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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