus occurs in several different strains that vary
from year to year - because of this, infection does not
always lead to complete future immunity, although usually
there is some immunity.
However, the influenza virus also has a capacity for changing
itself through a process called genetic shift. This versatility
allows the emergence of novel strains that can disseminate
rapidly and extensively, resulting in widespread infections
in human populations. This is known as a pandemic (from
Greek: pan = all; demos = people). Influenza pandemics
have swept the world several times in history, three times
in the 20th century alone, the most recent being the Hong
Kong flu of 1968/69. Researches and scientific modellers
have often suggested that statistically another pandemic
should be due soon.
During 2005, 98 persons in five Far-Eastern countries
developed a curiously severe form of influenza after
being exposed to similar infections in birds and 43
persons died (43% mortality). Although this lethal variant
of avian influenza had been observed two years earlier, it
had not affected so many so quickly and the impact had
seldom been this severe. Considerable speculation arose
as to whether this was in fact the start of a pandemic.
Such alarm turned out to be premature, as the outbreak
turned out be slow to expand, with a total of 395 persons
becoming infected over the next three years (20052008), of whom 250 died (43% mortality). However,
most countries, led by the World Health Organisation,
including Gibraltar, decided to err on the side of caution
by making extensive preparations.
In 2006, the Government’s Avian Flu Contingency
Group published the Pandemic Influenza Contingency
Plan which adopted an innovative response model based
on triggers and actions. The Public Health department
organised a series of six seminars to provide training to all
Emergency services and healthcare personnel in infection
risks, good practice and self-care. Stockpiles of anti-viral
Pneumococcal pneumonia and meningitis are serious illnesses with high death rates (about
20%) and frequently leave survivors with permanent damage like deafness or epilepsy.
11
The Human Papilloma Virus vaccine is Gibraltar’s first
vaccine against a sexually transmitted disease
drugs, vaccines and personal protection clothing were
established. Fortunately, despite the preparations, the threat
did not materialise, but the risk remains and will be kept
under surveillance.
Current preparations include the promotion of wider
usage of normal human influenza vaccine to bolster herd
immunity, procurement of a stockpile of pre-pandemic
vaccine to gain protection for front-line services in the
early days of the outbreak and negotiating a “sleeping
contract” with manufacturers for the expeditious supply of
pandemic vaccine when it becomes available. Key public
health messages like “Cough Into Your Sleeve” need to be
popularised further.
1.3 INFECTION CONTROL
GOOD PRACTICE IN INFECTION CONTROL
Since the start of 2007, the infection control team have
made recommendations for the advancement of infection
control in Gibraltar. These recommendations will reduce
and maintain infection rates below the national rates of
the UK.
A significant amount of staff training has been undertaken
in this last year. This has included:
• Hand-washing technique using the ultra-violet light and
the dye soap to see areas that have not been truly cleaned
which has led to improvement in hygiene practice.
• The setting-up of the ward infection control link nurses
to ensure the policing of the infection control policies and
a better understanding of wound management.
• Significant progress has been made in initiatives aimed at
reducing MRSA in the GHA. These include:
- Alcohol hand rubs have been placed at the entrances
to wards and departments for staff, patients and visitors
to use. If used correctly, it will remove most bacteria from
one’s hands. Individual bed-sited containers are also being
introduced.
- Patients needing Orthopaedic surgery are also screened for
MRSA and other harmful bacteria days before the surgery,
to guarantee less risk of infection after surgery.
- Patients booked for elective surgery are also being
nasally screened prior to surgery, to minimise any bacterial
infections after surgery.
- All patients admitted to ICU are also nasally swabbed
for any MRSA or other bacteria that could cause further
infections.
- An updated policy on MRSA has been produced and staff
will be up-dated in treatments and policies to minimise this
bacteria in our hospitals.
- The domestic staff have also been trained by the Infection
Control team in how to clean and maintain our hospital to
a high standard. The cleaning products are recommended by
the infection control team.
12
- It has also become mandatory for all GHA staff to
receive training in infection control. This will also create
awareness in staff that infection control is for all to follow
and to help minimise harmful bacteria in our hospital.
- To further support vital work, the GHA has funded an
additional Infection Control Nurse to support Kenneth
Orfila who has worked single-handed for many years.
Stop...be smart and don’t start
the womb) is a serious disease that affects on average about two women every year in Gibraltar, of whom around a quarter
will die. It is caused in over 70% of the cases following infection by the HPV virus, which is transmitted usually through
sexual activity and often acquired many years previously. For the vaccine to be effective, it should be given to girls before
they have their first sexual exposure.
An annual programme to offer HPV vaccination to 12 year old girls was commenced in September 2008 combined with
a “catch-up” programme to offer the vaccine to girls aged 17 or under, within the next two years. The vaccination is being
administered to girls at Westside School by the School Nurses.
1.4 IMMUNISATION
Routine immunisation programmes have continued to be
carried out every year as per schedule. The Five-in-One
vaccine introduced in 2003 has now been well-accepted
and become standard practice.The annual winter Influenza
vaccine campaign also continued every year.
A significant event in 2006 was the introduction of the
Pneumococcal vaccine.
This vaccine provides immunity against a major cause
of death and disability, particularly in babies and elderly
people. Pneumococcal disease, which includes pneumonia,
one type of meningitis and septicaemia (blood poisoning),
is caused by a bacterium called Streptococcus pneumoniae
(or Pneumococcus). Pneumococcal pneumonia and
meningitis are serious illnesses with high death rates (about
20%) and frequently leave survivors with permanent
damage like deafness or epilepsy. Pneumococcal disease
largely affects very young children and elderly people,
but also some people of adult age are susceptible too,
particularly those who fall into certain risk categories.
These groups were targeted to receive the vaccine.
All newborns were offered the Pneumococcal vaccine
along with their existing immunisation schedule and a
“catch-up” programme was devised to immunise children
up to the age of two years, after which the risks tail off. All
persons over the age of 60 were also offered the vaccine,
administered at the same time as the Flu programme for
convenience. In addition, persons with impaired immunity
(e.g. diabetes, HIV, cancer, etc.) and certain other diseases
were also eligible.
The Pneumococcal vaccines are very safe, having been
extensively tested and routinely used in Europe, Australia,
USA and Canada.
In 2008, the Human Papilloma Virus (HPV) vaccine was
introduced. This is a vaccine which when administered
to young children protects against infection by the HPV
virus, which is usually transmitted sexually and can cause
cervical cancer.
This vaccine was a landmark event in three respects:
1) it is the first instance of a vaccine to prevent a cancer
2) it is the first vaccine against a sexually transmitted disease
3) it is the most expensive vaccine ever used, its cost alone
being roughly equal to the rest of the childhood vaccination
programme put together.
Cervical cancer (also called cancer of the cervix, a part of
EVENTS IN 2005
1.5.1 No Smoking Day, March 2005
Gibraltar’s sixth consecutive No Smoking Day took place
on Wednesday 9th March 2005. The principal aim of the
event was to nurture a supportive environment for smokers
who want to take steps towards quitting and this was
achieved by highly visible public displays at the Primary
Care Centre and involvement of the local media.
The public reaction to the campaign was very supportive.
The many different posters on display, varieties of booklets
and visual props, helped to attract a keen interest and
helped enhance the impact of the year-round education
provided by the Health Promotion team through leaflets
and other means. It was also gratifying to see the many
teenagers approaching the stall for information.
Predictably, the questions that the public asked were
again about the commencement of a smoking cessation
clinic, prohibiting smoking in the workplace, smoke-free
restaurants and the risks of passive smoking. People this
year were also curious about the government’s stand on
smoking in public places.
In conclusion, No Smoking Day is a significant date for
many smokers who respond positively to the invitation
to stop on that day. Only research can determine the
effectiveness of the campaign and evaluate long-term
success of initiatives such as the No Smoking Day.
1.5.2 Diabetes Awareness Day,
September 2005
1.5 HEALTH PROMOTION
The Health Promotion department continued to have
active and busy years, maintaining the service within the
resources available to it.The entire work of the department
- running campaigns, organising events, producing
literature, community networking and leadership of
initiatives still continues to be borne by the sole Health
Promotion Office.
The multi-agency collaborative Health Promotion Group
has continued to meet regularly at approximately monthly
intervals throughout the three years.
Diabetes Awareness Day took place on Friday 23rd
September 2005.
Diabetes is a silent but often deadly condition that affects a
significant proportion of the population. While advances
in prevention and treatment are reducing the impact of
other conditions like heart disease and cancer, diabetes
is one of the fastest growing diseases in our society,
particularly in children and young adults.
A key factor is that diabetes can be silent, producing no
symptoms for a long time, and if untreated can lead to
heart attacks, stroke, kidney failure, blindness and leg
amputations, many of which result in disability if not
death. Increasing the public awareness of early detection
and treatment is therefore an essential component of the
13
The general focus of the campaign was on raising awareness of the “4 Cs” of Food Safety:
Cleanliness, Cooking, Chilling and Cross-contamination.
health education programme.
A campaign leaflet was produced in the lead up to the
event together with matching poster to build a campaign
image. Articles were printed in the Gibraltar Chronicle
on diabetes to raise awareness of this condition, including
the text from the campaign leaflet for reinforcement. The
Health Promotion Officer appeared on a radio Interview
in the GBC Healthfile slot, raising awareness of Diabetes
with the slogan, “Could YOU have diabetes?”
Various low sugar and sugar free products were supplied
by Morrison’s Supermarket and Luis Pharmacy. A visually
striking display of fruits and vegetables was created from a
hamper kindly donated by Gibmaroc.
GBC TV covered the event and broadcast a live interview
on the awareness day with Mrs. Julie Parker, Nurse
Practitioner. A striking media image was a specially
commissioned poster showing a local sportsperson
aspiring to sporting excellence despite having diabetes.
The powerful message was that provided diabetes was
properly controlled, it did not preclude a normal healthy
life or prevent excellence.
EVENTS IN 2006
No Smoking Day, March 2006
Wednesday 8th March 2006 was Gibraltar’s 7th consecutive
No Smoking Day. The Day’s combination of visible
public displays at the ICC foyer including free literature
and professional advice created a high level of awareness.
The ultimate aim of the day was to create a supportive
environment for individuals seeking to quit the habit.
The awareness stand outside the ICC building was a huge
success. There were many different posters on display, a
wide variety of leaflets including new visual props. These
props received huge interest and made the impact where
information leaflets could not. It was also great to see
14
teenagers approaching the stall for information and the
youth service officers helped immensely.
The public asked again about the commencement of
a smoking cessation clinic, NRT on prescription, no
smoking in public places and restaurants, and passive
smoking. The public also asked about government’s input
towards a smoke free community. It was also learnt with
some gratification that some people had given up as a
result of last year’s campaign. The Bayside students noted
that some people actually extinguished their cigarettes
once they found out it was No Smoking Day.
National Food Safety Awareness Week, June 2006
National Food Safety Week is an annual event, which
occurs across the country in the UK each year as a way
of promoting food safety awareness. Monday 12th June
2006 was Gibraltar’s 1st National Food Safety Awareness
Day. The general focus of the campaign was on raising
awareness of the 4 Cs of Food Safety: Cleanliness,
Cooking, Chilling and Cross- contamination.
• Cleanliness: Keep your kitchen, equipment and work
surfaces clean
• Cooking: Make sure food is properly cooked
before eating
• Chilling: Keep perishable foods cold until you cook
or eat them
• Cross-contamination: Don’t let harmful germs spread
around your kitchen
Working with local environmental health and health
promotion professionals, the campaign aimed to show the
public how to keep food safe from the time it is bought
until it is eaten.
Please remember to:
• Avoid spreading germs
Research shows that as many as 3 in every 4 smokers want to quit.
• Keep food safe
• Keep raw and cooked foods apart
• Wash hands thoroughly before and after touching food
• Control temperatures
• Keep kitchens clean; and
• Avoid waiting times between cooking,
preparation and eating.
Campaign resources from Foodlink (UK) were distributed
among the schools. Owing to resource limits, there were
not enough resources to distribute to ALL schools and the
youth service.
Diabetes Awareness Day, September 2006
Diabetes Awareness Day took place on Friday 29th
September 2006.
A display was erected at Casemates Square. A fruit and
vegetable hamper was kindly donated by Gibmaroc.
Mr. John Miles (Chiropodist from the College Clinic), Ms
J Parker (Nurse Practitioner) and Ms McLeod (Dietician)
were on hand to advise visitors.
A press release was sent to all newspapers and magazines.
WOT magazine was the only periodical to cover diabetes
awareness in their September issue. GBC TV covered the
event with an interview recorded on the awareness day.
The Health Promotion Officer also conducted a live radio
interview on the day with the slogan, “Could YOU have
diabetes?”
A follow-up display was set-up in the Primary Care Centre
during the following week and ran for a month.
Mental Health Day, October 2006
2006’s World Mental Health Day focused on preventing
suicide, an important cause of premature and preventable
death in young people. The theme was “Building
Awareness - Reducing Risk: Mental Illness and Suicide”
as suicide is often a consequence of failing to diagnose and
treat serious mental illness.
The awareness event took place on Tuesday 10th October
2006. Two stalls were erected - one outside the Cathedral
and the other at Casemates square.
The Psychological Support Group who manned the
Cathedral stall also used this as their flag day. They were
supported by the KGV Hospital staff team including the
Occupational Therapist and Mental Welfare Officers.
A wide variety of individuals approached the tables for
information and talked to the various professionals at hand.
Literature was varied including the Mind’s Understanding
series of leaflets. The leaflets on depression seemed to be
the most popular.
The Minster for Health gave an interview with GBC
TV together with the Clinical Psychologist. The Drugs
Strategy Co-ordinator also gave an interview about the
link between suicide and drugs / alcohol.
As part of the Mental Health Day campaign there were
public lectures organised by the Mental Health Promotion
Group and Psychological Support Group.These were held
at the John Mackintosh Hall (Charles Hunt Room) that
same day from 7 - 9pm.
Drugs and Alcohol Awareness Week,
November 2006
A Drugs Awareness Week was held culminating on
17th November 2006 with a Drugs Awareness Stall at
Casemates. This was the first such event bringing together
health, education, youth, the law and the media in such a
co-ordinated manner.
The Health Promotion department provided £2000 worth
of literature for the event. These were also distributed in
both comprehensive schools in the week leading up to
the awareness day ensuring the number of pupils exposed
to this information was maximised. A series of 4 posters
printed with kind permission from the ‘Health Promotion
Agency’ of Northern Ireland were launched in the weeks
leading up to the event. Additionally 600 copies of the
Level Magazine were handed out on the day. During the
weeks leading up to this event a number of presentations
took place in both comprehensive schools that reached
approximately 1000 children.
On the day in question the stall was staffed by members
of the Drug Strategy office, Youth Service, former users
and staff from Bruce’s Farm and a group of Year-12
pupils from the boys’ comprehensive school, who also
helped to distribute literature and posters throughout the
town area.
Feedback from pupils and teachers was very positive. Not
a single leaflet was left by the end of the week. Teachers
commented that they would like to see more of this type
of literature, as it helped productive discussions with
their pupils.
EVENTS OF 2007
No Smoking Day, March 2007
No Smoking Day, in its 24th year in the United Kingdom,
was promoted for 9th successive year in Gibraltar. It
continues to make a significant impact throughout the UK
and has played an important role in the overall reduction
in smoking. The fact that it is a longstanding national
initiative, taking place simultaneously in all four countries
of the UK has helped give it a high profile among the
public and media alike in Gibraltar. The theme this year
was ‘Making a Fresh Start’, the main emphasis of the
campaign being to make a difference by reducing tobacco
related illness and death.
A tremendous thrust to the campaign was gained when 20
15
The global problem of obesity is rising in the local
community in adults and especially children
One establishment joined the scheme in 2008*. The current 20 Awardees for 2008 are:
cafés/restaurants enforced a total smoking ban by staff or
the public within their establishments for the whole day.
Some of the proprietors were surprised that this did not
hinder business and in fact received praise, one customer
remarking that this was ‘the start of something good’.
This year, the Health Promotion Group carried out a small
voluntary public survey to gather views and perceptions
on a local ban on smoking in public places (for details see
box). A local activist announced that a pressure group had
been formed to campaign for laws to restrict smoking on
health grounds.
Teachers Workshop, November 2007
A Health Workshop for senior teachers was held, jointly
organised by the public health department and the
education authority, aimed at updating the teachers on
a range of relevant health topics and concerns, such as
the management of children with diabetes, healthy
eating, smoking, substance misuse, common school
infections, etc. Feedback from the teachers was positive,
the emphasis on ‘practical’ training being particularly
welcomed. Given this workshop’s success there are plans
to develop this idea further.
No Smoking Day, March 2008
Wednesday 12 March 2008 saw the 25th No Smoking
Day and its 10th year here in Gibraltar. The theme of
No Smoking Day was The Great No Smoking Day
Challenge. The campaign was the first after the smokefree legislation came into force in Wales, Northern
Ireland and England. The theme suggested a mass quit
attempt, and was a positive encouragement to join in.
And while it was also an acknowledgement that quitting
smoking can be tough, it was equally clear that it was an
achievable challenge.
No Smoking Day was limited to a display at the Primary
Care Centre. Articles where also written for the press and
the necessary Radio and TV interviews were arranged.
Gibraltar is still lagging behind the rest of Europe regarding
smokefree legislation and it is because of this that No
Smoking Day continues to be an important day in our
community. The campaign is about helping smokers to
quit. The emphasis is on support, not pressure.
GENERAL MATTERS
The GOOD Health Award
The GOOD Health Award scheme has been in operation now since 2001, aimed at awarding restaurants which provide
smoke-free dining, healthy options and hygienic food. The reason why the scheme exists is because:
Coronary Heart Disease (CHD) is one of the biggest killers globally as well as locally;
The global problem of obesity is rising in the local community in adults and especially children.
Clean and hygienic food is a universally valued standard
Bronze Award
Alfresco
Silver Award
Little Rock Café
Kowloon Chinese Restaurant
Solo Express
Paradiso
Thyme Dining Rooms
Corks Wine Bar
The Clipper
Shamiyana
AML Caterers
Corks Wine Bar
Pizzaghetti Factory
Rightstart Nursery*
Lek Bangkok
Gold Award
The Rock Hotel
Just Desserts
Rooke Officers’ Mess (MoD)
WO + Sgt’s Mess (MoD)
Devils Tower Camp (MoD)
Carpenters Arms
1.5.3 Head Lice
Head Lice continue to exercise the public mind, quite out of proportion to their significance. Head lice are fundamentally
parasites which rarely ever cause diseases, but decades of traditionally inflating their importance has left an impression in the
public mind that is shifting only very slowly (see box for details).
The department launched a major campaign of public education in 2000 on the subject and in 2004 produced a
comprehensive guidance document for schools. This was updated and reissued this year. The focus of this update was to
give teachers clearer advice on managing children with head lice in schools and importantly to arrest the bad practice of
excluding children because they had head lice.
The roles of parents, schools, the education service, the health authority, health visitors, child health nurses, general
practitioners, pharmacists, practice nurses and district nurses in preventing and controlling head lice have been spelt out and
support pathways more clearly identified.
The awardees in 2008 are:
Gold Award
The Rock Hotel
Just Desserts
Rooke Officers’ Mess (MoD)
WO + Sgt’s Mess (MoD)
Devils Tower Camp (MoD)
Carpenters Arms
16
Silver Award
Little Rock Café
Kowloon Chinese
Solo Express
Paradiso
Chez Nous
Corks Wine Bar
Shamiyana
From 2007:
AML Caterers
Corks Wine Bar
O’Briens Sandwich Bar
Pizzaghetti Factory
Thyme Dining Rooms
Bronze Award
Alfresco
17
Health Promotion Group web site: www.health.gov.gi
1.1.i.
What are lice?
Lice are blood-sucking insects which only live on humans. They are tiny but visible to the eye.
They hold onto human hairs with tiny claws at the end of their six legs. They come in three different forms :
Head lice, which usually live in the scalp, armpits, beard, and eye-brows
Pubic lice or “crabs”, which are usually found on pubic hair
Body lice, which occur anywhere, but most often in armpits and around the waist.
The eggshells of lice (“nits”), which can be seen as white specks attached to hair, are quite firmly attached and not easy to remove. 1.1.ii.
Is there a problem in Gibraltar?
Not more than average. Numbers tend to rise and fall. All countries have lice and no one has eradicated them yet. But with concerted effort and
community efforts such as Bug Busting, their numbers can be kept under control.
1.1.iii.
1.1.iv.
Are they damaging to health?
NO! Head lice are not really a medical problem. Head lice do not cause or spread disease. Symptoms only arise because of physical intolerance
to the parasite (rather like a “reaction”) and even this response may vary from person to person. A lot of avoidable hype, anxiety and overreaction is caused
by this simple misunderstanding.
1.1.v.
Head lice should be regarded in the same way as fleas or mites. The best place to address the problem of lice infestation is the home, not the
school or the doctor’s surgery.
1.1.vi.
Don’t School Nurses check the children’s heads?
Many people still think that the School Nurse’s role is to search for nits and lice. This is not true.
The Nit Nurse function of the School Nursing service used to be a tradition for many decades, but the practice was abandoned in most places in the
1980s, after repeatedly being shown in the research literature to be ineffectual, ineffective and a waste of money. The gradual withdrawal of Nit Nurse
inspections was begun in Gibraltar in the late 1990s and by 2000 it was completely stopped. The school nurses nowadays visit schools to deal with other
more important health matters and do NOT inspect children’s heads.
Checking their children is the parents’ responsibility. However, parents experiencing persistent head lice infestation with their children can seek an
appointment at the Child Welfare clinic at the Primary Care Centre. The School Nurse can give advice on how to search for lice, on wet combing
technique and on when to use lotions.
1.1.vii.
Will schools inform parents when lice are “going around”?
No. One of the principal causes of unnecessary public alarm is the “alert letter” sometimes sent out by head teachers, typically warning parents “we have
head lice in the school”. This is an unnecessary and illogical reaction:♦
it is unnecessary because most schools will have a few pupils with head lice at any one time. An “alert letter” could be sent out every day of the
school year.
♦
it is illogical because it is done in response to reported cases of head lice (which are not easily transmitted), but not for other diseases such as impetigo
or chickenpox, which are highly transmissible in schools.
♦
it is misleading because it converts the usual background level of infection in the school into a sensational “outbreak”, inciting worries among parents
that the school is riddled with lice.
♦
It is harmful because it forces some parents to use insecticidal lotions on their children “just in case” or because it makes children imagine they have
head lice and their heads are itching (psychogenic itch).
♦
How can head lice be removed or eradicated?
There are techniques like wet combing that help parents remove head lice from individual children’s hair. However, Bug Busting campaigns (which
promote the practice of synchronised wet combing of children’s hair by all parents) were begun in early 2000 and aim to reduce head lice in the whole
community. The rationale is that if the entire community carries out wet combing at the same time, the chances of eradicating head lice are considerably
increased. Two dates (1st February and 1st October) have been chosen usually around the time children return to school after holidays and have become
a well-accepted and recognised part of the social calendar.
Are “clean” children safe from lice?
No! Clean hair is no protection against head lice. Lice have no need of dirt. Anyone with hair on the scalp can catch them. There is a common belief
that children with lice must come from unhygienic families – this is simply not true. All we can say is that lice are more likely to occur on sociable
children who have plenty of friends.
ACTUAL SIZE
18
Health Promotion Group Website
With the rise of consumerism in health care, users are taking
ever greater ownership of information about themselves
and their health - which has been a longstanding goal of
health promoters, but whose time has only just begun to
come, thanks to cybertechnology. Access to the Internet
access can certainly hugely aid the dissemination of health
information, but the challenge for the newcomer to the
Internet world is to find reliable, relevant and trustworthy
information. The Health Promotion Group hopes to fill
that niche where the health information needs of Gibraltar
residents are concerned, by providing a website offering
information that can be used by the general public as well
as by health professionals and educators.
The site has been in existence since 2003 and has been
well received. However, time does not stand still and
obsolescence apparently comes more quickly in the 21st
century. An unavoidable feature of websites is that they
need regular updating, which involves cost and time. In
addition, the explosion of health information and public
demand has created a need to redesign the current
website. This is a big undertaking for what is a very small
department and will require considerable time and work.
However, this is now under way and the new website is
due for launch in 2009. This will not only expand the
range of health information but also enable the site to be
run more efficiently.
Other activities
Nutrition: The Health Promotion Officer and the
Dietician continue to meet regularly to discuss health
promotion issues and evaluate new approaches. The issue
of healthy school tuck shops remains on the agenda.
Education: The close collaborative work with the
Education department continues through direct liaison
with the Senior Education Advisor. Educational materials
are procured throughout the year and disseminated to
schools. Future plans include more structured partnership
work on health education in schools.
Radio: The Health Promotion Officer continues to provide the “HealthFile” slot at GBC on a monthly basis.The purpose
of these interviews is to raise public awareness in a variety of health-related issues and to encourage individuals to adopt a
healthier lifestyle. It is also used to publicise forthcoming campaigns.The interview is pre-recorded, but increasing workload
is impacting on frequency of aired radio talks.
Infomercials: The production of infomercials on local television has long been an ambition of the department, but lack of time
and funds have remained deterrents. There is similar scope for Radio infomercials, which require a lesser technical approach to
the construction of the product. The most important issues to tackle would be smoking, obesity and sun awareness
Patient Information: Demand for funding for patient information leaflets from health professionals and others continues
to grow, but the departmental budget is not designed to accommodate these.The department also needs to expand, improve
and update the existing resource base and that will also require financial input
Loan services: The HPO constantly visits the Primary Care Centre as well as St Bernard’s Hospital in order to restock
literature and resources that are requested from health professionals and for the general public. A resource list is circulated
through the health service, education department and youth services providing awareness of health information / packs that
are available for loan on a departmental basis when there are new additions or updates. However, the commencement of
the loan facility has been held back for quite a while by the lack of logistics support for the department. The department is
currently planning to update and improve the current resource library that will also involve a hefty financial input. This is
planned for early 2009.
19
Seawater samples taken from six beaches throughout the
bathing season were consistently of good quality.
1.6 Public Analyst Report
ACTIVITY
The Public Analyst’s work locally mainly encompasses the
following fields:
Analysis of food and drink samples submitted by the
Environmental Agency (routine samples, requirement
for import licence, and complaints), under the Food and
Drugs Act.
Chemical and microbiological analysis of potable water
samples submitted by the Environmental Agency, MOD,
AquaGib, GHA.
Analysis of various other samples including Sea Water and
Swimming Pool water submitted by the Environmental
Agency, Dialysis Water from the GHA, and Demineralised
Water from the MOD.
Drugs of abuse testing for the Royal Gibraltar Police,
(tablets, capsules, powders, substances, and associated
paraphernalia), under the Drugs (Misuse) Act. (See Table
1.17 in the Appendix)
Drugs of abuse, (substance), testing for the Customs
Department.
Blood and urine testing for alcohol and drugs for the
RGP under the Road Traffic Act.
20
Toxicology analysis of blood and urine in post mortem cases.
Screening for drugs of abuse in urine for HM Prison and
KGV Hospital.
Presenting evidence in Court on these cases.
In the United Kingdom Public Analysts’ laboratories are
mainly involved with the type of work summarised in
paragraph I and II above. The drugs listed in paragraph
IV would be carried out by three different laboratories
within the Forensic Science Service (FSS).
The total workload saw an increase of 4.5% from 2005 to
2006 and a 25.2% increase from 2005 to 2007.
1103 extra parameters were measured on potable water
samples in 2007 compared to 2006. Numbers of seawater
and filtration samples remained approximately the
same throughout the three years whilst work related to
swimming pool water increased from 2006 to 2007 by
27.6%.
Work on demineralised water used in nuclear submarines
increased steadily as the Ministry of Defence made
modifications to their reverse osmosis plant and storage
facilities.
Seawater samples taken from six beaches throughout the
bathing season were consistently of good quality.
The Dialysis Unit started operating in 2005. The Unit
processes raw water in order to reduce the total dissolved
solids from approximately 300 milligrams per litre to 3
milligrams per litre. The resulting water is used to dilute a
concentrated solution of salts against which the patient’s
blood is dialysed. Samples are taken of the raw water, after
decalcifying, and after deionising by reverse osmosis. As
part of the quality control program three microbiological
parameters and twenty-one chemical parameters are
measured in each of the samples.
Food and Drink work in 2007 represented a 94.7%
increase compared to 2006. More samples of ice cream
than in previous years were submitted in 2007 although
pasteurised milks were not sampled as often as in the past.
In 2007 there were several failures in the microbiological
quality of ready to eat foods with Listeria Monocytogenes
being isolated in some of these samples. (See Table 1.18 in
the Appendix)
Drugs work submitted by the Royal Gibraltar Police and
HM Customs during the years 1999 to 2007 averaged 235
cases and 503 items of evidence per year. A breakdown of
the results of the analysis is shown in Tables 2 and 3. Most
of the Class A drugs seized in 2005, 2006 and 2007 were
found to be cocaine.The next most commonly encountered
Class A drug was methylenedioxymethylamphetamine
(MDMA). The first case of methylenedioxyamphetamine
(MDA), was detected in 2006, and one item containing
LSD in 2007. Preparations containing the ecstasy type
drugs MDMA and MDA are usually encountered in
tablet form. However, three items containing high purity
crystalline MDMA were seen in 2006 and another two
in 2007. The last item containing diamorphine (heroin)
was seen in May 2003.Two large seizures of cannabis resin
of 765 kilograms and 697 kilograms were examined in
June 2006 and another one of 500 kilograms in June 2007,
and one of 133 kilograms of cocaine in August 2007.
These required working on-site in order to carry out the
preliminary examination and sampling.
The Public Analyst was asked to provide evidence
as an expert witness in Court on 34 occasions (24 for
Magistrates Court and 10 for Supreme Court) in 2006,
and on 30 occasions (23 for Magistrates Court and 7 for
Supreme Court) in 2007.
ACHIEVEMENTS
The routine sampling of ready to eat foods and dairy
products needs to be increased further by the Environmental
Agency to ensure that the quality of these products meet
the required specifications. Changes in procedures and
techniques will be introduced to shorten reporting times
for some of the microbiological parameters analysed.
A number of new chemical parameters such as Aluminium
and Manganese have been added to the repertoire of
tests available for water analysis. New techniques have
been introduced providing greater sensitivity for some
parameters that were already available.
21
2. PRIMARY CARE SERVICES
Wider and more timely access to dental and orthodontic services is being achieved.
2.1 Primary Care Centre
For Primary Care appointments data, see Tables 2.1 to 2.4
in the Appendix
ACTIVITY
2004
• Doctors’ filing taken over by Admin Staff
• Introduction of FrontDesk
• Dermatology Team appointed – Commencement of
Development of Service
2005
• Blue Area set up – Admin support allocated to take over
advanced appointments, checking of notes and assistance to
the area’s requirements
• Commencement of Re-Registration (EHIC)
• Audit – Requirement of repeat prescriptions
2006
• Audit – number of sick notes provided to patients during
consultations
• Proposal sent – PCC Pandemic Influenza
Contingency Plan
• Donation of plasma screen which currently Illustrates the
following: • Information on Doctors on duty per area
• Which doctor is 1st and 2nd on call on the day
• Information on which clinics, if any, have been cancelled
on the day
• PCC opening hours
• PCC contact numbers
• Information on release dates for 3 monthly advanced
appointments
• 2008 Annual total of DNA’s
• Weekly updated DNA’s
• Dental information – out of clinic hours
• Informing patients that PCC has a website www.gha.gi
holding information on our services
• Information on Dietician clinics
• Blood clinic information
• Zero Tolerance Policy
• Reminder for patients to make their 3 monthly
appointments prior to departing PCC.
• Isolation of Call Centre to avoid disruptions
22
2007
• Admin support allocated to the Dental Department
• Admin support allocated to the Nursing Department
• Introduction of uniforms
• Database for the recording of referrals from PCC to
SBH created
• Dermatology Sun Awareness Campaign 2007 – Led by
Admin
• Release of two admin, 1 Records + 1 Typist to assist
with the entering of repeat prescriptions
• Release of the Personal Secretary to assist with the
isolation of Medical Human Resources
• Admin entering house-calls on FrontDesk for
accountability and auditing purposes
2008
• Dermatology Sun Awareness Campaign 2008 Led by Admin
• Voice Mail - Patients are now able to leave their messages
via a voice mail should they not be able to get through, this
is only applicable to advanced appointments, a log is being
kept with all these requests.
• Registration of Groups - An exercise for patients to
register with their group of choice (GPs) is being carried out
and a submission audit is being kept on a daily basis.
• Newsletter - Discussions have taken place with regards
to the incorporation of a monthly newsletter in order
to inform the public of new developments and clinical
information. Sponsorship from Image Graphics has been
obtained and this will hopefully launch in 2009.
2.2 Dental Services
ACTIVITY
The ethos of the Dental Department has always been
driven by the desire to provide the best possible treatment
for our patients. (See Tables 2.1 to 2.4 in the Appendix for
clinic attendance statistics)
The resources required to achieve this were
comprehensively defined by Kevin Pizarro in his Dental
Department Review 2004. In this four year period, the
department has come very close to reaching the targets
set by this review.
The Department provides the following services:
• Children’s Dentistry
• Braces – both fixed and removable
• Oral Surgery - Emergencies, maxillo-facial surgery and
facial lesions
• Dentures - Welfare and Prisoners
• Fillings - Welfare and Prisoners
• 24/7 Dental emergency cover
23
Wider and more timely access to dental and orthodontic services is being achieved.
STAFF
The department began 2005 with the following resources:
• Consultant - Orthodontics
• Senior Dental Office- Specialty-Paedodontics (Children’s
Dentistry)
• Senior Dental Officer- Specialty- Oral Surgery
• Dental Officer-Paedodontics/Orthodontics
• Four nurses at different levels of expertise
• This has evolved over the four years into almost the target
complement specified in the Dental Review:
• Consultant- Orthodontics
• Senior Dental Officer- Orthodontics
• Senior Dental Officer- Paedodontics
• Senior Dental Officer- Oral Surgery (4 sessionsPaedodontics)
• Dental Officer- Orthodontics/Paedodontics
• Dental Officer- Paedodontics
• Five dental nurses
• AO Clerical Officer
The remaining resource which it is hoped will be acquired
during 2009 is the nurse to assist in supporting clinical
duties and cover for annual/sick and study leave.
24
3. SECONDARY CARE SERVICES
ACHIEVEMENTS
In 2004 the department commenced a Risk Assessment
programme which evolved in 2007, through the
intervention of the CEO into monthly departmental
and clinical meetings. These meetings are the motive
power which drives staff to constantly review and update
procedures and protocols to NICE (National Institute of
Clinical Excellence) standards. One of the outstanding
results of these meetings has been the development of
comprehensive Infection Control protocols which meet
the highest criteria. Other significant changes have
included changing from 15 minute appointments to 10
minute appointments and extending the working hours by
30 minutes daily. The department is also in the process of
moving the treatment of all adult patients to St. Bernard’s
Hospital thus dedicating the PCC clinics almost entirely
to Children’s Dentistry. Equipment provision over the four
years have almost reached target levels, and has included the
installation of a new chair in clinic 3, two new autoclaves,
in house steam distilled water production, equipping the
hospital clinic, four ultrasonic baths, computer facilities in
all the surgeries, computerised prescription services and a
computerised appointment system.
Waiting lists are due to be tackled across the board. The
new dental officer will be seeing all new children on our
waiting lists. The Orthodontic waiting list should see a
significant decrease with three dentists tackling this list
with an increase from 10 sessions to 19 sessions per week.
The Welfare dentures waiting list has been reduced over
the last year to less than three months. The Oral surgery
waiting list for skin lesions has been targeted with a two
week exclusive programme for the New Year.
This report would not be complete without commending
the sterling work done by the two Dental Officers in
producing a programme for the education of the Dental
nurses to a level which will allow them to be graded as
Dental Surgery Assistants within the GHA.
25
Since the GHA took over responsibility for the Ambulance Service, training and the
development of the clinical standards of the ambulance crew has been the top priority.
3.1 Ambulance Service
The Ambulance Service has travelled a long way since the old idea of “scoop and run”. This philosophy was based on the
principle that the ambulance was essentially a transport service, whose main function was to get patients to hospital as soon
as possible. Recent advances in medical science have shown that some interventions at the scene of an emergency can
significantly increase the chances of a patients’ survival or improve their health outcomes.
The move of the Ambulance Service to St Bernard’s in June 2007 brought pre-hospital emergency care together under
the same roof as the other hospital emergency care services and has assisted in achieving a seamless integration of the
service for the greater benefit of patients. Another benefit of the integration is that by working with experienced and
highly professional doctors and nurses in A & E, the ambulance crew’s skills have been enhanced and their knowledge,
understanding and experience increased. The experience of the last 18 months is that it will continue to improve the
delivery of out of hospital care substantially.
Since the GHA took over responsibility for the Ambulance Service, training and the development of the clinical standards
of the ambulance crew has been the top priority.
The GHA’s link to Kingston University and St George’s (University of London) has been of tremendous benefit to the
Ambulance Service. In August 2007, the Practice Research and Development Manager (International) South East Coast
Ambulance Service NHS Trust visited Gibraltar and produced a needs analysis report with the aim of modernising and
developing the Ambulance Service.
Training already provided has included:
Automated External Defibrillation Instructor Training; the Service now has four qualified instructors;
Specialised driver training which means that those driving ambulances in emergency situations are skilled to get patients
and staff to the hospital safely;
Specific management training for all ambulance management staff;
There have also been voluntary placements in which ambulance crews from Gibraltar have worked on the road in the south
of England, such as Brighton and Redhill. These experiences have not only developed the skills of Gibraltar’s Emergency
Medical Technicians (EMTs) but have also helped the Gibraltar ambulance service achieve and maintain the standards set
by UK ambulance services.
There were Refresher Skills training courses for the Patient Transfer and Emergency Service Crews in 2008. All ambulance
staff are now up to date with their mandatory training and, more importantly, over 92% (22 out of our 24) of the EMTs
achieved an ‘A’ grading in their assessment.
The results from examinations at the end of training, overall average of 81%, reflect the competence and the high standard
of patient care being provided by the GHA ambulance service.
3.2 General Medicine
STAFF
The Department of Medicine has four full-time consultants
with a team of five Non- Consultant Hospital Doctors
(NCHDs). (See Table 3.1 in the Appendix for consultation
statistics)
Specialities covered include:
• General Medicine
• Gastroenterology
• Geriatrics
• Endocrinology and diabetes
• Respiratory Medicine
Visiting Specialists
• Cardiologist
• Rheumatologist
• Respiratory physician
26
•
•
•
•
•
Haematologist
Neurologist
Gastroenterologist
Nephrologist
Cardiothoracic specialist
Human Resource changes
• Consultant staff increased from 3 to 4
• Dr Norbert Borge retired
• Dr Antonio Marin (Geriatrics) (2005), Dr Waqar Haider
(Respiratory Medicine) (2006) and Dr Aleksander Lorenc
(Diabetes) (2008) joined the department.
• Number of NCHDs increased to 5
ACTIVITY
• New services introduced
• 24 hour BP monitoring
27
• 24 Cardiac Holter
• Exercise stress test
• Lung function testing
• Sleep studies
• Dialysis service
Clinical Audits carried out
• Lung cancer in Gibraltar 2006-2008
• Bronchoscopy 2006-2008
• Service Goals for the Department
• Replace and modernise the endoscopy + bronchoscopy
equipment
• Upgrade PFT lab
• Recruit a 6th NCHD
• Recruit a 5th Consultant (additional geriatrician)
3.3 Paediatrics
See Table 4.1 in the Appendix for Paediatrics Data
STAFF
In 2005, the expansion of the paediatric service necessitated the appointment of a second Consultant Paediatrician. Dr
Daniel Cassaglia, born and educated in Gibraltar, had completed his specialist training in Paediatrics in the UK and was
unanimously appointed, starting work in September 2005.
His special interests are resuscitation, intensive care, allergy and developmental paediatrics. In the short time that he has been
with us the public, and especially the children, have taken him to their hearts and we wish him many years of rewarding
practice in Gibraltar.
2008 saw the departure of Dr Steve Higgs from the GHA. All who have had the pleasure of working with him will miss
him. The department welcomed Dr Annie Dai who was appointed as the new Consultant Paediatrician and started work
on 1st October 2008. Dr Dai is a General Paediatrician with extensive experience and an interest in Community Paediatrics
and Child Public Health. She qualified in Leeds University and trained in many different London hospitals. The Paediatric
Department will benefit tremendously from her expertise.
ACTIVITY
2005 was a landmark with the move to a new hospital and
a beautiful spacious 20 bedded paediatric ward.
Rainbow Ward has retained the cheerful and home-like
atmosphere which characterised the old hospital.
Sr Mary Sene dedicated many hours of planning and
work to ensure that the transition to the new hospital was
smooth and without incident.
Sr Mary Sene continues to provide a monitoring and
counselling service for the diabetic children and their
parents which is much appreciated. Rainbow Ward is run
by a cohesive team of professionals whose main focus
and consideration is for the child and for the (often
concerned) parent.
During 2005 Christine Shimitsu attended a Cystic Fibrosis
Clinic in London and continues to look after the small
group of children with this condition with great care.
In 2005, Sr Sene and Sr Pat Murphy also attended a
modified PALS course held by the MOD.A lot of attention
has been given to upgrade high care facilities in the ward.
The department recently acquired equipment to perform
overnight pulse oximetry sleep studies in children with
suspected Obstructive Sleep Apnoea. This new service
allows the targeting of surgical treatment (Tonsillectomy/
Adenoidectomy) for those children most in need. In 2007
about 8 sleep studies were conducted.
28
The first UK Resuscitation Council accredited EPLS
course was held in Gibraltar in March 2007. A second
EPLS course was held in November 2007. A third EPLS
course was held in April 2008 at the Princess Royal
Medical Centre. Dr Cassaglia will again be a member of
the faculty and some places will be open to GHA staff.
2008 has also seen a change in the way the BCG vaccine is
administered. Babies are now being recalled to have their
BCG in weekly clinics run by the midwifery staff.This will
reduce vaccine waste as more babies can be immunised at
the same time.The new system will require monitoring to
ensure the same high rate of uptake.
SERVICES OFFERED
Neonatal Care
In 2005, a review team from the UK assessed the Midwifery
unit, including the Newborn facility and a number of
amendments have been suggested which were put into
practice the following year.
With the opening of the new hospital in February 2005,
there is at last a well-equipped and functional High care
unit for newborns.
The CPAP machine, assisting breathing for newborns
with respiratory distress has been successfully used and will
further decrease dependence on referral of infants with
respiratory problems to Malaga or Seville. Not having to
29
Since the second paediatrician arrived, the Allergy Clinic has
now increased to weekly and the clinics are currently full.
move sick infants reduces their morbidity and allows them
to recover better.
There is a Neonatal Unit located within the Maternity
Department to provide short-medium term basic Neonatal
Care (Level 1 Care) to those babies who are preterm or
develop problems shortly after birth and cannot be cared
for at home.
The department is equipped to provide Neonatal High
Dependency/Intensive Care for short periods of up to 72
hours to those babies with more severe difficulties which
may be transient.
The department has been able to provide care for critically
ill babies where their difficulties were unexpected and who
may need a period of resuscitation and stabilisation prior
to transfer to a tertiary Neonatal Unit in Spain. New links
are being established with the Neonatal and Obstetric
Unit in Seville.They offer a wide range of tertiary services
and the new road links will allow transfers to take no more
than 1hr 45min.
Asthma/Allergy Clinic
This clinic is run jointly by the consultant and an asthma
nurse, who is responsible for counselling, lung function
testing and skin-prick testing.
Historically the allergy clinic took place once per month.
Since the second paediatrician arrived, this has now
increased to weekly and the clinics are currently full.
Diabetes Service
The Diabetic service is run by a multidisciplinary team
including the Paediatricians a diabetic nurse specialist, a
GP, Dieticians and a Psychologist. Each child is seen by
the team on 4 occasions per year in a specialist clinic held
in the Diabetes Association headquarters. Once per year
a Visiting Paediatric Endocrinologist from Northwick
Park visits to assess the progress of diabetic children (Total
number 28). There is access at all times to advice and
counselling.
Endocrine Service
Children with growth problems/endocrine disorders
are seen annually by the Paediatric Endocrinologist and
followed up in General Paediatric Clinic. An endocrine
clinic is foreseen for next year to group these children
together for follow-up.
Neurology Service
Children with Neurology problems are seen in the
General Clinics and managed by the Paediatricians who
are supported by a Consultant Paediatric Neurologist
from Bristol Children’s Hospital. He visits every 6 months
and advises on further management or investigation.
30
84 additional knee operations were performed during alternate weekends in 2006 with a total of 10 to 12
knees per session. These operations reduced waiting times from 7 years to 3 months for patients in pain.
screened for associated medical conditions, a neurological
assessment is done and the academic problems discussed.
In addition, a number of children are carefully considered
for trials on medication such as Ritalin and the effect of
the medication on their school performance monitored as
well as possible side effects of the medication. Children on
medication are reviewed at 3 month intervals.
He is always available for consultation during the year.
Occasionally patients are admitted to the Neurology Unit
in Bristol for further complex investigations.
Inpatient Care
The department runs a full acute Paediatric service
including a fully equipped High Dependency facility.
The children’s ward has 9 cubicles (2 of which are high
dependency and 2 are designed for adolescents) and
general 12 beds. Total capacity is 21 children.
Rainbow Ward is fortunate to have 9 excellent Paediatric
Staff Nurses, all UK trained, and in addition 3 enrolled
nurses, providing a high level of nursing care appreciated
by the parents and children alike. Two of the staff nurses
have completed modules in Asthma care, and Sister Mary
Sene continues to provide an excellent diabetic service.
Informal teaching on a regular basis is given to the nursing
staff covering a wide range of paediatric topics.
Child Welfare Clinics
Srs Rosemary Cox (who retired recently after many years
of excellent service) and Fiona McCoubrey have been
running the Child Welfare Centre with their able team.
(See Tables 2.1 to 2.4 in the Appendix for Child Welfare
Clinic Data)
A new protocol for immunisation has been introduced
and began in October 2006. This incorporates a new
Prevenar Vaccine active against Pneumococcal infection.
This will hopefully reduce the incidence of ear, eye and
chest infections as well as the incidence of Pneumococcal
Meningitis. The new protocol has been introduced
seamlessly and a catch-up programme to target all the
under 2 year olds has occurred already.
Child Protection
The Child Protection Team (Health Visitors, Social
Worker, A and E staff member, Psychologist, Child Line
representative, GP, and Paediatricians) meet every three
months to discuss common problems and improve
communication between the various disciplines. A
Child protection register is kept and key members have
access to this. The MOD paediatrician is also invited to
these meetings and the GHA Paediatrician is a member
of the MOD Child Protection Committee, attending
their meetings. The Paediatric Consultant has overall
responsibility for child protection within the GHA.
The Paediatrician also attends the Child Protection
Committee meetings. This is a statutory body headed by
social services and meets every 3-6 months.This committee
has overall responsibility for child protection in Gibraltar.
In the last year progress has been made in finalising the
Gibraltar Child Protection Protocol/Procedures and
organising training for all persons involved in child care.
3.4 Operating Theatre
and Day Surgery
Seminars in Child Protection have been organised and the
new NSPCC Training course will be implemented next
year to train all front-line staff in child protection.
Children with Special Needs
The paediatrician attends St Martin’s School on a weekly
basis to supervise common problems, medication, and
advise the staff on appropriate management. Each week a
child is reviewed in detail with his/her parents, teachers,
therapists and the paediatrician, and further planning and
investigation is discussed.
Each child is seen at least annually by the visiting
Paediatric Neurologist, Dr Philip Jardine from Bristol
who visits every 6 months and advises the paediatricians
on further management.
Learning Disabilities Clinic
Under the guidance of the Principal Educational
psychologist, a Learning Disabilities Clinic is run jointly
with the paediatrician every week.At this clinic the child is
ACTIVITY
During 2006-7, the GHA carried out a total of 2627
operations in an endeavour to cut down waiting lists.
A number of initiatives were performed within the
following specialities: Orthopaedic, Urology, General
Surgery and ENT. The main one was the Knee Initiative
which commenced in January - August 2006.The sessions
were done on alternate weekends, with a total of 10 to 12
knees per session, reaching a total of 84. Mr Earnshaw,
Consultant Orthopaedic Surgeon from Guys and St
Thomas Hospital, London, performed the operations. The
appointment of two further Orthopaedic Consultants has
seen a 21% increase in operations within this speciality.
A first for the Department and for Gibraltar was the
introduction of Laparoscopic Cholecystectomy. Thirty of
these operations were performed.These proved to be very
beneficial, both to patients and to the Department, as they
required minimum hospital stay.
The Day Surgery Unit has started to process more surgical
cases earmarked for the Andrew Correa Operating
Theatres which did not require lengthy recovery times or
an overnight stay. The adoption of this has provided more
effective operating time and fewer cancellations of cases
plus the benefit of freeing up more beds in the ward areas.
A new Datex/Ohmeda anaesthetic machine has been
installed in the Day Surgery unit to maintain the unit on
par with the Andrew Correa Operating Theatres. There has
been a substantial increase in CSSD supplies to Wards and
Departments such as Accident and Emergency, Intensive
Care, Ortho Trauma wards, Primary and Elderly Care.
The new services within Radiology, Primary and Elderly
Care have led us to introduce custom-made dressing and
preparation packs for these Departments. There has been
an overall increase in the service of 25% - 30% more than
the previous years. Undoubtedly the greatest increase in
workload has come from the Operating Theatre with the
vast amount of instruments that had to be reprocessed,
especially during the knee initiative. This year, two
members of staff attended Eastwood Park training centre
and successfully completed a course on Decontamination
Management and Processing of re-usable equipment. One
of the issues identified in this course was the introduction
of log sheets on Washer/Disinfectors and Sterilizers. The
department has also introduced photo images of all sets
31
Shorter operating times and nurse-led minor operations
have eliminated the minor operation waiting list.
The aim of this service is to prevent blindness due to diabetes.
The waiting list for this service was eliminated in 2007.
of instrumentation providing better and more effective checklist to assist staff members in the sorting and packing of
instruments. Since the winter of 2007, the unit has seen a marked increase of more day-surgery orientated suited procedures
which, in turn, has alleviated some of the surgical bed occupancy issues. This trend maintained a constant flow of surgical
cases with fewer cancellations of booked elective cases.
There has also been a marked increase of using the unit as a “day ward”, which has had a perceivable effect on the efficiency
of patient turn-over in contrast to those patients which are ward-based. The reason has been attributed to the less reliance
on 3rd party personnel for the transportation of the patients (i.e. theatre attendant and transfer nurse).The latter role has been
provisionally up taken by the day surgery personnel.
The client groups include all surgical specialities, but the bulk of the “in-house” surgery is currently taken up by dental, pain
clinic and “lumps & bumps” minor op procedures.
Patient care has been appreciated to be improved due to the more focused and “in-house” pathways being given by the same
dedicated personnel throughout the entire patient journey.
3.5 OPTHALMOLOGY
SERVICES
STAFF
The Ophthalmic Unit has a staffing complement of
1 Ophthalmologist, 1 Charge Nurse, 3 Staff Nurses,
1 Nursing Assistant, 1 Optometrist and 2 part-time
Orthoptists. The Services provided by the Ophthalmic
Team are outlined below:
ACTIVITY AND ACHIEVEMENTS
Cataract Service
220 cataract operations were performed during 2008. Of
these, only 4 were done under general anaesthesia; the
rest were done under local anaesthetic in the unit’s own
operating theatre. This has allowed us to maintain waiting
times to an all time low of 3 weeks including pre-operative
assessment. On average, patients have had their operations
pre-scheduled within a week of being listed for surgery.
2008 saw the introduction of the Alcon Infinity
Phacoemulsifier, one of the newest and most advanced
cataract extraction systems in existence. Surgical time
per patient has been reduced and the incidence of intraoperative complications has become negligible; even lower
than internationally accepted levels (0.6%).
Shorter operating times and nurse-led minor operations
have eliminated the minor operation waiting list.
100 minor operations were performed during 2008, 74 of
these carried out by the ophthalmic nurses.
The cataract clinic has kept its waiting time targets from
2005 to date. Since the Optometry service’s move to the
new Hospital, any minor post op complication detected in
this clinic has been dealt with by the Ophthalmologist on
the same appointment.
2006 saw the introduction of the cataract audit with input
from all the disciplines involved. The introduction of the
gold standard biometry equipment (the Carl Zeiss IOL
Master) for pre-operative assessment in 2008 is giving
improved refractive results.
32
Nurse-led Clinics
2008 saw the continuation and consolidation of numerous
nurse-led clinics. Of 133 patients seen, 96 were successfully
diagnosed/treated by the ophthalmic nursing staff, freeing
the same number of slots in the Ophthalmologist’s clinics
and reducing the waiting time for the latter. (For full
statistics, see Tables 2.1 to 2.4 in the Appendix)
Eye Casualty Service
During 2008 there were 1889 attendances to the Eye
Casualty service. This is an increase from 2007 (1640). In
fact, attendances have been steadily increasing since the
year 2000. In-house training in advanced ophthalmic
practices has allowed the ophthalmic nurses to see and
treat more ophthalmic conditions including various retinal
conditions. Casualty arrival and booking-in has been
streamlined allowing for less waiting time for casualties
and walk-ins and ensuring database numbers are more
accurate.
Laser Service
The old YAG laser was replaced with a Carl Zeiss Visulas
YAGIII, one of the most advanced YAG lasers available to
date. 194 laser procedures were performed in 2008. 89 of
these interventions required the YAG laser.
Fundus Angiography
This service has slowly been expanding and more and
more patients are undergoing this investigation locally. It
has become invaluable in diagnosing the treatable type of
Macular Degeneration. Previously patients had to travel to
Moorfields Eye Hospital in UK for this test. It has allowed
the unit to refer only patients which have been positively
diagnosed with the condition locally. In 2008, 23 of these
procedures were performed, compared to only 7 in 2007,
and 3 in 2006.
Diabetic Retinopathy Screening Service
The aim of this service is to prevent blindness due to
diabetes. The waiting list for this service was eliminated in
2007. Increased levels of screening has however resulted in
an increase in demand for Secondary Grading and DR
monitoring. The waiting list currently stands at 3 months.
We plan to eliminate this with the appointment of an
additional optometrist in 2009.
Glaucoma Screening Service
This service provides investigation for those whose test
shows possible evidence of Glaucoma and monitoring
of high risk groups. In 2005 the clinic was developed
into a joint one with the Orthoptist to improve patient
management. Patients now have all the relevant tests plus
their outcome on one appointment. The introduction
of a Pachymeter in 2008 has allowed us to accurately
diagnose true Ocular Hypertension and has been an
invaluable tool for deciding whether treatment is required
in this condition.
Glaucoma Co-Management
This service was introduced in 2007 bi-weekly and then
weekly in 2008 for the monitoring of stable Glaucoma
Patients. Patients now have all the relevant tests done
in one appointment by the Orthoptist and Optometrist.
This includes photographic documentation of the
optic nerve as per national guidelines, to help monitor
progression of the disease. There is also time to tackle
compliance to treatment which is one of the main causes
of treatment failure.
Visual Fields Service
The Ophthalmologist and Optometrist refer patients with
diagnosed or suspected Glaucoma or Neurological defects
to the Orthoptist for visual field assessment. This test is
essential in order to accurately diagnose and monitor
progression of the conditions mentioned. Before 2005
patients were given two separate appointments for visual
fields with the Orthoptist followed by an Ophthalmological
review. The move to the new hospital has resulted in
improved communication between clinicians and clerical
staff and has facilitated the development of the service to
enable us to offer patients one appointment in which both
examinations are carried out.
Child Refraction Service
This service provides general eye examination including
the need for spectacle prescription for children. Those
requiring Orthoptic or Ophthalmological review
are kept under the Unit’s care. Routine cases which
33
21.1% of 4-5 year olds children seen had either a squint or reduced visual acuity which
would have gone unnoticed had they not been screened via this programme.
would not ordinarily be seen in a hospital setting are
discharged after the age of 8 years, which is when the
visual system has finished its development and there
is no longer risk of developing a lazy eye. Exempt
patients and those with learning disabilities are kept
under review beyond this age.
Orthoptic Service
This service provides secondary eye care for children
and adults suffering from squints, lazy eye and double
vision. Patients are referred from the Ophthalmologist,
Optometrist, Paediatrician, General Practitioner and
Health Visitor. For the past three years there has been a
steady increase in the number of patients being seen, with
408 patients attending in 2006 to 578 attending in 2008.
Increased public awareness of sight threatening diseases in
children, and the service provided to prevent and treat these
conditions have had an impact on the number and type
of referrals received. The waiting time for an appointment
currently stands at 10 weeks but the aim is to improve
service delivery by obtaining an additional Orthoptic
session and therefore reduce this waiting time.
Paediatric Co-management Service
This clinic was implemented in March 2006 for children
up to 8 years of age to be seen for both Orthoptic and
Optometry assessment in one appointment. The aim
was to improve patient service by reducing the number
of visits to the hospital. It has proved invaluable to the
Orthoptic / Optometry team since discussions over the
patient’s treatment and management is conducted at
that visit. Because of its efficacy in terms of managing
paediatric patients the demand for this service has
increased tremendously, with the Orthoptist currently
referring three times as many patients into this clinic than
in 2006 (35 patients in 2006, 108 patients in 2008).
Vision Screening Service
This service is provided on an annual basis for all 4-5 year
olds who are entitled to GHA health care in our community.
Any problems with eyesight must be investigated and
corrected before the end of the Critical Period (8 years of
age) which is when the vision stops developing.The liaison
between the Orthoptists and the different schools involved
has been invaluable in increasing parents’ awareness of the
service which in turn has had a positive effect on the rate of
attendance. Improved clerical assistance in the Ophthalmic
Unit since 2006 has also had a most beneficial effect on
the delivery of the service, with all children being sent
appointments before the start of the following school year.
The service was audited in 2007 and it was found that
21.1% of 4-5 year olds children seen had either a squint or
reduced visual acuity which would have gone unnoticed
had they not been screened via this programme.
34
Future Plans
Ophthalmology
The present ophthalmic service is comprehensive and
the Ophthalmic Unit will match any internationally
recognised Ophthalmic Department. There is room for
further development of the service cannot be taken further
until there is more manpower. With the appointment of
a second Consultant Ophthalmologist and the second
Optometrist the service can be expanded resulting in a
dedicated Medical and possible Surgical retina service,
Glaucoma service and Ocular Plastic service.
Orthoptics
The plan for the coming year is to improve, expand and
develop the existing Paediatric, Glaucoma and Visual
Field services provided by obtaining additional sessions to
cater for the increased demand. The acquisition of a new
Humphrey Visual Field Analyser to improve patient care is
also one of the main goals for 2009.
Future plans involve obtaining the necessary clinical
teaching qualifications as directed by the British and Irish
Orthoptic Society, to enable the department to take on
Orthoptic students.
Optometry
In 2009 the department foresees the appointment of a
second optometrist which will enable the introduction
of a fully fledged Low Vision Service; the reduction
of waiting times for some of the clinics particularly
the more urgent ones like the Diabetic Retinopathy
Secondary Grading Clinic and the paediatric service;
the introduction of a pre-cataract operation refraction
clinic enabling refinement of post operative refraction
result; establishement of a therapeutic contact lens
service to minimise referrals to Moorfields Eye Hospital;
improvements to the current Glaucoma Screening and
Glaucoma and Ocular Hypertension Co-Management
clinic and a formal program of Quality assurance, clinical
audit and Continuous Professional Development.
3.6 ENT SERVICES
STAFF
The ENT Department consists of one Associate Specialist
(acting consultant), one senior enrolled nurse, one shared
medical secretary and, since June 2008, a part-time
outpatient receptionist.
Directly linked to the Department is the Audiology
Department based at the Primary Care Centre where
hearing tests are carried out and hearing aids are dispensed
by one audiologist (also Head of Speech and Language
therapy). The Department also has close links to the
Speech and Language Therapy Department.
35
The Activities Centre is a proud achievement. This has made a real difference to the quality of
patients’ lives by giving them therapeutic and social activities to improve the quality of their day
ACTIVITY
The Department moved to its new premises with the
opening of the new St Bernard’s Hospital in February
2005. The new outpatient facility includes a new
outpatient microscope through which all ears are
examined, facilitating accuracy of diagnosis, an ENT
work station with rigid and flexible endoscopy facilities
and stroboscopy for the assessment of functional laryngeal
(voice) disorders, as well as the diagnosis of sinus disease
and throat cancer.
ACHIEVEMENTS
The priority for reform at the start of the move to the
new hospital, especially with the availability of extra
theatre space and time, was to drive down the waiting
time for surgery. Before the move the waiting time for
routine children’s ENT surgery was around six months
and for adults around 18 months. Between February
and June 2006 a waiting list initiative was implemented
which resulted in the virtual elimination of the paediatric
waiting list and reduction of the adult waiting list to less
than six months.
The numbers of elective operations carried out during the
years are as follows:
2005 – 181
2006 – 244
2007 – 196
2008 – 202
Several new services have been introduced with the
opening of the Department at the new St Bernard’s
Hospital:
1. Joint Voice Clinic
This clinic is held with a speech and language therapist for
assessment, treatment and review of patients with voice
disorders. This has been operational since January 2006.
2. Early Access Clinic
This clinic is held on Friday mornings for new urgent
referrals and urgent follow ups.
There have been a number of adjustments to clinics in order
to meet the ever-increasing demand from general practice
and in-house referrals. It remains difficult to improve
waiting times for non-urgent referrals, with waiting times
being approximately 4 – 6 weeks for paediatrics and 8 –
12 weeks for new adult ENT cases.
The number of outpatients seen per year has steadily
increased since 2005. The numbers seen are as follows:
August – December 2005 – 1111
2006 – 2705
2007 – 3171
2008 – 3192
36
These numbers exclude patients who are unregistered and
who are not recordable for statistical purposes.
3. Repatriation of ENT Referrals previously sent to
the UK
Another priority for reform has been the provision of
more services for the local population onsite at St Bernard’s
Hospital. These include:
a) the provision of complex ear surgery here in
St Bernard’s Hospital
b) the provision of local tertiary otological services
This has involved the employment of a Visiting Professor
of Ear Surgery to carry out complex ear surgery in St
Bernard’s Hospital. This has been successful with the near
elimination of all ear referrals to the UK and for the first
time we have been able to carry out complex middle ear
reconstruction surgery in St Bernard’s. There has also
been further improvement in the Visiting Rhinology
Service which continues to expand, providing advanced
endoscopic sinus surgery as well as lacrimal duct surgery
and functional and cosmetic septorhinoplastic surgery.
The Head and Neck Service remains as before with an
ever increasing effort to localise the follow up of head and
neck cancer patients through maintaining close links with
the Head and Neck Department at the tertiary referral
hospital (The Royal Marsden Hospital).
Problems do remain despite the significant improvement:
1. The outpatient demand is greater than supply. The
employment of a second ENT Consultant would be
expected to alleviate this.
2. Reforms in the audiology services are pending. Again
the demand for audiological assessment and the provision
of hearing aids continues to increase. The increased activity
does impinge very significantly on the timely management
and diagnosis of hearing loss coming through the ENT
Service.
Hopefully, the implementation of these reforms will
improve the function of the ENT services as well as the
audiological services.
3.7 MENTAL HEALTH
SERVICES
It has been widely acknowledged that a new building to
house our Mental Health Service is desperately needed,
and the Government have committed to building us one
in the near future. What is special about the achievements
set out below is the staff philosophy that, in spite of
the restrictions of our facilities, this should not stop us
from providing the highest possible standard of clinical
care. Patients with mental illness are some of the most
vulnerable in our society and they deserve the best we
can offer them. With this aim in mind, the Mental Health
Management Team have been meeting regularly for the
last three years to develop the plans and proposals for their
new facility, but also more importantly to ensure that the
clinical developments are taking place now.The numerous
initiatives outlined below and testimony to the hard work,
commitment, dedication and enthusiasm of the staff
working in these services. Of these, the Activities Centre is
the one of which they can be most proud. This had made
a real difference to the quality of patients’ lives through
giving them therapeutic and social activities to improve
the quality of their day. The fact that two Staff Awards
have been given to our teams is further evidence of the
high regard in which this work is held. We know there
is still significant further work to do but are optimistic
with the additional investment promised we can deliver
on a Mental Health Service of which Gibraltar can be
justifiably proud.
The Government of Gibraltar has accepted the GHA
Strategy for Mental Health Services (MHS).This document
defines the blueprint for the direction of and growth of
services and is underpinned with the commissioning of a
new mental health facility. Simultaneously and additionally
to this facility, there will be a new site for the Community
Mental Health Centre. The GHA also plans to provide
expanded mental health services in Primary Care. The
GHA is now using evidence from research and studies
to underpin Clinical Practice. Guidelines from the Royal
College of Nursing and the National Institute for Clinical
Excellence are two examples of this initiative. Mental
health personnel are involved in developing policy and
procedures to enhance standards. The service has also
started to network with key community groups in order to
reduce the stigma of mental illness and to improve service
user accessibility and include the input of community
groups.
The GHA and the Government of Gibraltar has committed
funding to assist Mental Health Services in improving
clinical practice, supporting the Mental Health strategy and
leadership programmes, which will result in the provision
of a quality specialist service.With a new facility, a broader
range of clinical programmes and increased staffing levels
of all professional groups, the Mental Health Service stands
well placed to deliver on the clinical needs of the Gibraltar
community in a manner that exceeds expectations.
MENTAL HEALTH CONFERENCE
October 2006 saw Gibraltar host the first Mental Health
Conference. GHA Mental Health Staff presented to the
Conference on a range of topics and participants from
USA, Jersey, UK, Spain, Bermuda - along with multiagency participants from Gibraltarian participants working
in GHA, the Elderly Care Agency, Social Services,
37
Pain Control Guidelines have now been introduced in the GHA.
this condition is in no way limited to palliative care patients
some of our patients do have this condition so it is a huge
benefit to all to have staff able to manage this condition.
Formal and informal teaching sessions for staff take place
on a regular basis.
Pain Control Guidelines have now been introduced in the
GHA. This was compiled by a consultant anaesthetist, a
pharmacist and the palliative care department.
A care pathway for the care of a dying patient has been
introduced.
Ten new portable syringe drivers were purchased in
2006 to improve symptom control for our patients.
These are available to patients both in the community
and the hospital.
In April, 2008, the CNS in palliative care was seconded to
another post in the GHA and a palliative care nurse from
England was employed on an 18 month contract. New
assessment forms for the department have been introduced
plus an improved system for the collection of statistics.
This nurse is currently investigating how the department
might set up a bereavement service with input from other
health care professionals. Such a service would necessarily
the Police and the voluntary sector. It provided a
valuable learning opportunity for all with many useful
professional international networks developing which
have resulted in further exchanges and the fruitful
sharing of best practice.
March 2007 saw the introduction of a 7-days-a-week
activities program tailored to the current service users.
There is a wide range of diverse activities which include
recreational, social and entertainment aspects and are
aimed at meeting a wide range of clients’ needs. Staff
are very proud of their achievements with the activities
centre and also from the feedback from service users. The
activities centre and structure is a potential blueprint for
future day hospital services, as many key lessons have been
learnt regarding planning and implementation.
The clinical management structure is now clearly defined
within Nursing in Mental Health Services and this has
lead to increased levels of accountability and transparency
in practice. Other initiatives include the appointment
of senior nursing leaders, a GHA management training
scheme that has included middle managers and the
commencing of managerial supervision.
The appointment of a second Psychiatrist has had a
dramatic effect on clinical governance and facilitated a
greater range of Mental Health Services and clinics to
meet the health needs of the Gibraltarian community,
specifically for children and the elderly.
3.8 Palliative Care
ACTIVITY
Palliative care is a nurse-led service offering symptom
control, emotional and psychological support to patients
with newly diagnosed disease such as cancer and other
chronic, life-threatening conditions and patients suffering
from advanced terminal disease. The patient’s quality of
life and the well-being of the patient’s family are of prime
concern. Based in St Bernard’s Hospital, the palliative
care nurse specialist works closely with other members
of a multi disciplinary team, both in the hospital and the
community to realise those aims. The palliative nurse also
has an educational role within the GHA. (For Palliative
Care statistics, see Tables 6.1 to 6.3 in the Appendix)
From 2005 in the new St Bernard’s Hospital, an office was
made available for this nurse to set up a department space
to offer lymphoedema care, relaxation therapy and private
interviews with patients and their families.
From 1998 until 2005 the palliative care nurse post was
funded by the Gibraltar Society for Cancer Relief
(GSCR) but in April 2005 the GHA approved the full
time appointment.
38
In 2008, the first Breast Care Nurse in the GHA was appointed.
increase the work load and would therefore need support
from other areas of the GHA.
In November 2008, the hospice at home nurse working
within the department was appointed as the first Breast
Care Nurse in the GHA. She had identified the need
for this role some 18 months previously and had been
working very closely with the surgeon in the breast
clinic prior to this appointment. She is still based in
the department. Her role has been replaced by another
hospice- at -home nurse employed by GSCR.
The department works closely with all disciplines in the
GHA and beyond. We have very close links with the
Royal Marsden Hospital where we send many of our
patients for treatment.
In 2006 the hospice- at- home nurse, funded by the GSCR,
came from the community to be based within the palliative
care department in order to improve communication and
to manage the increasing workload. As can be seen from
the table below, the number of referrals continues to rise,
with an increase of 50% last year since 2005.
Education-ongoing professional development is essential
in this field and the post holder has attended palliative
care updates at the Royal Marsden Hospital and
in lymphoedema management - the palliative care
nurse specialist is a registered member of the British
Lymphology Society.
In November 2007, two members of the National Cancer
Action Team delivered an Advanced Communications
Skills Course for twelve members of staff, including
the palliative care nurses and other disciplines including
doctors and a physiotherapist.The course covered difficult
communication situations such as breaking bad news and
discussing end of life issues and involved role play with
professional actors, which was very demanding emotionally
but proved to be an effective learning method.
In November 2008 a lymphoedema management course
was held for GHA nurses and physiotherapists. Although
39
4. DIAGNOSTIC SERVICES
A major improvement has been the upgrading of the department’s Information System in
November 2008. This reduces the risk of errors in the identification of the sample.
4.1 Pathology Services
ACTIVITY
The Department of Pathology provides a wide range
of services in all pathology disciplines: Biochemistry,
Haematology, Transfusion Science, Microbiology,
Histology, Cytology and Anatomical Pathology. A staff
of 25 provides results using modern equipment and
techniques that are crucial in the diagnosis of disease and
patient management. Staff stay completely up to date by
engaging in Continuing Professional Development which
is a requirement to remain registered with the Health
Professions Council and other professional bodies. (For
Departmental Statistics, see Table 7.1 in the Appendix)
The department strives to provide the best and highest
quality service possible. Quality is monitored using internal
and external assessment schemes and our performance on
these schemes is excellent. All staff undergo competency
assessments. The move to the new hospital building at
Europort Avenue in February 2005 initiated a process of
change and improvement in the department and its staff.
STAFF
Staff represented the department and profession at the
Careers Fair (which generated a lot of interest from
students), and recruited new blood donors by participating
in World Blood Donor Day.The dedicated and professional
team in the department made possible the organization
and execution of a bone marrow appeal as well as the
successful participation in National Pathology Week.
ACHIEVEMENTS
These are some of the achievements and improvements
we have made:
• Continuing Professional Development and training
opportunities for staff including courses, attendance
at seminars and conferences, and industry-sponsored
exhibitions
• Organization of the Gibraltar 1st International
Conference of Biomedical Science
• Official change of the department’s name from
Laboratories of Clinical Pathology and Public Health to
Department of Pathology (announced by the Minister at the
Conference)
• Electronic provision of test results to wards, clinics and the
Primary Care Centre
• Testing for a comprehensive range of drugs including drugs
of abuse, therapeutic drugs and others
• Quantitative C-reactive protein and pre-albumin analyses
• Automated blood culture alert system
• Improved MRSA detection times
• Anaerobic incubation system for bacterial culture
• Provision of on-site blood gas, electrolytes, haemoglobin
and lactate analysis to the Critical Care Unit
40
• Improved HbA1c analysis for diabetes monitoring
• In-house RAST allergy testing
• Improved occult blood detection system
• Polymerase Chain Reaction (PCR) analysis capability in
Microbiology (both clinical and bioterrorism-related)
A major improvement has been the upgrading of the
department’s Information System in November 2008. This
allows the Unique Patient Identifier to be used and reduces
risk of typographical errors and wrong patient identifications
Electronic validation allows staff to assess results based on
past history and so improves safety and service quality. We
are fine-tuning this system with the help of the GHA’s
IT team, to provide comprehensive access to past results
and patient summaries and to allow comparisons of results
over time. Electronic requesting is also being developed. In
2008 we were able to resolve a long-standing issue related
to sending samples to the department. In conjunction with
the Technical and Maintenance Services Department we
installed a pneumatic vacuum tube system that delivers
samples from the Accident and Emergency Department,
Critical Care Unit and Operating Theatres within minutes
of sample collection. This significantly decreases result
turnaround times.
Future developments and plans
Workload has grown (Table) reflecting the increasing use
of pathology services as new and improved healthcare
initiatives are introduced in the GHA, and as the department
adds new tests and profiles to its existing repertoire.
The department is committed to its 3-year strategic plan
and the GHA’s strategic plan. Some of the projects we are
working on include:
• In-house autoantibody testing
• Improved anticoagulant clinic and coagulation analysis base
• Carbon dioxide incubation system for bacterial culture
• Expansion of Histology equipment base and updating of
Microscopy equipment
• Development of a protocol to govern testing at the
patient’s bedside
• National Vocational Qualification scheme for Biomedical
Assistants
• Introduction of flow cytometry in Haematology
• Full accreditation status for department (Clinical
Pathology Accreditation)
• Operational expansion in Transfusion Science to comply
with the European Union Blood Directive
All members of staff have enthusiastically been involved in
all processes of change in the department.The department
provides a quality pathology service that is essential
for patient management and the diagnosis of disease.
Staff development and training, together with modern
equipment, commitment to quality and its continuous
improvement, ensure the department continues to provide
a service that is aligned with best practice.
41
5. THERAPY SERVICES
4.2 Diagnostic Imaging Services
The Department provides diagnostic and interventional
Radiology for the population of Gibraltar covering all
age groups, from antenatal screening of pregnancies to
elderly patients.
It provides general radiography, fluoroscopy, CT
(Computerised Tomography), Obstetric and General
(including musculo-skeletal and Doppler) ultrasound
scanning and a diagnostic mammography service.
ACTIVITY
2005 was a particularly challenging and stressful year with
the move to a new hospital, adapting to a new environment,
new management structure and changing systems of work
throughout the imaging spectrum.
The challenges faced by the Radiology Department were
in themselves considerable: moving from an analogue
system to a digital system and the required training on
all new equipment and technology in a short period of
time while coping with the ever increasing workload was
a challenge.
New technology acquired recently includes a CR (digital)
acquisition system, a Computerised Tomography CT
Scanner, a Radiology Information System (RIS) and a
Picture Archiving and Communication System (PACS).
As can be seen from the table provided (Table 9.1 in the
Appendix) there has been a marked increase in investigations.
It is important to note that CT referrals have more than
doubled since the installation of the CT service.
Multislice CT
A 6 multi slice-CT-service started in November 2005.
Initial problems included the lack of experience of some
of the staff but with specialised training, within several
months, basic standards were achieved.
Currently image quality has now reached a high standard,
it includes CT angiography, multiplanar and 3-D
reconstructions. The department also implemented a new
emergency policy for polytrauma patients ensuring a fast
approach to total body CT.
Mammography
The Radiology Department offers a diagnostic
Mammography Service with the introduction of a one
stop symptomatic breast clinic in St. Bernard’s Hospital
which runs in conjunction with the Surgery and Pathology
departments. The Mammography unit was inaugurated in
November 2005.
A fast track mammography service was implemented
together with the surgery department. Patients with a
palpable lump have immediate access to breast imaging
which includes mammography and/or ultrasound.
If a suspicious mass is detected, core needle biopsy is
42
immediately performed. Symptomatic cysts, on the other
hand, require fine needle aspiration Since October 2005,
610 mammographies have been performed.
There has been a continuation of investment in this
department.A new 5 mega pixel reporting workstation was
purchased to meet the criteria for the future introduction
of a breast screening service. Further developments include
the replacing of one of the ultrasound scanning machine
by a new Philips IU22 ultrasound scanner.
In addition to the CT scans and the diagnostic Mammography
scans, Interventional Radiology is also being performed
locally e.g. drainage of cysts, pleural effusions etc.
TRAINING
1. An Intravenous Injection course was provided by
the University of Hertfordshire and sponsored by
Alfrend Swantex.
2. One radiographer attended a RIS/PACS course in
Hammersmith Hospital
3. The Sonographer attended an ultrasound course on
foetal heads
4. Another radiographer started a course on the Principles
and Practice of Mammography with St. George’s National
Breast Screening Training Centre.
As well as the above there has been ongoing in-house
training in CT scanning plus mandatory updates on BLS
and Manual Handling.
Ultrasound
From October 2005 to July 2006 a Siemens Elegra
machine was used.
From July 2006 an IU 22(Philips) has been installed.
A wide range of new ultrasound examinations has been
implemented.
• colour doppler of cranial and peripheral vessels musculoskeletal
• pediatric
• ultrasound of peripheral nerves.
• interventional ultrasound; see interventional radiology.
Outlook:
Currently only fetal ultrasound screening is performed locally.
To guarantee a better quality service to the people of
Gibraltar, it is recommended that further screening
programs should be introduced.
This should include:
- Neonatal hip screening
- Nuchal screening
- Aortic aneurysm screening
-Transrectal sonography for prostate assessment and biopsy.
-Cardiac ultrasound.
43
New services include a Falls Prevention programme and Parkinson’s groups
5.1 Physiotherapy Services
5.2 Occupational Therapy
STAFF
Physiotherapy is led by a Physiotherapy Services Manager
with a Senior I Physiotherapist leading each of the 4 main
Physiotherapy clinical areas; Outpatients, In-patients,Adult
Community and Paediatrics and Special needs supported
by Senior IIs, Technical Instructor and an assistant with
clerical support. Since the opening of the new hospital,
there have been the following appointments:
Physiotherapists:
• April 2006: A Senior II Physiotherapist was employed
for the Knee Initiative and subsequently retained following
appointment of 2 additional Orthopaedic Surgeons.
• May 2007: A Senior II Physiotherapist was appointed
as part of the Primary Care Strategy. This allowed for
increased Physiotherapy support to children and adults.
• Oct 2008: A Senior II Physiotherapist was appointed
to support of the new Cancer programme which allowed
the provision of a new Lymphoedema service and the
expansion of outpatient activity.
STAFF AND ACTIVITY
The 3 years since the move from the old St. Bernard’s
hospital have seen the department expand.The department
has been provided with new improved facilities, extra
human resources and improved administrative support.
This has led to an increase in OT availability in all areas.
The success of many OT interventions and the quality
of the OT staff at all levels have led to an increase in the
number of referrals to all areas of the department.
St Bernard’s referral rates have increased steadily over the
years. This is a direct result of the increase in medical staff
and the more thorough screening tools used by nursing
on admission.
(For Occupational Therapy statistics see Tables 2.1
to 2.4 in the Appendix)
There has been a big increase in the number of patients
who have been referred who have required lengthy
interventions by our department, many in the area
of palliative care or others requiring long term OT
support in the community who were referred because
of permanent disabilities usually due to neurological
conditions. The increase is being monitored and may
lead to the restructuring of the department to enable a
more specialised and robust response to those patients
while allowing a quicker response to the more routine
community cases.
The complement of staff in mental health has been increased
by one Senior II OT.This therapist will be working within
the KGV Hospital and will lead the Activity Centre. This
will then allow the other senior OT to concentrate on the
community role, which will hopefully be developed in
conjunction with the Community Mental Health Team.
The Activity Centre has proved to be a great success and
patients are very positive about this development as shown
in a recently held survey. This culminated with the team
receiving the Innovation Award in 2007. It would perhaps
also be correct at this stage to mention the department’s
technical instructor and the other three nursing staff
attached to the OT team without whom the group would
not have been such a great success.
ACTIVITY
The Physiotherapy Services moved to the new Hospital
alongside its rehabilitation colleagues; Occupational
Therapy, Speech and Language Therapy and Dietetics
and Nutrition in a purpose built Rehabilitation Unit
providing excellent facilities such as shared Reception,
Outpatient area, with well equipped multi-use gym,
catering for individual and group work, separate Neuro
area and Office space. The Hydrotherapy suite has yet to
come into use.
Some new services:
A dedicated Orthopaedic dedicated service is now
provided for inpatients
Community commenced a Falls Prevention programme
and Parkinson’s groups Out-patients provided Telephone
Triage and Power Back classes
Paediatric developed Multi-disciplinary working and a
child friendly service
The recommendations of the 2006 Therapy Review were
accepted in full by the Executive with some appointments
having already come into effect. Other changes are awaited
in accordance with the 3-year planned programme
including the introduction of a Hydrotherapy service.
In 2007 an Out-patient Waiting list initiative carried out
over 4 months reduced the waiting list from 6 months to
2 weeks.
(For Physiotherapy session statistics, see Tables 2.1 to 2.4
in the Appendix)
44
MENTAL HEALTH SERVICE
The mental health service was the success story of last
year and continues to shine as an example of true multidisciplinary team working. The incorporation into the
service of the second occupational therapist means that
apart from having an OT presence at all times within the
unit thereby opening the possibility of expanding the
range of groups within the activity centre, it also now
means that more individual sessions with in-patients can
now take place within the KGV. In turn the other OT
has been released from some of her responsibilities within
the activity centre and consequently is expanding her
links with the Community mental health service. In this
senior’s own words,
The centre also carried out an audit to measure service
user satisfaction. Clients made the following comments:
“I feel I’m doing something positive which keeps me busy
and while I’m busy I smoke quite a lot less”
“When I come I feel better. I’m always kept busy. I like
what we do”.
“I look forward to coming, it makes me feel good”
“I enjoy myself and it motivates me”
MOBILITY TRAINING
The OT department has been instrumental in arranging
mobility training for the visually impaired. Clinics have
been arranged in which all known potential service users
have been identified and their general needs in relation to
their visual impairments have been assessed. Though these
sessions were primarily aimed at the collation of data,
however, during these interventions service users have
also been provided with small assistive equipment (mainly
white canes) and shown how to use these. The result of
these studies has been used to provide an evidence-based
indication on the scope and extent of the local needs of
the visually impaired.
FUTURE PLANS
Projects for 2009:
The department has evolved from humble beginnings to
what it is now: a full district service. However with this
expansion has come a pull towards services becoming
more specialised, and therefore we feel that we must
as a department question and challenge ourselves on
whether the manner in which we are organised and all the
services we do provide, are in full accordance with GHA
operational objectives and with service user expectations.
To this end this year we will review and alter as necessary
our operational map, staff distribution, location of
services and all aspects of our operations in consultation
with service users, senior management, OT Staff and all
interested parties.
5.3 Speech & Language Therapy
The Speech and Language Therapist provides a
communication and dysphagia service to adults with
Acquired Neurological Disorders, Voice Disorders and
Learning Disabilities. The service covers in-patients in St
Bernard’s Hospital, outpatients in the community, Service
Users in St Bernadette’s Adult Learning Centre and
residents in KGV and Dr Giraldi Home.The adult caseload
consists of clients who have difficulties following strokes,
progressive neurological disorders, cancer, dementia, vocal
45
fold disorders and other disorders which are psychogenic,
genetic and congenital in origin. The range of disorders
which present include: aphasia, dysarthria, dyspraxia,
dysphonia, dysphagia and dysfluency. The department is
staffed by one full-time member of staff. (For SLT clinic
attendance data, see Tables 2.1-2.4 in the Appendix)
ACTIVITY AND ACHIEVEMENTS
• An electronic communication aid was purchased by the
GHA for a patient with Parkinson’s disease.
• A Laryngograph was purchased for the adult department
by the GHA, which records, measures and analyses
disordered voice.
• Together with the Occupational Therapist, two social skills
group has been set up and run in St Bernadette’s on a
weekly basis serving 17 service users.
• The Dysphagia Special Interest Group has been set up
and has focussed on developing a care pathway for patients
with dysphagia and developing a protocol for delivering
dysphagia awareness training to nursing staff.
• From September 2007 the Speech and Language
Therapist (SLT) joined the Multi-agency Team meetings,
which aim to develop closer links between many of the key
services in Gibraltar such as Social Services, The Elderly
Care Agency and GHA staff.
• From December 2007 the SLT has been a member
of the Palliative Care meetings. The regular meetings
focus on coordinating the care for all patients who have a
palliative condition.
• From January 2008 the SLT joined the Catering group
with the Dieticians and the Catering staff. This group aims
to develop close liaison to ensure appropriate consistency
meals are provided to inpatients with dysphagia in SBH
and KGV.
• The SLT has delivered training to kitchen staff regarding
the production of modified diets for patients with dysphagia.
Future plans include:
• To explore the possibility of obtaining funding for the
purchase of electronic communication aids for patients.
• The SLT will be completing an advanced research
methods training module, provided by the GHA in March
2009. It is planned to use the knowledge gained from this
course to carry out research investigating the voice quality
of the indigenous population of Gibraltar. The information
gained will be used as a baseline for measuring and treating
voice disorders.
• The SLT will organise a multidisciplinary training day on
Motor Neurone Disease (MND) in 2009. The focus of the
day will be care of the patient with MND and will include
input from Neurology, Occupational Therapy, Physiotherapy,
SLT, Dietician and the Palliative Care Team. The aim of
the day will be to increase shared knowledge and develop
46
a care pathway to ensure prompt referral and effective,
coordinated care for the patient with MND.
• The SLT will run a programme of Dysphagia Awareness
training for the nursing staff in SBH. Further, more
specialised, training will be offered to enable some nursing
staff to carry out a Dysphagia screening test with patients
suspected of having dysphagia.
• The SLT will present information on adult dysphagia at
the Nursing Conference in September 2009.
All referrals have been seen within 1 working day of receipt
of referral, with the vast majority (94 – 96%) being seen
within the same day of referral.
Paediatric Special Needs
This Paediatric SLT provides a service to children (0-18yrs).
This service is involved in the assessment, diagnosis and
ongoing management of children and young adults who
present with communication and/or feeding difficulties
secondary to conditions such as Cerebral Palsy, Autism,
Down Syndrome, Global Developmental Delay, Craniofacial
syndromes, Hearing Loss and Learning Disabilities. Service
delivery is multi-faceted and children are seen both
individually and/or as part of therapy groups in a variety
of locations including the Special school, Learning Support
Units within mainstream schools, the Primary Care Centre,
Saint Bernard’s Hospital and the community.
Developments 2005-2008.
• Joint Paediatrician/Therapist Clinics were set up.
• Paediatric Neurology Clinics were re-established
• The therapist responsible for this caseload undertook
Advanced Dysphagia Training at Manchester Metropolitan
University
• In 2007 a joint Dietician /Speech and Language
Therapist Feeding Clinic was set up at the Primary Care
Centre.
• In 2008 the Paediatric Therapy Team including
Speech and Language Therapists, Physiotherapists and
Occupational Therapists set up the Early Intervention
Assessment and Observation clinics.
Future Plans
• To continue developing the Early Intervention Assessment
Blocks by setting up a pathway that will lead to children
being able to access these clinics as early as possible after
developmental concerns are raised.
• To work jointly with the Consultant Paediatricians and
Paediatric Therapy Team in order to set up an efficient
pathway for the ongoing management of Children with
Down Syndrome. This initiative arose as a result of the
Down Syndrome Conference in Sept 2008.
• To continue to develop the effectiveness of the Feeding
47
• Clinic by attending a week’s placement at the Manchester
Feeding Clinic run by Gillian Harris, an expert
psychologist in the field of behavioural feeding difficulties.
• To complete an advanced research methods training
module provided by the GHA in March 2009. It is hoped
that this will help towards attempting departmental research
looking into the correlation between early feeding difficulties
and speech/language delay.
• To attend the Down Syndrome Conference in Dublin,
August 2009.
AUDIOLOGY
ACTIVITY
The number of appointments being offered per year has
remained steady over the last 3 years but is 20% less than
was being offered in 2005. (For full statistics, see Table 9.1
in the Appendix)
Hearing aid issues have also remained steady over the last
three years but 2008 saw a slight increase in referrals for
new hearing aids of 7.5% (approx.)
Hearing aid repairs are also up by 10%-15% which
is explained by a similar increase in the number of
current hearing aid users registered with the Audiology
Department.
Overall, the number of hearing aid users registered with
the Department has grown by 12% over the last 2 years.
2008 was an exciting year for audiology for three main
reasons:
a) In June 2008, the Bonita Trust pledged approximately
£25,000 in order to set up a paediatric diagnostic unit
which is expected to be up and running in 2009.
b) In February 2008, the Audiology Dept. together with
the Health Promotion Team and the Gibraltar Hearing
Impaired and Tinnitus Association (GHITA), held
Gibraltar’s first Deaf Awareness Day. Articles were
specially written for publication in the Gibraltar Chronicle,
an information stand was set up at the Piazza, and a series
of lectures was delivered by individual members of GHITA.
c) In September the Chief SLT/Audiologist received an
invitation to speak at an International Conference on
Educational Issues to be held in the Czech Republic in
February 2009.
2009 will see the opening of a paediatric diagnostic
audiology unit which will in turn lead to the establishment
locally of Universal Neo-natal Hearing Screening. Both of
these will bring local paediatric audiology services into
the 21st Century.
Plans are also underway to hold Gibraltar’s first Tinnitus
Awareness Day and to repeat the Deaf Awareness day
both of which are aimed at increasing public awareness of
distressing conditions which because of their ‘invisibility’
tend to be poorly understood and mostly ignored.
48
5.4 Department Of Nutrition
and Dietetics
STAFF
The department consists of 1 Specialist Dietician (Head of
Dept), 2 Senior I dieticians and 1 junior dietician employed
as part of the government’s vocational training scheme.
The Department of Nutrition and Dietetics provides
services to inpatients, outpatients (including patients at
home), schoolchildren, the general public and staff (of the
GHA and other organisations).
The Department of Nutrition and Dietetics aims to
address the nutritional needs and improve the nutritional
status of the people of Gibraltar by using evidence based
practice, education and support to better their overall
health and well-being.
Nutritional assessment and therapeutic advice/treatment is
offered for a wide variety of conditions and diseases. (For
Departmental statistics, see Table 10.1 in the Appendix)
ACTIVITY AND ACHIEVEMENTS
The complement of 2 dieticians was increased to 3 in Oct
2007 (Senior 1). This was probably the most significant
event since it has enabled new services to be introduced as
highlighted below. The dietician on the vocational training
scheme during this time (Sept 2007 onwards) has been given
the opportunity to experience several areas of dietetics as
well as take on a clinical workload, including research.
The services provided include:
• 5 adult outpatient clinics weekly
• 1 drop-in weighing clinic weekly
• 2 outpatient paediatric clinics weekly (one of which is a
feeding clinic in conjunction with the speech and language
therapist)
• 4 outpatient paediatric diabetic clinics every 3 months
(multidisciplinary)
• Weekly cardiac rehab (clinics and talks) as part of the
cardiac rehab team
• Monthly antenatal nutrition clinic
• Daily inpatient services (adults and paediatrics) to all wards
• Regular assessment of renal/dialysis patients
• Bi-weekly visits to KGV hospital to assess patients
• Monthly input to St Martin’s special school and St
Bernadette’s Occupational Therapy Centre
• Monthly palliative care meeting (multidisciplinary)
• Home visits following health professional’s referral
(including Elderly Care Agency, Lady Williams Centre, Dr
Giraldi Home)
• Public health nutrition (member of the Health Promotion
Group) - advice and talks/workshops to schools and other
organizations.
fruit &
veg fot
- a log of nutritional products issued to outpatients
resulting from non-availability in street pharmacies.
Research was conducted last year, the outcome of which
led to changes in relevant practice :
- comparison between nutritional supplements claiming
to have particular properties;
- the effect of sibutramine (appetite suppressant) in
achieving weight loss locally.
The department looks forward to the long awaited
appointment of 2 diabetic specialist nurses within the
GHA. This will undoubtedly affect the way in which
diabetic care is provided - the dieticians form an essential
part of this service.
The dieticians in conjunction with a nurse practitioner are
piloting a weight management programme with a group
of patients (weekly sessions x 8) as from January 2009.The
results will be evaluated and continuation/changes to the
programme will depend on the outcome.
The department also looks forward to the introduction of
menu choices within the hospital – a system which will
help to improve the nutritional status of inpatients.
5.5 Pharmacy
STAFF
The staff complement in pharmacy and pharmacy
stores (7 in total) remains the same. The Department
has submitted proposals for a restructuring of the
Department to reflect changing service needs to the
Executive for consideration.
• Monthly meeting with catering and regular education sessions
• Regular teaching sessions to a range of audiences (e.g.
student nurses, lab, multidisciplinary).
Nasogastric feeding has remained the most common method
of artificial nutritional support with 49 patients fed using this
method in 2008 (37 in 2007, 40 in 2006). The number of
patients in the community feeding via a PEG (percutaneous
endoscopic gastrostomy) is also on the increase. There are
presently 6 adults and 3 children with a PEG. The dieticians
are heavily involved in the care of these patients. The cost of
providing nutritional support to patients has remained as in
previous years: approximately £70,000.
The following clinical/quality audits are continuously
conducted by the department:
- written and electronic daily patient data collection,
recording patient details, referral details and advice given
- data collection on the use of parenteral/intravenous
nutrition data collection on the use of enteral tube
feeding (NG/PEG)
- a log of catering issues (both positive and negative)
brought up by patients and staff
ACTIVITY
The GHA Pharmacy Department continues to deliver
a high quality, responsive service to both the GHA and
wider community. The demand for services has increased
recently as a consequence of:
• Increased patient activity (including additional beds across
the hospital) which require pharmacy interventions.
• Increasing staff numbers and implementation of clinical
governance programme, leading to increasing demand for
drug and pharmaceutical advice.
• Increasing robustness of procurement systems requiring
additional workload to sustain the new system.
The hospital drugs bill each year still remains circa
£2 million.
• The introduction of the new Proactis programme to give
more accountability of the entire department’s expenditure
and stock records.
• The introduction of the Human Papilloma Virus vaccine
into the immunisation schedule for school girls.
• Procuring enough stocks of the MMR vaccine to keep up
with high demand during the measles outbreak.
49
6. NURSING
Nurses wanted a “back to basics” approach, where we take pride in our profession, treat patients with
respect and dignity, and ensure that our nursing practice is based on the most up to date research.
Nursing staff across the Gibraltar Health Authority have been following in Florence Nightingale’s footsteps in striving to
provide high quality, individualised care for all patients. Meetings were held with Sisters and Charge Nurses from across the
Gibraltar Health Authority in 2005 to find out from them what needed to improve and what help they needed in order
to improve patient care. Following this consultation, a development plan for nursing was drawn up to put these ideas into
practice. Having shone Florence’s lamp in to all corners of our work, there were three areas that were unanimously agreed
as priorities for improvement.
The first of these was the education and development of all our nursing staff to ensure they reach their full potential. One
nurse once famously said that the quality of patient care can only be as high as the level of competence of the nurse who is
giving that care. The Nursing Directorate firmly believes that investment in our staff leads to higher quality of care for our
patients.This report gives a flavour of just a few of the learning opportunities that have been made available to staff over the
last few years. The nurses themselves have valued these learning opportunities, and you will see from the examples given
how they have used these to develop new nurse led services and improve existing nursing practice.
The second main priority was to raise the standards of nursing across the GHA. Nurses wanted a “back to basics” approach,
where we take pride in our profession, treat patients with respect and dignity, and ensure that our nursing practice is based
on the most up to date research. This will ensure that patients in Gibraltar receive up to date clinical care, based on the best
standards set by leading organisations elsewhere in the world.
We have been looking to raise the standard of nursing care with regard to both what Nightingale called the “art” and
“science” of nursing. Our “art” is about the caring and compassionate side of our role. Treating people with respect and as
individuals is an important part of our work. This includes ensuring we respond sensitively to patients’ complaints and take
action to make improvements where these are necessary. It includes listening to patients and designing flexible treatment
programmes of care to suit their personal circumstances. Finally, it includes working in partnership with patients and families
to make sure they have the necessary information about their health to make informed choices about their treatment and
to take appropriate responsibility and control with regard to their own health needs.
The second area of practice we have been striving to improve deals with what Florence Nightingale called the “science” of
nursing. This has involved the setting of nursing standards, of policies, and procedures to guide the nurse in what to do, and
how to do it. Extensive guidance is being produced for staff covering essential topics such as infection control, administration
of patients’ medicines, guidance on treatment of specific conditions, and observation and treatment for critically ill patients.
Now these standards are in place, we are in the process of doing “spot checks”, (or what we call audits), to see how we are
measuring up to the guidelines. Feedback is given to staff on the results so they can be commended on their achievements
or areas for improvement highlighted.
The third and equally important priority we have been working on relates to managing our most valuable resource - our
staff. Our first piece of work has focused on ensuring we have the right numbers of nurses with the right skills in the right
place at the right time. Having identified what is required, many changes have been made to adjust our shift patterns and
staffing numbers to ensure they are on duty at the time our patients most need us. The results have enabled us to submit
proposals for additional trained staff, some of which have already been gratefully received. Nurse Managers have been
supported through new H.R. guidance notes which have enabled the nursing profession to set up annual performance
reviews for staff, improve our management of sickness and absence, and ensure all staff have a personal development plan to
ensure they meet their full potential.
We are proud of the significant achievements which
are a result of all the hard work put in by our Nursing
Midwifery and HealthVisiting staff.We recently completed
an audit of the core nursing standards we had identified
and measured two years ago. The results in 2008 showed
significant improvements overall for which staff have been
commended. We know we still have further work to do,
and thanks to our audit results, we now know where we
need to do it. We look forward to meeting this challenge
over the coming years.
The primary focus for the Nursing Directorate over the
past years has been to implement the corporate objectives
set out in its development plan as approved by the GHA
Board. In the first section below, we set out some key
achievements, followed by an update of progress in
50
individual Departments with respect to their specific
performance objectives.
The Nurse Executive Team has continued to strive
to ensure that the corporate vision for Nursing and
corresponding objectives are developed in collaboration
with Nurses, Midwives and Health Visitors from across the
GHA. The development of last year’s plan was overseen
by the two senior nursing groups of the GHA – The
Nurse Executive Team (consisting mainly of Clinical
Nurse Managers), and the Practice Development Forum
(a monthly Sister/Charge Nurse and Special Nurse
meeting). Representatives from these groups planned the
further dissemination of progress made in the preceding
year and objectives set for this annual cycle. Building
on the success of the first GHA Nursing Conference, a
51
second annual Nursing, Midwifery and Health Visitors
Conference was held in January 2007. It ran over two days
to enable good attendance with over 160 nurses (i.e. almost
half of the nursing workforce), managing to attend. This
provided an excellent opportunity to share development
work achieved in the preceding year amongst teams to
enable the spread of good practice. All members of staff
attending received their own personal copy of this year’s
Nursing, Midwifery and Health Visiting Development
Plan. In addition, each Ward or Department has been
issued with a portfolio, including the plan, and will be
developing evidence of progress against the key objectives
over the forthcoming year.
ACHIEVEMENTS
These are summarised below:
• The Skill Mix Review of Nursing in the main
departments of St Bernard’s and King George V Hospital
was completed and presented to the GHA Executive. This
detailed, comprehensive, and extremely robust analysis
identifies the nursing numbers and skill mix required to
deliver in excess of 70% of the quality assessment tool for
nursing which was used as part of the study. The Executive
Team have accepted the findings of this report. Further
work is now being undertaken in the form of a Workforce
Plan phased over a ten year period.
• Extensive work was undertaken with regard to
modifying shift patterns in key clinical areas in order
to better match nurse availability and patient demand.
Intensive Care and Maternity successfully implemented a
new 12-hour shift system which has progressed extremely
well both by for staff and with respect to improved
continuity of care for patients.
• The Nurse Executive Team has been implementing the
GHA Sickness and Absence Policy. Progress made thus far
has been:
- Production of sickness statistics to monitor trends
- Implementation of the Guidance Notes for Managers
on managing sickness and absence
- Training for all Sisters and Charge Nurses by the HR
Department on the new Policy
- Implementation of the new guidance which has
included:
Return to work interviews
- Verbal and written warnings given as per Policy, when
appropriate
- A number of disciplinary hearings
- Systematic referral of staff to Occupational Health for
screening as part of the process
The most significant outcome has been the drastic
reduction in the amount of absence. Absence (i.e. staff
failing to present for work with no prior notice) is now
virtually non-existent and tackled immediately on the
52
rare occasion it occurs. There has been some reduction
in sickness which a number of new initiatives currently
under development should reduce even further.
• A new Study Leave Policy was implemented for nurses
which has ensured that personal development objectives
arising from GHA appraisals are able to be met.
• Staff appraisals have been implemented throughout the
Nursing Directorate. The second cycle of appraisals is now
commencing.
• The process of recruitment and retention has improved
over the last year through:
- Streamlining processes to begin to reduce the amount of
time it takes to fill vacancies.
- Clinical Nurse Managers and Sisters and Charge Nurses
becoming actively involved in the recruitment and
retention process.
- Development of a more robust recruitment process
which includes group observation exercises, presentation
and evaluation against key criteria to ensure staff selected
have the necessary skills for the post.
• Health and Safety Committee established commencing
with a safety audit in the basement.
• GHA Interim Policy for reporting and investigating
clinical incidents and near misses drafted and ratified by the
Executive.
• Serious Clinical Incident de-briefing sessions attended by
over 200 GHA staff.
• Staff trained in dignified care and responsibility training.
• Extensive work on building leadership capacity for Nurse
Managers including:
- Four senior nurses successfully completed the Durham
Management Programme.
- GHA Durham Management Programme commissioned 40 GHA staff commenced in March 2007.
- Significant opportunities for nurses to attend overseas
conferences and exchange programmes from which they
have been implementing new aspects of practice on their
return to Gibraltar.
• The Directorate organised and held the first Gibraltar
International Multi-Disciplinary Mental Health Conference
in October 2006 which was extremely successful.
• The Nursing Directorate organised a successful Senior
Management ‘Working Live’ Conference facilitated by the
DeCapo Theatre Company from Denmark.
• The Nursing Directorate organised and ran a one day
Communication Skills Workshop for over 60 GHA staff
facilitated by the DeCapo Danish Theatre Company.
• The re-audit of the Action plan endorsed by the Board
with respect to the Rocca Enquiry by Sir Jonathan Asbridge
in November 2006. The work of the Nursing Directorate
and specifically the implementation of the modified Early
Warning System was highly commended by this re-audit.
• A re-audit against the Action plan from the Maternity
Services Review in 2005 highlighted significant progress
against all the key recommendations.
• Three GHA Sister/Charge Nurses were funded to
attend the Royal College of Nursing Practice Development
Programme and have been assisting in practice development
across the GHA on their return. Funding was secured for
a Practice Development post, with the post-holder due to
commence shortly.
• The establishment of a Pre-assessment Clinic which has
reduced the number of cancellations for Theatre.
• Significant contribution by the Nursing Directorate and
nursing staff to the “Knee Initiative” which enabled the
GHA to clear the waiting list for knee surgery.
The aims of the Nursing, Midwifery and Health Visiting
strategy are as follows:
Improving Corporate Performance
• To make effective use of the nursing workforce, ensuring
we have the right staff, with the right skills, in the right
place at the right time.
• To contribute to the continued work on the Nursing
Quality and Skill Mix Review.
• To manage staff sickness effectively and collate information
to enable effective use of workforce i.e. to ensure that staff
deficiencies due to sickness, absence, vacancies, maternity,
study and other leave are managed within available
resources; and that replacements through use of overtime,
bank, manning levels are accounted for and relevant issues
and concerns are managed and reported.
• To contribute to the delivery of the following corporate
projects;
- Implementation of the Mental Health Strategy
- Implementation of the Primary Care Strategy
- Service Developments in the GHA 3 year strategic plan
-Implementation of improved bed management and
reduction of waiting lists
-Agenda for Change
- Implementation of new I.T. systems
• To ensure nurses contribute to the efficient and effective
use of resources
• To work with other members of the GHA to improve
effectiveness of corporate systems to improve patient and
staff experience.
Improving Leadership Capacity
• To develop proposals for a succession plan based on a
clinical career ladder for Nursing, Midwifery and Health
Visiting for submission to the GHA Executive.
• To actively “role model” professional behaviours that create
a culture of accountability and responsibility. To empower
staff to reach their full potential as practitioners.
• To ensure all Nurses, Midwives, Health Visitors, Nursing
Auxiliaries and HCA’s have a personal development plan
and an annual performance review.
• To work towards developing clinical/managerial
supervision for all trained staff.
• To implement the GHA School of Health Studies
Development and Training Strategy
• To support the pre-registration training for student nurses
Improving Clinical Outcomes
• To ensure all patients have a documented plan of care
which includes an assessment, a plan, and is implemented
and evaluated by a trained nurse.
• To support the development of nursing practice in
continuing to improve :
- The reduction of cross infection
- The patients’ experience - ensuring they are treated with dignity and respect.
53
- The management of medication and
therapeutic interventions
- The management of continence
- The nutritional and hydrational status of patients
- Wound care management
- Observation of patients (including ‘MEWS’)
- Patient safety
- Continuity of nursing care through team
based nursing
• To audit nursing practice as a framework for continuous quality improvement
• To improve the standards of nursing documentation
• To ensure nursing practice has a sound evidence base
• To develop ward based portfolios with evidence of Practice
Development implementation as a resource pack for staff.
ESSENCE OF CARE
Essence of care is an initiative being developed within the
Nursing Directorate which involves the identification of
patient-focused best practice in the fundamentals aspects
of care, which are essential to the quality of the patient
experience in their journey through health care.
The fundamentals of care are identified as:
1. Food and Nutrition
2. Continence, bladder and bowel care
3. Pressure ulcers
4. Privacy and dignity
5. Personal and oral hygiene
6. Communication
7. Principles of self-care
8. Record keeping
9. Safety of patients with mental health needs.
This work continues to progress with nurses continuing
to show an interest in its development. Various training
sessions have been undertaken which have resulted in
increased awareness of issues such as nutrition. Essence
of care is a concern which features prominently within
the GHA Practice Development Forum, a monthly
meeting for Senior Nurses with the Director of Nursing.
This has led to:• Increased awareness of the fundamentals of nursing care.
• Better understanding of nutritional requirements of patients
• Continence Training
• Better awareness and understanding regarding pressure
relieving equipment
Looking ahead to next year the following action points have
been set:• An Essence of Care Group will be formed which will
decide on the approach required and will initially meet every
54
Number of admissions:-
Year
two weeks.
• Nutrition standards will be re-audited.
• Educational programmes will be established which will
include all aspects of patient care. This will include a
programme for Nursing Assistants as it is considered that
this grade of staff are essential to patient care delivery and
it is therefore important that they also be trained in the
delivery of the fundamentals of care.
A&E DEPARTMENT
The number of patients attending the Department
continues to rise placing extra pressure on the service and
staff, but with great effort and commitment from all they
have been able to meet the demands.
This table indicates the clear rise in the number of patient
visits to A&E.
Year
Old StBernard’s
Hospital
New St Bernard’s
Hospital
2004
2006
28,464
35,829
Continuing Professional Development has continued this
year with nurses attending the Advanced Paediatric Life
Support and the Triage training programme, all of which
will help improve the service provided. In addition, an
area has been identified to serve as a play area and child
friendly cubicle within the department.
RAINBOW WARD
Recent developments include the Advanced Paediatric
Life Support training programme which was well
attended. Night staff were also included in the training
programme which was facilitated by the recent purchase
of the training manikins.
CRITICAL CARE UNIT
The number of admissions has significantly risen when
compared to the admission rates at the old St Bernard’s.
Old St Bernard’s
Hospital
New St Bernard’s
Hospital
2004
2006
684
1184
The recruitment of the extra nursing staff and the change
in the shift patterns has been crucial to being able to
meet this increase in service demand by providing more
trained nurse cover and continuity in patient care. The
staff undertook several sessions to learn how to care for
a patient undergoing haemofiltration, and are currently
undergoing training but they will still require practical
supervision sessions to meet their competencies.
MIDWIFERY
Four Gibraltarian Midwives, Nathalie Lombard, Nancy
Aguilera and Nadine Galliano all successfully graduated as
Midwives after completing a three-year training program
in the United Kingdom and were appointed following
successful interviews. Denise Camilleri, a Registered
General Nurse, also completed a midwifery programme
and is now a permanent member of the team. The GHA
Board recently heard an account by one of these midwives
of her very positive experiences and of the benefits this is
bringing to new mothers locally. They have returned to
give us stability in a service which, in the past, has always
been mainly dependent on contracted non-local midwives.
The implementation of recommendations arising out of a
review of the management practices and work schedules
in the Midwifery Service, including the introduction of a
Midwifery Supervision programme, has had an enormous
positive impact on the morale of staff.
Consultants.
Our Orthopaedic/Trauma Department has also increased
in both size and specialist interventions, with the
appointment of two new Orthopaedic consultants.
In 2007, A&E saw an average of 2500 attendees per month
with a peak in March 2007 of 2864 patients seen. 132
medical admissions were processed during this peak month
compared to 32 emergency surgical and 30 paediatric.
Monthly meetings have been conducted in order to
capture complex cases early on with a view to identifying
discharge needs. A new addition to the group will be Mrs
Jennifer Poole a Hospital Social Worker.
Operating Theatre activity saw 2981 procedures in 2007
carried out between main theatres and the Day Surgery
Unit. This is a slight increase from the previous year.
CONCLUSION
The past few years have been a challenging yet productive
time for the Nursing Directorate. It is recognised that,
as well as significant progress, there is still a significant
amount we wish to achieve. The Nursing, Midwifery and
Health Visiting Plan sets out key objectives it wishes to
achieve over the next year. The plan is to continue to
involve staff in development work which will be shared at
annual Nursing Conferences.
OUTPATIENT SERVICES
A number of new out-patient facilities/services that have
been introduced over the past year led by nurses. These
include:
Cardiac and Blood Pressure halter monitoring is now a
service provided in-house. Previously, patients had to
travel to Spain for this.
There has also been an introduction of a Spyrometery
clinic which is led by Consultant Physician and an
Enrolled Nurse.
StressTesting has also seen a significant service improvement
and a greater number of patients are now accessing this
service when needed.
We have now increased the numbers of Endoscopic
procedures being carried out.
Increased numbers of visits by Specialist Visiting
55
7. Education
Lactation Study days.
In 2008 the development began of the first Master’s
module in Advanced Research Methods which will be
delivered in April 2009 and has been widely subscribed
to by all members of the multidisciplinary team within
the GHA.
7.1 School Of Health Studies
ACTIVITY AND ACHIEVEMENTS
Sheffield University, with whom GHA has had a long
and fruitful relationship, withdrew from providing any
pre-registration nursing education in the UK or abroad.
Therefore, a new educational partner was secured for
the delivery of the pre-registration nursing diploma
programme in September 2007. Kingston and St
George’s University were the successful organisations
appointed following a rigorous selection process.
The Department of Nurse Education provides
education for the pre–registration student nurse three
year training programme which has an intake once
every two years leading to the Diploma in Nursing. The
department also provides education for post registration
nurses within the GHA including some mandatory
training of nursing staff throughout the GHA. There
are currently six members of staff employed which
consist of 1 Principal Lecturer, 1 Senior Tutor, 1 School
Administrator, 1 Librarian and 1 full-time library clerk.
The Practice Development Sister Susan Rhoda has also
been part of the team since April 2008.
June 2008 saw the successful validation of the Kingston
University and St George’s University of London Diploma
in Nursing programme which commenced in September
2008. As part of the validation and the new curriculum
the School was also validated to deliver the first year of
Children’s Nursing, Mental Health Nursing and Learning
Disability Nursing programmes here in Gibraltar with
the remaining two years of these programmes delivered
in Kingston University and St George’s University of
London. These are all available subject to recruits meeting
the entry criteria.
56
The first cohort of the Faculty of Health and Social Care
Sciences, Kingston University and St George’s University
of London were successfully recruited in July 2008 and
12 student nurses commenced their Diploma in Nursing
(Adult) training in September 2008.
In July 2008 Christine Hibbert returned to the UK after
successfully completing her three year contract within the
Department of Education and in January 2009 Sharon
Urwin was successfully recruited to the post of Senior
Lecturer and will commence in the Department at the
end of April 2009.
There were also personnel changes in the Department of
Nurse Education during 2008 and Susan Rhoda joined
the Department on an 18 month secondment as Practice
Development Sister. The Practice development post is a
new one in the GHA. The aims of the post are to look
at nursing practice and identify areas for improvement
and development of nursing care. A particular focus
is nursing documentation. It is important that nurses
provide documentary evidence of assessment, planning,
implementation and evaluation of care and new
documentation has been introduced in order to facilitate
this. The post involves regular clinical placements and
supporting staff to identify training needs.
In 2008 the development of the Continuous Professional
Development (CPD) programme for post registered staff
commenced. The courses chosen are generic modules
which will allow the student to gradually build towards
a Diploma or a Degree in Health Care Practice and to
date have completed two successful modules, Mentorship
for Practice and Developing Practice in Diabetes Care.
There have also been a series of study days to enhance
practice for Midwives including Care of the Neonate and
Future
The September 2006 cohort of students will be the last
to graduate from the University of Sheffield in September
2009 and their graduation will take place in Gibraltar in
November 2009.
The team wishes to continue to develop the CPD
programme for 2009/10 with Kingston University and St
George’s University of London and looks to expand on
the options available for those who wish to pursue their
post graduate study.
The SHS library continues to expand and the collection
is comparable to any UK learning library of its size. The
focus has been on electronic material with the introduction
of the Royal Marsden Clinical Nursing Procedures, The
Cochrane Library, Clinical Evidence and the BNF all
available electronically. Further investment has been made
both within the stock and with the increase in availability
of electronic journals. Future plans are to continue towards
electronic access and for the library to act as depository for
all GHA policies.
57
8. Management
8.1 BED MANAGEMENT
8.2 Sponsored Patients
The past years have been challenging for Bed Management
with almost 5000 inpatients treated in St. Bernard’s per year.
Additionally, many outpatient interventions such as palliative
care procedures, plaster clinics, post biopsy observations
and wound management, have also been performed with
inpatient resources, augmenting this figure even further.
ACTIVITY
The Sponsored Patient Department forms part of the
Medical directorate of the Gibraltar Health Authority. It is a department which deals with referrals of patients’
care to tertiary hospitals for any specialised treatment
required. Referrals are made to UK and Spanish hospitals
for routine appointments and elective admissions as well
as emergency transfers. (See Table 5.1 in the Appendix
for referral statistics) Over the last few years there has
been a steady increase in the number of sponsored patients
being referred to tertiary hospitals in UK and Spain. Since
2002 the referrals to Spanish centres have also been on the
increase. The obvious benefit to patients is that they do
not have to travel far from the family while receiving their
care. They also have a choice made available to them. The
number of patient referrals to UK has also remained high
due to the ongoing care of oncology patients. Their initial
treatment can be complex and last over a year and the
follow-up regime can extend over a 5 year period. Many
UK tertiary service referrals in endocrine and respiratory
medicine have been repatriated back to St Bernard’s as
these services are now available locally.
The department deals with travel arrangements as well as
the administration of the clinical care involved with the
medical trip. It also provides a round-the-clock service to
ensure patients and their families feel secure while away
from Gibraltar.
In 2007 there was a significant increase in the maintenance
allowance which sponsored patients receive. Table 5.2 in
the Appendix shows the old and new allowances which
came into play in June 2007. The maximum allowances
staying in rented accommodation went up from £266 a
week each for patient and escort to £400 each a week
for patient and escort. When staying in Calpe House
or friends and family, the maximum allowance went up
from £98 each a week for patient and escort to £147
a week each. There was also an increase in the patient’s
inpatient allowance that went up from £5 a night to
£7.50 a night.
This increase has had a direct impact on many families who
would not have received an allowance before and now
they are entitled to a certain amount. The feedback the
department has received positive feedback from families.
In 2008 an additional Administrative Officer started
employment in the department. This helped both with
the day to day running of the department as well as
dealing with the public and counter duties. This officer
also joined in the on-call rota helping provide the 24 hr
on call emergency service. The team working is very kind
and efficient individuals. The team’s main aim is to help
patients and their relatives as much as possible with their
paperwork and travel arrangements.
The sponsored patient department has also recently
ACTIVITY
Calpe Ward was opened early in 2006 for the Knee
Initiative. This proved to be a popular development with
the use of Integrated Care Pathways and a Multidisciplinary
Team approach adopted throughout. A total of 53 joint
replacements were possible, thereby substantially reducing
the current waiting list. A grand total of 2649 surgical
interventions were carried out in 2006.
As a consequence of the closure of Calpe Ward, the
surgical wards were reconfigured in order to continue
joint replacement surgery in the cleanest environment
possible. This involved the review and change of
admission criteria for both Dudley Toomey and Captain
Murchison Wards. After much debate and advice from the
Infection Control Committee it was agreed that Dudley
Toomey Ward would provide care for all elective surgery
irrespective of speciality and that Captain Murchison
would become the Acute Admissions Ward for all adult
specialities. They would also retain a capacity for longstay/rehabilitation patients.
A comprehensive audit of all complex discharges was
also conducted with the care needs of each individual
documented and total needs quantified. Discussions have
commenced with the Elderly Care Agency, Social and
Community Services, the KGV Hospital and others in
order to scope the requirements for our aging population
throughout Gibraltar. These are promising and with
time may assist in addressing our client mix for both St.
Bernard’s and KGV, in turn upholding the principal of
treating the correct patient within the correct therapeutic
environment with the correct staff mix. Multi-disciplinary
team meetings are gradually becoming more frequent
with a more proactive approach to Bed Management
issues being adopted.
All acute adult wards, A&E and the Night Sister’s Office
now have a Bed Management Resource File on site,
which is periodically updated. Within these files are upto-date Elderly Care Agency waiting lists and application
forms for domiciliary care and Mount Alvernia. Contact
numbers for many services are also listed together with
Bed Management Policy and Guidelines for reference.
STAFF
Marie Carmen Lia retired as Bed Manager in 2006 after
many years of service. Wayne Barton has now taken over
this important role.
58
59
formed a closer liaison with the Calpe House trust. Both meet regularly with and remain in contact to discuss patient
and relative issues. All Calpe House requests are now only done a month prior to the patient leaving for UK. The new
process for Calpe House accommodation is now much fairer. While the Calpe House trustees still have the final decision,
the Sponsored Patients department now has a lot more involvement. 8.3 Patient Advice and
Complaints Office
The GHA Patient Advice and Complaints Office is available
to all users of the health service. Patients and their relatives
can contact the office to express their dissatisfaction as a
result of a direct experience of our current services, as
stated in the GHA Complaint’s Procedure. Complaints
may be informal (verbal) or formal (written).
ACTIVITY
All complaints are investigated by the Patient Advice
and Complaints Co-ordinator and reported to the GHA
Chief Executive to whom the Co-ordinator is directly
accountable. The Chief Executive responds to all formal
complaint letters personally informing the complainant of
the findings of the investigation into his/her complaint
and offering a meeting to clarify the findings of the
investigation.
If there is any evidence of poor practice or service, the
complainant is advised and informed of the actions to be
taken to improve the quality of care or service. Where poor
practice or service is identified, an action plan is devised
and implemented with a view to improving the GHA’s
quality of care. All complaints and resulting action plans
are reported to the GHA Board by the Chief Executive.
There are also other situations in which the findings of
investigations may either indicate that there was evidence
of good practice and the complaint is therefore not
upheld by the GHA or that it is not possible to verify the
complaint due to the absence of information; in the latter
case it is not possible to establish whether the complaint
is justified or not.
In the event that the complainant is not satisfied with
the GHA response, s/he may refer the complaint to
an Independent Review Panel via the Public Services
Ombudsman. All panel reports are considered by the
GHA Executive and any approved recommendations are
implemented and monitored by the GHA Board.
ACHIEVEMENTS
Shortly after the adoption of the Complaints Procedure in
September 2004, it became apparent that there was a need
for a Patient Advisory Service. Many users who needed
assistance or information began to contact the Office, not
to complain but to ask for help with their concerns. This
development was therefore user driven and has become
an established part of the service. Approximately 10 to 15
calls of this nature are made every week to the Office.
60
The trend in the number of formal complaints has reduced
since 2005 with a slight increase in 2008. The number of
informal complaints has increased and remained static in
the past two years. Of a total of 279 formal complaints, 17
of these were referred for Independent Review, which is
approximately 6% of the total number received. (See Table
11.1 in the Appendix)
The office also records the numbers of commendations
made to GHA staff on a “Thank You’s” database. A total of
1,307 commendations were recorded between 2005 and
2008. These took the form of letters, cards and tokens of
appreciation such as flowers or chocolates. The number
recorded must be viewed as a minimum as it is well known
that many commendations are not reported and therefore
not entered in the database.
The goals of the department continue to be to provide
a timely and efficient response to users who need advice
or assistance and to investigate complaints submitted by
users of the GHA. The department is planning to develop
further into the area of clinical quality improvement once
resources become available.
8.4 Human Resources
The Human Resources Department is dedicated to
providing human resource support to all customers,
both internal and external, through the implementation
of strategic initiatives. The department is dedicated to
continually assessing and developing our internal systems
and processes with the aim of improving the quality of the
service we provide.
The department is dedicated to the recruitment, selection
and retention of staff for all GHA departments, as well
as Industrial Relations and Workforce Planning. We
also provide support and guidance on the application of
conditions of service in accordance with General Orders,
Industrial Regulations and Employment Legislation.
ACTIVITY AND ACHIEVEMENTS
Since moving to the new Hospital in 2005, and as a result
of the expansion of existing departments and the creation
of new services, there has been a significant increase in
recruitment. Apart from recruiting additional staff, new
posts/grades were established: Catering Manager, TSSU/
CSSD Technicians and Receptionists to name a few. The
move also saw the Human Resources Department taking
on additional duties brought about by the devolution to
the department of responsibilities for Doctor and Locum
appointments. These, and other added responsibilities,
have resulted in the department considerably increasing
its staffing numbers since the move. The department now
employs 10.5 members of staff as opposed to the five
employed prior the move to the new hospital. Medical,
Industrial, IT, Administrative and Clerical areas have also
experienced a considerable increase in staffing numbers.
(See Table 12.1 in the Appendix)
The total number of staff employed by the GHA
as at January 2005 stood at 726 with 846 staff as at
December 2007.
In order to improve corporate performance a number
of GHA HR Policies were converted into Management
Guidance Notes.
Management Guidance Notes on Disciplinary Proceedings
have been adopted in order to assist in providing a fair
and clear method of dealing with alleged offences in a
manner that is consistent with both the requirements of
General Orders and Industrial Regulations.
Training was given to managers on these during 2005.
This has resulted in the GHA being more pro-active
in monitoring absence with line managers taking
responsibility for developing systems of work which help
to minimise absence, promote good health and safety
standards, while respecting a fair and reasonable application
of the guidance notes. 2005/2006 saw the introduction
of the GHA Personal Development Review Programme.
Over 170 GHA Managers and Staff received training in
the implementation of the initiative which is aimed at
ensuring that the development needs of all GHA staff are
identified and thus ensuring that they receive the training
and development necessary to ensure they maintain the
skills and knowledge required to enable them to do their
jobs to the highest standard. The GHA is committed to
achieving the “Investors in People” standard. The GHA
welcomed the Government initiative to encourage a
range of different public and private sector organisations in
Gibraltar to commit to achieving the “Investors in People”
standard in partnership with the University of Durham.The
GHA has signed for the organisation to be IIP accredited
within two years. IIP is an internationally recognised
organisational and staff development accreditation process
which provides a practical framework for the personal
development of staff. The adoption of this framework
dovetails well with the development and implementation
of the Personal Development Review Programme.
As from February 2006 the range of duties undertaken by
the Human Resources Department expanded considerably
following the delegation of certain responsibilities
previously undertaken by Government’s Central HR
Department. This move signified the secondment of
two officers from the Central HR Department in order
to facilitate such a transfer of powers and assist with the
increase in workload. As a result we are now responsible
for the administration and management of all conduct and
61
Appointments scheduling is now possible from all outpatient clinics, Main Reception
and Records Department providing an enhanced service to the public.
disciplinary issues, occupational health and sickness issues,
administration and organisation of all internal recruitment
prior to Public Service involvement and the approval of
Special Leave.
Staff Awards
The development of a GHA Staff Award Scheme was
approved in 2006, with the first ceremony taking place
in January 2007. The programme has been well received
by the organisation and the public at large. There are five
different categories – GHA Employee of the Year Award,
Patient Care Award, GHA Award, Innovation Award and
Ward/Department of the Year Award. Long Service Awards
are also given to employees with over 25, 30 and 35 years’
service respectively.
After a period of joint consultation the Ambulance
Service transferred to the Gibraltar Health Authority in
June 2007. This move has resulted in another group of
employees with its own particular conditions of service,
adding to the diversity of grades and professions already
working in the organisation.
In April 2007 the Director of Human Resources was
seconded to the Social Services Agency on a part-time basis
followed by full-time secondment as from June 2007. This
has resulted in staff in the HR Department adapting to this
change by adopting additional responsibilities in an acting
capacity. Despite the increase in workload, the department
continues to function in all areas offering the same high
standard of service and all managers have worked tirelessly
to respond to all the challenges before them.
The department is committed to continuously improve
the service we provide. In order to assist us in promoting
careers in healthcare we have compiled and continue to
compile information leaflets on healthcare professions
within the GHA.These leaflets have been well received by
our customers especially students at the Careers Fair who
have commented positively on their informative content.
Our participation in the Careers Fair has been significant in
the last two years with a high number of GHA departments
also contributing to the organisation’s presence at the
event. The availability of healthcare experts on the day has
proved positive in assisting the HR Staff with students’
queries concerning careers, as this helps them focus clearly
on the best way forward.
A number of these students will hopefully undertake
training in a healthcare related profession and might end up
embarking on a career within the GHA. In order to assist
with our workforce planning the HR Department will
shortly, in conjunction with the Department of Education,
enter into a Student Contact Programme, whereby the
GHA will periodically keep healthcare students updated
concerning career opportunities within the GHA.
62
GHA STAFF AWARDS
Winners for 2006
Michelle Gomez - Patient Care Award
A&E/Reception Attendants - Ward/Dept of the Year
Linda Castro - Innovation Award
Mariluz Key - GHA Award
Mary Sene - Employee of the Year
Winners for 2007
Susan Benitez - Patient Care Award
Rainbow Ward - Ward/Dept of the Year
Activities Centre Team (KGV) - Innovation Award
George Fromow - GHA Award
Aidan Lane - Employee of the Year
Winners for 2008
Jason Barcelo - Patient Care Award
Community Mental Health Team - Ward/Dept of the Year
Paediatric Dysphagia Clinic - Innovation Award
Clive Clinton - GHA Award
Dr Jawad Hashmi - Employee of the Year
8.5 Medical Records
and Reception
ACTIVITY AND ACHIEVEMENTS
The Gibraltar Health Authority contracted the services
of Micro Business Systems Ltd to undertake a process of
weeding, bar coding and colour coding of all patient files
in the Records Library. Last year saw the completion of
this exercise, which commenced in March 2005, and a
total number of 29,500 files have been successfully tagged
to date as follows:
• All files have been labelled with name, date of birth,
reference number and barcode and entered in patient
database. Patient files are now being electronically
tracked, using bar code readers, across the organisation
enabling the swift location of files.
• Non-active files for the last five years have been
weeded and archived in the Records Stores.
• All files have been colour coded. This has enabled
efficient and accurate retrieval and filing of Patient files.
A unique patient identifying number will be shortly
introduced in both Primary and Secondary Care.
In keeping with the strategic objectives of this department,
roles have been evaluated which resulted in splitting
functions in two main areas.
• Appointment Scheduling
• Medical Library
Appointments scheduling is now possible from all outpatient clinics, Main Reception and Records Department providing
an enhanced service to the public. This has been possible due to a new electronic appointments system (called Front Desk)
introduced in the Primary Care Centre and which has also been introduced very successfully at St Bernard’s Hospital. This
has given us the opportunity to be able to follow a patient’s appointment history from primary to secondary care.
Reception
The Helpdesk/Telephonist offers front of house services manning the reception desk from 08.00 to 20.00 Monday to Friday
and also provides a telephone and helpdesk service including manning the Hospital communication centre. This role has
now expanded and also includes providing assistance to the Primary Care centre in dealing with advanced appointments
which has been made possible via integration into the Primary Care Advanced Appointments telephone lines. This is
possible due to FrontDesk, an electronic appointment system introduced in Primary and Secondary Care.
Following on from improvements to Customer Services in the Gibraltar Health Authority, uniforms have been introduced
for all front line administrative staff. This initiative follows a campaign to provide the organisation with a corporate and
professional image. New uniforms have already been introduced at the Primary Care Centre, Records and Appointments
Department, Helpdesk/Telephonists, Clinic/Ward Clerks, Accounts Administrative Officers and Pathology Clerks.
8.6 Catering
ACTIVITY AND ACHIEVEMENTS
The past few years have seen great strides forward in
terms of quality management, financial efficiency and
the application of strict food safety principles within
the Catering Department. Over the space of one year,
we serve in the region of 173,000 meals to departments
such as St Bernard’s Hospital, KGV, St Martin’s School,
St Bernadette’s Occupational Therapy Centre and H.M
Prison. Three non-formal and one formal complaint were
logged in 2007 - when compared to the amount of meals
provided, this represents a minute number of unsatisfied
service users. However we will endeavour to improve
our service to unprecedented high standards and major
investment in the service is planned for the coming year.
Our main objective for the coming year is to enhance food
quality and give patients the much awaited menu choice.
We also aim to carry out patient surveys and gather as
much feedback as possible in order to seek improvements
in other areas of the service including the provision of a
cooked breakfast.
Provision budgets have been managed in the most efficient
manner without compromising the quality of the meals
and for the new financial year an in-house tender board
will be in place in order to ensure that the same continues
in the future.We will aim to purchase high quality products
in order to achieve a high quality service.
As far as staff are concerned, the continuous training
in conjunction with the Department of Nutrition and
Dietetics will continue in order to create more awareness
of pathological diets with the result that meals will
become better suited to the needs of patients and other
service users.
One of the major projects last year was the standardising
of all recipes in order to achieve a consistency in quality
and portion sizes at all times. Standardising is a common
practice within professional catering establishments around
the world and is a way of ensuring quality.
To conclude, there is still a lot of work to accomplish
and the following two years should see the consolidation
in areas such as quality management, food safety and
nutrition thanks to the investment and the continuous
support that the Government and senior management
gives the catering unit.
8.7 Information Management
and Technology
ACTIVITY
In a very short space of time, the Gibraltar Health
Authority has progressed to a technology rich organisation
whose aggressive rate of growth is dictated by a state of
the art facility that has been equipped with state of the
art technology.
Traditional clinical diagnostic electro-mechanical
equipment now depends on information technology.
For example, Radiological systems are now sophisticated
digital cameras with powerful front-end computers and
servers. The laboratory is another area that is heavily
reliant on new technology.
ACHIEVEMENTS
The short to medium term challenges were to deliver
improvements in services with systems fundamentally
similar to those that were already in place. Examples of
this are:• the database holding registration information on
the Gibraltar and European Health Cards where the
opportunity had already been taken to develop a Unique
Patient Identifier
• the extension of the appointments system for outpatients
from the Primary Care Centre to St Bernard’s Hospital
63
Non-Clinical
• Finance Systems
• Payroll – Standard Payroll System
• Procurement / Stores stock.
• Works Process
• Electronic Staff Record (Human Resource Department)
• Generic Software e.g. Microsoft Office etc
• Catering
• Gibraltar and European Health Cards.
• School of Health Studies systems.
• Sponsored Patients systems.
• the development of a database to capture the history of
admissions and discharges for patients at St Bernard’s
Hospital which included on-screen ward layouts for all
acute wards showing bed distribution, bed occupant, phone
extension and bed availability in each ward. Some of this
information is available to the staff at reception to enable
them to transfer calls and attend to queries. The Bed
Manager also has access to the database to assist him in
planning and easing the flow of patients into and out of
the wards.
The developments and improvements made during the
course of 2006 and 2007 created even higher demands
for and dependence on information technology. We have
been able to meet some of these ever increasing demands
with dramatic improvements to the delivery of care to
our patients. It is to our credit that improvements such
as these are only in their embryonic stage in the UK
and are on the wish list for many countries world-wide.
These include:• the provision of Laboratory results electronically to
our clinicians instantly at time of validation by the
biomedical scientists. These results can be accessed during
the patient consultation
• the display of Radiological images and reports which are
also accessible to clinicians throughout the GHA
64
• the facility for electronic prescribing and the availability
of electronic prescriptions at the point of dispensing was
introduced in September, 2007
The following are some of the systems supported by the
IMT Department:Clinical
• Radiology - PACS / Easyris Radiology system,
Mammogram, CT scanner, X-Ray machines.
• ITU Cardiac monitoring system.
• Ultrasound machines.
• Laboratory Systems (Gigalab)
• Electronic Patient Record - storage partially introduced
Operational
• Building Management System.
• Starwatch security system.
• Security Camera system.
• Patient Entertainment System Telecommunications,
Printers/Faxes/Copiers, Frontdesk Appointments and
Scheduling
• Bed Management
Network
• System Administration and user support.
• 350 PC’s / 370 Users
• 18 Network Servers Windows 2000/3
• 3 Radiology Servers
• 1 Critical Care Server
• 2 CCTV Servers
• 2 Backup tape libraries for all the GHA.
• Gigabit fibre core network for Local Area Network.
• 3000 Outlets on Structured Wiring
• 2 Edge Routers 18 Switches
• 100 Printers
• 20 Networked Copier/Scanner/Printers
• 2 Industrial Colour Network Printers
Telecommunications
• 500 Telephone Extensions
• 80 VOIP Phones
• Nortel Succession 1000 Telephone System
• Meridian Option 11 Telephone System
• Call-centre Management System Symposium server.
• Optivity Telephone Management System.
• Paging systems external and internal.
• Radio equipment.
8.8 Procurement and Supplies
The main function of the Procurement and Supplies
Department is to ensure that the GHA makes the most
effective use of its resources by getting the best possible
value for money when purchasing goods and services.
The prime target is to release money that could be better
spent on patient care by achieving purchasing savings and
improving supply performance across the GHA.
What do we mean by procurement?
• “Procurement” is the process of acquiring goods, works
and services, covering both acquisitions from third parties
and from in-house providers.
• The process spans the whole cycle from identification of
needs, through to the end of a services contract or the end of
the useful life of an asset. It involves options appraisal and
the critical “make or buy” decision which may result in the
provision of services in-house in appropriate circumstances.
• In the context of a procurement process, obtaining “best
value for money” means choosing the bid that offers “the
optimum combination of whole life costs and benefits to
meet the customer’s requirement”. This is not the lowest
initial price option and requires assessing the ongoing
revenue/resource costs as well as initial capital investment.
The requirement can include social, environmental and
other strategic objectives and is defined at the earliest
stages of the procurement cycle. The criterion of “best value
for money” is used at the award stage to select the bid that
best meets the requirement.
• Procurement is also about making informed choices.
ACTIVITY AND ACHIEVEMENTS
Using industry standards, frameworks, best practice and
continuous personal development, the Procurement and
Supplies team are available to offer their knowledge,
experience and resources to support all of the GHA’s
purchasing needs. Procurement and Supplies staff from the
GHA have recently successfully completed the Chartered
Institute of Purchasing and Supplies Level 4 Foundation
Course in Purchasing and Supplies.
The course comprised of six modules: Developing
Contracts,
Measuring
Performance,
Effective
Negotiation, Managing Relationships and Strategic
Procurement and Marketing. These modules were
delivered by a variety of experts from a UK specialist
training and consultancy company.
Over the past years the Procurement and Supplies
Department has modernised and streamlined its operations
by introducing new business processes and controls, reducing
maverick buying and implementing electronic purchasing,
requisitioning and stock control software. The department
is currently involved in a new business administration
software application whereby the procurement function
is empowered with tools that allow powerful sourcing of
goods and services, automated workflow and authorisation
of requisitions and orders, receipting, invoice registration
and matching, internal supplies and stores management, full
visibility of the cost pipeline and automated commitment
accounting support.
This full function e-solution will change the way GHA
administers and manages its Purchasing, Requisitioning,
Payment and Finance processes with more visibility,
accountability and spend control.
65
9. FINANCE
(ee tables 13.1-13.3 in the Appendix for annual expenditure breakdown)
The Procurement and Supplies department handled over
3000 internal requisitions, 4000 purchase orders and
processed approximately £4.2 million pounds worth of
goods during the 2007 / 2008 financial year.
In 2007-8, the TSD attended and completed a total of
1,971 requisitions of which 902 have been dealt with by
the Clinical Engineering Section, 658 by the Electrical
Section and 411 by the Mechanical section.
8.9 Technical Services
Department
ACHIEVEMENTS
The TSD is constantly looking at ways of improving
services and reducing costs.
To this end, the following works have been performed
during this past four years:
The inclusion of the Cardiac alarm system in both John
Ward and Victoria Ward
The streamlining of the Fire Alarm system to minimise
false alarms by replacing,
relocating and reprogramming fire sensors.
Various improvements to ventilation and
plumbing systems.
Technical Services staff carry out the day to day
maintenance of all medical equipment. Nevertheless,
we still have specialised equipment that requires regular
checks, calibration and certification by the manufacturer.
The Technical Services Department of the Gibraltar
Health Authority staff members are employed by the
Gibraltar Electricity Authority and seconded permanently
to the Gibraltar Health Authority. They are based within
St. Bernard’s Hospital.
The role of the Technical Services Department (TSD) is
to provide essential engineering and maintenance services
to all departments and sections of the GHA as well as to
the infrastructure and building fabric. For this purpose,
the TSD is divided into three main sections of different
engineering disciplines.
• The Clinical Engineering Section whose role is
to provide the full range of medical equipment
management, maintenance and repairs, and is composed
of a Clinical Engineering Officer, a Clinical Engineering
Supervisor and three Technicians.
• The Electrical Engineering Section whose role includes
all electrical services infrastructure and specialised systems
such as Fire alarm, Nurse/Patient call, Access Control,
CCTV, Lifts, UPS and IPS, Kitchen equipment, etc.
This section is composed of an Electrical Engineering
Officer and four Electricians.
• The Mechanical Engineering Section whose role
includes the entire mechanical services infrastructure
such as the Air Conditioning and Ventilation System, the
Hot Water System, the Space Heating System, Boilers,
Chilled Water System, Hydrotherapy Pool, Standby
Generator, Motor Vehicle fleet, etc.
This section is composed of a Mechanical Engineering
Officer and seven Mechanical Fitters with a new recruit
who started recently.
Staff Training
The GHA is committed to enabling its technical staff to
achieve a high standard of technical expertise.Throughout
the past few years, staff members have been trained in
Basic Fire Safety courses delivered by the Fire Brigade
and many specialised advanced course in, amongst others,
Anaesthetic Equipment - Safety & Basic Maintenance and
Philips radiology equipment.
Fot of
calculator
ACTIVITY
During 2005 and 2006, the TSD dealt extensively with all
teething problems of the first year of operation of the new
hospital. We have also been involved in identifying defects
from the main contractor specifications and making sure
these are completed satisfactorily.
During this time, the TSD completed a total of 2,334
breakdown requisitions of which 1190 have been
dealt by the Clinical Engineering section, 700 by the
Electrical Engineering section and 444 by the Mechanical
Engineering section.
66
67
1.5 Deaths (2005-08) showing Age-Sex Distribution
1. PUBLIC HEALTH
1.1 Births (2005-08) by Age of Mother
Total
194
1
1
216
410
187
1
4
5
33
59
55
35
6
1
2
5
3
2
6
24
45
67
42
2
1
2
5
4
6
11
57
104
122
77
8
2
2
199
199
398
10
2
3
3
5
36
52
58
22
5
3
4
2
33
63
71
31
4
2
6
7
7
69
115
129
53
9
F
Total
1
33
376
410
Place
Home
Royal Naval Hospital
St. Bernard’s Hospital
19
175
1
14
201
Total
194
216
211
186
397
2006
M
Total
0
18
169
0
11
167
0
29
336
187
178
365
F
2007
M
Total
0
14
185
0
16
183
0
30
368
199
199
398
F
2008
M
Total
1
16
194
0
11
175
1
27
369
211
186
397
F
F
2005
M
Total
F
2006
M
Total
F
2007
M
Total
F
2008
M
Total
January
December
14
14
14
22
15
14
15
14
20
17
19
16
17
14
24
18
17
19
12
25
25
14
19
12
31
28
38
40
32
33
27
39
45
31
38
28
13
24
21
8
9
15
13
15
15
21
20
13
19
16
14
7
11
18
10
21
20
13
13
16
32
40
35
15
20
33
23
36
35
34
33
29
22
11
18
13
13
15
15
18
17
17
28
12
14
14
14
23
16
25
15
16
19
19
12
12
36
25
32
36
29
40
30
34
36
36
40
24
25
14
11
26
16
18
22
11
23
16
15
14
16
12
14
14
13
14
14
18
22
15
12
22
41
26
25
40
29
32
36
29
45
31
27
36
Total
194
216
410
187
178
365
199
199
398
211
186
397
April
May
June
July
August
September
October
November
2
2005
M
Total
85+
1
4
5
12
50
59
1
2
4
11
9
22
33
26
1
2
5
15
14
34
83
85
Total
131
108
239
2005
35-44
45-54
55-64
65-74
75-84
grams
F
M
4500-
9
120
64
1
1
9
115
90
1
Total
194
216
0-1499
1500-2499
2500-3499
3500-4499
Total
F
M
1
18
235
154
2
0
15
115
57
0
6
103
65
4
410
187
178
2007
2005
M
Total
Elsewhere
107
13
11
0
83
20
2
3
190
33
13
3
Total
131
108
239
Place
Hospital
Home
Residential Home
Total
F
M
0
21
218
122
4
1
12
15
2
1
28
213
122
4
365
30
368
Total
F
M
Total
1
29
225
137
6
0
15
138
58
0
0
8
102
71
5
0
23
240
129
5
398
211
186
397
105
100
95
90
85
80
75
70
65
60
55
Total
1
1
3
1
10
18
45
47
3
4
11
22
40
24
6
5
21
40
85
71
124
105
229
2007
M
F
Total
F
1
1
0
2
5
14
30
57
3
5
9
14
36
21
3
7
14
28
66
78
0
0
0
2
4
11
25
61
108
89
197
100
2008
M
Total
0
1
1
4
13
22
32
17
0
1
1
6
17
33
57
78
90
194
F
2006
M
Total
100
8
14
2
84
13
2
6
184
21
16
8
124
105
229
F
2007
M
Total
75
12
20
1
81
4
3
1
156
16
23
2
108
89
197
F
2008
M
Total
79
5
19
0
73
12
5
1
152
17
24
1
103
91
194
F
1.8 Deaths (2005-08) by Cause of Death
cause
Heart disease
Cancers
Infections
2008
2006
M
F
1.7 Deaths (2005-08) by Place of Death
Cerebrovascular
2006
F
1-34
Respiratory disease
1.4 Births (2005-08) by Birth Weight
50
1.6 Deaths (2005-08) by Age and Sex
Under 1
Months
March
4
age
1.3 Births (2005-08) by Month of Birth
February
6
0
1.2 Births (2005-08) by Place of Birth
2005
M
8
45
365
MALE
12
40
178
Total
35
1
1
2
2
5
3
7
69
101
103
60
9
2
1
1
1
3
1
2
34
51
48
31
5
2008
M
F
30
1
1
1
2
2
5
35
50
55
29
4
2
Total
F
25
3
1
1
9
8
51
129
127
66
13
2007
M
Total
20
1
1
1
5
2
25
63
75
36
6
2006
M
F
15
4
6
26
66
52
30
7
Total
10
2
2005
M
5
F
0
age
14
15
16
17
18
19
20-24
25-29
30-34
35-39
40-44
45
46
48
FEMALE
F
M
37
23
26
15
12
32
30
18
6
5
4
6
Injuries & poisoning
Degenerative disease
16
2005
Total
69
53
44
21
17
4
22
%
F
M
29%
22%
18%
9%
6%
2%
9%
21
26
24
22
11
1
16
35
25
15
12
3
3
7
2006
Total
56
51
39
34
14
4
23
%
F
M
24%
22%
17%
15%
6%
2%
10%
26
24
24
11
7
0
17
26
18
7
10
0
Other
2
7
9
4%
3
5
8
3%
3
3
2
8
Total
131
108
239
100%
124
105
229
100%
108
Old Age
Renal failure
Alco. Liver disease
2007
Total
2008
Total
%
F
M
43
50
42
18
17
0
22%
25%
21%
9%
9%
0%
20
23
20
16
7
0
27
28
22
2
1
1
47
51
42
18
8
1
24%
26%
22%
9%
4%
0%
%
2
2
2
5
5
5
4
13
3%
3%
2%
7%
7
0
0
10
1
2
1
6
8
2
1
16
4%
1%
0%
8%
89
197
100%
103
91
194
100%
N.B: Following improvements in coding practices, the category “Degenerative” is being discontinued from 2007. Instead, three more
causes (Old Age, Renal Failure and Alcoholic Liver Disease) are presented.The category “Other” is inflated by these changes and its figures
are not comparable with those of previous years.
68
69
1.9 Top Two Causes of Death 1998-2008
1.11 Laboratory confirmed Infectious Diseases (2005)
Top Two Causes of Death 1998 - 2008
Heart disease
Organism Isolated
Jan
Feb
Mar
Rotavirus
32
2
5
2
1
14
0
4
3
5
2
Campylobacter
Cancer
Respiratory Syncytial Virus
10 0
Salmonella
90
Chlamydia
80
8
3
0
1
6
2
1
1
1
1
Jun
Jul
1
3
1
Giardia lamblia
60
Cryptosporidium
50
2
Hepatitis B
40
Shigella
30
Hepatitis A
20
Streptococcus pneumoniae
10
Trichomonas vaginalis
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
10
20
9
7
Lung
Breast
Colon
Pancreas
Prostate
Other cancers
3
5
2
5
1
34
Total
96
Stomach
Brain
Melanoma
Ovary
Leukaemia
Total
31
0
10
7
10
7
4
3
3
34
41
20
19
14
10
10
9
5
5
4
68
109
205
1
1
1
1
1
43
24
14
15
22
12
18
4
17
206
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
2
2
3
4
1
3
2
2
1
3
1
5
1
1
10
1
5
8
2
6
4
2
6
6
4
1
1
5
3
1
6
1
9
4
8
11
1
1
1
1
1
1
1
2
1
2
1
5
1
1
1
1
1
2
48
31
27
22
18
14
9
7
5
5
5
4
3
2
1
1
1
1
1
Respiratory Syncytial Virus
1
1
3
1
1
Hepatitis C
Trichomonas vaginalis
2
1
Hepatitis B
Cryptosporidium
Mycobacterium tuberculosis
Clostridium difficile
1
1
1
Giardia lamblia
Influenza A virus
Stomach
10
Strep. Group A (Scarlet Fever)
1
1
1
1
1
Strep. pneumoniae (BC/CSF)
Total
9
10
1
1
2
1
Neisseria meningitidis
10
4
3
1
1
1
1
Chlamydia trachomatis
Prostate
Leukaemia
7
Jan
Neisseria gonorrhoae
5
9
Organism Isolated
Rotavirus
14
Ovary
10
50
38
29
28
10
9
6
6
6
4
3
3
3
2
1
1
1
1
1
1
1
1
1
Campylobacter species
Mycoplasma pneumoniae
19
5
1
Total
1.12 Laboratory confirmed Infectious Diseases (2006)
20
Melanoma
1
1
1
1
Pathogenic E coli
41
Brain
1
1
Niesseria meningitidis B
Cancer deaths by Site
Pancreas
3
11
2
Mycobacterium tuberculosis
Cancer Deaths by Site (2005-08)
Colon
Dec
1
Influenza A virus
Total
1
1
2
2
3
1
Hepatitis C
Influenza B virus
6
2
2
1
Nov
1
Adenovirus
Breast
2
1
1
Oct
1
Salmonella species
Lung
4
2
2
1
1
1
1
Enteropathogenic E coli
Males
5
Adenovirus
1.10 Cancer Deaths (2005-08) aggregated by site
Sep
3
1
6
1
Cryptococcus neoformans
Females
Aug
3
Clostridium difficile
0
1
15
9
8
13
18
7
7
21
34
26
17
30
205
4
All other cancers
67
0
70
May
4
3
Mycoplasma pneumoniae
70
Apr
10
20
30
40
50
60
70
80
71
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
6
9
8
10
1
1
2
4
1
5
3
18
6
3
15
5
10
1
1
9
1
1
4
7
5
3
1
6
2
4
2
3
1
1
1
1
2
1
2
1
1
2
7
1
4
2
1
5
4
8
10
1
2
67
55
44
26
14
11
5
4
4
3
3
3
2
2
2
1
1
1
1
249
All years
Rotavirus
Mycoplasma pneumoniae
Respiratory Syncytial Virus RSV
Salmonella species
Chlamydia trachomatis
2
4
Hepatitis C
1
1
Adenovirus
1
Hepatitis A
1
1
2
1
1
1
Clostridium difficile
2
3
Giardia lamblia
1
1
1
Neisseria gonorrohae
1
Influenza A virus
Pathogenic E coli
1
1
1
1
1
1
Trichomonas vaginalis
Bordetella pertussis
Cryptosporidium
1
1
Hepatitis B
19
17
1
33
Mycobacterium tuberculosis
37
Total
23
28
26
16
12
11
16
11
1.14 MRSA (Multi Resistant Staphylococcus Aureus) Infections (1994 - 2008)
Source of Infection
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
6
3
1
10
3
6
4
13
11
6
6
23
8
21
8
37
3
17
4
24
3
16
1
20
65
78
27
170
1
2
1
4
14
5
9
6
20
33
2
1
2
5
28
6
0
3
9
46
2
8
2
12
36
0
3
0
3
23
16
44
18
80
250
St. Bernard’s Hospital
Imported
1
2
2
3
1
7
2
9
2
1
1
3
2
3
1
9
11
1
1
1
1
4
1
3
1
4
1
1
2
5
4
9
18
3
1
4
15
Hospital Acquired
Intrinsic
Sub-total
2
4
1
7
4
1
1
6
6
4
6
13
4
10
Outside hospital
ECA Resident
Community
Details unavailable
Sub-total
Total
1.15 Measles Outbreak (2008) Notifications by week
Week
no.
Cases
Week
1*
Week
2
Week
3
14
10
7
Week
4
Week
5
Week
6
Week
7
Week
8
Week
9
Week
10
Week
11
Week
12
11
19
34
31
35
43
36
17
9
Week
13
Week
14
5
2
Week
15
3
Week
16
3
Week
17
2
Total
283
*commencing 1 August 2008
1.16 Measles Outbreak (2008) Notifications showing Vaccination (MMR) status
0-15 months
15 months-4 years
5 years-9 years
10 years-14 years
15 years-19 years
20 years-29 years
30 years-39 years
>40 years
21
11
24
49
52
37
10
8
212
One dose only
2
13
10
14
29
2
1
71
Full two doses
0
0
0
0
0
0
0
0
0
Total
23
24
34
63
81
39
11
8
283
(%)
8%
8%
12%
22%
29%
14%
4%
3%
100%
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Total
No vaccination
Notifications
Age Group
01-Aug-08
03-Aug-08
05-Aug-08
07-Aug-08
09-Aug-08
11-Aug-08
13-Aug-08
15-Aug-08
17-Aug-08
19-Aug-08
21-Aug-08
23-Aug-08
25-Aug-08
27-Aug-08
29-Aug-08
31-Aug-08
03-Sep-08
04-Sep-08
07-Sep-08
09-Sep-08
11-Sep-08
13-Sep-08
15-Sep-08
17-Sep-08
19-Sep-08
21-Sep-08
23-Sep-08
26-Sep-08
27-Sep-08
29-Sep-08
01-Oct-08
03-Oct-08
05-Oct-08
06-Oct-08
08-Oct-08
10-Oct-08
12-Oct-08
14-Oct-08
16-Oct-08
18-Oct-08
20-Oct-08
23-Oct-08
24-Oct-08
25-Oct-08
30-Oct-08
29-Oct-08
31-Oct-08
02-Nov -08
04-Nov -08
06-Nov -08
08-Nov -08
10-Nov -08
12-Nov -08
10-Nov -08
14-Nov -08
18-Nov -08
20-Nov -08
22-Nov -08
24-Nov -08
26-Nov -08
Organism Isolated
Campylobacter species
Epidemic Curve of Measles Outbreak (2008)
1.13 Laboratory confirmed Infectious Diseases (2007)
72
73
2. PRIMARY CARE
2.1 Clinics and other services attendance for 2005 (number of appointments)
1.17 Class A Drug seizures submitted for analysis during between 2005 and 2008.
CLASS ‘A’ DRUGS Year
Cocaine
2005
2006
2007
2008
40
33
50
63
MDMA
5
7
3
6
MDA
Methadone
0
1
0
0
0
0
3
4
LSD
Morphine
0
0
1
0
0
1
0
0
Heroin
TOTAL
0
0
0
1
45
42
57
74
1.18 Samples submitted for analysis by Public Analyst 2005-7
2005
Feb
‘05
Mar
‘05
Apr
‘05
May
‘05
Jun
‘05
2006
2007
Aug
‘05
Sep
‘05
Oct
‘05
Nov
‘05
Dec
‘05
Total
GP Clinics
7108
8838
8011
7698
7506
7222
6626
6959
8018
7370
7712
6045
89113
Weekends
487
425
461
400
401
293
455
318
322
448
314
404
4728
Jul ‘05
DMS
15
14
24
28
14
18
11
16
20
15
29
27
231
Visitors
7
5
10
19
6
3
5
13
15
13
8
3
107
House-Calls
692
661
583
681
503
521
410
308
435
347
324
407
5872
Nurse Practitioner
240
593
724
1125
834
1066
1162
1093
969
1231
1139
871
11047
Dr Vassallo (WWC,
Post-natal)
186
231
194
233
198
182
138
179
290
240
216
190
2477
Dermatologist
D.N.A.
76
D.N.A.
75
D.N.A.
104
D.N.A.
75
D.N.A.
91
D.N.A.
90
511
974
Dietitian
45
64
75
97
106
89
88
75
95
87
90
63
Eye Department
Orthoptist (Deidre)
62
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
62
46
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
46
33
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
33
37
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
37
23
Samples
Parameters
Samples
Parameters
Samples
Parameters
Drugs of Abuse, RGP, Customs, HM Prison, GHA
400
1041
795
1696
530
1637
Potable Water, Environmental Agency, MOD, GHA
834
5473
777
4475
806
5578
Swimming Pool Water
46
337
49
323
72
412
Optometrist (Isabella) Diabetic
Optometrist (Isabella)
Refraction
Optometrist (Isabella) Children
Sea Water
163
489
138
414
169
507
Optometrist (Isabella) General
23
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
SBH
Child Health Dept
Weighing Clinic
607
608
568
660
661
683
586
522
665
652
586
533
7331
Filtrations
13
52
12
48
10
42
Deminerialised Water
28
112
41
164
51
204
Dr’s Clinic
75
101
74
120
96
89
55
73
105
82
106
71
1047
Dialysis Water
4
96
34
732
12
288
H.V. Development Assessments
111
80
73
117
68
55
83
71
69
65
75
31
898
143
619
157
815
407
1587
School Visits
65
248
48
10
6
0
0
0
2
192
145
21
737
Immunisation Clinic
286
327
260
357
445
448
201
212
299
312
402
233
3782
Food and Drink
74
Jan
‘05
Others
122
168
39
97
112
249
Total
1753
8387
2042
8764
2169
10504
Nursing Duties
Treatment Room
527
565
691
618
714
708
652
659
684
545
587
720
7670
Phlebotomy Clinic
641
879
840
984
859
796
732
652
924
743
814
697
9561
Ear Syringing Clinic
34
23
43
38
49
52
49
49
54
13
57
35
496
ECG Clinic
78
142
127
127
97
106
75
81
81
94
82
72
1162
Cryotherapy
22
53
21
36
28
129
124
143
182
77
116
119
1050
1626
Flu Vaccinations
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
1343
283
S.N.A.
Dental Department
Mrs E Caetano
375
398
230
361
347
304
241
153
403
325
396
308
3841
Mr C Clinton
314
429
405
650
446
114
396
408
370
527
335
444
4838
Mr F Morillo
386
291
461
447
539
444
385
373
454
364
305
265
4714
Mr K Pizarro
127
189
178
218
125
177
101
100
154
227
163
189
1948
Speech and Language
Adults
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A
S.N.A
S.N.A
0
Paediatrics
181
228
107
188
196
185
155
38
242
132
177
58
1887
Audiologist
154
155
171
173
196
200
214
59
279
151
193
66
2011
Mental Welfare
151
184
186
193
204
208
204
208
194
224
216
136
2308
District
Insulin
936
910
1220
682
598
683
609
556
204
328
413
500
7639
Dressings
461
522
661
504
498
593
444
392
373
316
327
385
5476
Injections
71
74
103
53
69
99
100
71
78
76
76
92
962
Baths
138
135
185
106
116
133
100
121
112
118
112
143
1519
No. of Visits
1867
1852
2459
1490
1577
1847
1533
1248
968
1062
1095
1270
18268
Macmillan
127
56
118
50
70
123
87
150
75
99
67
24
1046
INR and Blood Samples
113
122
160
114
149
166
122
105
98
120
111
144
1524
Flu Vaccinations
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
S.N.A.
87
9
0
96
Physio
157
122
166
180
212
176
169
150
182
184
167
166
2031
Occupational Therapy
Adults No. of patients
132
141
129
166
157
102
117
126
97
110
126
81
1484
Paediatrics No of visits
53
81
62
94
73
64
36
6
6
61
70
48
654
Totals
16828
19478
19471
18652
17721
17840
16143
15480
17233
18029
17071
14656
210729
75
2.2 Clinics and other services attendance for 2006 (number of appointments)
Jan ‘06
Feb ‘06
Mar ‘06
Apr ‘06
May ‘06
Jun ‘06
Jul ‘06
Aug ‘06
Sep ‘06
Oct ‘06
Nov ‘06 Dec ‘06
Total
6295
7626
7705
5888
7187
6653
6273
6393
7000
7121
7164
6184
81,489
357
424
322
458
334
319
404
292
371
302
318
577
4,478
DMS
17
19
31
21
41
35
26
29
33
31
25
27
Visitors
11
6
12
22
18
18
11
23
17
23
12
House-Calls
413
510
659
467
457
539
422
508
583
397
Nurse Practitioner
875
1092
1142
737
1012
777
797
1099
763
Dr Vassallo (WWC,
Post-natal)
202
181
234
172
189
205
158
108
S.N.A
96
S.N.A
S.N.A
83
106
S.N.A
93
91
86
89
79
105
GP Clinics
Weekends
Dermatologist
Dietitian
Child Health Dept
Jan-07
Feb-07
365
330
5,650
1009
959
858
11,120
27
21
316
1060
194
211
165
131
2,150
198
62
201
163
137
197
233
79
119
123
198
173
1883
107
S.N.A
96
S.N.A
95
583
75
80
82
109
104
70
1,063
0
76
573
96
44
19
279
391
98
107
476
64
57
19
15
375
1016
761
70
94
135
0
455
53
457
57
313
47
184
43
208
25
159
89
173
127
368
66
83
852
42
88
0
224
205
147
0
105
576
130
65
21
4
279
860
634
70
67
220
0
449
61
550
107
115
29
0
0
183
34
152
118
150
183
327
199
122
956
45
101
0
188
92
108
103
100
494
93
38
17
4
292
1
770
498
28
57
66
0
397
56
358
72
230
31
126
48
128
31
121
83
186
166
356
62
114
862
26
89
0
165
124
123
0
118
597
90
64
17
397
659
4
1060
797
58
90
201
0
344
43
551
130
253
31
216
57
177
35
158
119
176
163
476
57
119
1028
28
124
0
241
223
149
146
106
543
62
57
13
10
240
1
822
701
50
64
109
0
403
65
238
90
277
7
245
80
129
26
81
88
184
173
365
54
96
855
23
101
0
137
165
99
0
72
574
105
41
18
6
258
1
816
617
35
57
129
0
409
97
257
68
508
101
237
80
9
49
100
205
140
350
86
184
887
54
72
0
134
207
90
123
110
605
88
50
4
0
289
2
983
667
77
72
171
0
265
68
452
117
574
157
411
194
50
95
131
645
65
55
22
3
444
8
1085
825
40
121
156
0
402
57
431
118
270
75
232
299
58
138
131
183
224
537
177
105
1412
129
114
0
71
58
45
0
96
584
95
41
19
13
416
5
1026
711
35
96
189
935
201
80
367
67
257
83
139
177
38
137
91
178
221
336
170
84
1095
71
107
84
170
62
146
114
37
451
81
47
23
0
247
2
884
465
30
64
86
748
311
48
297
57
98
36
113
171
58
48
58
156
184
312
107
84
917
67
73
5
152
37
72
679
1162
6698
1074
609
198
737
4226
11286
7936
578
940
1742
1683
4444
27
106
230
172
577
82
110
1238
86
106
0
50
132
0
0
104
580
105
50
6
6
336
5
984
619
42
66
158
0
401
85
392
139
224
79
226
139
38
127
92
215
368
1019
219
196
2361
175
200
0
114
82
59
House-Calls
Nurse Practitioner
Dr Vassallo (WWC,
Post-natal)
Dermatologist
Dietitian
Child Health Dept
Weighing Clinic
554
621
393
621
Dr’s Clinic
108
92
89
88
95
78
66
98
100
99
104
77
1,094
HV Assessments
60
64
66
47
60
74
51
57
60
54
64
36
693
HV Primary Visits
HV Primary Visits
26
30
22
12
36
18
19
21
20
0
8
0
212
School Health Visits
School Health Visits
167
309
300
8
322
2
0
0
1
510
161
65
1,845
Immunisation Clinic
Immunisation Clinic
256
251
380
207
328
190
154
184
196
300
414
274
3,134
Eneuresis Clinic
587
862
846
853
752
908
832
837
692
785
Dr’s Clinic
HV Assessments
Nursing Duties
9,190
Treatment Room
Phlebotomy Clinic
753
629
996
959
748
761
587
705
657
732
673
437
8,637
Ear Syringing Clinic
19
44
51
53
71
72
66
80
46
32
39
39
612
Ear Syringing Clinic
ECG Clinic
81
105
118
79
71
74
49
86
96
90
74
52
975
ECG Clinic
Cryotherapy
131
104
154
108
126
170
146
154
156
94
176
121
1,640
Cryotherapy
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
1344
125
1,469
Flu Vaccinations
425
319
382
382
355
427
271
229
307
513
529
272
4,411
76
46
77
71
42
71
70
62
32
74
64
36
(721)
Mr C Clinton
403
473
551
sick
403
495
278
449
430
357
457
244
4,540
DNA’s
108
88
117
sick
97
174
84
160
126
101
90
73
(1,218)
Mr F Morillo
400
428
398
482
411
668
223
281
436
309
464
329
4,829
DNA’s
0
47
54
72
74
149
38
41
98
42
85
70
(770)
Mr Morillo SBH
103
73
196
150
189
144
855
DNA’s
18
28
46
21
41
40
(194)
177
200
244
185
190
252
117
129
150
225
257
144
2,270
36
26
57
50
35
51
31
24
8
0
0
0
(318)
DNA’s
Speech and Language
Mrs E Caetano
DNA’s
Mr C Clinton
DNA’s
Mr F Morillo
DNA’s
Mr Morillo SBH
DNA’s
Mr K Pizarro
DNA’s
136
138
135
97
136
117
12
38
111
166
105
57
1,248
Audiologist
Audiologist
154
92
187
96
160
121
142
94
131
170
139
114
1,600
Mental Welfare
Mental Welfare
184
186
186
172
184
164
180
168
188
186
164
175
2,137
District
Insulin
216
166
228
129
238
246
344
382
148
130
104
104
2,435
Dressings
Dressings
379
310
394
264
490
460
497
560
475
785
366
364
5,344
Injections
Injections
65
61
114
50
74
93
78
85
54
78
46
55
853
Baths
127
134
172
106
128
167
189
119
73
110
93
100
1,518
No. of Visits
No. of Visits
964
902
1241
709
1243
1184
1088
1398
956
1168
870
860
12,583
Macmillan
Macmillan
47
49
42
28
50
39
59
63
51
78
23
76
605
INR & Blood Samples
21
105
138
84
113
94
107
150
82
116
78
95
1,183
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
S.N.A
28
108
6
142
167
204
229
175
200
188
203
179
175
162
202
149
2,233
Adults No. of patients
129
111
120
108
101
151
159
87
214
270
194
170
1,814
Paediatrics No of visits
117
93
139
53
118
94
31
76
68
108
98
67
1,062
Totals
Flu Vaccinations
Physio
Occupational Therapy
194,835
407
68
440
120
481
78
207
53
216
Speech and Language
Paediatrics
980
641
43
92
122
0
Dental Department
Paediatrics
District
79076
4469
360
315
2709
11669
Total
Visitors
535
Mr K Pizarro
Dec-07
5083
617
15
6
280
874
183
528
DNA’s
Nov-07
7408
297
32
32
253
989
10
479
Mrs E Caetano
Oct-07
7306
344
36
33
175
1366
459
520
Dental Department
Sep-07
6494
363
33
29
209
777
DMS
596
Flu Vaccinations
Aug-07
6172
263
22
66
185
950
335
535
Phlebotomy Clinic
Jul-07
6223
319
30
34
177
969
7406
366
28
28
296
1150
672
624
Jun-07
6492
354
40
15
140
881
7590
595
612
May-07
6199
240
21
6
154
657
GP Clinics
593
Treatment Room
Mar-07 Apr-07
6807
5896
416
431
40
36
15
30
321
203
1088
908
Weekends
Weighing Clinic
Nursing Duties
76
2.3 Clinics and other services attendance for 2007 (number of appointments)
Insulin
Baths
INR and Blood Samples
Flu Vaccinations
Physio
Adults
Occupational Therapy
Adults No. of patients
Paediatrics No of visits
Totals
131
185
184
136
478
98
110
1051
52
111
0
149
199
96
781
4790
1142
3600
754
2336
281
2101
402
1328
1260
2220
2257
5501
1377
1407
13514
798
1286
89
1795
1586
1134
196212
77
4. PAEDIATRICS
2.4 Clinics and other services attendance for 2008 (number of appointments)
Department
Jan08
Feb08
Mar08
Apr08
May08
Jun08
Audiology
32
126
102
140
103
124
Dietician
64
0
50
111
129
Clinic sister
2082
2019
2211
1816
School health
368
372
351
Speech & language
135
146
Mental welfare
186
Gp clinic
Jul08
Aug08
Sep08
Oct08
Nov08
Dec08
Total
134
130
88
131
132
111
1,353
96
59
72
69
98
68
74
890
1829
1908
2044
1642
2385
2506
2683
2058
25,183
407
662
295
306
809
931
911
968
431
6,811
74
187
166
79
3
24
109
109
140
60
1,232
Neonatal Admissions
175
181
198
163
195
218
231
196
183
176
195
2,297
9636
9057
6760
8437
7788
6933
7533
6265
8329
8430
7504
7618
House calls
377
319
212
210
222
174
177
171
216
300
210
Dental
1476
1190
1237
1806
1356
1398
1355
1377
1394
1951
Child welfare
913
1297
950
1190
781
756
896
684
650
Nurse practitioners
639
203
211
356
333
339
384
312
519
4.1 Paediatric consultations 2005-8
2005
2006
2007
2008
Rainbow Admissions
763
865
865
834
Medical Admissions
419
407
461
435
Newborn Examinations
376
338
370
373
No data
13
No data
No data
Rapid Access/Review Clinic
799
1186
1007
1084
94,290
Allergy Clinic
727
802
385
402
341
2,929
General Clinic
445
363
1830
1384
17,754
Specialist Clinics
695
763
563
10,138
Total Hospital Paediatric Outpatients
489
579
565
4,929
140
142
145
145
1666
2112
1982
1994
8 Week Baby Clinic
372
1094
325
343
Health Visitor referral Clinic
355
429
326
3. GENERAL MEDICINE
2-year checks (Dr Vassallo)
336
Approx. 350
213
3.1 Consultations by speciliaty (2006-8)
Learning/ADHD
128
120
75
66
Approx. 120
195
135
125
1311
1409
1314
1073
St Martin’s
2006
2007
2008
Total number of patients seen
3900
4200
4000
Cardiology
214
207
225
Cardiothoracic
114
57
68
5. SPONSORED PATIENTS
Respiratory
100
61
34
5.1 Number of sponsored patients 2002-8
Nephrology
-
61
-
Neurology
120
107
110
Sleep Apnoea
58
41
55
-
262
223
Cardiac Holters
87
213
200
BP Monitors
32
109
120
Sleep Studies
-
56
53
150
Stress Tests
Spirometry
Total Community Clinics Outpatients
SPONSORED PATIENTS STATISTICS
Financial Year
U.K.
Number of Patients
Spain
Other
EEC
Non
EEC
Total
U.K.
Number of Referrals
Total
Spain
Other
EEC
Non
EEC
2002/03
631
185
816
1090
393
1483
57
2003/04
679
259
938
1164
598
1762
75
2004/05
753
291
1044
1252
644
1896
Bronchoscopies
Average 35 per year
2005/06
720
270
1
991
1314
738
4
2056
Endoscopies
Average 300 per year
2006/07
727
323
2
1
1053
1249
802
2
1
2054
2007/08
666
369
1
1036
1351
874
1
(All numbers are approximate)
2226
5.2 Change in sponsored patient allowance
Prior 26.06.07
£266
£400
£98
£147
£5
£7.50
Max rented Spain (week)
£266
£266
Max friends Spain (week)
£98
£98
Inpatient Spain (a night)
£5
£5
Max rented UK (week)
Max calpe /friends UK (week)
Inpatient UK (a night)
78
Post 26.06.07
79
6. PALLIATIVE CARE
6.3 Palliative care referrals and deaths
6.1 Palliative care referrals by medical condition
Diagnosis
Year
Referrals
Deaths
2005
54
32
2006
76
46
2007
77
46
2008
108
47
2005
2006
2007
2008
13
10
8
14
Ca colon/rectum/bowel
5
11
5
12
Renal/kidney cancer
1
3
0
1
Ca tongue/jaw
1
0
1
1
Myelodysplasia AML
1
0
0
1
Ca cervix
1
2
0
0
Ca oesophagus
1
4
3
1
7. PATHOLOGY
Ca Bladder
1
2
3
2
7.1 NUMBER OF LABORATORY ANALYSES 2005-8
Ca Ovary
1
1
3
4
Ca pancreas
2
3
4
3
SCC Pinna
1
0
0
0
Total analyses
Reflex dystrophy
1
0
0
0
% increase from 2005
Liposarcoma
1
0
0
0
Multiple Myeloma
4
4
3
2
Brain tumour
3
1
1
4
Malignant Melanoma
1
0
0
1
Lymphoedema
2
4
5
0
Prostate cancer
1
5
7
9
Stomach cancer
1
3
2
3
Liver cancer
2
0
0
2
Breast cancer
6
11
15
29
Leukaemia
1
2
0
Bone cancer
2
0
Other
3
MND
Unknown primary
Ca lung
Year
2005
2006
2007
2008
510292
574555
598193
641011
12.6
17.2
25.6
8. DIAGNOSTIC IMAGING SERVICES
8.1 Number of examinations
Type of examination
2004-2005
2005-2006
CT
891
1565 (+75%)
MRI
615
659 (+7%)
1
Mammography
506
610 (+20%)
2
0
CR
9570
13009 (+35%)
3
7
10
Ultrasound (General and Doppler)
2174
4866 (+123%)
0
1
2
1
RF
350
407 (+16%)
0
3
0
0
Densitometry
237
306 (+29%)
Testicular cancer
0
1
0
0
14343
28157 (+96%)
Gall bladder cancer
0
2
2
1
Endometrium cancer
0
0
2
1
Vulval cancer
0
0
2
1
Total
9. AUDIOLOGY
9.1 General statistics 2005-8
6.2 Palliative care referrals by source
2006
2007
2008
1850
1820
1506
1537
2005
2006
2007
2008
41
64
60
51
Number of hearing aids issued
100
50
70
49
Wards
1
0
5
24
Number of hearing aid repairs
60
21
41
65
Self/family
2
3
3
7
Unknown
3
3
3
1
750
850
900
950
District nurses
1
0
2
4
7
4-8
8
8-10
Accident/Emergency
2
0
0
0
Pain Clinic
1
0
0
0
GP
3
3
1
3
Other
0
2
3
2
United Kingdom Hospitals
0
0
2
2
Breast Clinic
0
0
0
15
Oncology Clinic
0
0
0
4
Hospital doctors
80
2005
Number of appointments
Number of registered hearing aid users
Waiting list time (in weeks)
81
10. NUTRITION AND DIETETICS
10.1 CONSULTATIONS 2005-8
Classification
By location
By caseload
By age group
Outpatients
Inpatients
New contacts
Follow ups
Children (<18)
Adults (>18)
TOTAL
2008
2007
2006
2005
1953
1899
879
2973
343
3509
3852
2062
1437
888
2611
219
3280
3499
2044
944
723
2265
226
2762
2988
1782
1138
737
2183
268
2665
2920
11. COMPLAINTS AND PATIENT ADVICE
11.1 Number Of Complaints 2005-8
2005
2006
2007
2008
Formal complaints (written)
96
74
52
57
Informal complaints (verbal)
119
122
140
140
3
2
7
5
Independent Review Panels
Pay & Related
12. HUMAN RESOURCES
12.1 Total staff complement 2005-2007
No of Officers Employed
Administrative and Clerical
Ambulance Service
January 2005
December 2007
94
102
N/A
33
117
143
61
68
372
388
PAMs
52
71
Support Staff
30
726
Industrial
Medical and Dental
Nursing
TOTAL
13.2 GHA actual expenditure 2005/06
£24,940,578
Drugs & Pharmaceuticals
£9,229,391
Interest, Leases & Accommodation
£5,008,357
Sponsored Patients & Visiting Consultants
£2,607,527
Other Operational
£3,740,366
Dressings / Gases & Tests
£1,201,604
Ambulance & Boards
£972,667
Insurance, Fees, Claims
£1,126,489
Med & Surg Appliances
£746,587
Elec,Water & Tels
£939,236
School of Health Studies
£300,383
41
Capital
£759,150
846
TOTAL
£51,572,335
13. FINANCE
13.1 GHA Actual Expenditure 2004/05
Pay & Related
£23,117,859
Drugs & Pharmaceuticals
£10,059,172
Interest, Leases & Accommodation
£4,849,148
Sponsored Patients & Visiting Consultants
£2,196,319
Other Operational
£1,999,543
Dressings / Gases & Tests
£1,273,109
Non-GHA
£919,123
Insurance, Fees, Claims
£857,927
Med & Surg Appliances
£563,880
Elec,Water & Tels
£538,651
School of Health Studies
£204,964
Capital
TOTAL
82
£61,727
£46,641,422
83
Notes
13.3 GHA actual expenditure 2006/07
Pay & Related
£27,295,330
Drugs & Pharmaceuticals
£10,197,221
Interest, Leases & Accommodation
£5,214,891
Sponsored Patients & Visiting Cons
£2,216,263
Other Operational Expenses
£5,490,095
Dressings, Gases & Med Tests
Ambulance & Boards
£1,235,508
Insurance Fees & Claims
£1,122,327
Medical & Surgical Appliances
£747,148
IT Recurrent
£149,668
Electricity,Water & Telephone
£1,052,915
School of Health Studies
£369,915
Capital Works
£786,501
TOTAL
84
£940,467
£56,818,249
85
Notes
86